NHIEIVITRUNG BENH VIEN TAI KHOA DIEU TRj TICH Cl/C B I N H VIEN BENH NHIETDdl TRUNG UONG NAM 2014
Vu Dinh Phu', D^ng Phu Khi&m', Nguyen Van Kinh'.
Nhiem tiling benh vien (NTBV) da trd thanh van de sure khoe toan cau, dac biet la tai khoa diiu tri tich cue (ICU), lam tang ganh nang cho he thong y te, chi phi dieu tri, sue khde va ca tinh mang ngucri benh. Tai Viet Nam, NTBV tai mot s6 ICU tvr 19,3% - 31,3%. Muc tieu: Mo ta thi;c trang nhiem triing benh vien tai khoa Dieu tri tich cue Benh vien Benh nhi$t ddi Trung uong nam 2014. Phucmg phdp nghien ciru: mo ta cat ngang moi thang mpt lan trong mot ngay, thu thap thong tin ve dac diem va can nguyen gay NTBV. Ket qud: Trong 217 benh nhan du tieu chuSn duac chgn vac nghien cuu, co 56 benh nhan mac NTBV chiem 25,8%. Loai NTBV thudng g^p nhat la viem phoi chiem 69% va nhilm trimg dudng tiet nieu 12,1%. Can nguyen gay NTBV phd bien la A. baumannii 34,1%, P. aeruginosa 18,2% vaK. pneumonia 11,4%. Kit luan: 'NTBV tai ICU van con cao (25,8%) nhung da giam dang ke so vdi nam 2013, viec giam sat va thuc hi$n cac bien phap kiem soat NTBV thucmg quy tai ICU gop ph4n lam giam ty le NTBV.
TIT khda: Nhiem triing benh vien, ICU.
DAT VAN DE
Nhiem trung benh vien (NTBV) la nhiem trung xuat hien khi benh nhan dang dddc dieu hi tai benh vien hoae ed sd y te va khong u benh trddc khi nhap vient^J. Khoang thdi gian de chan doan MTBV phu ttiupc vao thdi gian u benh cua tiihg b§nh cu the, thifdng nhiem tiling khdi phat sau nhap vien tren 48 gid dude chap nhan la HTBWK
NTBV dang tid thanh van de sut khoe cong dong tren quy mo toan cau, vdi hau qua lam tang ganh nSng cho ca he thong cham sdc y te va ngudi benh, lam tang ty le tif vong, keo dai thcfi gian nam vien va tang ehi phi dieu tri, dae biet la d eac nu'dc thu nhap thap va trung b\ntP\
Ty le NTBV trung binh khoang 7% cac benh nhan nSm vien d eae nudc phat tiien va 10% d eac nddc co thu nhap ttiap va tnjng binh'^i. NTBV tai khoa Dieu b-j b'ch cdc
"'Benh vifn B^nh nhi4l d&i Trung irang Ngiy nh^n bii; 10/3/2015.
NR4> pban bi^n xon(>: 27/3/2015 Nei> duyft ding: 27/4/2015
VgiriM cbju tricb nbifm HQI dung kboa hQc: Vu Dinh Phu. B^nh vi HOnh Nhifl dai Trung utmg
Dien Ihw/i. 09S6SII999. E-mail \-udinhphu07^^gmailcom
(ICU) cao hdn dang ke, khoang 30% d cac nddc co ttiu nhap cao'^i va 35,2% (95% a 24,2 - 48,0) d eac nddc co thu nhap thap va b-ung binh, tiiam chi cao tdi 88,9% da du'dc bao eao tai cac nu'dc nay^^.
Tai Viet Nam chda ed he thong giam sat quoc gia ve NTBV Mot sd It nghien cdu ve NTBV tai ICU ciia mpt so benh vien d ca Mien Bae va Mien Nam cho ttiay ty le NTBV tai khu vdc nay dao dpng tiJ* 19,3% den 31,3%i*'].
Benh vien Benh nhiet ddi Trung u'dng da tien hanh khao sat NTBV tai ICU tif nSm 2012. Ket qua ban dau cho thay ty le NTBV tai ICU n3m 2012 - 2013 la 33,5%, gan eao bang ty le trung binh tai ICU d cac nu'dc co thu nhap thap va trung binh.
Nham danh gia ehieu hu'dng cua tinh trang NTBV cung nhd hieu qua eae bien phap kiem soat nhilm khuan da du'dc trien khai tai ICU ciia Benh vien Benh nhiet ddi Trung ddng, chung toi thdc hien nghien culi nay vdi muc tieu; Mo ta thdc trang nhiem triing benh vien tai khoa Oieu b-j ti'ch ci/c Benh vien Benh nhiet 6d\ Trung ddng nSm 2014.
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0 0 1 TU'ONG VA PHUONG PHAP
Ooi tu'dng nghien cihi: Toan bp benh nhan vao khoa Oieu trj tfch cu'c tn/dc 8 gid sang ngay tien hanh khao sat va con dieu tn tai khoa vao thdi diem khao sat.
•niu chuan x i c ffinh NTBVvien: NTBV la nhiem triing xuat hien sau vao vien > 2 ngay, loai NTBV diroc xac * n h theo Ueu chuan ciJa Trung tam phong ngiiS va kiem soat benh tat chau Au(ECDC).
Phu'dng phap nghien cilu: nghien culi mo ta c i t ngang tien ciJu ttiiTc hien tf-ong mot ngay, l i p lai mpt thang mpt lan, tirthang 2 den thang 10 nam 2014.
So lieu nghien citu du'dc thu thap 1 thang mpt lan theo mau thu thap thong tfn thong nhat, bao gom: tuoi, gidi, noi benh nhan dieu tn tn/dc khi vao khoa, chan doan benh, benh ly nen, cac can thiep xam lan va b'nh trang NTBV tai thcli diem khao sat, ngay khdi phat NTBV, noi mac NTBV va can nguyen gay NTBV
XiJr ly so lieu: So lieu du'dc nhap vao cti sd diJ lieu va phan tfch bang phan mUm thong ke SPSS 22.
KET QUA VA BAN LUAN Olic diem chung
Tir thang 2 den thang 10 nam 2014 qua 12 lan khao sat CO tong so 217 benh nhan du tfeu chuan chpn vao nghien cirtj vdi benh nhan nam chiem chu yeu 68,2%, tuoi trung binh la 51,1 ± 19,2 tuoi.
Benh ly thu'dng gap nhat la nhiem trung than kinh trung u'dng vdi 62 benh nhan chiem ty le 28,6%, tiep theo la viem phoi 57 benh nhan (26,3%), soc nhiem khuan 56 benh nhan (25,8%) va uon van 39 benh nhan (18%).
Co 132 benh nhan c6 yeu to benh nen trong tong so 217 b^nh nhan chiem ty le 60,8%. Trong so cac benh nen nghien rUdu chiem ty le cao nhat 31,1% (36 benh nhan), tfep theo la COPD 12,1% (16 BN) va tieu du'dng 9 , 1 % (12 BN).
Trong so 217 benh nhan vao nghien cuii, ty le dat NKQ (MKQ) la 76,5% (166 benh nhan), thd may 66,8%
(145), catheter TMTT 59,9% (130 benh nhan), ong ttiong tieu 76% (165 benh nhan), ty le sir dung khang sinh la 65,4% (142 benh nhan).
B i c diem NTBV
Trong 217 benh nhan khao sat cd 56 benh nhan mac NTBV tai ttidi diem khao sat chiem ty IS 25,8% (trong dd
00 2 benh nhan mac dong thdi 2 NTBV cung luc). Ty le nay cao hdn ty le NTBV 19,5% tai ICU ciia cac benh vien tai chau Au[8] nhung da giam hdn nhieu so vdi ty le 33,5%
nam 2013 cung tai ICU nay va ttiap hdn ty le NTBV 31,3%
tai khoa ICU Benh vien Bach Mai nam 2006H Dieu nay cho thay ket qua cua no lu'c kiem scat NTBV tai ICU Benh vien Benh nhiet ddi Trung uttng trong ttidi gian qua.
Bleu do 1 : Ty le NTBV
Bieu do 2: Vj tri NTBV thu'dng gap Trong tong so 58 NTBV, NTBV mac tir benh vien khac chuyen den la 16 tn/dng hdp (27,6%), mac tai khoa Bleu b l tfch ci/c la 33 tn/dng hdp chiem 56,9%, mac tai khoa khac tfu'dc khi vao khoa Oieu tfi tf'ch a/c la 9 tfi/dng hdp chiem 15,5% tong so tnrdng hop NTBV. Day la cd sd de lang cu'dng cong tac phdng ngiia NTBV cho cac khoa khac ngoai khoa Bleu tfi b'ch cu'c.
Nhiem triing tai phoi chiem ty le cao nhat 40 tru'dng (69%), nhiem tfiing he ttian kinh 6 tfuSng hdp (10,3%),
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nhiem tfiing he Bet nieu 7 tfu'dng hdp (12,1%), nhiem tfiing huyS 5 frl/dng hdp (8,6%). Co 2 tfi/dng hdp nhiem khuan ciing luc ca d ho hap va tfO: nieu.
Ket qua nghien cuU cua Tmng tam phong ngua va kiem soat benh tat chau Au ding dio ttiay ty le NTBV cao nhat la d phoi nhung vdi ty le chi la 40%™, ttiap hdn nhieu so vdi nghien ciiU nay. Nghien culi ciia Enjem va cpng si/
cung cho ttiay ty le NTBV tai khoa dieu tfi tfch cUc cao nhat la d phoii'i.
Yeii t o nguy cd NTBV
Hau het cac yeu to nguy cd doi vdi NTBV di/dc danh gia deu cd moi lien quan si/ khac biet vdi ty le TBV nhung khong cd y nghTa thong ke ngoai 3 yeu to la benh nhan co catheter TMTT, chuyen t i / khoa khac den Bleu tri tich cue va tuoi tir 15 - 40 hjoi. NhuTig cac yeu to nay deu cd khoang tfn cay 95% gan vdi 1 nen viec ap dung vao thi/c te cac ket luan nay a n phai can nhac than trpng (Bang 1 - 4).
Bang 1 : Moi lien quan giO'a tuoi, gidi t i n h , benh ly nen va NTBV
Bang 3: Benh ly vao vi@n va NTBV
Yeu to r
Gidi
T u o i ( n i m )
nen guy ca
Nam Nir 15 • « 41-60
>60 Co Khong
Tong so b^nh nhan
147
68 78 69 132
B e n h n h a n Pn"BV % ( n )
24,5% (36) 29% (20) 32,4"/. (22j 26,9% (21) 17,4% (12) 28°/c (37}
22,6% (19) T y s u a t c h e n h
OR (95% a ) 0,8 (0,4 - 1,5)
Tham chieu 2,27(1,02-5,07) 1,75(0,79-3,89) Tham chieu 1,33(0,70-2,52)
Tham chieu P 0,29
0,045 0,17
0,38
Bang 2: Ntfi dieu trj tri/dc khi vao Dieu t r i tich cu'c va NTBV
N g u S n B N
Kfioakhac B^hvl^n khk
b^nh nhan 127
89
Benh nhan rflBV
% ( n ) 31,5% (40)
18% (16)
Ty suat chenh OR (95% a ) "*
2,10 (1,09 - 4,05)
Tham diieu 0,026
C h a n d o a n v a o v i f n
Soc nhiem khuan
Viem p h a
N h i l m t r u n g than kinh t w
Uon v a n Tfingso b^hnhan 56
57
"'
39
B^nhDhanHTBV
% ( n ) 3 2 , 1 % ( 1 8 )
2 2 , 8 % ( 1 3 )
27,9% ( 1 7 )
2 0 , 5 % (8)
T y s u S t d t e n h O R ( U % C I ) 1,84(0,70-4,79)
1,14(0,42-3,09)
1,50(0,57-3,90)
Thamdueu P
0,21
0,79
0,41
Bang 4: Cac can thiep xam lan va ^^TBV
C a c c a n t h i e p x a m l i i n
N p i k h i q u a n ( M K Q )
C a t h e t e r T M T T
O n g
t i e u Co Khong
C6 Khong
Cd Khong
Co Khong
T o n g s o b e n h n h a n
165 51 130 36 165 51 144 70
B e n h n h a n N T B V % ( n )
27,3% (45)
21,6% (11)
30,8% (40)
18,6% (16)
29,7% (46)
19,6% (10)
29,9% (43)
18,6% (13) TVsuStchMi O R ( 9 5 % C q 1,36(0,64-2,89)
Tiiam chieu
1,94(1,01-3,76)
T])amdueu
1,58(0,73-3,42)
T h a m d i i & j
1,87 (0,93 - 3,76)
Tham chieu P
0,27
0 , 0 «
0,24
0,07
Can nguyen gay NTBV
Trong 56 tn/cJng hdp NTBV, c6 32 tru'dng hOp tim di/dc can nguyen gay benh vdi tong so 44 chung phan lap di/dc. A. baumannii la can nguyen thu'dng gap nhat v6i ty le 34,1% (15 Chung), tiep theo la fi aeruginosa 18,2% (8 chung) va K. pneumoniae 11,4% (5 chiing). Ket qua nghien CU\J cua Nguyen Xuan Quang va cpng SLT nam 2008 tai 3 khoa Cap culi, Oieu tri tich cut va Oiong d6c Benh vien Bach Mai, can nguyen NTBV hay gap nhat la A.
Baumanniiya R aerug/nosa deu chiem 27,3% ^ n g so cac can nguyen gay NTBV^°]. Ty le A. baumannii gap trong nghien CLTU nay nhieu hdn co the phan anh dac ^em xu hu'dng NTBV do A. baumannii dang gia tang.
Ty le A. baumannii ti\ang cartapenem la 10/15 chung phan lap du'dc va d fi aeruginosa la 7/8 chiing. Day la ty le l<hang thudc cao dang quan ngai vi caitapenem la mot trong nhlJtig thuoe cuoi ding de dieu tri vi khuan da khang. Ty le khang khang sinh trong nghien CLIIJ nay cao
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hdn dang ke so vdi nghien culi ciia Nguyen Xuan Quang la 8,2% v a R aemginosava 13,6% vdi A. baumannil^^''\
KET LUAN
Ty le NTBV tai khoa dieu tri tfch a/c Benh vien Nhiet ddi Trung Udng nam 2014 la 25,8% giam nhieu so vdi ty le 33,5% nam 2013.
NTBV hay gap nhat la viem phoi chiem tdi 69% tong so cac tru'dng hdp NTBV.
Can nguyen HiUdng gap nhat gay NTBV la A. bau- mannii 34,1%, fi Aeruginosa 18,2% va K. Pneumoniae 11,4%.
KHUYEN NGHI
Nen giam sat NTBV thu'dng quy tai khoa Dieu tri tich aic, qua do giup trien khai cac bien phap phong ngij^ va kiem soat NTBV hieu qua hdn gdp phan han che ty le rfTBV.
TAI LIEU THAM KHAO
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2. Vincent, J.L, Nosocomial infections in adult inten- sive-care units. Lancet, 2003. 361 (9374): p. 2068 - 77.
3. WHO, Report on the Burden of Endemic Health Care-Associated Infection Worldwide: a system review of the literature. .http://vKhqlibdoc.vi/ho.intypublica- tions/2011/9789241501507_eng.pdf., 2011.
4. Thu, T.A., et al., A point-prevalence study on healthcare - associated infections in Vietnam: public health implications. Infect Control Hosp Epidemiol, 2011.
32 (10): p. 1 0 3 9 - 4 1 .
5. Vu Van Giang, Nguyen Vuet Hung, Pham Le Tuan ca cgng SLT, 'Tinh hinh nhiem khuan benh vien va mot so yeu to lien quan tai mpt so benh vien thupe Sd Y te Ha Npi 2006". Y Hpc Lam sang, 2008 (6): Tr. 39 - 45.
6. Tru'dng Anh ThU, Nguyen Viet Hung va cpng SLT,
"Tinh hinh nhiem khuan benh vien va cac yeu td lien quan tai Benh vien Bach l^lai nam 2006". Y Hoc Lam sang, 2008
(6): Tr. 51 - 55.
7. Nguyen Hong Sdn, Tran Quoc Viet va cpng sd, 'Tinh hinh nhiem khuan benh vien tai khoa Hoi su'c b'ch c i i t Benh vien Quan dpi 175". Y Hpc Lam sang, 2008(6):
Tr. 63 - 66.
8. ECDC, Point prevalence survey of healthcare-asso- ciated infections and antimicrobial use in European acute care hospitals 2011 - 2012. Stockholm; European Centre for Disease Prevention and Control 2013, 2013.
9. Erdem, H., et al.. Surveillance, control and man- agement of Infections in intensive care units in Southern Europe, Turkey and Iran ~ a prospective multicenter point prevalence study. J Infect, 2014. 68 (2): p. 131 - 40.
10. Nguyen Xuan Quang, Doan Mai Phu'dng, Nguyen Viet Hiing, "Mdc dp de khang khang sinh ciia mot so vi khuan gay nhiem khuan benh vien tai cac ddn vj Hoi sut cap ciJti, Benh vien Bach Mai 2003". Y Hpc Lam sang, 2008 (6): Tr. 89 - 95.
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