HOI NGHj TOAN QUdC Vg CAC BENH NHI^M TRONG VA HIV/AIDS 6 TRg EM NAM 2013
TINH HINH sir DUNG K H A N G SINH VA DAC DIEM K H A N G K H A N G S I N H C U A T A C N H A N VI KHUAN GAY NHIEM KHUAN
BENH VIEN TAI BENH VIEN NHI TRUNG U'CXNG
Le Kien Ngai*, Nguyen Thj Hoai Thu*,Tran Van Hudng*, L6 Thanh Hai*
TOM TAT
Khang sinh la loal thuoc dffdc sff dung nhieu nhat trong benh vien. Tuy nhien co thffc sff can phai chi djnh khang sinh rong rai nhff vay? Mffc dp de khang khang sinh cua vl khuan gay nhiem khuan benh vien (NKBV) hien nay ra sao? Muc tieu: Md ta tinh hinh sff dung khang sinh tai cac khoa hoi sffc tich effc (HSTC) va dac diem khang khang sinh cua cac vi khuan gay NKBV. Ket qua:
Cd 669 lieu khang sinh dffdc sff dung, trung binh moi benh nhan dffdc dieu tri 1,6 khang sinh;
21,2% lieu khang sinh dffdc sff dung khi khdng cd chi dinh ro rang; 44,5% cac Cephalosporin the he 3 va 4 dffdc sff dung khi khong co trieu chffng nhiem khuan va ty le nay la 11,4 % doi vdi nhdm Carbapenem. Cd 36 lieu Collstin dffdc sff dung 1 chi djnh dieu tri cho nhiem khuan cong ddng, 35chi dinh dieu tn NKBV. 37 lieu Quinolon dffdc sff dung dieu tri NKBV. 100% Staphylococcus aureus khang vdi methicillln, tuy nhien chffa ghi nhan trffdng hdp nao khang Vancomycin; 50%
Pseudomonas aeruginosa va 85% Acinetobacter baumannli khang vdi Carbapenem. Ket lu|n;
Khang sinh dffdc sff dung pho bien tai cac khoa HSTC va cdn nhieu chi djnh khong ran thiet, thffdng dffdc dieu tn phoi hdp.^ Cd xu hffdng tang sff dung Collstin trong nhi khoa. Vi khuan gay NKBV dffng hang dau la cac vi khuan gram am khang vdi nhieu loai khang sinh va khang cao vdi nhdm Carbapenem; 100% can nguyen S.aureusla MRSA.
* Benh vien Nhi Trung uang Phan bi?n khoa hoc: TS. Tr^n Minh fiiln
Tit khoa: Khang sinh, vl khuan, nhiem Jjhuan benh vien, khang khanh sinh
SUMMARY
ANTIBIOTIC USE AND ANTIBIOTIC RESISTANCE IN BACTERIA CAUSING HOSPITAL ASSOCIATED INFECTIONS AT
THREE ICUs, NATIONAL HOSPITAL OF PEDIATRICS
Antibiotic have been using popularly in the hospital. How is bout antibiotic indication in the hospital? and how is about antibiotic resistant in bacteria cause hospital associated infections (HAIs) Aims: Assessment of antibiotic indication and combination at three intensive units, National hospital of Pediatrics; Identification of prevalence and antibiotic resistant in bacteria which cause HAIs Result: 669 antibiotics were used, in average 1.6 antibiotic per one patient. 21,2%
antibiotics were prescribed without any infectious evidence; 44.5% cephalosporin third and fourtih generation and 11.4% carbapenem were used in uninfectious situations. 36 doses of collstin were prescribed, only one was used for community acquired infection. Quinolons were used quite a lot for nosocomial infections with 37 doses.
100% Staphylococcus aureus are MRSA, but all are sensitive with vancomycin; 50%
Pseudomonas aeruginosa ax\6 85% Acinetobacter spp are carbapenem-resistant. Conclusion: Its very necessary to develop an antibiotic stewardship in the hospital. Prevention of HAIs is much effective than treatment of HAI
Y HOC VI$T NAM THANG 10 - SO 2/2013
Keywords: antibiotic, bacteria, hospital asscoclated Infections, resistance
I. DATVANOE
Hi8n nay khang sinh duac sff' dung rong rai tai benh vien, tren 50% sd benh nhan trong benh vien, gan nhu toan bd benh nhan tai cac khoa dieu tri tich cue duoc dieu tri khang sinh (5). Tinh trang khang khang sinh dac biet la su de khang khang sinh cua cac vi khuan gay nhiem khuan benh vien (NKBV) dang trd thanh vSn de mang tinh toan cau va gay ra nhieu tac dpng nghiem trong nhat la tai cac nude dang phat tridn (3,4). Mac du vay viec lam dung khang sinh, sff dung khang sinh khdng hgp Iy, khong dung chi dinh van tiep tuc dien ra. Hau qua la cd den 70% vi khuan gay NKBV khang lai it nh^t mot loai khang sinh thong dung, 35-40% sd do khang vdi thuoc dugc uu tien lira chon dieu tri vi khuan do (2) cac khang sinh the he mdi cung dang mat dan hieu luc tham chi mot so vi khuan chi cdn cd the dugc dieu tri bang nhffng thudc cd kha nang gay ddc hoac dang trong qua trinh thff nghiem.
NKBV do cac vi khuan khang thudc lam tang ty Ie tff vong thd (OR,2.4; 95% CI:
1.03-5.61), keo dai thdi gian di^u tn (22,9 ngay so vdi 12,8 ngay;p=0.04)(4) va chi phi dieu trj cao hem han so vdi nhiem khuan do vi khuan nh^y cam cung Ioai, keo theo dd la nguy CO lay lan nhanh chong tren dien rpng cac chffng khang thudc nay.
Do dd cung vdi viec thuc hien cac bien phap kiem soat nhilm khuan (KSNK) nham ngan ngffa lay, nhiem NKBV, thi viec lien tuc cap nhat tinh hinh sff dung khang sinh hgp ly va md hinh khang khang sinh cua vi khuin gay NKBV la rat can thiet nham nang cao hieu qua dieu tri cung nhu giam thieu hau qua cua NKBV
Muc tieu cua nghien ciiu
Mo Id linh tinh chi dinh vd phoi hop khdng sinh tai cac khoa hoi sue lich cue, Benh vien Nhi Trung uang
Xac dinh ty le phan Icip duac tdc vd dac diem khdng khdng sinh cua cac tdc nhan vi khuan gay nhiem khuan benh vien
11.001 TLTONG VA PHLTONG PHAP NGHIEN CLTU Ddi tugng nghien cffu: Benh nhan tai ba khoa dieu tri tich cue, Benh vien Nhi Trung uang
Phuong phap nghien cffu: dieu tra ngang lap Iai ket hpp mo ta, phan tich
Dia diem nghien cffu: Khoa Dieu tri tich cue, Khoa Hoi sffc so sinh va Khoa Hoi sffc Ngoai, Benh vien Nhi Trung ucmg
Thdi gian nghien cffu: thang Gieng den thang Ba nam 2013
Tieu chuan lua chpn benh nhan: Toan bd benh nhan nhap ba khoa dieu tri tich cue trudc hoac tai thdi diem 8 gid sang ngay tien hanh khao sat va van cdn dieu tri tai thdi diem Ihuc hien khao sat
2.1. Bien so nghien cii'u:
- Du' lieu ca ban cffa doi tuong nghien cffu:
tudi. gidi, khoa dieu tri
- Kieu sff dung khang sinh: don dgc hay phdi hgp
- Cac chi dinh sff dung khang sinh: NKBV, nhiem khuan cdng ddng (NKCD), du phdng
2.2. Thu th^p va xu' ly so lieu:
Thu thap dff lieu tff benh nhan va benh an bang phieu dieu tra
- Thu thap dir lieu khang khang sinh tff k6t qua khang sinh dd
- Sd lieu dugc nhap va xff ly bang phan mem Microsoft Office Excel 2007
- Cac bien sd dugc bieu dien dudi dang tin suat va ly le phan tram (%); ap dung ki^m dinh x^ khi cd so sanh cac bi^n so dinh tinh
HOI NGHI TOAN QUfiC V f CAC B$NH NHlf M TRONG VA HIV/AIDS d T R 6 EM NAM 2013
III. K I T Q U A
3.1. Thong tin co' ban ve floi tu'p'ng nghien ciiu vi ty 1^ hiSn mic NKBV tai cac khoa dieu trj tich cu'c
Co t6ng s6 408 b$nh nhan dugc chpn v4o nghien ciru sau 3 dot diSu tra, phan bo nhu sau:
Bang I: D6i tugng nghien cuu
Tuoi So sinh 1 thang - 5 tuoi
> 5 tu6i Gio'i tinh
Tre trai Tre gai Khoa
Hoi sire ngoai So sinh Hoi sire Cap ciru
So luvng 270 127 11 253 155 86 236 86
%
66,2 31,1 2,7 62,0 38.0 21,1 57,8 21,1 3.2. Tinh hinh sir dung khang sinh
3.2.1. Ph6i hop khdng sinh
Co 385 benh nhan trong s6 408 benh nhan thu thap du lieu dugc sir dung khang sinh de diSu trj chiim 94,4%. Trong s6 do 155 benh nhan dugc diing 1 loai khang sinh (40,3%); 177 benh nhan dugc diing 2 loai khang sinh (46,0%); 52 benh nhan dugc diing 3 loai khang sinh (13,5%) va 1 benh nhan dugc diing 4 loai khang sinh mot thcri diem (0,3%).
3.2.2. Chi djnh liiiang sinh Bang 3: Chi dinh dieu trj khang sinh Nhom khang sinh
Cephalosporin the he 3&4 Carpapenem (meronem- imipenem) Vancomycin Collstin Quinolon Amynoglycosyd Khac (Metronidazole, Amphotericin...) Tong so (%)
Chi dinh NK
cong dong 71 47 16 1 11 35 39 220(32,9)
NK benh vien
26 91 12 35 37 28 56 285(42,6)
Du-phong phau thuat
17 2 0 0 0 0 3 22(3,3)
Khong CO chi dinh ro rang
73 18 1 0 3 19 28 142(21,2)
T5ng so
(%)
187(28) 158(23,6)
29(4,3) 36(5,4) 51(7,6) 82(12,3) 126(18,8) 669(100)
Y HOC VI$T NAM THANG 10 - SO 2/2013
3.3. TAc nhan vi khuan gay NKBV \h mu'c do khang khang sinh 3.3.1. Dac diim tdc nhan vi khuin g&y NKB V
Bang 4: Ty le phan lap dugc vi khudn gay nhilm khu4n benh vien Vi Idiuan
Staphylococcus aureus Enterococus Klebsiella pneumoniae Pseudomonas aeruginosa Acinetobacter spp Eschrichia coli Enterobacter spp Stenotrophomonas Seratia Candida Tong
n 9 1 16 10 7 6 2 1 1 12 65
%
13,8 1.5 24.6 15,4 10,8 9,2 3,1 1,5 1,5 18,5 100
3.3.2. Dac diim de khdng hltdng sinh cua vi khuhn gay NKBV
Trong 65 loai vi khu4n gay NKBV phan l^p dupe: 100% (9/9) S.aureus khang vdi Methicillin nhumg van cdn nhay cam vdi Vancomycin; 65% (17/26) nhdm true khuan Gram (-hao gdm K.pneumoniae, E. coli.
Enterobacter spp, Stenotrophomonas, Serratia da khang vai carbapenem. Trong 9 trudng hop cdn nhay cam vdi carbapenem thi chi cdn 2 trudng hpp la cdn nhay cam vdi cephalosporin the he 3; P.aeruginosa va Acineto spp hlu h^t da &h khang vdi cephalosporin thd he 3; (5/10) 50%
Pseudomonas va 85% (6/7) Acinetobacter da de khang vdi carbapenem;
Trong 32 trircmg hgp viem phoi benh vien cd tim thdy can nguyen cd 25 trudng hpp (67,6%) vi khuan gram am khang carbapenem va S.aureus khang Methicillin.
0 nhdm benh nhan nhiem khdng mac viem phdi benh vien ty le nay la 7/28 (25%) (X2;p<0,05)
IV. BAN LUAN
4.1. Tinh hinh chi dinh va phoi hop khang sinh
Cd 669 lieu khang sinh dupe dieu tri cho 385 benh nhan trong nghien cffu, trung binh mdi benh nhan dupe sff dung 1,6 khang sinh.
Trong do phdi hgp dieu tri hai den ba khang sinh la phd bien nhat. chiem den (59,5%). cd mdt trucmg hgp phdi hgp dieu tn 4 khang sinh tai Khoa hdi sffc So sinh tren benh nhan mac ddng tlidi 3 Ioai NKBV. Da cd su chenh Iech Idn ve ty Ie phdi hpp khang sinh khi so sanh vai viec sff dung khang sinh tai tai cac khoa dieu trj tich cue nhi cua cac nude phat Iri^n. Tai Thuy sy: ty ie sff dung hai khang sinh trong dieu tn nhiem khuan chi cd 5.3%;
>3 khang sinh: 2,7%; 92% chi dung mdt khang sinh(7).
Cd 142 (21.2%) lilu'kh'kng sinh dugc sff dung khi khdng co chi djnh dieu tri ro rang.
Khang sinh dupe dung ngay khi benh nhan nhap khoa dff chua cd dau hieu nhilm khu&i, hoac da het bieu hien nhiem khuan nhung II
HQI NGH! TOAN QUdC v £ CAC BgNH NH|£M TRIJNG VA HIV/AIDS 6 TRg EM NAM 2013
vSn tiep tuc dieu trj. Nhan thay cd den 44,5%
(73/164) nhdm Cephalosporin the h? 3 va 4 dupe chi dinh cho cdc trudng hpp khong cd bieu hien nhilm khuan. Ty le nay doi vdi nhdm Carbapenem la 14,4%(I8/158). Nhu vay da cd den 58,9% chi djnh sff dyng cephalosporins v^ carbapenem khi khdng cin thi^t. Theo Martin Stocker Cephlosporins tlie h? 3 v^ Carbapenems khdng nim trong so 5 loEii kh^ng sinh dugc khuyin c^o khdng nen sff dyng rpng r§i do nhanh chdng gia tSng khang thudc va nguy CO nhiem nam dd nguy co vi khuan khang Cephalosporins va tham chi Carbapenems gia tSng nhanh chdng (6.11) Ghi nhan Colistin dugc sff d\ing 36 lieu (35 nhiem khuan benh vien. 1 cho nhiem trung cdng dong) la cao khi so vdi mpt sd nghien cffu khac (28 Heu cho 22 benh nhan ngudi Idn trong 5 nam 2000-2005 tai mdt benh vien a Canada (8);
38 lieu tren 29 benh nhan trong ca nam 2011 tai khoa dieu tri tich cue nhi, Thd NhT Ky (9).
Mac du tdi chua ghi nhan Colistin bi de khang nhung viec sff dung rong rai cd the se dan den nguy ca khang thuoc , da cd bao cao ve khang colistin d chau Au (10).
4.2. D | c diem k h a n g k h a n g sinh ciia tac nhan vi k h u a n gay NKBV
Ket qua phan lap tac nhan gay NKBV tucmg tu nhu cac nghien cffu iruac tai Viet Nam, trong dd tac nhan la cac vi khuan gram am chiem ty Ie chu yeu. Trong 65 loai vi khudn gay NKBV phan lap dupe, ghi nhan 100% S.aureus (9/9) khang vdi Methicillin (MRSA) cho Ihdy tinh trang MRSA lan rpng hoan toan co kha nang xay ra tai cac benh vien cffa nuoc ta. Viec cac Ioai vi khuan graam am nhu K. pneumoniae. E. coli, Enterobacter spp. Stenotrophomonas, 12
Serratia dac biet la Acinetobacter da gan nhu dd khang vdi nhdm Cephalosporin va cd ty 1? khang cao vdi nhdm Carbapenem cho thAy kha nang khdng cdn khang sinh de lira chgn d'lku tn nhilm khuln benh vien da rk hi?n hffu. Viec tap trung dau tu de phdng ngffa NKBV se thuan Ipi han vice phat trien khdng sinh didu tri NKBV (1).
V. KET LUAN
Chi djnh dieu tri khang sinh rpng rSi van con dang la tinh trang phd bien tai cac dan vj dieu tri tich cue. Khang sinh thudng dupe diSu tri phdi hgp, it dilu tri don le. Sff dung cac khang sinh it sff dung trudc day (Colistin) dang cd xu huong tang len. Tac nhan vi khuan gay NKBV dung hang dau la cac vi khuan gram am. Cac tac nhan vi khuan gay NKBV da khang vai nhi6u loai khang sinh, dac biet nhdm vi khuan gram am khang cao vdi nhdm Carbapenem, 100% can nguyen S aureus la MRSA.
TAI LIEU THAiM K H A O
1. Bill Nghia Thjnh va cong su-. Khao sat tinh hinh de khang khang sinh ciia vi khuan t?i khoa Hdi sffc tich eye va chong dgc Benh vi?n cap ci'rii Trung vuang 2010. Hpi thao khoa hpc ky thuat benh vien c5p cffu Trung vuang 2010.
2. Centers for Disease Control and Prevention. 2000. Public health focus:
surveillance, prevention and control of nosocomial infections. Morb. Mortal Wkly.
Rep.A\.7Z3-lZ7.
3. Gaynes R, Monnet D. Contribution nf antibiotic use on the frequency of antibiotic resistance in hospitals. Ciba Found Symp.
207:47-56
Y HOC VIET NAM THANG 10 - S6' 2/2013
IMonnet D, Archibald L, Phillips L, Tenover F, McGowan J , Jr, Gaynes R.
Antibiotic use and resitance in eight US hospitals: complexities of analysis and modeling. Intensive care antimicrobial resistance epidemiology project and National Nosocomial Infections Surveillance System Hospitals. Infect Control Hasp Epidemiol 19:388-394
Levy ER. G3-175. Trends in Antimicrobial Prescribing at an Academic Children's Hospital, 2007-2010. Presented at: 51st ICAAC. Sept. 17-20, 2011. Chicago Greenwood D. "Antimicrobial treatment.
Sixty years on: antimicrobial drug resistance comes of age". Abstracts of the IJih Annual Meeting of the Society for Health Care Epidemiology of America. 2001; Toronto, p 60 (abstr 96).
Fischer JE, Ramser M, Fanconi s. Use of antibiotics in pediatric intensive care and
potential savings. Intensive Care Medicine July 2000, Volume 26. Issue 7: 959-966 8. Deana M, Kevin L, Johann P, Bruce D,
Harvey R, John C. Utilization of colistin for treatment of multidrug resitance Pseudomonas aei'uginosa. Can .1 Infect Dis Med Microbiol 2008 NOV-DL'C: 19(6): 413-418
9. Karbuz A, Kendirli T, Cift?" E, Ozdemir H, Aysev AD, Aldemir B. of colistin in pediatric patients al a pediatric intensive care unit in Turkey. Ankara University Medical School. Ankara. Turkey.
10. Li J, Nation RL. Old polymyxins are back:
Is resistance close? Clin Infect Dis.
2006:43:663-4.
I!. Stocker ef al. Antibiotic surveillance on pediatric intensive care unit: easy attainable strategy at low cost and resources. BMC Pediatrics 20n, 12:196
