4/19/2014

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NGUYN TC S DNG KHNG SINH
i tng: Dc 4, h chnh quy
Thi lng: 4 tit
TS. ng Nguyn oan Trang
ThS. on Vn Khnh
Ni dung
A. Tnh hnh khng khng sinh
B. Nguyn tc s dng hp l KS trong iu tr
1) Ch nh KS ph hp vi tc nhn gy bnh
2) La chn KS iu tr thch hp
a) KS iu tr theo kinh nghim lc u
b) KS iu tr sau khi c kt qu vi sinh
3) ng s dng KS hp l
4) Liu lng v khong cch dng phi v hiu qu
5) Thi gian iu tr vi KS thch hp
6) Phi hp vi cc phng php iu tr h tr
C. Nguyn tc s dng hp l KS trong d phng phu thut
D. Chin lc ci thin tnh hnh s dng khng sinh
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Mc tiu hc tp
1) Gii thchc ldophi tunth ccnguyntc s dng KS
2) Trnhbyc nguyntc xcminhs nhimkhun
3) Trnh by c cc yu t nh hng n vic la chn
KS/phi hp KSv ng s dng KStrongiu tr theo kinh
nghimlcu viu tr saukhi ckt qu vi sinhhc
4) Trnh by c nguyn l dc ng-dc lc hc ca KS
trongvic la chn liu vkhong cchdngca KS
5) Trnhbyc ccyu t nh hng lnthi gianiu tr KS
6) Trnhbyc nguyntc la chn loi KS, ng s dng v
thi gians dng KSd phngtrongphu thut
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A. Tnh hnh khng khng sinh
Nm 1969: Bnh nhim trng b ch ng - bc s William
Stewart, M
Bo co thin tai-dch bnh th gii nm 2000 ca WHO: Bnh
nhim trngl k git ngi ln nht (13triu ngi cht trong
nm1999)
A. Tnh hnh khng khng sinh
S ti xut hin (hi sinh) ca mt s bnh nhim trng:
lao, st rt, st xut huyt, t...
Cc vn mi ny sinh trong bnh nhim trng:
Nhim trng lin quan n chm sc y t
Cc k thut xm ln, suy gim min dch, qu ti bnh nhn, thiu
nhn lc y t...
Vi khun a khng thuc:
MRSA: Methicillin-resistant Staphylococcus aureus
VRE: Vancomycin-resistant Enterococci
ESBLs: Extended-spectrum Beta-lactamases
MDR-TB: Multi-drugs resistant Tuberculosis
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A. Tnh hnh khng khng sinh
L s khng li khng sinh, VK khng c kh nng chu ng 1
nng KS cao hn so vi VK bnh thng m khng b tiu dit
A. Tnh hnh khng khng sinh
VK khng P. aeruginosa A. baumannii
Meropenem 18% 46.2
Imipenem 25% 47.1
MRSA T l nhy cm (%)
BV Ch Ry 91
BV Bch Mai 100
T l MRSA cn nhy cm vi vancomycin:
T l khng vi cc carbapenem:
S liu nm 2008. Ngun GARP. SITUATION ANALYSIS-Antibiotic Use and Resistance in Vietnam. 2010
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A. Tnh hnh khng khng sinh
K. pneumoniae E. coli
BV Ch Ry nm 2005 61.7% 51.6%
BV Bch Mai nm 2005 20.1% 18.5%
BV Bch Mai nm 2006 28.7% 21.5%
BV Bch Mai nm 2007 32.5% 41.2%
BV Bch Mai nm 2008 33.6% 42.2%
T l tit ESBLs ca cc trc khun gram (-) ng rut:
S liu nm 2008. Ngun GARP. SITUATION ANALYSIS-Antibiotic Use and Resistance in Vietnam. 2010
C ch khng
khng t nhin:
Do h gen t nhin ca vi khun quy nh
VD: E.coli khng vancomycin do phn t vancomycin rt ln khng
thm c vo TB vi khun
khng thu nhn:
t bin gen sinh ra gen khng v truyn gen ny cho
cc th h vi khun tip sau ( khng theo chiu dc)
Thu nhn gen khng t cc vi khun khc qua cc
plasmid, transposon ( khng theo chiu ngang)
Ryback. Pharmacotherapy 2004; 24:203S-215S
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VK khng mi
VK nhy cm
VK khng
Di chuyn gen khng
C ch khng
Cch thc khng ca vi khun
To enzym bt hot/ ph hy
khng sinh
Bin i im tc ng ca khng
sinh
Gim tnh thm ca khng sinh vo
trong vi khun
Thay i con ng chuyn ha
To ra bm ngc (P-gp)
Levy SB. Scientific American. 1998: 46-53
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Yu t gp phn gy khng
Yu t thuc v vi khun:
Kh nng nhn i rt nhanh
Xc sut t bin gen trong qu trnh sao m
Yu t thuc v ngi s dng:
V sinh bnh vin (qu ti BN, iu kin VS, st trng)
S dng KS khng hp l:
Khng ng KS, dng KS khi khng cn thit
Khng nng KS (liu, khong cch, dc ng hc ca KS)
Khng thi gian
Dng KS thng xuyn (bnh vin, cng ng, gia sc)
Lm dng khng sinh ph rng
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S pht trin khng sinh
Gerard D. Wright. Nature Reviews. Microbiology 5, 175-186 (2007)
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S pht trin khng sinh mi
Ch 7 hot cht trong tng s 225 thuc mi trong giai on
1998-2002 (3%) l cc KS
12 KS mi c a vo s dng t 1998
Boucher, et al. CID 2009; 48:1-12
S pht trin khng sinh mi
Khng sinh Nm ph duyt Nhm KS mi
Rifapentine 1998 Khng
Quinupristin/dalfopristin 1999 Khng
Moxifloxacin 1999 Khng
Gatifloxacin 1999 Khng
Linezolid 2000 Oxazolidinone
Cefditoren pivoxil 2001 Khng
Ertapenem 2001 Khng
Gemifloxacin 2003 Khng
Daptomycin 2003 Lipopeptide
Telithromycin 2004 Khng
Tigecycline 2005 Khng
Doripenem 2007 Khng
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S pht trin khng sinh mi
Tn hot cht Nhm
ng
dng
Ch nh Liu
Ceftobiprole Cephalosporin IV
cSSSI
Phase III: CAP, HAP
Phase II: NT mu
500mg BID
Ceftaroline Cephalosporin IV
cSSSI, CAP
FDA duyt nm 2010
600mg Q12h
Iclaprim
Diamino-
pyrimidine
IV
cSSSI
Phase III: HAP, HCAP, VAP
0.8- 1.6 mg/kg BID
Telavancin Glycopeptide IV
cSSSI
Phase III: HAP
10mg/kg hng ngy
Oritavancin Glycopeptide IV
cSSSI
Phase II: NT mu t
catheter
400-800mg hng
ngy
1200mg x1
Cethromycin
2nd generation
ketolide
PO
CAP
Phase II: vim xoang
300mg daily
Ramoplanin
Glycolipo-
depsipeptide
PO CDAD 200 hoc 400mg BID
Hot
tnh
trn
MRSA
!!
cSSSI: complicated skin and skin structure infection
CDAD: Clostridium difficile-Associated Diseases
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Tin trnh iu tr mt bnh nhim trng
Bc 1
Xc minh yu cu iu tr KS v c gng xc nh tc
nhn gy bnh
Bc 2
Bc 3
Bc 4
Bc 5
Tin trnh iu tr mt bnh nhim trng
Bc 1
Xc minh yu cu iu tr KS v c gng xc nh tc
nhn gy bnh
Bc 2 La chn phc KS iu tr theo kinh nghim lc u
Bc 3 Theo di iu tr KS ban u: hiu qu v c tnh
Bc 4
Bc 5
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Tin trnh iu tr mt bnh nhim trng
Bc 1
Xc minh yu cu iu tr KS v c gng xc nh tc
nhn gy bnh
Bc 2 La chn phc KS iu tr theo kinh nghim lc u
Bc 3 Theo di iu tr KS ban u: hiu qu v c tnh
Bc 4
iu chnh KS iu tr theo tc nhn gy bnh
c xc nh
Bc 5 Theo di iu tr: hiu qu v c tnh
B, Nguyn tc s dng hp l KS trong iu tr
1) Ch nh KS ph hp vi tc nhn gy bnh
2) La chn KS/ phi hp KS iu tr phi thch hp
a) KS iu tr theo kinh nghim lc u
b) KS iu tr sau khi c kt qu vi sinh
3) ng s dng KS phi hp l
4) Liu lng v khong cch dng phi v hiu qu
5) Thi gian iu tr vi KS phi hiu qu
6) Phi hp vi cc phng php iu tr h tr
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1. Ch nh dng KS phi ph hp vi tc nhn
gy bnh
Ch dng KS khi c nhim khun:
Cn xc minh s nhim khun chng minh yu cu v
l do s dng KS
Dng KS d phng nhim khun: cn ph hp
S dng sai/ khng hp l/ lm dng KS:
Lm tng nhanh s khng ca VK
Tng nguy c c tnh
Tng chi ph iu tr
Xc minh s nhim khun
a, Triu chng v du hiu:
Ton thn: st
Vt thng: sng, , chy m
Cc du hiu khc c th hu ch
Cc ch du vim nhim: VS (ESR), CRP, procalcitonin
S lng bch cu (WBC), BC trung tnh, band
C BC hoc VK hin din trong mu, dch no ty,
nc tiu*
Cc xt nghim khc: ng huyt, phn tch nc tiu
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Xc minh s nhim khun
b, XN tm vi khun gy bnh
Cy vi khun (v th nhy cm vi KS)
Nhim trng nng hoc nhim trng vi khun khng
Nhum Gram, soi knh hin vi
Phn ng huyt thanh hc, PCR
Lu : mu lm sng (mu, BAL, m, dch r vt thng,
nc tiu) cn ly trc khi khi u KS iu tr
Th nghim nhy cm ca VK vi KS
(th nghim KS )
Gi tr MIC:
S: Nhy cm
I: Nhy cm va phi
R: khng

MIC l nng thp nht ca KS ngn s tng sinh ca VK quan st

c sau khi trong mi trng nui cy c hiu trong 24 gi.
Gi tr ny c hiu cho c khng sinh v vi khun
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B, Nguyn tc s dng hp l KS trong iu tr
2. La chn phc KS iu tr phi thch hp:
Cho hiu qu ti u nht:
iu tr hoc ngn nga c nhim trng vi thi gian
dng KS ngn nht
t tc dng ph nht
Gim thiu ti a s xut hin v lan truyn VK
khng
Chi ph hp l nht
B, Nguyn tc s dng hp l KS trong iu tr
2. La chn KS/ phi hp KS iu tr phi thch hp:
a, La chn KS/ phi hp KS iu tr theo kinh
nghim lc u
b, La chn KS/ phi hp KS iu tr sau khi c kt
qu cy vi khun v KS
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Thi im
chn
on/nghi
ng nhim
trng
Thi im
c kt qu
cy VK v
KS
KS theo kinh nghim lc u KS sau khi c kt qu vi sinh hc
nh nhanh !
nh mnh !
nh lin tc !
Cc yu t cn cn nhc/ xem xt khi la chn KS iu tr
Bnh nhn
Nhng VK gy bnh thng gp
ti ni iu tr
VK c kh nng gy bnh cao
nht bnh nhn
Mc khngti ni iu tr
Cu trc ha hc, c ch tc ng
Dc ng/ Dc lc ca KS
c tnh ca KS
S khng ca VK vi KS
Chi ph
V tr nhim trng
Mc nhim trng
Tui
Tnh trng BN (c thai, )
Chc nng gan-thn, h min dch
Bnh km theo, kh nng tun th
Khng sinh
Vi khun
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a. La chn KS/phi hp KS iu tr theo kinh
nghim lc u
Hiu qu lmsnglquantrng nht:
KSla chn cn ph hp vi tc nhn VKnghi ng/ bit
vphhp vi kt qu KS/mc khngca VKti
ni iu tr
La chn KS/phi hp KSda trn:
V tr nhimtrng
D on nhng VKckh nng gybnh (Phn thamkho-t hc)
Cncth gipchn liu vng s dng KS(VD: nhim trngni
tmmc, mngno, xng khp cn dngKSng tim, liu cao
vthi giandi)
Tnhtrng bnh vc a bnh nhn
Nhim trng phi-VPC
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Vim tai gia
Vim mng no
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Nhim trng da-m mm
Nhim trng bng
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Nhim trng ng tiu di/ vim bng quang
Nhim trng ng tiu trn/ vim thn-b thn
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Vim vng chu
Tnh trng, c a bnh nhn
Tin s d ng thuc:
D ng penicillin: cn nhc khi chn KS nhm beta-
lactam
Type I (shock phn v, co tht PQ): chng ch nh cc
penicillin, cephalosporin, carbapenem
Non-type I (ban da): c th dng cephalosporin (d ng
cho 5-10%)
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Tnh trng/ c a bnh nhn
Suy gim chc nng gan-thn:
Thn l c quan o thi phn ln cc KS:
Aminoglycosid, vancomycin, beta-lactam
Gan l c quan chuyn ha chnh o thi mt s KS:
Clindamycin, macrolid, metronidazol, chloramphenicol v rifampin
Tch t cc KS, tng nguy c c tnh nu khng chnh liu:
c thn: aminoglycosid, vancomycin, colistin, sulfamid, tetracyclin th
h 1, mt s cephalosporin
c gan: thuc khng lao, nitrofurantoin, chloramphenicol,
Thng phi chnh liu KS thi qua thn khi Clcr < 30 mL/pht
Tnh trng/ c a bnh nhn
Ph n c thai:
Nguy c d tt thai nhi do KS:
Penicillin, cephalosporin v erythromycin: an ton
Ticarcillin, metronidazol: qui thai ng vt
Tetracyclin: vng rng, h men rng, nh hng pht trin xng
Quinolon, rifampin, trimethoprim: sinh qui thai cha bit r
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Tnh trng/ c a bnh nhn
Tui tc:
VK gy bnh thay i theo tui: VD: vim mng no do VK:
Tr s sinh: Listeria spp. V Streptococcus spp. nhm B
Ngi trng thnh: S. pneumoniaev Neisseria meningitidis
Ngi gi: Streptococcus pneumoniaeand Listeria spp.
Chc nng gan - thn thay i theo tui:
Chc nng thn gim tr sinh non, tr s sinh, ngi gi
Mt s KS khng nn dng cho tr nh: quinolon, tetracyclin
Tnh trng/ c a bnh nhn
Ccbnh l/ bt thng kmtheo:
Ccbnh gygimmin dch: khi u, BNghpc quan, HIV:
D a n nhimtrng
Thng phi chn KSmnh, loi dit khun vdngthi giandi hn
Bt thng trn di truyn hay chuyn ha:
BN bnh mch mu ngoi bin: gim hp thu KS ng IM
BN thiu G6PD: b tn mu khi dng sulfonamid, nitrofurantoin,
dapson, thuc tr st rt v cloramphenicol
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Tnh trng/ c a bnh nhn
nh hng ca cc thuc dng ng thi/ trc :
KS la chn cn khc nhm KS iu tr trc
S hp thu ca KS quinolon b gim bi cc thuc cha
cation a ha tr (antacid; thuc b cha Ca, Fe)
Phi hp KS iu tr mt cch hp l
Ch phi hp KSkhi cn thit: mc ch phi hp:
Hip ng tcdng trnVK khngcao
Phc KS iu tr theo kinh nghim BN bnh nng khi
cha xcnh c VKgybnh vkt qu KS
Ni rng ph khng khun trong nhng nhim trng gy ra
bi nhiu VK
VD: cepha 3 hoc fluoroquininolon + metronidazol trong iu tr
nhim trng bng*
Ngn nga s xut hin ca chng VK khngthuc (iu tr
lao, phong)
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Mt s phi hp KS cho tc dng hip ng
c ch cc bc khc nhau/ qu trnh chuyn ha:
Sulfamethoxazol +trimethoprim
Sulfadoxim +pyrimethamin
c ch s bt hot KS gy bi enzym:
Cht c ch beta lactamase + KS beta-lactam
Clavulanat +amoxicillin
Sulbactam +ampicillin
Tazobactam +pipericillin
Tng cng s thu nhn KS vo TB VK:
Cc beta-lactam +aminoglycosid *
Ampicillin v gentamicin
Ceftazidim v amikacin
Vancomycin +aminoglycosid
Bt li khi phi hp khng sinh
i khngtcdng:
Penicillin+clortetracyclin<penicillintrongiu tr vimmngnodoph
cu (LeppervDowling, 1951)
Ampicillin+cloramphenicol +streptomycin<ampicillintrongiu tr vim
mngno(Mathiesvcs, 1967)
Trn chung penicillin ph rng v aminoglycosid bt hot
aminoglycosid* (McLaughlinvcs, 1971; Riff LJ vcs, 1972)
Tng chi ph iu tr
Tng tcdng bt li (phn ng d ng vc tnhca KS)*
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b. La chn KS khi c kt qu vi khun v KS
La chn theo kt qu vi khun gybnh phnlp
c vKS
Chnhxcnht
Vic cy VK v lmKS: cn thi gian v tn chi ph,
thng ch p dng trong nhim trng nng, lmsng
khngrrnghoc khngp ng vi iu tr
Lu : tnh trng, c a BN, kh nng tun th,
tnhcht dc ng-dc lc ca KS, githnh
3. ng s dng khng sinh cn ph hp
Ty vo mc nng ca nhim trng:
Nhim trng nh, iu tr ngoi tr: ng ung
Nhim trng nh-trung bnh, iu tr trong BV: ng tim
IM, IV hoc c th dng KS ung nhng phi c SKD cao
Sinh kh dng cao vi Linezolid, fluoroquinolon, SMZ/TMP;
metronidazol (gn 100%)
Nhim trng nng, e da tnh mng: ng tim IV
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4. Liu lng KS v khong cch dng phi
thch hp, hiu qu
Huyt tng
Ni tc
ng
Nng khng sinh
Hiu qu
iu tr
Ch
liu
Dc ng hc ca KS
Cmax
Tmax, T
1/2
AUC
Dc lc hc ca KS
MIC
0 6 18
24
12
N

n
g

MIC
AUC >MIC
AUC / MIC
T >MIC
Thi gian C
KS
>MIC
C
max
Cmax / MIC
Thi gian (h)
4. Liu lng KS v khong cch dng phi
thch hp, hiu qu
Thng s PK/ PD ca KS:
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55
c im khng khun ca KS
Kiu dit khun:
Dit khun ph thuc nng :
Dit khun ph thuc thi gian(khngph thuc
nng )
Hot tnhkhngkhun ch tng trongmt khong nng
nh (1xMICti 4xMIC)
Khong thi gianmnng KStrnMICtng quan
vi hiu qu dit khun
56
c im khng khun ca KS
Hiu ng hu KS(PAE=post-antibioticeffect):
Hiu lc c ch VK tng trng vn xy ra khi
khngtip tc dngKS
Thng xy ravi VKgramdng, t trnVKgram
m
Ch c vi mt s nhm KS: aminoglycosid,
fluoroquinolon, beta-lactam,
Thng PAEinvivo>invitro
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Kiu tc ng ca KS
Kiu 1 Kiu 2 Kiu 3
c im khng
khun
Dit khun ph
thuc nng
PAE di
Dit khun ph
thuc thi gian
PAE ti thiu
Dit khun ph
thuc thi gian
PAE di
Khng sinh
Aminoglycosid
Ketolid
Fluoroquinolon
Metronidazol
Cc -lactam
Erythromycin
Clindamycin
Linezolid
Azithromycin
Tetracyclin
Streptogramin
Vancomycin
Mc tiu Ti u ha nng
Ti u ha thi
gian tip xc vi KS
Ti u ha
lng thuc
Thng s PK/ PD
quyt nh hiu qu
Cmax , AUC
Thi gian C
KS
trn
MIC
AUC
4. Liu lng KS v khong cch dng phi
thch hp, hiu qu
fCmax/ MIC =8-10
Kiu 2 Kiu 3 Kiu 1
f Time >MIC
>70% DI (Gr m)
>40-50%DI (Gr. +)
fAUC
0-24h
/ MIC
Fluoroquinolon:
fAUC
24h
/MIC >125 (Gr m)
fAUC
24h
/MIC >40 (Gr +)
Vancomycin:
fAUC
24h
/MIC >125
(>400 vi VK khng)
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Khng sinh aminoglycosid
Khong cch dng:
Theo truyn thng: tng liu chia 3 ln/ ngy
Tng liu dng 1 ln/ ngy
Nng nh cao hn
Dit khun tt hn, hiu qu hn
PAE di hn
Nng y thp hn
t c tnh hn (gim tnh thm ca KS vo thn/ thi gian?)
PAE pht huy tc dng khi nng thp hn ngng tr liu
Khng sinh aminoglycosid
Dng 1 ln/ ngy so vi phc truyn thng
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Khng sinh aminoglycosid
p dng ch tng liu dng 1 ln/ ngy:
Di 65 tui
Chc nng thn bnh thng
Thi gian iu tr <1 tun
Khng phi nhim khun do Enterococci hoc
Pseudomonasspp
5. Thi gian iu tr vi KS phi hiu qu
Khng c quy nh c th
Ty thuc tng BN da vo p ng LS v kt qu X-quang, c th cn
hng dn ca chuyn gia nhim trng
iu tr ngn ngy:
NTT khng phc tp/ n: 3 ngy
Vim phi ngoi cng ng: 5 ngy
Vim phi lin quan my th: 8 ngy (tr BN nhim Pseudomonas
hoc suy gim MD)
iu tr di ngy:
Vim ni tm mc, vim ty xng v apxe bng (4-6 tun)
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5. Thi gian iu tr vi KS phi hiu qu
Nguyn tc chung: sau khi ht VK dng thm KS:
2-3 ngy BN bnh thng
5-7 ngy BN suy gim min dch
Tiu ch lm sng nh gi ht VK:
Th trng BN ci thin (au gim, gim ho, ht m )
S lng BC v thn nhit tr v bnh thng
Ci thin trn X-quang (c th mun hn ci thin LS)
6. Theo di p ng iu tr vi KS
Thng s trn LS :
Ci thin triu chng v du hiu (gim st, tim nhanh hoc ln ln),
Ci thin gi tr cn LS (s lng BC gim) v X-quang (kch thc vng
apxe gim)
Kt qu vi sinh hc:
Theo di nng KS/ mu:
Aminoglycosid
Vancomycin
Xt nghim khc (chc nng thn, gan)
Kh nng dung np vi KS ca BN
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6. Theo di p ng iu tr vi KS
Vi BN khng cho p ng vi iu tr KS trong 2-3
ngy, cn nh gi li nhm xc nh:
Chn on ng?
t c nng tr liu KS/ mu?
BN c suy gim MD?
BN c nhim trng bi nhim (apxe, vt l/ c th)?
Pht trin VK khng?
7. Phng php iu tr h tr
Dn lu phu thut hoc ct b m b nhim*
iu chnh p ng vim ca k ch vi nhim trng:
Corticosteroid ton thn: c li trong iu tr vim mng no, vim
phi do Pneumocystis BN AIDS
Tm thi ngng hoc gim liu iu tr vi cc thuc c ch MD
Yu t kch thch dng BC ht (BN gim BC ko di b nhim nm si
xm ln)
Globulin min dch, IV: trung ha c t/ VK trong iu tr vim mc
hoi th do Streptococci nhm A
Probiotic (cc chng Lactobacillusv Saccharomyces): iu tr
tiu chy do C. difficile
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C. Nguyn tc s dng KS d phng trong phu thut
Khng sinh d phng: l KS s dng trc, trong v sau
mt qui trnh chn on, iu tr hoc phu thut
ngn s nhim trng
Phu thut
c im
Sch
Vt m khngnhim khun, khngvimcp, khngthngvi ng h
hp, tiu ha, ming hu, ng sinh dc, ng tiu, ng mt.
Khngcginon trongquytrnhm vkhun.
Sch-nhim
M thngc kim sot ng h hp, tiuha, ming hu, ng sinh
dc, ng tiu, ng mt vi lng rrt nh/sai st k thut nh
Nhim
C tnhtrng vimcp, khngm hin din vt m. Clng r nhiu
t ng tiuha/Ginon lutrongk thut m
D Tnhtrng nhimkhun hin r(apxe, m hoc mhoi th hin din)
Tc nhn gy nhim thng gp
Phu thut Vi khun thng gy nhim
Lng ngc-tim Staphylococcus aureus, staphylococci coagulase (-)
Tiu ha
Trc khun gram m ng rut, vi khun k kh,
enterococci
Phn ph (m o,
bng, ct t cung qua
bng)
Trc khun gram m ng rut, streptococci nhm
B, enterococci, vi khun k kh
Chnh hnh S. aureus, staphylococci coagulase (-)
Mch mu
S. aureus, staphylococci coagulase (-), Trc khun
gram m ng rut
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C. Nguyn tc s dng KS d phng trong phu thut
KS la chn phi:
An ton
Tng i r tin
Hot tnh dit khun vi ph khng khun in vitro
bao ph c loi vi khun c kh nng gy
nhim trong khi phu thut
Khng chn lc ra chng khng thuc
Cc cephalosporin Ph khng khun
Cepha th h 1:
ng ung: Cefadroxil,
Cephalexin,
ng tim: Cefazolin
VK Gram dng: Strep. pyogenes,
Strep. viridans, Staph. aureus, S.
pneumoniae
VK Gram m: E. coli, Klebsiella
pneumoniae, Proteus mirabilis
Cepha th h 2:
ng ung: Cefaclor,
cefprozil, Cefuroxime axetil
ng tim: Cefotetan,
Cefoxitin, Cefuroxime
VK Gram dng: tng t cepha I tr
Cefotetan, Cefoxitin
VK Gram m: E. coli, Klebsiella
pneumoniae, Proteus mirabilis,
Haemophilus influenzae
Neisseria spp. (tr Cefotetan,
Cefoxitin)
VK k kh: Cefotetan, Cefoxitin
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Cc cephalosporin Ph khng khun
Cepha th h 3:
ng ung: Cefdinir,
Cefditoren, Cefpodoxime
proxetil, Ceftibuten, Cefixime
ng tim:
Cefotaxime,Ceftazidime,
Ceftizoxime, Ceftriaxone
VK Gram dng: Strep. pyogenes, Strep. viridans,
Staph. aureus (mc trung bnh), S. pneumoniae
VK Gram m: E. coli, Klebsiella pneumoniae,
Proteus spp., Haemophilus influenzae
Neisseria spp. , Borrelia burgdorferi, vi
Enterobacteriaceae
Cepha th h 4:
ng tim: Cefepime,
cefpirom
VK Gram dng: Strep. pyogenes, Strep. viridans,
Staph. aureus (mc trung bnh), S. pneumoniae
VK Gram m: E. coli, Klebsiella pneumoniae,
Proteus spp., Haemophilus influenzae
Neisseria spp. , nhiu Enterobacteriaceae,
Pseudomonas aeruginosa
Cepha th h 5:
ng tim: ceftaroline
VK Gram dng: nhiu loi k c MRSA
VK Gram m: nh cepha 3
La chn KS d phng
Phu thut Vi khun thng gy nhim Cc KS khuyn co
Lng ngc-tim
Staphylococcus aureus, staphylococci
coagulase (-)
Cefazolin, cefuroxime ,
vancomycin*
Tiu ha
Trc khun gram m ng rut, vi
khun k kh, enterococci
Cefoxitin, cefotetan,
ampicillin/sulbactam,
cefazolin +metronidazol
Phn ph (m o,
bng, ct t cung qua
bng)
Trc khun gram m ng rut,
streptococci nhm B, enterococci, vi
khun k kh
Cefoxitin, cefotetan,
cefazolin,
ampicillin/sulbactam
Chnh hnh S. aureus, staphylococci coagulase (-)
Cefazolin, cefuroxime,
vancomycin*
Mch mu
S. aureus, staphylococci coagulase (-),
Trc khun gram m ng rut
Cefazolin, vancomycin*
*: Ch dng khi nghi ng MRSA hoc t cu coagulase (-), khng khuyn co dng thng quy
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37
C. Nguyn tc s dng KS d phng trong phu thut
ng s dng:
u tin ng tim IV v cho nng ti u ti v tr phu
thut trong sut qu trnh phu thut
Thi im dng KS d phng:
Lc rch da
Kt thc PT
Qu tr Qu sm ng thi im
C. Nguyn tc s dng KS d phng trong phu thut
Thi im dng KS d phng:
Trong vng 1 gi trc khi rch da (ti u l trc rch da
30 pht), trong vng 2 gi nu dng vancomycin
C th phi cn nhng liu b sung trong khi phu thut
nhm duy tr nng c hiu qu/ mu
Thi gian dng KS d phng:
Khng qu 24 gi sau khi kt thc phu thut (khng qu
48 gi vi phu thut tim-lng ngc)
KS d phng sau khi ng vt m: cho thy khng c li
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D. Chin lc ci thin s dng KS trong BV
Nng cao hiu qu o to
Xy dng cc phc v hng dn iu tr
Ci thin cc xt nghim chn on
Gii hn s dng KS
C chin lc quay vng khng sinh s dng
Ti liu tham kho
1. Infectious Disease Society of America. Bad Bugs and No Drugs 2004.
2. Steven C. Ebert. Application of Pharmacokinetics and Pharmacodynamics
to Antibiotic Selection. P&T community. Vol. 29 No. 4 (2004).
3. Surbhi Leekha et al. General Principles of Antimicrobial Therapy. Mayo
Clin Proc. 2011;86(2):156-167.
4. Treatment Guideline. The Medical Letter. Vol. 5 (Issue 57). 2007.
5. G. S. Guven and O. Uzun. Principles of good use of antibiotics in hospitals.
Journal of Hospital Infection (2003) 53: 9196.
6. Alan R. Salkind and Kavitha C. Rao. Antibiotic Prophylaxis to Prevent
Surgical Site Infections. American Family Physician, Volume 83, Number
5, March 1, 2011.