I
KHAO SAT Sir KHANG KHANG SINH CtJA KLEBSIELLA PNEUMONIAE TREN BENH PHAM PHAN LAP OlTOC
TAI VIEN PASTEUR, TP HO CHI MINH
PHAIVI TH! HOAl AN', VO LE NGOC LAN", UONG N G U Y E N DLrC NINH", PHAN NGOC THAO", CAO HIJU NGHlA"
TOM TAT
Klebsiella pneumoniae Id mpt trong nhirng tde nhdn hdng ddu gdy nhiim khudn benh vicn Chimg tdi phdn lap dime 35 chimg tir 680 mdu binh phdm lai Vien Pasteur TP Ho Chi Minh tir thdng 1-6/2014. kit qud nhu saw K pneumonia khdng cao nhdt vdi AM (94.29%). tiip do SXT (79.31%). CN. PIP (62.86%). CAZ (51.43%). chi mpt ti li nho khdng lai CS IPM. MEM (2.86%): 65.71% chung sinh ESBL vd 20% chung sdn xudt carbapeneinase.
Tir khda: P lactamase phd rpng. carbapenemase, khdng khdng sinh, Klebsiella pneumoniae.
ABTRACT
Surveying the antibiotic resistance of Klebsiella pneumoniae in isolated specimens in Pasteur Institute - Ho Chi Minh City
Klebsiella pneumoniae is one of the factors causing nospcpmial infectians. This study aimed lo investigate 35 strains isolated from 680 clinical samples at the Pasteur Institute - Ho Chi Minh City from .lamiary to June 2014. The results showed that the resistant rates on AM. SXT, CN. PIP. CAZ were 94 29%. 79 31%. 62.86%, 62.86%, 51.43%, respectively. There was only a small proportion resistant to CS, IPM, MEM (2 86%), 65.71% of 35 tested K pneumoniae can produce ESBL and 20 % of isolates strains are capable of carbapenemase production.
Keywords: Extended Spectrum Beta Lactamase, carbapenemase, antibiotic resistance Klebsiella pneumoniae.
1. Dat van de
Ke tir khi dugc con nguoi phat hien ra khang sinh vao the ki XX, khang sinh da tro thanh mgt trong nhiing thit vu khi hiru hieu nhat trong viec chdng lai vi khuan va cac benh nhiem khuan do chiing gay ra. Tuy nhien, hien tugng khang khang sinh ngay cang lan rgng khien cho cugc chien giua con nguoi va vi khuan trcr nen kh6c liet. De chien thing trong cugc chien do, con nguai phai luon tim toi, sang tao va phat Men vi khuan khang thuoc cang stim cang t6t. Hien nay, tai Viet Nam da xuit hien mgt trong
HVCH, Truang Dai Hoc Su pham TPHCM
" BS. Vien Pasteur TPHCM
Tap chi KHOA HOC DHSP TPHCM Pham Thi Hodi .An vd tgk
nhung vi khuan da khang thuoc hang dau do la true khuan Gram am Klebsiella pneumoniae. Su khang thuoc ciia nhom vi khuan nay cue ki ngu\ hiem bcri \i ban than loai vi khuan nay co kha nang sinh dugc hai loai enzsme: p lactamase pho rgng \a carbapenemase [3]. Cac enzyme nay lam bien doi. pha huy cau true hoa hpc cua khang sinh [1]. [8], p lactamase pho rpng co kha nang phan giai hau het cac loai khang sinh thupc nhom p lactam dac biet doi \'ai penicillins va cephalosporins the he thii 3 [12].
Quan trpng hon nua la Klebsiella pneumoniae con co kha nang san sinh dugc carbapenemase phan giai carbapenem nhu imipenem. meropeneni.... trong khi carbapenem dugc xem nhu la ciiu canh cuoi cimg trong viec lua chgn khang sinh de dieu trj [13]. De tranh tinh trang da khang tren lam sang, dieu cap thiet nhiit dat ra cho chiing ta la lam the nao de phat hien nhanh. chinh xac dugc vi khuan Klebsiella pneumoniae sinh p lactamase pho rpng \a carbapenemase cang som cang tot giiip cac bac sT lira chgn khang sinh phii hgp nhat de dieu tri cho benh nhan. Do do. chung toi thuc hien de tai "Khao sat su khang khang sinh ciia Klebsiella pneumoniae tren benh pham phan lap dugc tai Vien Pasteur TP Ho Chi Minh" \6i muc tieu:
+ Danh gia su khang khang sinh cua Klebsiella pneumoniae qua khang sinh do;
+ Xac dinh ti le \i khuan Klebsiella pneumoniae co kha nang sinh p lactamase pho rpng va carbapenemase.
2. Doi tiroTig va phiroiig phap nghien ciru 2.1. Doi tuffng nghien cuu
Cac chiing Klebsiella pneumoniae phan lap dugc tir cac benh pham khac nhau (dam, mii. mau. dich nao tiiy. nuoc tieu) tai Phong Vi sinh benh pham, Khoa LAM.
vien Pasteur TP H6 Chi Minh tir thang 01-6/2014 theo quy trinh dat chuan ISO 15189:2007.
2.2. Phuffng phdp nghien ciru
Phuong phap thu mau, nuoi cSy. phan lap. djnh danh. lam khang sinh do, sang lpc chung \i khu^n Klebsiella pneumoniae sinh p-lactamases pho rgng. carbapenemase dugc thuc hien theo quy trinh chu^n ciia Vien Pasteur TP Ho Chi Minh dat chuan ISO 15189:2007.
+ Phan lap vi khu4n tren moi trudng: Columbia agar +5% mau cim va chocolate agar d6i vai benh phSm: dam. mii, mau. djch nao tuy; moi trucmg Bromocresol purple d6i voi benh pham la nuoc tieu.
+ Nhugm Gram: xac dinh vi khuan Gram {-).
+ Diing cac thir nghiem sinh hoa: oxidase, di dpng. KIA {Kligler iron agar).
Urea/lndol. Citrate, Nitrate... hoac dinh danh b3ng each cha\ API 20E ciia hang Biomerieux (Phap) de dinh danh Klebsiella pneumoniae.
+ Lam khang sinh d6 theo phuong phap Kirby- Bauer de xac dinh miic dp khang khang sinh ciia cac chung Klebsiella pneumoniae phan lap dugc, sir dung moi truong 147
.Mueller Ilinton (MH) va khoanh gia\ khang sinh ciia hang Bio- Rad. dgc ket tjua theo tieu chuin CLSI (2013).
f Thit nghiem sang Igc kieu hinh cac chiing Klebsiella pneumoniae sinh P- lactamase pho rgng bang phuong phap dia doi phat hien sir cong huang giira mot cephalosporin the he thir ba va amo.\icillin/cla\uIanic acid tren khang sinh do, tag nen vong khang khuiln dtlng "nui chai champagne" tren cac chiing sinh men ESBL. [14]
Hinh 1. K. pneumoniae sinh ESBL
+ Thu nghiem Hodge test sang loc cac chung Klebsiella pneumoniae sinh carbapenemase [10]
• Chimg san xuat carbapenemase (duong tinh): bieu hien bjng cac khuan Ijc t^o hinh nan quat (do su tang sinh t ^ vung giao thoa giiia vet cay va chu vi viing tie che cua chung chi dinh E. cob ATCC 25922).
Chimg khong san xuat carbapenemase (am tinh): khong bieu hien su tang sinh.
Chiing K, pneumoniae (+)
K. pneumoniae control (+)
coli ATCC25922
Chung K. pneumoniae i
Hinh 2. K. pneumoniae sinh carbapenemase Chung duang tinh (san xuat carbapenemase): so 615
Cac chung am tinh (khong san xuat Carbapenemase): so 721, 824,189, 912
T9P chi KHOA HOC DHSP TPHCM Pham Thi Hodi An vd tgk
Ghi nhan va xir 11 ket qua bang phin rnhrn Microsoft Excel 2007.
3. KSt qua nghien ciiu 3.1. Bac tinh miu
Trong thai gian tii 01-6/2014 chiing toi phan lap dugc 35 chiing Klebsiella pneumoniae.
Trong do co 26 benh phSm tit benh nhan nam chiem lA,l'y/« phan lap dugc Klebsiella pneumoniae cao han gin gSp 3 lin so vai ti le benh nhan nii (co 9 benh phim) chiem 25,71 %.
Bieu do 1. Ti le nhiim Klebsiella pneumoniae theo dp tuoi
1
ig s
•is 2 U
Ti le nhilm Ktebsiellapneiimoniae theo d$ tail 40.00
30.00 20.00 10.00
3L43
2 2 ^ ^ 1
1M3 H ^ 1M3
jkillli
0-15 16-30 31-45 46-60 61-75 75+
Can cu bieu do I ta co ti le nhiem Klebsiella pneumoniae cao nhat la dp tuoi 46- 60 CO 11 benh nhan chiem 31,43%, ki den la dp tuoi tir 31-45 tuoi co 8 benh nhan chiSm 22,86% va thdp nhit 0-15 tu6i co 2 benh nhan, chi^m ti le 5,71 %.
3.2. Sir phdn bo vi khudn Klebsiella pneumoniae trong cdc loai benh phdm Tat ca cac chiing Klebsiella phat hien dugc la loai Klebsiella pneumonia Bdng 1, Ti le Klebsiella pneumoniae phdn Igp duac tic cdc loai benh phdm khac nhau
Loai benh phSm Bam
Mu Mau Nutjc tieu Dich nao tiiy T6ng c6ng
Tan so (n=35) 12 12 2 9 0 35
Ti le (%) 34,29 34,29 5,71 25,71 0 100
149
Trong 24 chiing phan lap dugc tit benh phim dam va mil. m6i loji benh pham chiem 34,29%, benh pham nuijc tieu phan lap dugc 9 chiing chiem 25,71%, benh pham mau phan lap dugc 2 chiing chiem 5,71%. Con a djch nao tuy khong tim thay tac nhan gay benh la Klebsiella pneumoniae.
3.3. Khdo sdt mirc dp khdng khdng sinh cua Klebsiella pneumoniae
Biiu ad 2. Ti le di khdng khdng sinh ciia Klebsiella pneumoniae trong nghien dm
Ti If Idling khang sinh coa Klebsiettapneianoniae 94.29
• KBANCSmA ^ AM: Ampiciline lOfig, AMC: Amoxicillin/clavulanlc acid 20/lOpg, AN:
Amikacin lOpg, CAZ: Ceftazidime 30pg, CIP: Ciprofloxacin 5pg, CN: Cephalexine 30pg CS: Colistin 50pg, FT: Nitrofurantoin SOOpg , GM: Gentamicin lOfig, MEC:
Micillinam lOpg, NET: Netilmlcine 30pg, PIP: Piperacillin 75pg, SXT:
Trimethoprim/sulfamethoxazol I,25/23,75pg, TE: Tetracycline 30pg, IMP: Imipenem lOpg, MEM: Meropenem lOpg.
Phan tich ket qua khang khang sinh cua 35 chung thuc hien khang sinh do cho thay Klebsiella pneumoniae co mirc de khang vtji hau het cac khang sinh. Trong 14 khang sinh dugc thuc hien thi Klebsiella pneumoniae khang 8 khang sinh 6 miic tren 40%. Trong do Klebsiella pneumoniae dc khang cao nhat voi AM (94,29%), tiep do la SXT (79,31%), CN, PIP (62,86%); CAZ (51,43%); MEC (37,14%); AMC (32,35%);
NET (22,86%); AN (20%); GM (28,57%); FT (45,71%); CIP (42,86%); TE (40%) va cu6i ciing ti le khang vai CS, IPM, MEM thip nhit (2,86%).
3.4. TI li Klebsiella pneumoniae sinh fi-lactamase phi rpng
Co 23 chiing Klebsiella pneumoniae sinh p-lactamase pho rgng chiem ti le 65,71%, bieu d6 3.
Tap chi KHOA HOC BHSP TPHCM Pham Thi Hodi An va tgk
Bieu do 3. Ti le Klebsiella pneumoniae sinh fi-lactamase phd rpng
Ti If Klebsiellapnenmomae sinh ESBL ESBL (-)
• ESBL (+)
3.5. Ti le Klebsiella pneumoniae sinh carbapenemase
Bdng 2. Ti le Klebsiella pneumoniae sinh carbapenemase Hodge
test
Carbapenemase + Carbapenemase - Tgng cong
Tan so (n=35)
7 28 35
TI le (%) 20 80 100 Ti le Klebsiella pneumoniae sinh carbapenemase la 20%.
4. Ban luan 4.1. DQC tinh mdu
Trong 35 mlu benh pham co 26 benh phim tit benh nhan nam phan lap dugc Klebsiella pneumoniae chiSm ti le 74,29%, uu the cao hon gin gip 3 lan so voi 9 benh pham tir berth nhan nir phan lap dugc vi khuan nay v6\ ti le 25,71%. Ket qua ciia chiing toi cao hem ket qua nghien cim ciia tac gia Ngo The Hoang, Que Lan Huong tai Benh vien Th6ng Nhit TPHCM (57% nam bj nhilm Kpneumoniae) [2]. Su chenh lech nay chua the ket luan ring nhilm Kpneumoniae a nam cao han nii ma chi co the phan anh dac diim benh nhan. Mat khac, ti le mlc benh theo nhom tuoi 46-60 tuoi chiem uu thi (31,43%). Ti le khac biet vl dg tuoi bi nhilm K. pneumoniae cho thiy benh nh&i cang
\dn tu6i thi sire de khang cang yeu va nguy eg bi nhiem khuan cang cao.
4.2. Suphan bo vi khuan Klebsiella pneumoniae trong benh pham
0 nghien cim ciia chiing toi, Klebsiella pneumoniae phan lap dugc chu yiu tit cac
151
benh phim dam va mil. Bieu nay phii hryp vtji kit qua nghien ciiu ciia Ngu-yln SI Tuan 6 Benh vien Da khoa Th6ng Nhit Ddng Nai tir thang 12/2012-5/2013 [4], va chirng to Klebsiella pneumoniae la mgt trong nhiing nguyen nhan hang diu gay ra viem phoi, nhiem triing beiih vien.
4.3. Khdo sdt mirc dp khdng khang sinh cda Klebsiella pneumoniae
Trong nghien cim cua chiing toi, ampicilline khong con tac dving doi Klebsiella pneumoniae vtji ti le khang toi 94,29%. Tuy nhien, doi vol cac khang sinh thugc nhom penicillin co b6 sung them chit itc chi P - lactamase thi ti le khang thap han (ti le de khang AMC 32,35%i). D6i vol khang sinh nhom cephalosporins thi ti le khang cung kha cao >50%, ti 16 khang CN: 62,86%, CAZ: 51,43%. Ti le nh^y cao nhit la colistin, imipenem, meropenem voi ti le 97,14%. Kit qua tren cQng tuang tu v6\ nghien cuu cua Pham Hiing Van [6], Ngo Thi Hoang. [2]
Bdng 3. So sdnh ti le khdng khdng sinh vdi cdc nghien ciru trudc
Tac gia Pham Hiing Van 5/2008 din 11/2009 [6]
Ngo The Hoang, Que Lan Huang 2012 [2]
Nghien ciru nay 1-6/2014
Ti If khang (%) Tin
SO
n=346
n=42
n=35 AM
98
95
94,3 AMC
39
44,5
32,35 CN, CAZ 45
54,8 CN (62,86);
CAZ (51,43)
PIP, MEC
42,9 MEC(
37,14);
PIP (62,86)
NET, AN.GM
30
AN(52,4) NET(47,5)
NET (22,86); AN
(20); GM (28,57)
CIP
53
61,2
42,86 TE
64
40
4.4. Ti l{ Klebsiella pneumoniae sinh fi-lactamases phS rpng
Til 35 chung Klebsiella pneumoniae phan lap dugc trong 680 miu benh pham, chung toi thuc Men sang Igc nhanh cac chiing Klebsiella pneumoniae sinh ESBL, co 23 chung san xuit ESBL chiim 65,71%. Kit qua nay co su khac biet so vtJi cac nghien cira
Tgp chi KHOA HQC DHSP TPHCM Pham Thi Hoai An vd tgk
Bdng 4. Ket qud cua mot sd nghien ciru ve Klebsiella pneumoniae sinh ESBL
Nghien cihi Ankur Goyal, K.N.
Prasad, Amit Prasad [9]
Fatemeh Ashrafian, Emran Askari [11]
Pham Hung Van [61 Biji Thj Mill [3]
Ngo Tha Hoang [21 Nguyin Dac Trung [5]
Nghien cim nay
So mau
n=57
n=128
n=346 n=267 n=42
n=24 n=35
Thai gian
2-6/ 2006
2007-2008
1/2007 - 5/2008 7/2009-7/2010 1/2010-3/2011
4/2012-4/2013 1-6/2014
Noi nghien ciru Sanjay Gandhi Postgraduate Institute of Medical Sciences, North India the Imam
Reza hospital unit in Mashhad, Iran
Da trung tam
Benh vien Nhi Trung uong Benh vien Thing Nhat TPHCM
Benh vien Da khoa Trung uong Thai Nguyen Vien Pasteur TPHCM
Ti le sinh ESBL(%) 66,7
43
66 56,9 45,2
33,33 65,71 Vm phucmg phap thir nghiem sang lgc tiia doi thi ket qua nghien cuu cua chiing toi thu dugc ti le vi khuan sinh ESBL la kha cao chiem 65,71%. Dieu nay chiing to viec Igm dung cac khang sinh thugc nhom cephalosporins the he thir ba la mdt trong nhimg li do ngay cang xuat hien nhieu chiing Klebsiella pneumoniae co kha nang sinh p- lactamase pho rgng.
4.5. TI If Klebsiella pneumoniae sinh carbapenemase
Theo nghien ciru cua Pham Himg Van va nhom nghien cim MIDAS ti le khang IMP la 3,2%; MEM la 1,2%) [7], Ti le nay tuang d6ng vai kit qua tir khang smh d6 cua chiing toi thu dugc ti le Klebsiella pneumoniae khang IMP; MEM la 2,86%. Tuy nhien, kit qua Hodge test a nghien cim cua chiing toi thu nhan dugc ti le Klebsiella pneumoniae sinh carbapenemase la 20%. Vay co 17,14% s6 chiing Klebsiella pneumoniae sinh carbapenemase cho kit qua nhay vol khang sinh do. Dieu nay cho thiy ring niu chi dua tren kit qua cua khang sinh d6 dl diiu tr] cho benh nhan bj nhilm Klebsiella pneumoniae bing cac khang sinh thugc nhom carbapenem co the din din thit bai.Vdi kit qua nghien ciiu nay ciing da bao dgng cho cac bac si nen lua chgn khang sinh phii hgp cho timg benh nhan de tranh tinh trang da khang thuoc.
5. Kit luan
Ti le Klebsiella pneumoniae phan lap dugc tir cac mau benh pham cua benh nhan din xet nghiem tai Vien Pasteur TP H6 Chi Minh thu nhan dugc tir 35 mau benh phim co:
Ti le Klebsiella pneumoniae phan lap dugc theo giiii nam la 74,29%i chiem ira thi 153
hon so voi nit la 25,71 %i. Ti ie Klebsiella pneumoniae phan lap dugc theo nhom tuoi chiim uu thi a nhom 46-60 tuoi viJi ti le 31.43%.
Klebsiella pneumoniae phan bo chil yeu tren benh pham dam va mil chiem 68,58%.
Klebsiella pneumoniae co mirc dl khang voi hiu hit cac khang sinh dac biet la cac loai khang sinh thugc nhom penicillin (AM: 94,29%i), cephalosporins (CN:
62,86%; CAZ: 51,43%), cacbarpenem (IMP: 2,86%; MEM: 2,86%>).
Ti le Klebsiella pneumoniae sinh ESBL la 65,71%.
Ti le Klebsiella pneumoniae sinh carbapenemase la 20%i.
TAI LIEU THAM KHAO
1. Dang Diic Anh (2009), Nhiim trimg binh vien, Nha xuat ban Y hgc Ha Npi.
2. Ngo Thi Hoang, Qui Lan Huong, Nguyin Ba Luong (2012), 'Tinh khang thulc ciia Klebsiella pneumoniae trong viem phoi benh vien tai Benh vien Thong Nhat", Hdi nghi Khoa hpc Ki thuat Binh vien Thong Nhdt TP Ho Chi Minh, 16(1).
3. Bill Thi Mill, Le Thi Anh H6ng, Nguyin Thanh Liem (2010), "Ti le sinh men Beta - lactamaes pho rgng va tinh nhay cam khang sinh cita Klebsiella Pneumoniae gay nhilm khuan duong ho hap tre em tir sa sinh den 6 tuoi a Benh vien Nhi Trung uong'". Tap chi Y hpc duphdng, 21(7).
4. Nguyen Si Tuan (2014/ '"Nghien ciru mo hinh khang khang sinh cua vi khuan gay benh tai Benh vien Da khoa Thong Nhat Dong Nai", Tap chi Y hpc thuc hdnh, 1(903),'tr.2.
5. Nguyen Dac Trung (2013), "Phat hien gen blaTEM va blaCTX-M a cac chiing Escherichia coli va Klebsiella pneumoniae bang phan img Muhiplex-PCR", Tap chi Y-Dupc hpc Qudn su, 9, tr.76-85.
6. Pham Hiing Van (2009), "Vi khuan Gram am de khang khang sinh thuc trang tai Viet Nam va cac diem mdi ve chuan muc bien luan de khang". Tap chi Y hpc TP Hd Chi Minh, Tap 13(2), tr.138-148.
7. Pham Hiing Van va nhom nghien cihi MIDAS (2010), "Nghien ciiu da trung tam ve tinh hinh de khang imipenem va meropenem cua true khuan Gram (-) dl mgc gay ket qua tren 16 benh vien tai Viet Nam", Tap chi Y hpc TP Hd Chi Minh, 14(8), h-.279- 287.
8. Ahmad Metal (1999),"Clinial characteristics and molecular epidemiology associated with imipenem-resistant Klebsiellapneumoniae", Clin Infect Dis, 29, pp. 352-55.
9. Ankur Goyal, K.N. Prasad, Amit Prasad, Sapna Gupta, Ujjala Ghoshal & Archana Ayyagari (2009), "Extended spectrum P-lactamases in Escherichia coli and Klebsiella pneumoniae & associated risk factors", Indian J Med Res, 129, pp. 695- 700.
Tap chi KHOA HOC DHSP TPHCM Pham Thi Hodi An vd tgk
10. Delphine Girlich, Laurent Poirel, and Patrice Nordmarm (2012),"Value of the Modified Hodge Test for Detection of Emerging Carbapenemases in Enterobacteriaceae", J Clin Microbiol, 50(2), pp. 477-479.
11. Fatemeh Ashrafian, Emran Askari, Elnaz Kalamatizade, Mohammad Javad Ghabouli Shahrodi (2013), '"The frequency of Extended Spectrum Beta Lactamase (ESBL) in Escherichia coli and Klebsiela pneumoniae: a report from Mashad, Iran", J Med Bacteriol, Vol. 2, pp. 12-19.
12. Hsueh Po-Ren, Peter Michael Hawkey (2007),"Consensus statement on antimicrobial therapy of intra-abdominal infections in Asia", International Journal of Antimicrobial Agents, 30, pp. 129-133.
13. Pfaller MA, Jones RN (1997), '"A review of the in vitro activity of meropenem and comparative antimicrobial agents tested against 30,254 aerobic and anaerobic pathogens isolated world wide", £)/ag« M;cro6zo//w/ec/D;^, 28(4), pp. 157-63.
14. Thomson K. S. & Sanders C. C. (1992), "Detection of extended-spectmm p- lactamases in members of the family Enterobacteriaceae: comparison of the double- disk and three-dimensional tests". Antimicrobial Agents and Chemotherapy, 36, pp. 1877-82.
(Ng^y T6a soan nh$n du^c b^i: 12-6-2014; ngay phin bi$n dinh giif 15-8-2014;
ngdy chip nh$n dang: 20-8-2014)
155
