4/19/2014

NGUYN TC S DNG KHNG SINH

TS. ng Nguyn oan Trang

ThS. on Vn Khnh
i tng: Dc 4, h chnh quy
Thi lng: 4 tit

Ni dung
A. Tnh hnh khng khng sinh
B. Nguyn tc s dng hp l KS trong iu tr
1)
2)

Ch nh KS ph hp vi tc nhn gy bnh
La chn KS iu tr thch hp
a)
b)

3)
4)
5)
6)

KS iu tr theo kinh nghim lc u

KS iu tr sau khi c kt qu vi sinh

ng s dng KS hp l
Liu lng v khong cch dng phi v hiu qu
Thi gian iu tr vi KS thch hp
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 thch c l do phi tun th cc nguyn tc s dng KS
2) Trnh by c nguyn tc xc minh s nhim khun
3) Trnh by c cc yu t nh hng n vic la chn
KS/phi hp KS v ng s dng KS trong iu tr theo kinh
nghim lc u v iu tr sau khi c kt qu vi sinh hc
4) Trnh by c nguyn l dc ng-dc lc hc ca KS
trong vic la chn liu v khong cch dng ca KS
5) Trnh by c cc yu t nh hng ln thi gian iu tr KS
6) Trnh by c nguyn tc la chn loi KS, ng s dng v
thi gian s dng KS d phng trong phu 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 trng l k git ngi ln nht (13 triu ngi cht trong
nm 1999)

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

T l MRSA cn nhy cm vi vancomycin:
MRSA
BV Ch Ry
BV Bch Mai

T l nhy cm (%)
91
100

T l khng vi cc carbapenem:
VK khng
Meropenem
Imipenem

P. aeruginosa
18%
25%

A. baumannii
46.2
47.1

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

T l tit ESBLs ca cc trc khun gram (-) ng rut:
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%

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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C ch khng
VK nhy cm
VK khng

Di chuyn gen khng

VK khng mi

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

Ceftobiprole

Cephalosporin

IV

Hot
Cephalosporin
tnh
DiaminoIclaprim
trn pyrimidine
MRSAGlycopeptide
Telavancin
!!

Ceftaroline

IV

Ch nh

cSSSI
Phase III: CAP, HAP
Phase II: NT mu
cSSSI, CAP
FDA duyt nm 2010

Liu

500mg BID
600mg Q12h

IV

cSSSI
Phase III: HAP, HCAP, VAP

0.8- 1.6 mg/kg BID

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

Glycolipodepsipeptide

PO

CDAD

200 hoc 400mg BID

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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KS theo kinh nghim lc u

KS sau khi c kt qu vi sinh hc

Thi im
c kt qu
cy VK v
KS

Thi im
chn
on/nghi
ng nhim
trng

nh nhanh !
nh mnh !
nh lin tc !

Cc yu t cn cn nhc/ xem xt khi la chn KS iu tr

Vi khun
Nhng VK gy bnh thng gp
ti ni iu tr
VK c kh nng gy bnh cao
nht bnh nhn
Mc khng ti ni iu tr

Khng sinh

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

Bnh nhn

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

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a. La chn KS/phi hp KS iu tr theo kinh

nghim lc u
Hiu qu lm sng l quan trng nht:
KS la chn cn ph hp vi tc nhn VK nghi ng/ bit
v ph hp vi kt qu KS /mc khng ca VK ti
ni iu tr

La chn KS/phi hp KS da trn:

V tr nhim trng
D on nhng VK c kh nng gy bnh (Phn tham kho-t hc)
Cn c th gip chn liu v ng s dng KS (VD: nhim trng ni
tm mc, mng no, xng khp cn dng KS ng tim, liu cao
v thi gian di)

Tnh trng bnh v c 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 betalactam
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. pneumoniae v Neisseria meningitidis
Ngi gi: Streptococcus pneumoniae and 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

Cc bnh l/ bt thng km theo:
Cc bnh gy gim min dch: khi u, BN ghp c quan, HIV:
D a n nhim trng
Thng phi chn KS mnh, loi dit khun v dng thi gian di 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 KS khi cn thit: mc ch phi hp:
Hip ng tc dng trn VK khng cao
Phc KS iu tr theo kinh nghim BN bnh nng khi
cha xc nh c VK gy bnh v kt 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 khng thuc (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 khng tc dng:
Penicillin + clortetracyclin < penicillin trong iu tr vim mng no do ph
cu (Lepper v Dowling, 1951)
Ampicillin + cloramphenicol + streptomycin < ampicillin trong iu tr vim
mng no (Mathies v cs, 1967)
Trn chung penicillin ph rng v aminoglycosid bt hot
aminoglycosid* (McLaughlin v cs, 1971; Riff LJ v cs, 1972)

Tng chi ph iu tr
Tng tc dng bt li (phn ng d ng v c tnh ca KS)*

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b. La chn KS khi c kt qu vi khun v KS

La chn theo kt qu vi khun gy bnh phn lp
c v KS
Chnh xc nht
Vic cy VK v lm KS: cn thi gian v tn chi ph,
thng ch p dng trong nhim trng nng, lm sng
khng r rng hoc khng p ng vi iu tr

Lu : tnh trng, c a BN, kh nng tun th,

tnh cht dc ng-dc lc ca KS, gi thnh

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
Ch
liu

Nng khng sinh

Dc lc hc ca KS
MIC

Huyt tng
Hiu qu
iu tr

Ni tc
ng
Dc ng hc ca KS
Cmax
Tmax, T1/2
AUC

4. Liu lng KS v khong cch dng phi

thch hp, hiu qu
Cmax

Thng s PK/ PD ca KS:

Cmax / MIC

Nng

AUC / MIC
AUC > MIC

Thi gian CKS > MIC

MIC

T > MIC

12

18

24

Thi gian (h)

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c im khng khun ca KS
Kiu dit khun:
Dit khun ph thuc nng :
Dit khun ph thuc thi gian (khng ph thuc
nng )
Hot tnh khng khun ch tng trong mt khong nng
nh (1xMIC ti 4xMIC)
Khong thi gian m nng KS trn MIC tng quan
vi hiu qu dit khun

55

c im khng khun ca KS
Hiu ng hu KS (PAE = post-antibiotic effect):
Hiu lc c ch VK tng trng vn xy ra khi
khng tip tc dng KS
Thng xy ra vi VK gram dng, t trn VK gram
m
Ch c vi mt s nhm KS: aminoglycosid,
fluoroquinolon, beta-lactam,
Thng PAE in vivo > in vitro
56

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Kiu tc ng ca KS
Kiu 1
c im khng
khun

Dit khun ph
thuc nng
PAE di

Khng sinh

Mc tiu

Aminoglycosid
Ketolid
Fluoroquinolon
Metronidazol

Ti u ha nng

Thng s PK/ PD
Cmax , AUC
quyt nh hiu qu

Kiu 2

Kiu 3

Dit khun ph
thuc thi gian
PAE ti thiu

Cc -lactam
Erythromycin
Clindamycin
Linezolid

Dit khun ph
thuc thi gian
PAE di

Azithromycin
Tetracyclin
Streptogramin
Vancomycin

Ti u ha thi
Ti u ha
gian tip xc vi KS lng thuc
Thi gian CKS trn
MIC

AUC

4. Liu lng KS v khong cch dng phi

thch hp, hiu qu
Kiu 1

Kiu 2

fCmax/ MIC = 8-10

f Time > MIC

> 70% DI (Gr m)
> 40-50% DI (Gr. +)

Kiu 3

fAUC0-24h/ MIC
Fluoroquinolon:
fAUC24h/MIC > 125 (Gr m)
fAUC24h/MIC > 40 (Gr +)
Vancomycin:
fAUC24h/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
Pseudomonas spp

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 Lactobacillus v 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 khng nhim khun, khng vim cp, khng thng vi ng h

hp, tiu ha, ming hu, ng sinh dc, ng tiu, ng mt.
Khng c gin on trong quy trnh m v khun.

Sch-nhim

M thng c kim sot ng h hp, tiu ha, ming hu, ng sinh

dc, ng tiu, ng mt vi lng r rt nh/sai st k thut nh

Nhim

C tnh trng vim cp, khng m hin din vt m. C lng r nhiu

t ng tiu ha/Gin on lu trong k thut m

Tnh trng nhim khun hin r (apxe, m hoc m hoi 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:
VK Gram dng: tng t cepha I tr
ng ung: Cefaclor,
Cefotetan, Cefoxitin
cefprozil, Cefuroxime axetil VK Gram m: E. coli, Klebsiella
ng tim: Cefotetan,
pneumoniae, Proteus mirabilis,
Cefoxitin, Cefuroxime
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 Cefazolin, cefuroxime ,

coagulase (-)
vancomycin*

Tiu ha

Trc khun gram m ng rut, vi

khun k kh, enterococci

Cefoxitin, cefotetan,
ampicillin/sulbactam,
cefazolin + metronidazol

Phn ph (m o, Trc khun gram m ng rut,

bng, ct t cung qua streptococci nhm B, enterococci, vi
bng)
khun k kh

Cefoxitin, cefotetan,
cefazolin,
ampicillin/sulbactam

Chnh hnh

S. aureus, staphylococci coagulase (-)

Cefazolin, cefuroxime,
vancomycin*

Mch mu

S. aureus, staphylococci coagulase (-),

Cefazolin, vancomycin*
Trc khun gram m ng rut

*: Ch dng khi nghi ng MRSA hoc t cu coagulase (-), khng khuyn co dng thng quy

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4/19/2014

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 sm

ng thi im

Qu tr

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.
2.
3.
4.
5.
6.

Infectious Disease Society of America. Bad Bugs and No Drugs 2004.

Steven C. Ebert. Application of Pharmacokinetics and Pharmacodynamics
to Antibiotic Selection. P&T community. Vol. 29 No. 4 (2004).
Surbhi Leekha et al. General Principles of Antimicrobial Therapy. Mayo
Clin Proc. 2011;86(2):156-167.
Treatment Guideline. The Medical Letter. Vol. 5 (Issue 57). 2007.
G. S. Guven and O. Uzun. Principles of good use of antibiotics in hospitals.
Journal of Hospital Infection (2003) 53: 9196.
Alan R. Salkind and Kavitha C. Rao. Antibiotic Prophylaxis to Prevent
Surgical Site Infections. American Family Physician, Volume 83, Number
5, March 1, 2011.

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