Professional Documents
Culture Documents
S: 708/Q-BYT
QUYT NH
V vic ban hnh ti liu chuyn mn
Hng dn s dng khng sinh
B TRNG B Y T
Cn c Lut khm bnh, cha bnh nm 2009;
Cn c Ngh nh s 63/2012/N-CP ngy 31/8/2012 ca Chnh Ph quy
nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t;
Theo ngh ca Cc trng Cc Qun l Khm, cha bnh,
QUYT NH:
iu 1. Ban hnh km theo Quyt nh ny ti liu chuyn mn Hng dn
s dng khng sinh.
iu 2. Ti liu Hng dn s dng khng sinh ban hnh km theo Quyt
nh ny c p dng ti cc c s khm bnh, cha bnh.
Cn c vo ti liu ny v iu kin c th ca n v, Gim c c s khm
bnh, cha bnh xy dng v ban hnh ti liu Hng dn s dng khng sinh ph
hp thc hin ti n v.
iu 3. Quyt nh ny c hiu lc k t ngy k ban hnh.
iu 4. Cc ng, b: Chnh Vn phng B, Chnh Thanh tra B, Cc trng
Cc Qun l Khm, cha bnh, Cc trng v V trng cc Cc, V thuc B Y
t, Gim c cc bnh vin, vin c ging bnh trc thuc B Y t, Gim c S
Y t cc tnh, thnh ph trc thuc trung ng, Th trng Y t cc B, Ngnh v
Th trng cc n v c lin quan chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 4;
- B trng B Y t ( b/c);
- Cc Th trng BYT;
- Bo him X hi Vit Nam ( phi hp);
- Cng thng tin in t BYT;
- Website Cc KCB;
- Lu VT, KCB.
KT. B TRNG
TH TRNG
( k)
Nguyn Th Xuyn
B Y T
H NI - 2015
Ch bin
PGS.TS. Nguyn Th Xuyn
ng ch bin
PGS. TS. Lng Ngc Khu
GS. TS. Trn Qu
GS.TS. Hong Th Kim Huyn
Trn Qu
GS.TS
GS.TS
Nguyn Ln Vit
GS.TS
Ng Qu Chu
GS.TS
L Quang Cng
PGS.TS
Trn Hu Khang
PGS.TS
Nh Hn
PGS.TS
PGS.TS
Trn An
PGS.TS
PGS.TS
PGS.TS
PGS.TS
Bi V Huy
PGS.TS
PGS.TS
Th Liu
PGS.TS
o Vn Long
PGS.TS
on Mai Phng
PGS.TS
Nguyn Hu Su
PGS.TS
PGS.TS
Nguyn Th Vinh
TS.BS
Trn Th T Chu
TS.BS
L Xun Cung
TS.BS
Phm Ngc ng
TS.BS
Nguyn Hi Anh
TS.BS
V Vn Gip
TS.BS
Chu Th Hnh
TS.BS
Nguyn Thanh Hi
TS.BS
V Trng Khanh
TS.BS
Nguyn Vn Knh
TS.BS
TS.BS
Trn Qu Tng
TS.BS
L Th Dim Tuyt
TS.BS
L Th Kim Xun
TS.DS
TS.DS
Phm Th Thy Vn
TS.DS
V Th Thu Hng
Ths.BSCKII V B Quyt
BSCKII
Ths.DS
Ths.DS
Ths.BS
Lu Vn i
Ths.BS
Ths.BS
Bi Hi Bnh
Ths.BS
Nguyn ng Tun
Ths.BS
L Th Ngc Lan
Ths
V Quc t
Ths
Ths
on Th Phng Lan
B Y t | BAN BIN SON 3
Ths
T Th Diu Ngn
Ths
Nguyn Kim Th
BS
T TH K V BIN TP:
Ths
Nguyn c Tin
Ths
Ng Th Bch H
Ths
Trng L Vn Ngc
Ths
Nguyn Th i Phong
Ths
Nguyn Th Thy
B mn Dc lm sng Trng i hc Dc H Ni
MC LC
Ban bin son ................................................................................................ 2
Mc lc .......................................................................................................... 5
Danh mc bng.............................................................................................. 8
Danh mc hnh v ....................................................................................... 10
T vit tt ting Anh ................................................................................... 11
T vit tt ting Vit ................................................................................... 13
Li ni u .................................................................................................. 15
PHN I. I CNG V KHNG SINH V VI KHUN HC ............. 17
CHNG I. I CNG V KHNG SINH................................................................................ 19
M u......................................................................................................... 21
Cc nhm khng sinh v tc dng............................................................... 22
C ch tc dng ca khng sinh v phi hp khng sinh ........................... 35
Khi nim Dc ng hc/Dc lc hc (PK/PD) v ng dng ............... 39
Cc nguyn tc s dng khng sinh ............................................................ 46
CHNG II. I CNG V VI KHUN HC ......................................................................... 56
i cng v vi khun hc................................................................................................................ 58
Vai tr ca vi sinh lm sng vi s dng khng sinh hp l ...................... 63
S khng khng sinh ca vi khun ......................................................... 67
PHN II. IU TR CC BNH NHIM KHUN ................................... 74
CHNG I. NHIM KHUN H HP ............................................................................................ 76
Vim ph qun cp ngi ln .................................................................. 78
Gin ph qun.............................................................................................. 82
t cp bnh phi tc nghn mn tnh........................................................ 87
Vim phi mc phi cng ng ............................................................... 93
S dng khng sinh iu tr vim phi cng ng tr em ....................... 99
Vim phi bnh vin ................................................................................. 110
Vim phi lin quan n th my ............................................................. 117
p xe phi ................................................................................................. 128
Trn m mng phi ................................................................................... 132
CHNG II. NHIM KHUN HUYT V SC NHIM KHUN...................................137
Nhim khun huyt v sc nhim khun .................................................. 139
CHNG III. NHIM KHUN TIM MCH ................................................................................149
Thp tim .................................................................................................... 151
Vim ni tm mc nhim khun ............................................................... 155
CHNG IV. NHIM KHUN DA V M MM...................................................................159
Nht ........................................................................................................... 161
Vim nang lng ......................................................................................... 164
Vim m bo ............................................................................................. 168
B Y t | MC LC 5
B Y t | MC LC 7
DANH MC BNG
Bng I.1. Phn loi khng sinh theo cu trc ha hc ........................................ 22
Bng I.2. Phn nhm khng sinh Penicilin v ph khng khun ........................ 24
Bng I.3. Cc th h Cephalosporin v ph khng khun .................................. 25
Bng I.4. Khng sinh carbapenem v ph tc dng ............................................ 26
Bng I.5. Cc th h khng sinh nhm quinolon v ph tc dng ...................... 33
Bng I.6. Phn loi khng sinh lin quan n c tnh dc lc hc ................. 42
Bng I.7. Phn loi khng sinh theo ch s PK/PD ............................................. 43
Bng I.8. Sinh kh dng ca mt s khng sinh ng ung............................. 51
Bng I.9. C quan bi xut chnh ca mt s khng sinh ................................... 52
Bng I.10. Nguyn tc MINDME trong s dng khng sinh ............................. 53
Bng II.1. La chn khng sinh trong iu tr vim ph qun cp ..................... 80
Bng II.2. T l mi mc VPC hng nm tr < 5 tui theo khu vc trn th
gii (WHO).......................................................................................................... 99
Bng II.3. 15 nc c s tr mc vim phi cao nht ....................................... 100
Bng II.4. 15 nc c s tr t vong do vim phi cao nht ............................ 100
Bng II.5. Tnh hnh khng khng sinh ca 3 vi khun thng gp gy vim phi
tr em .............................................................................................................. 105
Bng II.6. La chn khng sinh iu tr theo kinh nghim .............................. 112
Bng II.7. La chn khng sinh cho mt s chng vi khun a khng thuc .. 114
Bng II.8. Yu t nguy c v cc vi sinh vt c bit....................................... 119
Bng II.9. Liu dng, ng dng c th ca mt s khng sinh .................... 124
Bng II.10. La chn khng sinh theo kinh nghim ......................................... 145
Bng II.11. Liu dng - cch dng ca mt s khng sinh ............................... 146
Bng II.12. Ngh ngi theo mc vim.......................................................... 152
Bng II.13. Thuc v cch s dng trong iu tr bnh thp tim...................... 153
Bng II.14. Phn loi mc nng ca nhim khun ng mt .................... 182
Bng II.15. Cc la chn khng sinh trong nhim khun ng mt .............. 184
Bng II.16. Cc la chn khng sinh trong p xe gan do vi khun .................. 187
B Y t | DANH MC BNG 8
B Y t | DANH MC BNG 9
DANH MC HNH V
Hnh I-1. Lin quan gia mt vi khun (CFU) vi thi gian cc mc MIC
khc nhau (Th trn chng P. aeruginosa ATCC27853 vi tobramycin,
ciprofloxacin v ticarcilin cc nng t 1/4 MIC n 64 MIC) ................... 42
Hnh I-2. Cc ch s PK/PD ................................................................................ 43
Hnh I-3. S cu to t bo vi khun .............................................................. 59
Hnh I-4. Vi h bnh thng c th ngi........................................................ 61
Hnh I-5. S tc ng (ring r/ phi hp) ca beta-lactamase (c ESBL), gim
tnh thm qua mng ngoi (porin), thay i PBPs v h thng bm y dn n
s khng beta-lactam trc khun Gram-m. ............................................... 68
Hnh II-1. Cc cu trc ca mt c lin quan n ............................................. 245
B Y t | DANH MC HNH V 10
Acid 6-aminopenicilanic
A7AC
Acid 7-aminocephalosporanic
ADN
Deoxyribonucleic acid
ADR
AFB
BK
CFU
CK
Creatine kinase
CLSI
CPIS
CRP
CT
ESBL
Hib
HIV
ICU
INR
KPC
MBC
MIC
MDR
MRI
MRSA
MSSA
PAE
PALE
PaCO2
PaO2
PCR
PD
PDR
PK
SpO2
TDM
TMP-SMX
Trimethoprim/Sulfamethoxazole
WHO
Bnh vin
CTM
Cng thc mu
KC
Khuyn co
KSDP
NCPT
Nc ct pha tim
NK
Nhim khun
NKBV
NKN
TB
Tim bp
TCV
T cu vng
TE
Tr em
TM
Tnh mch
TTT
Thi tm thu
VK
Vi khun
B Y t | LI NI U 14
LI NI U
T khi pht hin ra khng sinh Penicilline n nay hng trm loi khng sinh v
cc thuc tng t c pht minh v a vo s dng. S ra i ca khng sinh
nh du mt k nguyn mi ca y hc v iu tr cc bnh nhim khun, cu sng
hng triu triu ngi khi cc bnh nhim khun nguy him. Khng sinh cn c s
dng rng ri trong trng trt, chn nui gia sc, gia cm v thy sn,
Tuy nhin cng do vic s dng rng ri, ko di v lm dng, cha hp l, an
ton nn tnh trng khng khng sinh ca cc vi sinh vt (vi khun, vi rt, k sinh
trng, nm, ) ngy mt gia tng. Mc khng thuc ngy cng trm trng lm nh
hng n hiu qu iu tr, tin lng xu, nguy c t vong cao, thi gian iu tr ko
di, chi ph iu tr tng cao, nh hng n sc khe ngi bnh v cng ng.
Cng vi cc nc trn th gii, Vit Nam hng ng tch cc li ku gi
ca T chc Y t th gii Khng hnh ng hm nay, ngy mai khng c thuc
cha v K hoch hnh ng quc gia v chng khng thuc giai on t nm
2013 n nm 2020 c ban hnh (Quyt nh s 2174/Q-BYT ngy
21/6/2013) nhm y mnh cc hot ng phng, chng khng thuc gp phn nng
cao cht lng, hiu qu ca cng tc phng, chng dch bnh, khm bnh, cha bnh,
bo v, chm sc v nng cao sc khe nhn dn.
Bin son ti liu Hng dn s dng khng sinh l mt trong nhiu nhim
v ca K hoch hnh ng trn. Ban bin son c thnh lp theo Quyt nh s
4259/Q-BYT ngy 31/10/2012 gm cc chuyn gia u ngnh v y v dc. Ti liu
cung cp nhng kin thc v k nng c bn, cp nht ng thi ph hp vi thc t
ca Vit Nam v vic s dng khng sinh hp l, an ton ng dng trong cng tc
khm, cha bnh, phng bnh, bo v chm sc v nng cao sc khe nhn dn, gp
phn hn ch tnh trng khng khng sinh ang c nguy c gia tng hin nay.
Ti liu gm c 11 Chng v 55 bi, bao gm i cng v khng sinh v vi
khun, s dng khng sinh trong cc bnh nhim khun thng gp (nhim khun h
hp, tim mch, tiu ha, thn - tit niu,).
Ti liu c bin son cng phu, cht lng, cp nht v thc t Vit Nam,
tuy nhin cng cn nhng thiu st. Rt mong cc gio s, cc chuyn gia v cc ng
nghip, bn c gp kin b sung ti liu c hon chnh hn.
Chng ti trn trng cm n s ch o st sao ca PGS. TS. Nguyn Th Kim
Tin - B trng B Y t, cc Gio s, Ph Gio s, Tin s, Thc s, Bc s, Dc
s, cc thnh vin Ban bin son, cc chuyn gia u ngnh ca cc chuyn khoa
rt c gng, dnh nhiu thi gian qu bu bin son, sa cha, thm nh cun sch
ny v trn trng cm n s h tr ca AstraZeneca cho vic t chc v in n hon
thin hng dn ny. y l ln n bn u tin ca cun sch, chc chn cn nhiu
thiu st, chng ti rt mong nhn c s ng gp t Qu c gi v ng nghip
cun sch ngy mt hon thin.
B Y t | 16
B Y t | 17
B Y t | 18
B Y t | 19
B Y t | 20
M U
Khng sinh l mt nhm thuc c bit v vic s dng chng khng ch
nh hng n ngi bnh m cn nh hng n cng ng. Vi nhng nc
ang pht trin nh Vit Nam, y l mt nhm thuc quan trng v bnh l
nhim khun nm trong s nhng bnh ng hng u c v t l mc bnh v
t l t vong.
S lan trn cc chng vi khun khng khng sinh l vn cp bch nht
hin nay. S xut hin cc chng vi khun khng nh hng n hiu qu iu
tr v sc khe ngi bnh. Vic hn ch s pht sinh ca vi khun khng khng
sinh l nhim v khng ch ca ngnh Y t m ca c cng ng nhm bo v
nhm thuc ny.
Khng sinh c nh ngha:
Khng sinh (antibiotics) l nhng cht khng khun (antibacterial substances)
c to ra bi cc chng vi sinh vt (vi khun, nm, Actinomycetes), c tc
dng c ch s pht trin ca cc vi sinh vt khc.
Hin nay t khng sinh c m rng n c nhng cht khng khun c
ngun gc tng hp nh cc sulfonamid v quinolon.
bo m s dng thuc hp l, cn nm vng nhng kin thc lin
quan n khng sinh, vi khun gy bnh v ngi bnh.
Trong ti liu ny, cc thuc khng sinh c cp n bao gm tt c
cc cht c tc dng trn vi khun gy bnh. Nhng cht c tc dng n vi rt
v nm gy bnh s c cp n ti liu tip theo.
B Y t | M U 21
Tn nhm
Beta-lactam
Phn nhm
Cc penicilin
Cc cephalosporin
Cc beta-lactam khc
Carbapenem
Monobactam
Cc cht c ch beta-lactamase
Aminoglycosid
Macrolid
Lincosamid
Phenicol
Tetracyclin
Th h 1
Th h 2
Peptid
Glycopeptid
Polypetid
Lipopeptid
Quinolon
Th h 1
Cc fluoroquinolon: Th h 2, 3, 4
Phn nhm
Ph khng khun
Cu khun Gram-dng (tr cu khun tit
penicilinase, do khng c tc dng trn phn
ln cc chng S. aureus).
Hot tnh khng khun km hn trn cc vi
khun nhy cm vi penicilin G, nhng do c
kh nng khng penicilinase nn c tc dng trn
cc chng tit penicilinase nh S. aureus v
S. epidermidis cha khng methicilin.
Nafcilin
Carbenicilin
Cc penicilin ph khng
khun rng ng thi c
tc dng trn trc khun
m xanh
Ticarcilin
Mezlocilin
Piperacilin
Tn thuc
Cefazolin
Cephalosporin th h 1
Cephalexin
Cefadroxil
Cefoxitin
Cefaclor
Cephalosporin th h 2
Cefprozil
Cefuroxim
Ph khng khun
C hot tnh mnh trn cc chng vi khun
Gram-dng nhng hot tnh tng i yu
trn cc chng vi khun Gram-m. Phn ln
cu khun Gram-dng nhy cm vi
cephalosporin th h 1 (tr enterococci,
S. epidermidis v S. aureus khng
methicilin). Hu ht cc vi khun k kh
trong khoang ming nhy cm, nhng vi B.
fragilis thuc khng c hiu qu. Hot tnh
tt trn cc chng Moraxella catarrhalis, E.
coli, K. pneumoniae, v P. mirabilis.
Cc cephalosporin th h 2 c hot tnh
mnh hn trn vi khun Gram-m so vi th
h 1 (nhng yu hn nhiu so vi th h 3).
Mt s thuc nh cefoxitin, cefotetan cng
c hot tnh trn B. fragilis
Cefotetan
Ceforanid
Cefotaxim
Cefpodoxim
Ceftibuten
Cefdinir
Cephalosporin th h 3
Cefditoren
Ceftizoxim
Ceftriaxon
Cefoperazon
Cc cephalosporin th h 3 ni chung c
hot tnh km hn th h 1 trn cu khun
Gram-dng, nhng c hot tnh mnh trn
vi khun h Enterobacteriaceae (mc d
hin nay cc chng vi khun thuc h ny
ang gia tng khng thuc mnh m do kh
nng tit beta-lactamase). Mt s cc thuc
nh ceftazidim v cefoperazon c hot tnh
trn P. aeruginosa nhng li km cc thuc
khc trong cng th h 3 trn cc cu khun
Gram-dng.
Ceftazidim
Cephalosporin th h 4
Cefepim
Tn khng sinh
Imipenem
Meropenem
Doripenem
Ertapenem
b) Nhm monobactam
- Khng sinh monobatam l khng sinh m cng thc phn t c cha
beta-lactam n vng. Cht in hnh ca nhm ny l aztreonam.
- Ph khng khun ca aztreonam kh khc bit vi cc khng sinh h
beta-lactam v c v gn hn vi ph ca khng sinh nhm aminoglycosid.
Thuc ch c tc dng trn vi khun Gram-m, khng c tc dng trn vi khun
Gram-dng v vi khun k kh. Tuy nhin, hot tnh rt mnh trn
Enterobacteriaceae v c tc dng i vi P. aeruginosa.
c) Cc cht c ch beta-lactamase
Cc cht ny cng c cu trc beta-lactam, nhng khng c hot tnh
khng khun, m ch c vai tr c ch enzym beta-lactamase do vi khun tit ra.
Cc cht hin hay c s dng trn lm sng l acid clavulanic, sulbactam v
tazobactam.
1.4. Tc dng khng mong mun (ADR) ca cc khng sinh nhm betalactam:
- D ng vi cc biu hin ngoi da nh m ay, ban , mn nga, ph
Quincke gp vi t l cao. Trong cc loi d ng, sc phn v l ADR nghim
trng nht c th dn n t vong.
- Tai bin thn kinh vi biu hin kch thch, kh ng. Bnh no cp l
ADR thn kinh trm trng (ri lon tm thn, ni sng, co git, hn m), tuy
nhin tai bin ny thng ch gp liu rt cao hoc ngi bnhngi bnh
suy thn do tr thuc gy qu liu.
- Cc ADR khc c th gp l gy chy mu do tc dng chng kt tp
tiu cu ca mt s cephalosporin; ri lon tiu ho do lon khun rut vi loi
ph rng.
2. KHNG SINH NHM AMINOGLYCOSID
Cc aminosid c th l sn phm t nhin phn lp t mi trng nui
cy cc chng vi sinh, cng c th l cc khng sinh bn tng hp. Cc khng
sinh thuc nhm ny bao gm kanamycin, gentamicin, neltimicin, tobramycin,
amikacin.
2.1. Ph khng khun
Cc khng sinh nhm aminoglycosid c ph khng khun ch yu tp
trung trn trc khun Gram-m, tuy nhin ph khng khun ca cc thuc trong
nhm khng hon ton ging nhau. Kanamycin cng nh streptomycin c ph
hp nht trong s cc thuc nhm ny, chng khng c tc dng trn Serratia
hoc P. aeruginosa. Tobramycin v gentamicin c hot tnh tng t nhau trn
cc trc khun Gram-m, nhng tobramycin c tc dng mnh hn trn
P. aeruginosa v Proteus spp., trong khi gentamicin mnh hn trn Serratia.
Amikacin v trong mt s trng hp l neltimicin, vn gi c hot tnh trn
cc chng khng gentamicin v cu trc ca cc thuc ny khng phi l c cht
ca nhiu enzym bt hot aminoglycosid.
2.2. Tc dng khng mong mun (ADR):
- Gim thnh lc v suy thn l 2 loi ADR thng gp nht. C 2 loi
ADR ny s tr nn trm trng (ic khng hi phc, hoi t ng thn hoc
vim thn k) khi s dng ngi bnhngi bnh suy thn, ngi cao tui
(chc nng thn gim) hoc dng ng thi vi thuc c cng c tnh
(vancomycin, furosemid).
- Nhc c cng l ADR c th gp khi s dng aminoglycosid do tc
dng c ch dn truyn thn kinh c. ADR ny t gp nhng t l tng ln khi
s dng phi hp vi thuc mm c cura (do cn lu ngng khng sinh
trc ngy ngi bnhngi bnh cn phu thut). Tc dng lit c h hp c
th gp nu tim tnh mch trc tip do to nng cao t ngt trong mu; v
vy khng sinh ny ch c truyn tnh mch (truyn qung ngn) hoc tim
bp.
- Nhng ADR thng thng nh gy d ng da (ban da, mn nga) hoc
sc qu mn cng gp vi nhm khng sinh ny.
3. KHNG SINH NHM MACROLID
3.1. Phn loi
Cc macrolid c th l sn phm t nhin phn lp t mi trng nui cy
cc chng vi sinh, cng c th l cc khng sinh bn tng hp. Ty theo cu trc
ha hc, c th chia khng sinh nhm macrolid thnh 3 phn nhm:
- Cu trc 14 nguyn t carbon: erythromycin, oleandomycin,
roxithromycin, clarithromycin, dirithromycin.
- Cu trc 15 nguyn t carbon: azithromycin.
- Cu trc 16 nguyn t carbon: spiramycin, josamycin.
3.2. Ph khng khun
- Macrolid c ph khng khun hp, ch yu tp trung vo mt s chng
vi khun Gram-dng v mt s vi khun khng in hnh.
- Macrolid c hot tnh trn cu khun Gram-dng (lin cu, t cu),
trc khun Gram-dng (Clostridium perfringens, Corynebacterium
diphtheriae, Listeria monocytogenes). Thuc khng c tc dng trn phn ln
cc chng trc khun Gram-m ng rut v ch c tc dng yu trn mt s
chng vi khun Gram-m khc nh H. influenzae v N. meningitidis, tuy nhin
li c tc dng kh tt trn cc chng N. gonorrhoeae. Khng sinh nhm
macrolid tc dng tt trn cc vi khun ni bo nh Campylobacter jejuni,
M. pneumoniae, Legionella pneumophila, C. trachomatis, Mycobacteria (bao
gm M. scrofulaceum, M. kansasii, M. avium-intracellulare nhng khng tc
dng trn M. fortuitum).
3.3. Tc dng khng mong mun (ADR):
- ADR thng gp nht l cc tc dng trn ng tiu ho: gy bun
nn, nn, au bng, a chy (gp khi dng ng ung), vim tnh mch huyt
khi (khi tim tnh mch). Thuc b chuyn ho mnh khi qua gan nn c th
gy vim gan hoc mt. C th gy ic, lon nhp tim nhng vi t l thp.
- Nhng ADR thng thng nh gy d ng da (ban da, mn nga) hoc
sc qu mn cng gp vi nhm khng sinh ny.
4. KHNG SINH NHM LINCOSAMID
Nhm khng sinh ny bao gm hai thuc l lincomycin v clindamycin,
trong lincomycin l khng sinh t nhin, clindamycin l khng sinh bn tng
hp t lincomycin.
4.1. Ph khng khun
B Y t | CC NHM KHNG SINH V TC DNG 28
Cinoxacin
Th h 2
Loi 1:
Lomefloxacin
Norfloxacin
Enoxacin
Loi 2:
Ofloxacin
Ciprofloxacin
Th h 3
Levofloxacin
Sparfloxacin
Gatifloxacin
Moxifloxacin
Th h 4
Trovafloxacin
cao, thm ch t vong. c tnh trn gan thn: gy tng transaminase, vim gan,
vng da, mt hoc suy thn cp (thiu niu, v niu). Trn mu gy thiu mu
do tan mu gp nhiu ngi thiu men G6PD.
9.2. Nhm oxazolidinon
- y l nhm khng sinh tng hp ha hc, vi i din l linezolid.
Thuc c tc dng trn vi khun Gram-dng nh staphylococci, streptococci,
enterococci, cu khun Gram-dng k kh, Corynebacterium spp., Listeria
monocytogenes. Thuc hu nh khng c tc dng trn vi khun Gram-m c
hiu kh v k kh. Trn lm sng, linezolid thng c ch nh trong cc
trng hp vi khun Gram-dng khng cc thuc khng sinh khc nh
S. pneumoniae khng penicilin, cc chng staphylococci khng methicilin trung
gian v khng vancomycin, enterococci khng vancomycin.
- Tc dng khng mong mun (ADR)
Thuc c dung np tt, c th gp mt s tc dng khng mong mun
nh ri lon tiu ha, au u, pht banng lu nht l tc dng c ch ty
xng, vi cc biu hin thiu mu, gim bch cu, gim tiu cuTrong ,
xut huyt gim tiu cu hoc s lng tiu cu gim xung mc rt thp c th
gp vi t l ti 2,4% trn cc ngi bnhngi bnh s dng linezolid, thng
lin quan vi di t iu tr. Cn gim st cht ch tc dng khng mong
mun ny.
9.3. Khng sinh nhm 5-nitro-imidazol
- Nh tn gi ca nhm thuc, cc thuc nhm ny l dn xut ca 5-nitro
imidazol, c ngun gc tng hp ha hc. Mt s thuc thng c s dng
trong lm sng l metronidazol, tinidazol, ornidazol, secnidazol Cc thuc
ny ch yu c ch nh trong iu tr n bo (Trichomonas, Chlamydia,
Giardia) v hu ht cc vi khun k kh (Bacteroides, Clostridium)
- Tc dng khng mong mun (ADR)
Thuc c th gy mt s ri lon tiu ha nh nn, bun nn, v kim loi,
chn nNc tiu c th b sm mu do cht chuyn ha c mu ca thuc.
Thuc c th gy ADR trn thn kinh nh bnh thn kinh ngoi bin, co git,
au u, mt phi hp nhng him gp v thng lin quan n dng liu
cao. Do tc dng ging disulfiram, khng nn ung ru khi dng thuc.
Cc Penicilin
Imidazol
Cc Cephalosporin
Fluoroquinolon
Monobactam (Aztreonam)
Glycopeptid
Macrolid
Tetracyclin
Carbapenem
Lincosamid
Hnh I-1. Lin quan gia mt vi khun (CFU) vi thi gian cc mc MIC khc
nhau (Th trn chng P. aeruginosa ATCC27853 vi tobramycin, ciprofloxacin v
ticarcilin cc nng t 1/4 MIC n 64 MIC)
Hnh I-1biu din tc dit khun theo thi gian ca 3 khng sinh tobramycin,
ciprofloxacin v ticarcilin i din cho 3 nhm khng sinh trn chng
Pseudomonas aeruginosa ATCC 27853 vi cc nng tng dn. Nhn vo
th c th thy: khi tng nng ca tobramycin v ciprofloxacin, tc v mc
dit khun tng nhanh, th hin bng dc ng dit khun gim nhanh
theo thi gian v do c gi l cc khng sinh c kiu dit khun ph thuc
vo nng . Vi ticarcilin, ch c s thay i dc ca ng cong dit
khun khi nng tng t 1 n 4 ln MIC cn khi tng nng cao hn (t
trn 4 ln n 64 ln MIC) dc ng cong ch tng rt t; do cc khng
sinh nhm ny c gi l cc khng sinh dit khun t ph thuc nng hay
khng sinh ph thuc thi gian (ch lin quan n thi gian c nng trn MIC
t 1-4 ln).
2. NG DNG CH S PK/PD TRONG S DNG KHNG SINH
a) Cc ch s PK/PD:
- Ch s PK/PD i vi khng sinh c thit lp trn c s nng
thuc trong huyt tng (PK) v nng c ch ti thiu ca khng sinh i vi
B Y t | KHI NIM DC NG HC/DC LC HC 42
(PK/PD) V NG DNG
Nhm i din
T>MIC
Aminoglycosid,
Khng sinh dit khun ph thuc nng
fluoroquinolon,
v c tc dng hu khng sinh trung
daptomycin,
bnh ti ko di
metronidazol
Cpeak/MIC
Macrolid,
Khng sinh dit khun ph thuc thi
clindamycin,
gian v c tc dng hu khng sinh
glycopeptid,
trung bnh
tetracyclin
AUC0-24/MIC
v AUC0-24/MIC
-Trong phu thut sch, liu php khng sinh d phng nn p dng vi
mt s can thip ngoi khoa nng, c th nh hng ti s sng cn v/hoc
chc nng sng (phu thut chnh hnh, phu thut tim v mch mu, phu thut
thn kinh, phu thut nhn khoa)
- Phu thut nhim v phu thut bn: khng sinh ng vai tr tr liu.
KSDP khng ngn nga nhim khun m ngn nga nhim khun xy ra
khng pht trin.
b) La chn khng sinh d phng:
- Khng sinh c ph tc dng ph hp vi cc chng vi khun chnh
thng gy nhim khun ti vt m cng nh tnh trng khng thuc ti a
phng, c bit trong tng bnh vin
- Khng sinh t hoc khng gy tc dng ph hay cc phn ng c hi,
c tnh ca thuc cng t cng tt. Khng s dng cc khng sinh c nguy c
gy c khng d on c v c mc gy c nng khng ph thuc liu
(VD: khng sinh nhm phenicol v sunfamid gy gim bch cu min dch d
ng, hi chng Lyell).
- Khng sinh khng tng tc vi cc thuc dng gy m (VD
polymyxin, aminosid).
- Khng sinh t c kh nng chn lc vi khun khng khng sinh v
thay i h vi khun thng tr.
- Kh nng khuch tn ca khng sinh trong m t bo phi cho php t
nng thuc cao hn nng khng khun ti thiu ca vi khun gy nhim.
- Liu php khng sinh d phng c chi ph hp l, thp hn chi ph
khng sinh tr liu lm sng.
c) Liu khng sinh d phng: Liu KSDP tng ng liu iu tr mnh nht
ca khng sinh (Ph lc 2).
d) ng dng thuc
- ng tnh mch: Thng c la chn do nhanh t nng thuc
trong mu v m t bo.
- ng tim bp: c th s dng nhng khng m bo v tc hp
thu ca thuc v khng n nh
- ng ung: Ch dng khi chun b phu thut trc trng, i trng
- ng ti ch: Hiu qu thay i theo tng loi phu thut (trong phu
thut thay khp, s dng cht xi mng tm khng sinh)
e) Thi gian dng thuc
- Thi gian s dng khng sinh d phng nn trong vng 60 pht trc
khi tin hnh phu thut v gn thi im rch da.
B Y t | CC NGUYN TC S DNG KHNG SINH 47
Bng I.8).
- Sinh kh dng t 50% tr ln l tt, t 80% tr ln c coi l hp thu
ng ung tng t ng tim. Nhng trng hp ny ch nn dng ng
tim khi khng th ung c. Vic chn khng sinh m kh nng hp thu t b
nh hng bi thc n s bo m c s tun th iu tr ca ngi
bnhngi bnh tt hn v kh nng iu tr thnh cng cao hn.
- ng tim ch c dng trong nhng trng hp sau:
+ Khi kh nng hp thu qua ng tiu ho b nh hng (do bnh l
dng tiu ho, kh nut, nn nhiu).
+ Khi cn nng khng sinh trong mu cao, kh t c bng ng
ung: iu tr nhim khun cc t chc kh thm thuc (vim mng no, mng
trong tim, vim xng khp nng), nhim khun trm trng v tin trin
nhanh.
Tuy nhin, cn xem xt chuyn ngay sang ng ung khi c th.
nh hng ca thc n n
hp thu
Ampicilin
40
Amoxicilin
90
Lincomycin
30
Clindamycin
90
Erythromycin
50
Azithromycin
40
Tetracyclin
50
Doxycyclin
90
Pefloxacin
90
Ofloxacin
80
Khng sinh
6. DI T IU TR
- di iu tr ph thuc vo tnh trng nhim khun, v tr nhim khun
v sc khng ca ngi bnhngi bnh. Cc trng hp nhim khun nh
v trung bnh thng t kt qu sau 7 - 10 ngy nhng nhng trng hp
nhim khun nng, nhim khun nhng t chc m khng sinh kh thm nhp
(mng tim, mng no, xng-khp), bnh lao th t iu tr ko di hn
nhiu. Tuy nhin, mt s bnh nhim khun ch cn mt t ngn nh nhim
khun tit niu sinh dc cha bin chng (khong 3 ngy, thm ch mt liu
duy nht).
- S xut hin nhiu khng sinh c thi gian bn thi ko di cho php
gim c ng k s ln dng thuc trong t iu tr, lm d dng hn cho
vic tun th iu tr ca ngi bnhngi bnh; v d: dng azithromycin ch
cn mt t 3 5 ngy, thm ch mt liu duy nht.
- Khng nn iu tr ko di trnh khng thuc, tng t k xut hin tc
dng khng mong mun v tng chi ph iu tr.
7. LU TC DNG KHNG MONG MUN V C TNH KHI S
DNG KHNG SINH
- Tt c cc khng sinh u c th gy ra tc dng khng mong mun
(ADR), do cn cn nhc nguy c/li ch trc khi quyt nh k n. Mc d
a s trng hp ADR s t khi khi ngng thuc nhng nhiu trng hp hu
qu rt trm trng, v d khi gp hi chng Stevens Johnson, Lyell ADR
nghim trng c th dn ti t vong ngay l sc phn v. Cc loi phn ng qu
B Y t | CC NGUYN TC S DNG KHNG SINH 51
mn thng lin quan n tin s dng khng sinh ngi bnhngi bnh, do
phi khai thc tin s d ng, tin s dng thuc ngi bnhngi bnh
trc khi k n v phi lun sn sng cc phng tin chng sc khi s dng
khng sinh.
- Gan v thn l 2 c quan chnh thi tr thuc, do s suy gim chc
nng nhng c quan ny dn n gim kh nng thi tr khng sinh, ko di thi
gian lu ca thuc trong c th, lm tng nng dn n tng c tnh. Do
phi thn trng khi k n khng sinh cho ngi cao tui, ngi suy gim chc
nng gan thn v t l gp ADR v c tnh cao hn ngi bnh thng.
- V tr bi xut chnh ch ni khng sinh i qua dng cn hot tnh. T
Bng I.9 cho thy hai khng sinh c th cng mt nhm nhng c tnh dc
ng hc khng ging nhau. c im ny gip cho vic la chn khng sinh
theo c a ngi bnh.
- Cn hiu chnh li liu lng v/hoc khong cch a thuc theo chc
nng gan thn trnh tng nng qu mc cho php vi nhng khng sinh
c c tnh cao trn gan v/hoc thn.
- Vi ngi bnhngi bnh suy thn, phi nh gi chc nng thn theo
thanh thi creatinin v mc liu tng ng s c ghi mc Liu dng
cho ngi bnhngi bnh suy thn.
- Vi ngi bnhngi bnh suy gan, khng c thng s hiu chnh nh
vi ngi bnhngi bnh suy thn m phi tun theo hng dn ca nh sn
xut, thng l cn c vo mc suy gan theo phn loi Child-Pugh.
Bng I.9. C quan bi xut chnh ca mt s khng sinh
Khng sinh
V tr bi xut chnh
Cefotaxim
Thn
Cefoperazol
Gan
Lincomycin
Gan
Clindamycin
Gan
Erythromycin
Gan
Azithromycin
Gan
Tetracyclin
Thn
Doxycyclin
Gan
Pefloxacin
Gan
Ofloxacin
Thn
KT LUN
iu tr thnh cng nhim khun ph thuc nhiu yu t, bao gm tnh
trng bnh l, v tr nhim khun v sc khng ca ngi bnh. Cc kin thc
v phn loi khng sinh, v PK/PD s gip cho vic la chn khng sinh v xc
nh li ch liu ti u cho tng nhm khng sinh, l c s thc hin cc
nguyn tc s dng khng sinh hp l. y cng l nhng ni dung quan trng
i vi mi thy thuc bo m hiu qu - an ton - kinh t v gim t l
khng khng sinh trong iu tr.
TI LIU THAM KHO
1. Antibiotic Expert Group (2010), Principles of antimicrobial use, in: Therapeutic
Guidelines: Antibiotic, Melbourne (pp. 1 28).
2. Andes D., Craig W. A. (2002), Animal model pharmacokinetics and pharmacodynamics: A
critical review. Int J Antimicrob Agents,19(4): pp 261-268.
3. Bergman S. J., et al.(2007), Pharmacokinetic and pharmacodynamic aspects of antibiotic
use in high-risk populations, Infect Dis Clin North Am, pp 821-846.
4. Bennett P. N., Brown M. J. (2003), Antibacterial drugs, Churchil Livingstone
5. British National Formulary 64th (2012), Chapter 5. Infection Antibacterial Drugs, Royal
Pharmaceutical Society.
6. Goodman & Gilman's Pharmacology (2011), General Principles of Antimicrobial Therapy,
The McGraw-Hill Companies.
7. Jacobs M. R.(2001), Optimisation of antimicrobial therapy using pharmacokinetic and
pharmacodynamic parameters, Clin Microbiol Infect, 7(11) 589-596.
8. Lampiris H.W, Maddix D.S (2009), Clinical Use of Antimicrobial Agents, in:Basic &
Clinical Pharmacology (Bertram G. K. Masters S. B., Trevor A.J.), The McGraw-Hill
Companies.
9. Nightingale C.H, et al.(2007), Antimicrobial Pharmacodynamics in Theory and Clinical
Practice, Informa healthcare, New York.
Chng II.
i cng v vi khun hc
B Y t | 56
B Y t | I CNG V VI KHUN HC 57
I CNG V VI KHUN HC
Th gii sinh vt bao gm ng vt, thc vt v sinh vt n bo
(protista); v kch thc nh b ca chng nn ngi ta thng gi chung l vi
sinh vt. Da vo cu to chng c chia thnh 2 loi: Vi sinh vt bc cao v
vi sinh vt bc thp. Vi sinh vt bc cao l nhng t bo c nhn tht (Eucaryota,
ging t bo ng hoc thc vt) bao gm nm v ng vt nguyn sinh. Vi
sinh vt bc thp tri li, c tin nhn (Procaryota, khng c mng nhn) bao
gm vi khun v to lam (khng gy bnh). Virus l vi sinh vt nh hn v cu
to n s hn na tc khng phi l t bo m ch l nhng ht c chc nng
sng - nhn ln (sinh sn) khi trong nhng t bo sng. Bi ny ch gii thiu
v vi khun.
1. KHI QUT V VI KHUN
a) ln: rt nh (ng knh thn thng t 0,5 n 1m v chiu di t 2
n 5m); n v tnh ln ca vi khun l micromet, vit tt l m (10-6 m
hay 10-3 mm).
b) Hnh th: c 3 loi hnh th chnh l hnh cu (gi l cu khun; v d: t cu,
lin cu, ph cu, lu cu, no m cu), hnh ng (gi l trc khun; v d E.
coli, m xanh, than, un vn) v hnh cong mm mi xon l xo (gi l xon
khun; v d giang mai). Ngoi ra, c mt s hnh dng khc nh: trc khun
ngn gi l cu trc khun nh vi khun dch hch hoc trc khun cong cng
hnh helix nh Helicobacter pylori hay hnh du phy nh vi khun t.
c) Tnh cht bt mu: v vi khun rt nh nn phi nhum cho chng c mu rc
r mi c th pht hin c hnh th ca chng di knh hin vi phng i
1000 ln.
- Nhum Gram: l phng php nhum quan trng, c p dng cho
phn ln cc loi vi khun v h tr c lc cho vic chn on & iu tr sm
bnh nhim khun. Nhum Gram va gip ta nhn nh c hnh dng ca vi
khun, va phn bit c n l Gram-dng hay Gram-m; t ta c hng
chn khng sinh thch hp dit vi khun nghi ng l tc nhn gy bnh. V
d, nu tc nhn gy bnh nghi ng l vi khun Gram-dng th nn chn nhng
khng sinh c ph tc dng chn lc trn Gram-dng nhiu hn nh penicilin
G hoc cephalosporin th h 1; ngc li nu vi khun gy bnh nghi ng l trc
khun Gram-m th nn chn amoxicilin hay cephalosporin th h 3 hoc nhm
aminosid. S khc bit c bn gia vi khun Gram-dng v Gram-m l cu
trc vch ca t bo (cell wall).
- Nhum Ziehl-Neelsen l phng php nhum dnh ring cho cc vi
khun khng cn v acid (do vch c cha nhiu lipid v acid mycolic) nh vi
khun lao, phong.
d) Tnh cht chuyn ha: da vo nhu cu oxy t do cho qu trnh chuyn ha,
ngi ta chia vi khun thnh cc loi sau:
B Y t | I CNG V VI KHUN HC 58
B Y t | I CNG V VI KHUN HC 59
B Y t | I CNG V VI KHUN HC 60
B Y t | I CNG V VI KHUN HC 62
Ngi bnh
Vi khun
Beta-lactamase
PBP
H thng bm y ra
+ Phi la chn ng khng sinh v ng cho thuc thch hp. Phi hiu
c xu hng khng khng sinh ti a phng mnh.
+ Phi s dng khng sinh ng liu lng, ng khong cch liu v
ng thi gian qui nh.
+ Phi c s hiu bit v th trng ngi bnh, c bit i vi cc ph n
c thai, ngi gi, ngi b suy gan, suy thn
+ Phi bit cc nguyn tc ch yu v phi hp khng sinh. Kt hp ba
bi hoc kt hp qu nhiu khng sinh c th gia tng c tnh, i khng dc
l v gia tng khng.
+ S dng khng sinh d phng theo ng nguyn tc.
+ C chin lc quay vng khng sinh hp l.
- Thc hin tt cng tc kim sot nhim khun
+ Ngn nga ly truyn vi khun khng mnh gia ngi bnh vi
ngi bnh, gia ngi bnh vi nhn vin y t hoc ngn nga ly lan t mi
trng trong cc c s chm sc y t bng ra tay v phng nga bng cch ly
i vi ngi bnh v nhn vin y t mang cc vi khun khng mnh.
+ s dng khng sinh hp l v thc hin tt cng tc kim sot
nhim khun cc c s y t cn thnh lp Ban qun l s dng khng sinh
gm c cc thnh vin l cc nh qun l, cc bc s lm sng, dc s lm
sng, vi sinh lm sng, kim sot nhim khun phi hp tt gia cc hot
ng, xy dng cc hng dn iu tr thch hp.
B Y t | 74
B Y t | 75
B Y t | 76
B Y t | 77
nguyn
Mycoplasma
pneumoniae
hoc
Beta-lactam
Macrolid, doxycyclin
Macrolid, doxycyclin
GIN PH QUN
1. I CNG
Gin ph qun (Bronchiectasis) c nh ngha l gin khng hi phc
mt phn ca cy ph qun, c th gin ph qun ln trong khi ph qun nh
vn bnh thng hoc gin ph qun nh trong khi ph qun ln bnh thng.
2. NGUYN NHN
Bnh c th do nhiu nguyn nhn: gin ph qun tin pht hay bm sinh,
gin ph qun th pht do d vt, u ni ph qun, so c ca cc chn thng, vim
nhim... t bi nhim cc loi vi khun thng gp: Streptococcus
pneumoniae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus
aureus, Escheria coli...
3. TRIU CHNG
3.1. Lm sng
a) Triu chng ton thn
Triu chng ton thn ph thuc vo mc , nguyn nhn v bin chng
ca bnh. C th c st cn, thiu mu...
b) Triu chng c nng
- Khc m: Thng gp, khc m nhiu t 500-1000 ml/24 gi, m
m, c khi hi thi do vi khun him kh. Khi lng m c 3 lp: lp trn l
bt; lp gia l nhy m; lp di l m c. t cp thng c st v khc
m nhiu.
- Ho ra mu: Ti pht nhiu ln, ko di trong nhiu nm.
- Kh th: Biu hin ca suy h hp, c th c tm.
- au ngc: L du hiu sm ca nhim khun phi vng gin ph
qun.
c) Triu chng thc th
- Khm phi c thy ran m, ran ph qun nhng vng c tn thng.
- Khm tai mi hng: c th thy vim mi hng mn tnh, vim xoang
mn tnh.
- Mng tay khum, ngn di trng.
3.2. Triu chng cn lm sng
a) X-quang phi: Cc tn thng thng gp
- Cc m m hnh ng biu hin ca cc ph qun b lp y cht nhy.
- Thnh ph qun to thnh cc ng song song (ng ray).
B Y t | GIN PH QUN 82
- phng v ly sm d vt ph qun.
- Rn luyn thn th thng xuyn. Gi m c ngc, phng cc t
bi nhim khi b gin ph qun.
TI LIU THAM KHO
1. Barker AF (2002), Bronchiectasis, N Engl J Med, 346(18):1383-93.
2. Michael D. Iseman, Edward D. Chan (2010), Bronchiectasis, Murray and Nadels
Textbook of Respiratory Medicine 5nd ed, Philadelphia, Pa: WB Saunders and Co, 1398-1417.
3. Morrissey D (2007), Pathogenesis of Bronchiectasis, Clin Chest Med, 28:289-296.
4. Rosen MJ (2006), Chronic cough due to bronchiectasis: ACCP evidence-based clinical
practice guidelines, Chest, 129(1 Suppl):122S-131S.
B Y t | GIN PH QUN 86
BPTNMT
EPAP
FiO2
IPAP
PEEP
TKNTKXN
in: http://www.uptodate.com/online/content/topic.do?topicKey=copd/8006&selectedTitle=1~
39&source=search_result.
3.2. Cn lm sng
- Cng thc mu: S lng bch cu tng >10 Giga/lt, bch cu a nhn
trung tnh tng trn 75%. Khi s lng bch cu gim < 4,5 Giga/lt: Hng ti
vim phi do virus.
- Tc lng mu tng, CRP tng > 0,5
- Cy mu hoc m c th thy vi khun gy bnh.
- X-quang phi: m m hnh tam gic nh pha rn phi, y pha
ngoi hoc cc m m c hnh ph qun hi, c th m gc sn honh.
- Chp ct lp vi tnh ngc: C hi chng lp y ph nang vi du hiu
ph qun hi, thu phi vim khng gim th tch, bng m ph nang hoc m
fluoroquinolon
(ciprofloxacin,
ofloxacin,
levofloxacin,
Royal Oak,
Fishmans Pulmonary
S tr < 5 tui
T l mi mc
S tr mc /nm
(triu)
(t/tr/nm)
(triu)
Chu Phi
105,62
0,33
35,13
Chu M
75,78
0,10
7,84
Trung ng
69,77
0,28
19,67
Chu u
51,96
0,06
3,03
ng Nam chu
168,74
0,36
60,95
133,05
0,22
29,07
523,31
0,29
151,76
Cc nc pht trin
81,61
0,05
4,08
T l t/tr/nm
0,37
0,22
0,41
0,41
0,34
0,28
0,35
0,39
0,35
0,27
0,48
0,45
0,33
0,43
0,11
S tr mi mc (triu)
43,0
21,1
9,8
6,4
6,1
6,0
3,9
3,9
2,9
2,7
2,0
2,0
1,9
1,8
1,8
S tr t vong (nghn)
408
204
126
112
91
87
74
50
47
46
38
36
32
30
25
T l t vong/ 10.000 tr
32,2
84,7
110,1
84,6
48,1
185,9
8,6
26,6
157,1
173,9
67,6
52,6
147,8
50,3
99,4
2. NGUYN NHN
2.1. Vi khun:
Nguyn nhn thng gp gy vim phi tr em c bit cc nc
ang pht trin l vi khun. Vi khun thng gp nht l Streptococcus
pneumoniae (ph cu) chim khong 30 35% trng hp. Tip n l
Hemophilus influenzae (khong 10 30%), sau l cc loi vi khun khc
(Branhamella catarrhalis, Staphylococcus aureus, Streptococcus pyogens...)
(5,16).
- tr nh < 2 thng tui cn c th do cc vi khun Gram m ng
rut nh Klebsiella pneumoniae, E. coli, Proteus...
- tr ln 5 15 tui c th do Mycoplasma pneumoniae, Clammydia
pneumoniae, Legionella pneumophila...(thng gy vim phi khng in hnh)
2.2. Virus:
Nhng virus thng gp gy vim phi tr em l virus hp bo h hp
(Respiratory Syncitral virus = RSV), sau l cc virus cm A,B, cm
Adenovirus, Metapneumovirus, Severe acute Respiratory Syndrome = SARS).
Nhim virus ng h hp lm tng nguy c vim phi do vi khun hoc c th
kt hp vim phi do virus v vi khun (t l ny vo khong 20 30%).
2.3. K sinh trng v nm
Vim phi tr em c th do Pneumocystis carinii, Toxoplasma,
Histoplasma, Candida spp...
3. CHN ON
Chn on vim phi cng ng tr em ch yu da vo du hiu lm
sng kt hp X-quang phi v mt s xt nghim khc nu c iu kin.
3.1. Da vo lm sng: Theo ngin cu ca TCYTTG vim phi cng ng
tr em thng c nhng du hiu sau: (Khuyn co 5.1 Ph lc 1).
- St: Du hiu thng gp nhng c hiu khng cao v st c th do
nhiu nguyn nhn. St c th c nhiu bnh, chng t tr c biu hin nhim
khun trong c vim phi.
- Ho: Du hiu thng gp v c c hiu cao trong cc bnh ng
h hp trong c vim phi
- Th nhanh: Du hiu thng gp v l du hiu sm chn on vim
phi tr em ti cng ng v c nhy v c hiu cao (Khuyn co 5.1
Ph lc 1). Theo TCYTTG ngng th nhanh ca tr em c quy nh nh
sau:
+ i vi tr < 2 thng tui: 60 ln/pht l th nhanh.
+ i vi tr 2 - 12 thng tui: 50 ln/pht l th nhanh.
+ Tr t 1 5 tui: 40 ln/pht l th nhanh.
B Y t | S DNG KHNG SINH IU TR VIM PHI 101
CNG NG TR EM
+ Th rt khi nm yn
+ V cc du hiu nguy him khc
4.2. Vim phi (vim phi nh)
- Tr c cc triu chng
+ Ho hoc kh th nh
+ St
+ Th nhanh
+ C th nghe thy ran m hoc khng
- Khng c cc triu chng ca vim phi nng nh:
+ Rt lm lng ngc
+ Php phng cnh mi
+ Th rn: tr < 2 thng tui
+ Tm ti v cc du hiu nguy him khc
Lu : i vi tr nh < 2 thng tui tt c cc trng hp vim phi
la tui ny u l nng v phi vo bnh vin iu tr v theo di.
4.3. Vim phi nng
- Tr c cc du hiu:
+ Ho
+ Th nhanh hoc kh th
+ Rt lm lng ngc
+ Php phng cnh mi
+ Th rn (tr < 2 thng tui)
+ C th c du hiu tm ti nh
+ C ran m hoc khng
+ X-quang phi c th thy tn thng hoc khng
- Khng c cc du hiu nguy him ca vim phi rt nng (Tm ti nng,
suy h hp nng, khng ung c, ng li b kh nh thc, co git hoc hn
m...).
4.4. Vim phi rt nng
- Tr c th c cc triu chng ca vim phi hoc vim phi nng.
- C thm 1 trong cc du hiu nguy him sau y:
+ Tm ti nng
+ Khng ung c
+ Ng li b kh nh thc
+ Th rt khi nm yn
+ Co git hoc hn m
+ Tnh trng suy dinh dng nng
Cn theo di thng xuyn pht hin cc bin chng, nghe phi
pht hin ran m nh ht, ting thi ng, r ro ph nang gim, ting c mng
phi... V chp X quang phi pht hin cc tn thng nng ca vim phi
v bin chng nh trn dch mng phi, trn kh mng phi, p xe phi... iu
tr kp thi.
5. IU TR
iu tr vim phi do vi khun ch yu l s dng khng sinh sau l
cc iu tr h tr khc.
5.1. V sao phi dng khng sinh cho tt c cc tr vim phi
- V nguyn tc vim phi do vi khun bt buc phi dng khng sinh
iu tr, vim phi do virus n thun th khng sinh khng c tc dng. Tuy
nhin trong thc t rt kh phn bit vim phi do vi khun hay virus hoc c s
kt hp gia virus vi vi khun k c da vo lm sng, X-quang hay xt
nghim khc.
- Ngay c khi cy vi khun m tnh cng kh c th loi tr c vim
phi do vi khun. V vy WHO khuyn co nn dng khng sinh iu tr cho
tt c cc trng hp vim phi tr em. (Khuyn co 5.6 Ph lc 1).
5.2. C s la chn khng sinh trong iu tr vim phi cng ng
Vic la chn khng sinh trong iu tr vim phi l tng nht l da
vo kt qu nui cy vi khun v lm khng sinh chn khng sinh thch
hp. Tuy nhin trong thc t kh thc hin v:
+ Vic ly bnh phm nui cy vi khun v lm khng sinh rt kh
khn, c bit l ti cng ng
+ Thi gian ch kt qu xt nghim mi quyt nh iu tr l khng kp
thi, nht l nhng trng hp vim phi nng cn iu tr cp cu.
V vy vic la chn khng sinh iu tr vim phi tr em ch yu da
vo c im lm sng, la tui, tnh trng min dch, mc nng nh ca
bnh cng nh tnh hnh khng khng sinh ca cc vi khun gy bnh thng
gp c quyt nh thch hp.
Theo tui v nguyn nhn:
+ i vi tr s sinh v < 2 thng tui: Nguyn nhn thng gp l lin
cu B, t cu, vi khun Gram-m, ph cu (S. pneumoniae) v H. influenzae.
+ Tr t 2 thng n 5 tui nguyn nhn hay gp l ph cu (S.
pneumoniae) v H. influenzae.
+ Tr trn 5 tui ngoi S. pneumoniae v H. influenzae cn c thm
Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila...
(6).
- Theo tnh trng min dch: Tr b suy gim min dch bm sinh hay mc
phi c bit l tr b HIV AIDS thng b vim phi do k sinh trng nh
Pneumocystis carini., Toxoplasma, do nm nh Candida spp, Cryptococcus spp,
hoc do virus nh Cytomegalo virus, Herpes simplex hoc do vi khun nh S.
aureus, cc vi khun Gram-m v Legionella spp.
B Y t | S DNG KHNG SINH IU TR VIM PHI 104
CNG NG TR EM
S. pneumoniae (%)
H. influenzae (%)
M. catarrhalis
Penicilin
8,4%
Ampicilin
84,6
24,2
Cephalothin
14,5
64,3
6,8
Cefuroxime
50,0
1,7
64,6
13,2
17,3
Cefortaxim
2,6
4,9
Gentamycin
35,1
8,3
Cotrimoxazole
62,9
88,6
65,8
Chloramphenicol
31,9
73,2
65,8
Erythromycin
- Vim phi khi pht sm thng l cc chng vi khun ngoi bnh vin:
Streptococcus pneumoniae, Haemophilus influenzae, S. aureus nhy cm vi
methicilin (MSSA)
- Vim phi khi pht mun thng l cc vi khun bnh vin v a
khng thuc: Pseudomonas aeruginosa, Escherichia coli, Enterobacter, Klebsiella
pneumoniae v Acinetobacter baumannii, S. aureus khng methicilin...
- Vim phi lin quan n chm sc y t thng l nhng trng hp c nguy
c nhim vi khun a khng.
3. TRIU CHNG
a) Lm sng
- St > 38oC hoc < 35oC
- Tng s lng dch tit ph qun nh m
b) Cn lm sng
- Bch cu mu ngoi vi trn 10000/mm3 hoc di 5000/mm3. Tuy nhin
cc ngi bnhngi bnh c suy gim min dch hoc ang c iu tr ha
cht, corticoid, bnh mu bch cu c th khng tng mc d ngi
bnhngi bnh c nhim khun nng.
- Cc thay i trn X-quang: Hnh nh thm nhim ph nang, hnh nh
bng m, hang, m rnh lin thy, xp phi v cc thm nhim khng i xng
trn nn phi c tn thng i xng trc .
c) Phn loi mc nng
- Vim phi bnh vin mc nh, va: Khng c cc biu hin sau: Tt
huyt p, khng phi t ni kh qun, khng c hi chng nhim khun huyt,
khng c tnh trng tin trin nng ln nhanh tn thng trn X-quang phi,
khng c biu hin suy a ph tng.
- Vim phi bnh vin mc nng: C cc biu hin ni trn v c
S.aureus khng methiciline (MRSA).
4. IU TR BNG KHNG SINH
a) Nguyn tc chung
- X tr tu theo mc nng. Nhng trng hp vim phi bnh vin
nng cn c iu tr ti khoa Hi sc tch cc.
- La chn khng sinh ban u thng da theo cc yu t nguy c ca
vim phi mc phi bnh vin, m hnh vi khun gy bnh thng gp ti a
phng, mc nng ca bnh, tui ngi bnhngi bnh, cc bnh km theo,
cc tng tc v tc dng ph ca thuc.
- Cn phi hp khng sinh cho cc trng hp nghi ng nhim khun do
cc vi khun a khng hoc cc trng hp VPBV nng.
B Y t | VIM PHI BNH VIN 111
Cephalosporin, th h III:
Streptococcus spp.,
MSSA,
H.influenzae,
Hoc
E.coli,
Cephalosporin, th h IV:
Klebsiella spp.,
Enterobacter,
Hoc
Proteus spp.
Beta-lactam-cht c ch beta-lactamase
v Serratia spp.
VPBV mun
(c nguy c
nhim VK
S. pneumoniae,
Streptococcus spp., MSSA,
Phn loi
a khng)
mc nh
v va
Hoc
E.coli
Klebsiella spp.,
Enterobacter
Proteus spp.
v Serratia spp.
P. aeruginosa
Acinetobacter spp.
Hoc
Beta-lactam-cht c ch beta-lactamase
(Piperacilin-tazobactam 4,5 g mi 6h, TM)
Hoc
Carbapenem:
Imipenem 500mg mi 8h truyn TM hoc meropenem
500mg mi 8h, ng TM
Hoc
Fluoroquinolon:
Levofloxacin 750 mg mi 24h, TM hoc
Moxifloxacin 400 mg mi 24h, TM
Phi hp hoc khng:
VPBV mun
nng phi
iu tr ti
ICU
C th gp MRSA
S. pneumoniae,
Streptococcus spp.
MRSA
H. influenzae,
Escherichia coli,
Klebsiella spp.
Enterobacter
Proteus spp. v
Serratia spp.
P. aeruginosa
Acinetobacter spp.
Legionella spp.
Hoc
Beta-lactam-cht c ch beta-lactamase
(Piperacilin-tazobactam 4,5 g mi 6h, TM)
Hoc
Carbapenem:
Imipenem 500mg 1g mi 6h, truyn TM hoc
meropenem 1g mi 8h, ng TM
Phi hp vi:
Fluoroquinolon:
Ciprofloxacin 400 mg mi 8h TM hoc Levofloxacin
750 mg mi 24h, TM
Hoc
Aminoglycosid:
Gentamicin hoc tobramycin 5-7 mg/kg mi 24h, TM
hoc amikacin 15-20 mg/kg mi 24h, TM
Phi hp hoc khng:
Vancomycin 1g mi 12h, TM hoc linezolid
600 mg mi 12h, TM (nu c hoc nghi ng MRSA)
Bng II.7. La chn khng sinh cho mt s chng vi khun a khng thuc
Chng vi khun
Thuc u tin
Thuc thay th
S. aureus khng
methicilin (MRSA)
Linezolid
K. pneumoniae v cc
Enterobacteriaceae
khc (ngoi tr
Enterobacter) sinh
ESBL
Carbapenem (imipenem,
meropenem)
Piperacilin-tazobactam,
aminoglycosid
Enterobacter
Carbapenem (imipenem,
meropenem), beta-lactam cht c
ch beta-lactamase (piperacilintazobactam, ticarcilin-clavulanat),
cefepim, fluoroquinolon,
aminoglycosid
Cephalosporin th h 3
+ aminoglycosid
MDR P. aeruginosa
MDR Acinetobacter
Cefoperazon-sulbactam phi
hp vi colistin
Cc phi hp c th:
aminoglycosid
Carbapenem + ampicilin-sulbactam
Doxycyclin + amikacin
Colistin + rifampicin ampicilin-sulbactam
5. D PHNG
- Tn trng nguyn tc v sinh: Ra tay k bng x phng, kh trng tay
bng cn trc v sau khi thm khm ngi bnhngi bnh, trc lc lm th
thut nhm trnh ly nhim cho. Tun th tuyt i nguyn tc v trng khi
lm cc th thut. Cch ly sm cc ngi bnhngi bnh nhim vi khun a
khng thuc.
- Theo di cht ch tnh trng nhim khun trong khoa, trong bnh vin
nhm pht hin nhng chng vi khun khng thuc a ra hng dn iu tr
khng sinh hp l cho cc trng hp nghi ng c vim phi mc phi bnh
vin.
NKQ
Ni kh qun
VPTM
VPCSYT
4. Coleman Rotstein, Gerald Evans, Abraham Born, Ronald Grossman, R Bruce Light,
Sheldon Magder, Barrie McTaggart, Karl Weiss (2008), Clinical practice guidelines for
hospital-acquired pneumonia and ventilator-associated pneumonia in adults AMMI Canada
guidelines.
5. ATS (2005), Guidelines for the Management of Adults with Hospital-acquired, Ventilatorassociated, and Healthcare-associated Pneumonia Am J Respir Crit Care Med Vol 171. pp
388416
Vi sinh vt
H. influenzae,
Moraxella catarrhalis,
S. pneumoniae
P. aeruginosa,
Acinetobacter baumannii
T cu
Vi khun k kh
Ht phi
Legionella
Aspergillus
Candida albicans
Influenza virus
Virus hp bo h hp
3. TRIU CHNG
3.1. Lm sng
Cc triu chng xut hin sau 48 gi k t khi c th my (qua ng ni
kh qun hoc qua canuyn m kh qun).
- Dch ph qun c m, c v s lng nhiu hn.
- St > 38C hoc < 35,5C.
- Nghe phi c ran bnh l.
3.2. Cn lm sng
- X quang c m thm nhim mi, tn ti dai dng, hoc thm nhim tin
trin thm sau 48 gi k t khi th my.
- Tng bch cu > 10G/l hoc gim bch cu < 4G/l.
- Procalcitonin tng cao hn.
- Cy dch ht ph qun >105 CFU/ml, hoc
- Cy dch ra ph qun ph nang > 104 CFU/ml, hoc
- Cy mu bnh phm chi ph qun c bo v > 103 CFU/ml.
B Y t | VIM PHI LIN QUAN N TH MY 119
+ Ceftriaxone.
+ Quinolon (levofloxacin, moxifloxacin, ciprofloxacin).
+ Ampicilin-sulbactam, hoc ertapenem.
b) Vim phi lin quan n th my c nguy c nhim cc vi sinh vt a khng
- Cc yu t nguy c nhim vi sinh vt a khng thuc:
+ Ngi bnhNgi bnh tng nhp vin >2 ngy trong vng 90 ngy
gn y.
+ Nm iu tr cc c s chm sc di ngy.
+ Lc mu chu k trong vng 30 ngy.
+ ang iu tr tim truyn ti nh.
+ C ngi thn trong gia nh b nhim vi khun a khng.
+ iu tr khng sinh trong vng 90 ngy gn y.
+ ang nm vin >5 ngy (khng nht thit iu tr ti khoa Hi sc).
+ ang iu tr ti bnh vin hoc mi trng khc c lu hnh vi khun
c tnh khng cao.
+ Ngi bnhNgi bnh c bnh l suy gim min dch, hoc ang dng
thuc gy suy gim min dch.
- iu tr tp trung vo cc tc nhn: T cu khng methicilin, P.
aeruginosa, Acinetobacter, Klebsiella, Enterobacter, Serratia, Stenotrophonas,
Burkhoderia cepacia.
- La chn 1 loi khng sinh nhm A kt hp vi 1 khng sinh nhm B;
cn nhc thm nhm C hoc D, ty theo nh hng tc nhn gy bnh (nu vi
khun sinh ESBL: Carbapenem kt hp vi fluoroquinolon).
Nhm A:
+ Cephalosporin khng trc khun m xanh (cefepim, ceftazidim).
+ Carbapenem khng trc khun m xanh (imipenem, meropenem).
+ Beta-lactam c hot tnh c ch beta-lactamase (piperacillintazobactam).
Nhm B:
+ Fluoroquinolon khng trc khun m xanh (ciprofloxacin,levofloxacin).
+ Aminoglycosid (amikacin, gentamycin, tobramycin).
Nhm C (nu nghi ng t cu khng methicilin):
B Y t | VIM PHI LIN QUAN N TH MY 121
+ Linezolid.
+ Vancomycin.
+ Teicoplanin.
Nhm D (nu nghi ng nhim nm):
+ Khi s dng khng sinh ph rng > 7 ngy, hoc c a suy gim min
dch.
+ Thuc chng nm: Fluconazol, itraconazol, amphotericin B,
caspofungin. iu chnh liu theo kt qu vi sinh vt v p ng lm sng.
Ch :
+ Ngi bnh suy thn cn iu chnh theo mc lc cu thn, kt qu nh
lng khng sinh trong mu (nu c) v tnh trng ngi bnh.
+ Nu vim phi lin quan n th my mun, c khng nh hoc
c nguy c nhim vi khun Gram-m a khng: Colistin kt hp vi
carbapenem, fluoroquinolon, rifampicin
c) Theo di v thi gian iu tr khng sinh:
- Tin hnh iu tr theo kinh nghim da trn nh hng ban u, nh
gi li sau 48 72 gi, hay ti khi c kt qu nui cy vi sinh.
- Liu trnh khng sinh phi c xem xt li ti cc thi im sau 3 ngy,
5 ngy, 7 ngy iu tr. p ng tt: im CPIS (Clinical Pulmonary Infection
Score) gim, ci thin st, ci thin t l PaO2/FiO2, bch cu gim,
procalcitonin gim, tnh cht m m gim, tn thng trn phim X quang phi
c ci thin.
- nh gi v theo di hng ngy v cc triu chng lm sng, xt nghim
mu, xt nghim vi sinh:
+ Triu chng lm sng ci thin nhanh, kt qu nui cy vi khun m
tnh: Xem xt ngng khng sinh hoc rt ngn liu trnh khng sinh.
+ Khi c kt qu cy xc nh c vi khun gy bnh v cc triu
chng lm sng c ci thin: iu chnh phc khng sinh (liu php iu tr
xung thang) da trn kt qu vi sinh vt v nhy cm ca vi khun. Cn
nhc lm li xt nghim vi sinh nh k, c bng chng v hiu qu iu tr.
+ Khng thy c du hiu ci thin tnh trng nhim khun phi: Loi tr
cc bin chng (v d: p xe, trn m mng phi) v cc nguyn nhn khc
(k c nguyn nhn nhim khun v khng nhim khun). Ngoi ra, phi nh
gi li i vi cc vi khun gy bnh khng khng sinh m phc khng sinh
ban u khng bao ph c, hoc nng khng sinh cha tha ng. Cn
nhc lm li cc xt nghim vi sinh nu cn thit.
B Y t | VIM PHI LIN QUAN N TH MY 122
Cch s dng
Ceftriaxon
Cefepim
Ceftazidim
Ampicilin-sulbactam
Imipenem
Meropenem
Piperacillin-tazobactam
Levofloxacin
Moxifloxacin
Ciprofloxacin
Amikacin
Tobramycin
Gentamicin
Linezolid
Teicoplanin
Vancomycin
Liu dng 1g/12 gi. Nhim khun nng c th tng n 1,5g/12 gi trn
ngi bnhngi bnh c thanh thi creatinin 90ml/pht, nn gim st
nng y (t 10-20 g/ml).
Fluconazol
Itraconazol
Amphotericin B
Truyn tnh mch, liu ngy u 0,1 - 0,3 mg/kg/ngy, tng liu 5 10mg/ngy cho ti liu 0,5 - 1mg/kg/ngy.
(dng desoxycholate)
Caspofungin
Truyn tnh mch chm trong khong 1 gi, liu np duy nht (ngy th
nht ca t iu tr) 70mg; sau mi ngy 50mg.
6. D PHNG
6.1. Vim phi do ht phi
- u tin s dng th my khng xm nhp nu khng c chng ch nh.
- Rt ngn thi gian th my.
- Dng ng ht m kn v thay nh k.
- Ht m di thanh mn lin tc.
- T th na ngi (45).
- Trnh tnh trng t rt ng.
- Duy tr p lc bng chn (cuff) ti u.
- Trnh tnh trng cng gin d dy qu mc.
- Trnh thay ng ng dy th khng cn thit.
- Lm m bng HME (Heat and Moisture Exchangers).
- Trnh ng nc ng th.
- Trnh vn chuyn ngi bnh khi khng cn thit.
6.2. Vim phi do cc vi khun c tr (colonization) gy bnh
- Ra tay thng quy ng k thut v c hiu qu.
- Tp hun v m bo s lng nhn vin, c bit l iu dng ch
cng tc chm sc v sinh rng ming, t th ngi bnh.
- Trnh s dng khng sinh khng cn thit.
- D phng lot d dy do stress.
- t ni kh qun ng ming.
- S dng khng sinh ngn ngy.
P XE PHI
1. I CNG
p xe phi l m trong nhu m phi do vim nhim hoi t cp tnh
khng phi lao, sau khi c m to thnh hang. p xe phi c th c mt hoc
nhiu . Khi iu tr ni khoa qu 6 tun tht bi th gi l p xe phi mn tnh.
2. CHN ON
2.1. Chn on xc nh
2.1.1 Triu chng lm sng
- St: 3805C - 390C hoc cao hn, c th km rt run hoc khng.
- au ngc bn tn thng, c th c au bng nhng ngi bnhngi
bnh p xe phi thu di.
- Ho khc m c m, m thng c mi hi hoc thi, c th khc m
s lng nhiu (c m), i khi c th khc ra m ln mu hoc thm ch c ho
mu nhiu, c khi ch ho khan.
- Kh th, c th c biu hin suy h hp: Th nhanh, tm mi, u chi,
PaO2 gim, SaO2 gim.
- Khm phi: C th thy ran ngy, ran n, ran m, c khi thy hi chng
hang, hi chng ng c.
2.1.2 Cn lm sng
- Cng thc mu: Thng thy s lng bch cu > 10 giga/lt, tc
mu lng tng.
- X-quang phi: Hnh hang thng c thnh tng i u vi mc nc
hi. C th c 1 hay nhiu p xe, mt bn hoc hai bn.
- Cn chp phim X-quang phi nghing (c khi phi chp ct lp vi tnh)
xc nh chnh xc v tr p xe gip chn phng php dn lu m ph hp.
- Cy mu tm vi khun trong trng hp st > 3805C v lm khng sinh
(nu c iu kin).
- Nhum soi trc tip v nui cy vi khun t m, dch ph qun hoc
m p xe. Lm khng sinh nu thy vi khun.
2.2. Chn on nguyn nhn
- Vic xc nh cn nguyn phi da vo xt nghim vi sinh vt m, dch
ph qun, mu hoc bnh phm khc.
- Cc tc nhn gy p xe phi thng l Staphylococcus aureus,
Klebsiella pneumoniae, Pseudomonas aeruginosa, E. coli, Proteus, vi khun k
B Y t | P XE PHI 128
- Nu nghi ng p xe phi do vi khun k kh th kt hp nhm betalactam-clavulanat vi metronidazol liu 1- 1,5g/ngy, truyn tnh mch chia 2-3
ln/ngy, hoc penicilin G 10 50 triu n v kt hp metronidazol 11,5g/ngy truyn tnh mch, hoc penicilin G 10 50 triu n v kt hp
clindamycin 1,8g/ngy truyn tnh mch.
- Nu nghi ng p xe phi do t cu: Oxacilin 6 - 12g/ngy hoc
vancomycin 1-2 g/ngy, kt hp vi amikacin khi nghi do t cu khng thuc.
- Nu p xe phi do amp th dng metronidazol 1,5g/ngy, truyn tnh
mch chia 3 ln /ngy kt hp vi khng sinh khc.
- Ch xt nghim creatinin mu 2 ln trong mt tun i vi ngi
bnhngi bnh c s dng thuc nhm aminoglycosid pht hin sm bin
chng suy thn do thuc.
d) p ng vi phc v thi gian iu tr
- Ngi bnhNgi bnh p xe phi thng s c ci thin lm sng sau
3-4 ngy dng phc khng sinh u tin (nh gim st). Ct st sau khong 7
n 10 ngy. Nu sau thi gian ny m ngi bnhngi bnh vn st chng t
ngi bnhngi bnh chm p ng vi phc u v cn phi xt nghim vi
sinh tm nguyn nhn.
- Thi gian dng khng sinh t nht 4 tun (c th ko di n 6 tun tu
theo lm sng v X-quang phi).
- Mt s chuyn gia khuyn co rng nn tip tc dng khng sinh cho ti
khi trn phim X-quang khng cn tn thng hoc ch cn nhng vt tn
thng nh v n nh.
3.1.2. Dn lu p xe
- Dn lu t th, v rung lng ngc: Da vo phim chp X-quang phi
thng nghing hoc chp ct lp vi tnh lng ngc chn t th ngi bnhngi
bnh dn lu t th kt hp vi v rung lng ngc. Dn lu t th nhiu ln
/ngy, ngi bnhngi bnh t th sao cho p xe c dn lu tt nht,
lc u trong thi gian ngn vi pht, sau ko di dn thi gian ty thuc vo
kh nng chu ng ca ngi bnhngi bnh c th n 15 20 pht/ln. V
rung dn lu t th mi ngy 2-3 ln.
- C th ni soi ph qun ng mm ht m ph qun dn lu p xe.
Soi ph qun ng mm cn gip pht hin cc tn thng gy tc nghn ph
qun v gp b d vt ph qun nu c.
- Chc dn lu m qua thnh ngc: p dng i vi nhng p xe phi
ngoi vi, p xe khng thng vi ph qun; p xe st thnh ngc hoc dnh
vi mng phi. S dng ng thng c 7- 14F, t vo p xe ht dn lu m
qua h thng ht lin tc.
B Y t | P XE PHI 130
3.1.3. Cc iu tr khc
- m bo ch dinh dng cho ngi bnhngi bnh.
- m bo cn bng nc in gii, thng bng kim toan.
- Gim au, h st.
3.2. iu tr phu thut
- M ct phn thu phi hoc thy phi hoc c 1 bn phi tu theo mc
lan rng vi th trng ngi bnhngi bnh v chc nng h hp trong gii
hn cho php (FEV1>1 lt so vi s l thuyt):
+ p xe > 10cm.
+ p xe phi mn tnh iu tr ni khoa khng kt qu.
+ Ho ra mu ti pht hoc ho mu nng e do tnh mng.
+ p xe phi hp vi gin ph qun khu tr nng.
+ C bin chng r ph qun khoang mng phi.
4. PHNG BNH
- V sinh rng ming, mi, hng.
- iu tr tt cc nhim khun rng, hm, mt, tai, mi, hng. Thn trng
khi tin hnh cc th thut cc vng ny trnh cc mnh t chc ri vo kh
ph qun.
- Khi cho ngi bnhngi bnh n bng ng thng d dy phi theo di
cht ch, trnh sc thc n.
- Phng nga cc d vt ri vo ng th.
TI LIU THAM KHO
1. Antoni Torres, Rosario Menyndez, Richard Wunderink (2010), Pyogenic Bacterial
Pneumonia and Lung Abcess, Murray and Nadels Textbook of Respiratory Medicine (5th
ed), Saunder.
2. Guidelines for antimicrobial usage. Cleverland Clinic, 2011-2012.
3. Jay A. Fishman (2008), Aspiration, empyema, lung abcesses and anaerobic infections,
Fishmans Pulmonary Diseases and Disorder (4th ed), McGraw-Hill, 21412161.
4. "Lung abcess". The Merck Manual (18th ed), Gary Zelko, 437-439.
5. Tice AD, Rehm SJ, Dalovisio JR, et al (2004), Practice guidelines for outpatient
parenteral antimicrobial therapy, IDSA guidelines, Clin Infect Dis, 38(12):1651-72
6 p xe phi. Hng dn v iu tr bnh ni khoa. Nh xut bn Y hc 2011: 354-358.
B Y t | P XE PHI 131
B Y t | 135
B Y t | 136
B Y t | 137
B Y t | 138
Vi khun Gram-m
ng rut h
Enterobacteriaceae
(khng sinh ESBL)
400mg x 2 n 3 ln/ngy, ti a
khng qu 1200mg/ngy, truyn
tnh mch
Vi khun Gram-m
ng rut h
Enterobacteriaceae
(sinh ESBL)
Pseudomonas
aeruginosa
Burkholderia
pseudomallei
Streptococcus
pneumoniae
Staphylococcus aureus
(nhy Methicilin)
Staphylococcus aureus
(khng Methicilin)
Streptococcus suis
Clostridium perfringens
Cch s dng
Ceftriaxon
Cefepim
Ceftazidim
Ampicilin-sulbactam
Ertapenem
Imipenem
Meropenem
Piperacilin-tazobactam
Levofloxacin
Moxifloxacin
Ciprofloxacin
Amikacin
Tobramycin
Gentamicin
Linezolid
600mg x 1 ln/ngy.
B Y t | 149
THP TIM
1. NH NGHA
- Thp tim l mt bnh vim cp tnh c tnh cht ton thn (c lin quan
n min dch) ch xy ra sau mt hay nhiu t vim hng do lin cu beta tan
huyt nhm A theo phn loi ca Lancefield. Bnh biu hin bng mt hi
chng bao gm: Vim a khp, vim tim, chorea, ht di da, ban vng.
- Bnh thp tim c bit n t th k 17. Nm 1944, J.Duckett Jone
a ra bng hng dn chn on thp tim. Nm 1988, WHO cng nhn
bng tiu chun chn on thp tim ca Jone c sa i.
- Hin nay trn th gii bnh thp tim c gii quyt cc nc pht
trin. Cc nc khc t l bnh vn cn cao. Vit Nam t l thp tim tr em
di 16 tui l 0,45%.
2. NGUYN NHN
- Do vi khun Lin cu beta tan huyt nhm A gy ra.
3. TRIU CHNG
a) Lm sng
- Vim hng: Hay gp trc 1-2 tun. Ton thn: Ngi bnhNgi
bnh c st nh hoc st cao; ton thn mt mi, n ung km; c th ho, au
ngc...
- Vim van tim: Hay gp mi xut hin TTT mm do HoHL; thi tm
trng gia mm (thi carey coomb), c th do tng cng ting T3; thi
tm trng y tim do HoC.
- Vim c tim: Nhp tim thng nhanh, tng ng vi tng 1 C- nhp
tim tng 30 n 35 ck/ph, c th c ngoi tm thu nh hoc tht, c th c ting
nga phi mm hoc trong mm.
- Vim mng ngoi tim: Ting tim m, c th nghe thy ting c mng
tim.
- Vim khp: Thng hay gp cc khp nh hoc khp ln nh: u
gi, c chn, khuu tay, c tay... khp au di chuyn, hn ch vn ng, sngnng - . c im ca vim khp: p ng rt nhanh vi salicylat, khi khi
khng li di chng, khng iu tr cng t khi sau 4 tun.
- Ma git (Sydenham): Do tn thng thn kinh trung ng. Ngi
bnhNgi bnh c nhng ng tc mt hoc hai chi vi c im: Bin
rng, t ngt, khng c thc, tng ln khi thc v gim hoc ht ng tc nu
tp trung vo mt vic no hoc khi ng. Thng ht ma git sau 4-6 tun.
Mc
i li trong phng
2 tun
2 tun
4 tun
4 tun
6 tun
6 tun
3 thng
Liu lng
Khng sinh
Cch dng
Ghi ch
Benzathin
penicilin
Tim bp su
T 30 kg tr ln: 1.200.000 v. (tim mng) mt
ln duy nht.
Hiu qu
nht (>97%).
Penicilin V
Ung 2 ln/24
gi. Ung 10
ngy.
Hiu qu nh
tim.
Ung 2 ln/24
gi. Ung 10
ngy.
Dng khi d
ng vi
Penicilin.
Tc dng tt
(>70%).
Erythromycin
c) Xt nghim nc tiu: Ngoi Protein niu ngi ta thy trong khong 70 80% cc trng hp c i ra mu vi th, c xc nh thng qua xt nghim
cn Addis.
d) Siu m tim: Nu nhn thy r cc tn thng si th chng ta c th chn
on xc nh bnh (d l c cy mu m tnh). Nhng nu khng thy r cc
tn thng si th chng ta cng khng c loi tr chn on, v c th chm
tia siu m cha qut c ng vng tn thng, hoc l tn thng si cn
qu nh nn cha pht hin c trn siu m. i khi siu m tim cn pht
hin c hin tng t cc dy chng, ct c hoc thng cc vch tim, l
nhng bin chng c xy ra trong ni tm mc bn cp nhim khun.
4. IU TR
4.1. iu tr khi cha c kt qu cy mu: iu tr khng sinh sm (ngay sau
cy mu 3 ln) vi mc ch l dit khun tn thng si. Dng khng sinh c
tc dng dit khun, liu cao, phi hp hai khng sinh; nn dng ng tnh
mch; thi gian t 4-6 tun. La chn khng sinh tt nht nn da vo kt qu
cy mu v khng sinh .
4.2. Trong khi ch i kt qu cy mu:
a) Vim ni tm mc nhim khun van t nhin: mt trong 3 la chn sau:
- Ampicilin-sulbactam: 12g/24h, chia 4 ln, tim TM x 4-6 tun v
gentamicin sulfat 3mg/kg/24h chia 3 ln tim TM/TB x 5-14 ngy.
- Vancomycin 30mg/kg/24h chia 2 ln pha vi 200ml NaCl 0,9% hoc
glucose 5% truyn TM t nht l trong 60 pht x 4-6 tun v gentamicin sulfat
3mg/kg/24h chia 3 ln tim TM/TB x 5-14 ngy v ciprofloxacin 1000 mg/24h
ung x 4-6 tun hoc 800mg/24h chia 2 ln truyn TM x 4-6 tun.
Ch :
+ Vancomycin dng cho ngi bnhngi bnh c d ng penicilin.
+ Tr em khng c vt qu liu lng thuc cho mt ngi ln bnh
thng.
- Ampicilin-sulbactam 300mg/kg/24h chia 4-6 ln tim TM v gentamicin
sulfat 3mg/kg/24h chia 3 ln tim TM/TB x 5-14 ngy. V vancomycin
40mg/kg/24h chia 2-3 ln truyn TM nh trn. V ciprofloxacin 20-30mg/24h
chia 2 ln truyn TM hoc ung.
b) Vim ni tm mc nhim khun van nhn to xy ra < 1 nm sau phu thut
thay van tim:
- Ngi ln: Phi hp 4 loi khng sinh sau:
+ Vancomycin 30mg/kg/24h chia 2 ln truyn TM nh trn x 6 tun.
+ Gentamicin sulfat 3mg/kg/24h chia 3 ln tim TM/TB x 2 tun.
B Y t | VIM NI TM MC NHIM KHUN 156
Chng IV.
Nhim khun da v m mm
B Y t | 159
B Y t | NHT 160
NHT
1. NH NGHA
- Nht (Furuncle) l tnh trng vim cp tnh gy hoi t nang lng v t
chc xung quanh.
- Bnh thng gp v ma h, nam nhiu hn n. Mi la tui u c th
mc bnh, tuy nhin bnh thng gp hn tr em.
2. NGUYN NHN
- Nguyn nhn gy bnh l t cu vng (S. aureus). Bnh thng vi khun
ny sng k sinh trn da nht l cc nang lng cc np gp nh rnh mi m,
rnh lin mng hoc cc hc t nhin nh l mi. Khi cc nang lng b tn
thng kt hp vi nhng iu kin thun li nh tnh trng min dch km, suy
dinh dng, ngi bnhngi bnh mc bnh tiu ng vi khun pht trin
v gy bnh.
3. TRIU CHNG
a) Lm sng
- Biu hin ban u l sn nh, mu nang lng sng n, chc, ty .
Sau 2 ngy n 3 ngy, tn thng lan rng ha m to thnh p xe gia
hnh thnh ngi m. au nhc l triu chng c nng thng gp nht l cc
v tr mi, vnh tai, i khi lm cho tr quy khc nhiu. V tr thng gp l
u, mt, c, lng, mng v chn, tay. S lng tn thng c th t hoc nhiu,
km theo cc triu chng ton thn nh st, mt mi, hi chng nhim khun.
- Bnh c th khi nhng c th ko di thnh nhiu t lin tip.
- Bin chng nhim khun huyt c th gp nht l nhng ngi
bnhngi bnh suy dinh dng. Nht vng mi trn, m c th dn n vim
tnh mch xoang hang v nhim khun huyt nng.
- Nht cm cn gi l nht by hay hu bi l tnh trng nhim khun cp
tnh da gm mt s nht xp thnh m. Bnh thng gp nhng ngi b
suy dinh dng, gim min dch hoc mc cc bnh mn tnh nh tiu ng,
hen ph qun, lao phi.
- Chn on ch yu da vo lm sng. giai on sm cn chn on
phn bit vi vim nang lng, Herpes da lan ta, trng c v vim tuyn m hi
m.
b) Cn lm sng
- Tng bch cu trong mu ngoi vi.
- Mu lng tng.
- Procalcitonin c th tng, nht l nhng ngi bnhngi bnh c
nhiu tn thng.
B Y t | NHT 161
B Y t | NHT 163
+ M Neomycin, bi 2- 3 ln/ngy.
+ Kem Silver sulfadiazine 1%, bi 1-2 ln/ngy.
+ M mupirocin 2% bi 3 ln/ngy.
+ Erythromycin 1-2 ln/ngy.
+ Clindamycin 1-2 ln/ngy.
Bi thuc ln tn thng sau khi st khun, thi gian iu tr t 7-10
ngy.
e) Trng hp nng cn phi hp iu tr ti ch kt hp vi ton thn bng
mt trong cc khng sinh sau:
- Penicilin M (cloxacilin) 2g/ngy.
- Amoxicilin-clavulanat:
+ Tr em 80mg/kg/ngy chia 3 ln.
+ Ngi ln 1,5-2 g/ngy chia 2 ln.
- Roxithromycin vin 150mg:
+ Tr em 5-8mg/kg/ngy chia 2 ln.
+ Ngi ln 2 vin/ngy chia 2 ln.
- Azithromycin 500mg ngy u tin sau 250mg/ngy x 4 ngy.
- Pristinamycin:
+ Tr em 50mg/kg/ngy chia 2 ln.
+ Ngi ln 2-3g/ngy chia 2 ln.
- Acid fucidic vin 250mg:
+ Tr em liu 30-50mg/kg/ngy chia 2 ln.
+ Ngi ln 1-1,5 g/ngy chia 2 ln.
- Thi gian iu tr t 7- 10 ngy.
5. PHNG BNH
- V sinh c nhn.
- Trnh cc yu t thun li nh mi trng nng m, cc ha cht du
m.
- iu tr sm khi c tn thng da.
- Trng hp ti pht cn lu v sinh tt loi b cc vi khun trn da
nh vng rnh mi m, rnh lin mng
VIM M BO
1. NH NGHA
Vim m bo (Cellulitis) l tnh trng vim khu tr hoc lan ta do nhim
khun cp tnh, bn cp hoc mn tnh t chc lin kt ca da.
2. NGUYN NHN
- Nguyn nhn gy bnh thng do lin cu nhm A. T cu vng c th
gy vim m bo n thun hay kt hp vi lin cu.
- Mt s vi khun khc cng c th l nguyn nhn gy bnh nh
S. pneumoniae, H. influenzae. Vim m t bo do A. hydrophilia c th ly
nhim t nc hoc t. P. aeruginosa, Camylobacter, V. alginolyticus,
P. multocida cng c bo co l nguyn nhn gy bnh nhng rt him
gp.
3. TRIU CHNG
a) Lm sng
- Cc triu chng lm sng thng xut hin t ngt. Mt vng da ca
c th tr nn sng, nng, v au, gii hn khng r c tnh cht lan ta.
Gia tn thng c th c bng nc, xut huyt. Ngi bnhNgi bnh c
biu hin cc triu chng ton thn nh st, mt mi. Cc biu hin ny gim
nhanh chng khi c iu tr.
- Trng hp nng c th c hoi t, p xe di da, vim c, cn c,
nhim khun huyt v nhng nhim khun nng khc c th xy ra, nht l
nhng ngi suy gim min dch, mc bnh tiu ng hoc tr em.
- Cng chn l v tr thng gp nht. Sang chn nh ngay c nhng tn
thng nng, b mt, hoc lot, vim k u l ca ng vi khun thm nhp
vo c th v gy bnh.
- vng mt, bnh thng xy ra sau sang chn ti ch. Tuy nhin mt
s trng hp vi khun gy bnh t vim xoang. Trng hp vim m t bo
quanh mt, ngoi nhng biu hin da, ngi bnhngi bnh c th b lit
nhn cu, mt th lc, tc tnh mch xoang hang, p xe quanh mt, p xe no
hoc vim no. Vim m t bo vng mt tr nh, thng kt hp vi vim tai
gia cng bn do H. influenzae nhm B. Ngi bnhNgi bnh thng c biu
hin ton thn mt mi, da vng m, quanh mt sng n, chc mu tm.
- Nhng trng hp ti pht nhiu ln, cc triu chng ban u khng th
hin r v gy ra tnh trng tn thng bch mch lu di gy hin tng ph
bch mch v suy tnh mch.
- Vim m t bo c bit chi di cn lu chn on phn bit vi
vim tc tnh mch su: Siu m Doppler hoc chp mch gip chn on phn
B Y t | VIM M BO 168
B Y t | 170
B Y t | 171
B Y t | 172
+ Tiu chy do E. coli sinh c t rut (ETEC): i ngoi phn lng khng
nhy mu, khng st. Bnh thng t khi.
+ Tiu chy do E. coli (EIEC, EPEC, EHEC): st, au qun bng, mt
rn, phn lng c th ln nhy mu (hi chng l).
- Tiu chy do Salmonella: Tiu chy, st cao, nn v au bng.
c) Xt nghim:
- Cng thc mu: S lng bch cu tng hay gim ty cn nguyn.
- Xt nghim sinh ho mu: nh gi ri lon in gii, suy thn km
theo.
- Xt nghim phn:
+ Soi phn: Tm xem c hng cu, bch cu, cc n bo k sinh, nm,
trng k sinh trng...
+ Cy phn tm vi khun gy bnh.
4. IU TR
4.1. Nguyn tc:
- iu tr khng sinh ty cn nguyn. Cn d on cn nguyn v iu tr
ngay. iu chnh li khng sinh nu cn sau khi c kt qu cy phn.
- nh gi tnh trng mt nc v bi ph nc in gii.
- iu tr triu chng.
4.2. S dng khng sinh trong tiu chy nhim khun do mt s cn nguyn
thng gp:
- Khng sinh thng hiu qu trong trng hp tiu chy xm nhp .
- Thng dng khng sinh ng ung. Khng sinh ng truyn ch
dng trong trng hp nng c nhim khun ton thn.
- Liu dng khng sinh y ch yu p dng cho ngi ln. i vi tr
em, tham kho thm Hng dn x tr tiu chy tr em (B Y t 2009).
a) Tiu chy do E. coli (ETEC, EHEC), Campylobacter, Yersinia, Salmonella,
Vibrio spp.
- Thuc u tin: khng sinh nhm quinolon (ung hoc truyn) x 5 ngy
(ngi >12 tui) :
+ Ciprofloxacin 0,5 g x 2 ln/ngy.
+ hoc norfloxacin 0,4 g x 2 ln/ngy.
- Thuc thay th:
+ Ceftriaxon ng tnh mch (TM) 50-100 mg/kg/ngy x 5 ngy.
B Y t | TIU CHY DO VI KHUN 174
EHEC
EPEC
ETEC
1.Cunha, B.A(2006), Antimicrobial therapy 2006, Philadelphia, PA: Saunders. xiv, p. [1049]1289.
2.Kasper, D.L., A.S. Fauci, and T.R. Harrison (2010), Harrison's infectious diseases, 1294 p.,
McGraw-Hill Medical, New York.
3.Mandell, G.L., J.E. Bennett, and R. Dolin (2010), Mandell, Douglas, and Bennett's
principles and practice of infectious diseases. 7th ed2010, Philadelphia, PA: Churchill
Livingstone/Elsevier.
4.Papadakis, M., et al.(2013), Current Medical Diagnosis and Treatment 2013, McGraw-Hill
Medical Publishing Division McGraw-Hill Companies, The Distributor: New York
5. Antibiotic Essentials 2011.
4. IU TR
a) Nguyn tc
- Cn bt buc lm xt nghim H.p trc.
- S dng khng sinh ng ung, khng dng khng sinh ng tim.
- Phi iu tr phi hp thuc gim tit acid vi t nht 2 loi khng sinh.
- Khng dng mt loi khng sinh n thun.
b) Phc la chn u tin: Ch ni khng clarithromycin < 20%. Khi dng
14 ngy hiu qu hn 7 ngy:
- Thuc c ch bm proton (PPI) v 2 trong 3 khng sinh:
+ Clarithromycin 500 mg x 2 ln/ngy.
+ Amoxicilin 1000 mg x 2 ln/ngy.
+ Metronidazol 500 mg x 2 ln/ngy.
c) Phc 4 thuc thay th: Khi c khng khng sinh hoc ti vng c t l
khng clarithromycin trn 20%, dng 14 ngy bao gm:
- Thuc c ch bm proton (PPI).
- Colloidal bismuth subsalicylat/subcitrat 120 mg x 4 ln/ngy.
- Hoc thay PPI+ bismuth bng RBC (ranitidin bismuth citrat).
- Metronidazol 500 mg x 2 ln/ngy.
- Tetracyclin 1000 mg x 2 ln/ngy.
Nu khng c Bismuth c th dng phc k tip hoc phc 3 khng sinh:
- Phc 3 khng sinh dng 14 ngy:
+ PPI.
+ Clarithromycin 500 mg x 2 ln/ngy.
+ Amoxicilin 1000 mg x 2 ln/ngy.
+ Metronidazol 500 mg x 2 ln/ngy.
- Phc k tip:
+ 5 - 7 ngy PPI + amoxicilin 500mg x 2 vin x 2 ln/ngy.
+ Tip theo PPI + clarithromycin + metronidazol hoc tinidazol trong 5 7 ngy.
Trong trng hp H.p vn khng thuc c th dng phc thay th sau dng
14 ngy:
- PPI.
- Levofloxacin 500mg x 1 vin x 1 ln/ngy.
B Y t | DIT HELICOBACTER PYLORI TRONG BNH L 179
D DY T TRNG
Heliobacter pylori
PPI
RBC
NHIM KHUN NG MT
1. I CNG
Nhim khun ng mt (biliary infection) l tnh trng vim ng mt
do vi khun, thng gp ngi c tc nghn ng mt do cc nguyn nhn
nh: si ng mt, ung th ng mt, u u ty, ; sau ni mt rut.
2. NGUYN NHN
a) Nguyn nhn
- Hay gp l cc vi khun Gram-m t ng rut nh: Escherichia coli,
Klebsiella, Enterococcus, Enterobacter. Cc vi khun Gram-m khc nh:
Streptococcus, Pseudomonas, v Proteus t gp hn.
- Cc vi khun k kh: Clostridium v Bacteroides, thng gp vi khun
k kh khi nhim khun ng mt nng. Trong trng hp nhim khun ng
mt nng thng nhim nhiu loi vi khun trong c vi khun k kh.
- Nhim khun ng mt ti cng ng hay gp l do E.coli, Klebsiella
v Enterococcus. Nhim khun ng mt ti bnh vin thng l do
Staphylococcus aureus khng methicilin, Enterococcus khng vancomycin v
Pseudomonas.
b) Cc yu t thun li
Cc yu t gy tc nghn ng mt:
- Cc nguyn nhn lnh tnh: Si mt, giun chui ng mt.
- Cc nguyn nhn c tnh: Ung th ng mt, u bng vater, u u ty.
- Sau ni mt rut.
3. TRIU CHNG
a) Lm sng
- Biu hin chnh l cc triu chng: au, st v vng da.
- Tin s: C bnh l gy tc nghn ng mt nh: si mt, giun chui
ng mt
- St cao 39-40oC, c nhng cn rt run.
- Vng da tng dn t t nhng cng c th vng da tng rt nhanh trong
trng hp tc mt cp nh kt si bng Vater.
- au m vng h sn phi, c th c cn au qun mt.
- Gan to, mm, au tc khi khm.
- Ri lon tiu ha: Chn n, ri lon phn.
- C th c ti mt to.
B Y t | NHIM KHUN NG MT 181
- Trng hp nng c sc, tinh thn chm chp, ngi bnhngi bnh c
th biu hin l ln.
b) Cn lm sng
- Xt nghim mu:
+ Biu hin vim nhim: Bch cu tng, ch yu l bch cu a nhn
trung tnh; mu lng tng, CRP tng, Pro Calcitonin tng.
+ mt: Tng bilirubin, ch yu l bilirubin trc tip.
+ C th biu hin suy gan, suy thn trong trng hp nhim khun nng.
+ Cy mu c th thy vi khun do nhim khun huyt.
- Chn on hnh nh gip thm d hnh thi cng nh nguyn nhn gy
tc mt: Siu m, C.T, MRI, ni soi siu m v ni soi chp mt ty ngc dng
(ERCP). Cho thy c gin ng mt trong v ngoi gan, c th thy kh trong
ng mt, nguyn nhn gy tc mt. Ngy nay, ni soi chp mt ty ngc
dng t dng chn on, m ch yu dng iu tr nguyn nhn gy tc
mt.
c) Mc nng
- Mc nng ca nhim khun ng mt:
Bng II.14. Phn loi mc nng ca nhim khun ng mt
Mc
Nh (I)
Nng (III)
Khng
Khng
p ng iu tr ban u
Khng
Khng
Cc cephalosporin th h 3,4
Monobactam
Nu c nhim khun k kh dng mt trong 4 loi khng sinh trn + metronidazol TM 500
mg/8 gi.
La chn s 2
Fluoroquinolon
P XE GAN DO VI KHUN
1. I CNG
p xe gan do vi khun (pyogenic liver abscess) l tn thng m ti gan
gy ra do vi khun. Bnh thng gp ngi c bnh l ng mt t trc
hoc trn ngi bnhngi bnh b bnh mn tnh nh i tho ng, ang
dng cc thuc gim min dch hoc bnh c tnh.
2. NGUYN NHN
a) ng dn ti p xe gan
- Bnh l ng mt: Hay gp nht, thng do tc mt v gy vim
ng mt dn ti p xe gan.
- ng tnh mch ca: T cc vim nhim ti vng bng nh vim ti
tha, vim rut tha, vim m b thn. Vi khun theo ng tnh mch ca gy
p xe gan.
- ng ng mch gan: Vi khun t mu n do nhim khun ton thn
nh vim ni tm mc, vim ng tit niu.
- Khng r ng vo: Khong 50% s ngi bnhngi bnh khng r
ng vo, thng gp p xe gan ngi b i tho ng hoc c bnh c
tnh.
b) Cc loi vi khun
- Eschericha coli.
- Klebsiella pneumoniae.
- Cc chng Bacteroides.
- Cc chng Streptococcus.
- Hay gp nht l E. coli v K. pneumoniae.
3. TRIU CHNG
a) Lm sng
- au h sn phi au m , c th c cn au qun mt nh trong si
ng mt.
- St cao 39- 40o, c rt run.
- Gan to mm v au khi thm khm.
- Vng da khi c bnh l gy tc mt.
- C th c a lng, mt mi chn n.
b) Cn lm sng
- Xt nghim:
B Y t | P XE GAN DO VI KHUN 185
+ Biu hin vim nhim: Bch cu tng c bit bch cu a nhn trung
tnh, mu lng tng, CPR tng, Pro Calcitonin tng.
+ Cy m t p xe c th thy vi khun.
+ Cy mu c th thy vi khun trong trng hp c nhim khun huyt.
- Chn on hnh nh: Trn siu m l khi gim m hoc hn hp m
trong trng hp cha ha m hon ton. C.T hoc cng hng t c hnh nh
p xe. Ngoi ra c th pht hin thy nguyn nhn gy tc mt nh si mt, giun
trong ng mt.
4. IU TR BNG KHNG SINH
a) Nguyn tc
- Tt nht l la chn theo khng sinh .
- Trong khi ch i nn dng khng sinh c hot ph rng, nu ngi
bnhngi bnh nng s dng ngay khng sinh c tc dng mnh v c hot ph
rng nh carbapenem.
- Khng sinh cephalosporin th h ba v aminoglycosid c tc dng tt
vi cc vi khun Gram-m.
- Khng sinh metronidazol c tc dng tt vi vi khun k kh.
- Thi gian dng khng sinh t 2 - 4 tun.
- Cn chc ht p xe nui cy vi khun, chc ht m hoc dn lu
khi p xe ln trn 5 cm. Nu chc ht m v dn lu tht bi, tin hnh phu
thut dn lu.
- Nu c tc nghn ng mt phi m bo lu thng ng mt bng
dn lu qua da, t stent qua chp mt ty ngc dng hoc phu thut.
- Kim sot tt ng huyt nu c i tho ng.
- iu tr vi khun nguyn pht nu c.
b) C th
Cc khng sinh c s dng trong p xe gan do vi khun c th hin
Bng II.16.
Aminoglycosid
Cc cephalosporin
th h 3,4
Monobactam
Nu c nhim khun k kh dng mt trong 4 loi khng sinh trn + metronidazol TM 500
mg/8 gi.
La chn s 2
Fluoroquinolon
Ty trn C.T
im s
Mc hoi t
ca ty
im s
Bnh thng
Khng hoi t
Hoi t 30%
Ty to v c dch quanh ty
Hoi t 30-50%
C t hai dch tr ln
VIM PHC MC
1. I CNG
- Vim phc mc (VPM) l tnh trng vim ca phc mc do vi khun gy
nn.
- Vim phc mc c th khu tr hoc ton th.
- Nguyn nhn thng do nhim khun t ng tiu ha, chn thng bng
hoc l vim phc mc tin pht.
2. PHN LOI V CN NGUYN GY BNH
2.1. Vim phc mc tin pht
- L vim phc mc lan ta do vi khun khng do v cc tng rng trong
bng, bao gm cc vim phc mc t pht tr em, ngi ln, ngi mc
bnh lao, x gan.
- Cn nguyn vi khun thng gp l E. coli, ph cu hoc lin cu.
tr em, vim phc mc t pht do vi khun c th l bin chng ca hi chng
thn h v cn nguyn thng gp l ph cu.
2.2 . Vim phc mc th pht
- L vim phc mc kh tr hoc lan ta xy ra sau thng, v hoc chn
thng cc tng trong bng, bao gm: thng d dy rut, hoi t thnh rut,
VPM tiu khung, bc ming ni, ch khu sau phu thut, sau chn thng kn
hoc vt thng h ca bng.
- Cn nguyn vi khun thng gp l E. coli, Klebsiella pneumoniae, B.
flagilis, ngoi ra c th gp cc chng Streptococcus, Enterococcus, hoc
Clostridium.
2.3. Vim phc mc th ba
- L vim phc mc tin pht hoc th pht c iu tr nhng vn
tip tc tn ti cc triu chng hoc ti xut hin li cc triu chng ca vim
phc mc.
- Thng hay xy ra trn c a ri lon p ng min dch ca c th.
- Cn nguyn gy vim phc mc th pht l trc khun m xanh, vi
khun Gram-m ng rut khng thuc, c th l nm C. albicans.
2.4. Vim phc mc sau thm phn phc mc
- Cn nguyn hay gp nht l t cu khng methicilin, trc khun m xanh.
3. LM SNG V XT NGHIM
3.1. Lm sng
Bng II.18. Liu lng v cch dng khng sinh iu tr vim phc mc
Tn khng sinh
Ciprofloxacin
Levofloxacin
Moxifloxacin
Ceftriaxon
Cefotaxim
Ertapenem
Piperacilin-tazobactam
Truyn TM 4,5g, mi 8h
Imipenem- cilastatin
Meropenem
Tim/truyn TM 1g, mi 8h
Doripenem
Metronidazol
Chng VI.
Nhim khun c xng khp
B Y t | 197
B Y t | 198
b) Cn lm sng
- Xt nghim t bo mu ngoi vi: Thng c s lng bch cu tng cao,
t l bch cu trung tnh tng; tc mu lng, CRP (protein C phn ng)
thng tng.
- Procalcitonin thng tng khi c nhim khun nng, c bit l nhim
khun huyt.
- Xt nghim dch khp: Ly bnh phm m t bo, soi ti, nhum
Gram, nui cy dch khp tm vi khun gy bnh.
- Cy mu tm vi khun gy bnh.
- Chn on hnh nh: Chp X-quang quy c, siu m khp, chp ct
lp vi tnh, chp cng hng t, chp x hnh xng ty trng hp.
c) Chn on xc nh
Khi c t nht 1 trong 2 tiu chun:
- Xt nghim dch khp c m (bch cu a nhn trung tnh thoi ha
hoc t bo dch khp cao trn 100.000/ml vi trn 80% l bch cu a nhn
trung tnh) hoc tm thy vi khun qua soi ti, nhum Gram.
- Cy mu hoc dch khp dng tnh vi vi khun.
Kt hp vi t nht 1 trong 2 tiu chun:
- Lm sng vim khp in hnh.
- Du hiu X-quang vim khp in hnh: hnh nh soi gng.
4. IU TR
4.1. Nguyn tc:
- Chn on v ch nh khng sinh sm; thc hin ngay cy mu, cy
dch khp, soi ti dch nhum Gram tm vi khun trc khi cho khng sinh.
- La chn khng sinh ban u da vo kinh nghim, tnh hnh khng
khng sinh ti cng ng, bnh vin; kt qu nhum Gram (m hay dng), la
tui, ng ly nhim d on vi khun gy bnh.
- Cn dng t nht mt thuc khng sinh ng tnh mch. Thi gian iu
tr khng sinh thng t 4-6 tun.
- Dn lu m khp, bt ng khp, can thip ngoi khoa khi cn thit.
4.2 iu tr c th
4.2.1 iu tr khng sinh
a) Trng hp vim khp nhim khun khng do lu cu:
- Khi cha c kt qu cy mu, dch: Dng ngay khng sinh oxacilin hoc
nafcilin 2g ng tnh mch (TM) mi 6 gi mt ln (8g/ngy), hoc
clindamycin 2,4g TM/ngy chia 4 ln.
- Trng hp soi ti nhum Gram dch khp pht hin cu khun Gramdng: Oxacilin hoc nafcilin 2g mi 6 gi mt ln (8g/ngy), hoc clindamycin
2,4g TM/ngy chia 4 ln. Nu ti cng ng hay bnh vin nghi ng nhim t
cu vng khng khng sinh: Vancomycin 2g/ngy chia hai ln pha truyn tnh
mch hoc daptomycin 4-6 mg/kg cn nng ng TM 1 ln/ngy hoc
teicoplanin 6mg/kg 1ln/ngy trong nhng ngy u, sau gim cn 3mg/kg
TM hoc TB.
- Trng hp nghi nhim trc khun m xanh cn phi hp ceftazidim
2g/ln x 2-3 ln/ ngy vi khng sinh nhm aminoglycosid (nh gentamicin 5
mg/kg/ngy hoc amikacin 15mg/kg/ngy tim bp hoc pha truyn TM
1ln/ngy).
- Trng hp cy mu, dch khp dng tnh th iu tr theo khng sinh
(hoc tip tc duy tr khng sinh theo nh iu tr ban u nu thy p ng
tt):
+ Nhim khun do t cu vng nhy cm vi khng sinh th dng
oxacilin, hoc nafcilin, hoc clindamycin (liu nh trn); t cu vng khng
methicilin th dng vancomycin, hoc daptomycin, hoc teicoplanin (liu nh
trn) trong 4 tun.
+ Nhim khun do ph cu hoc lin cu do vi khun nhy vi penicilin:
Penicilin G 2 triu n v TM mi 4 h trong 2 tun.
+ Nhim khun do H. influenzae v S. pneumoniae tit beta-lactamase:
Ceftriaxon 1-2 g mt ln /ngy, hoc cefotaxim 1 g 3 ln/ngy trong 2 tun.
+ Phn ln cc nhim vi khun Gram-m ng rut: Khng sinh
cephalosporin th h 3 hoc 4 ng TM trong 3-4 tun, hoc thuc nhm
fluoroquinolon nh levofloxacin 500mg ng tnh mch hoc ung mi 24h.
+ Nhim khun do trc khun m xanh: Phi hp khng sinh nhm
aminoglycosid vi ceftazidim 1g mi 8 h (hoc vi mezlocilin 3g tnh mch mi
4h). Thi gian dng trong khong 2 tun, sau dng khng sinh nhm
fluoroquinolon nh ciprofloxacin 500 mg ung 2 ln/ngy n c hoc phi
hp vi ceftazidim.
b) iu tr vim khp do lu cu
- Trng hp lu cu nhy cm penicilin c th dng amoxicilin ung
1500 mg/ngy chia 3 ln, hoc dng ciprofloxacin ung 1000 mg chia hai
ln/ngy (ngoi tr) trong 7 ngy.
- Trng hp nghi ng lu cu khng penicilin: Khi u ceftriaxon 1g
tim bp hoc tim tnh mch mi 24 gi trong 7 ngy, sau chuyn dng
B Y t | VIM KHP NHIM KHUN 201
thng trn X-quang thng ch r khi nhim khun c t 10-14 ngy. Xquang bnh thng khng loi tr chn on vim ty xng.
- X hnh xng: C ch trong chn on sm vim xng ty cp.
Thng lm x hnh xng ba pha. Thuc s dng l Technecium-99, c tch
ly trong v tr gia tng lu lng mu v hnh thnh xng phn ng.
- Chp ct lp vi tnh (CT scan) v chp cng hng t (MRI) rt c gi
tr trong chn on v nh gi ca vim ty xng.
- nh danh vi khun:
Sinh thit m xng vim l tiu chun vng chn on vim ty
xng v la chn mt loi khng sinh ph hp.
Cn thit phi cy mu, cy m hoc cc vt cy ghp vo c th v
cn nui cy trn mi trng k kh.
4. IU TR
4.1. Nguyn tc chung
Chn on bnh sm, dng khng sinh (liu cao, ng tnh mch, kt
hp khng sinh, ko di t nht 6 tun), cn cy mu hoc m nh danh vi
khun trc khi dng khng sinh, dn lu m v t chc hoi t, loi b cc vt
cy ghp vo c th.
4.2. iu tr c th
4.2.1. Khng sinh
a) Giai on u: La chn khng sinh da theo kinh nghim
- T cu vng (Staphylococcus aureus) l nguyn nhn hng u:
+ T cu vng nhy cm vi methicilin (MSSA): Nafcilin hoc oxacilin
2g tim mch mi 6 gi 1 ln (8g/ngy).
+ T cu vng khng methicilin (MRSA): Vancomycin 1g pha truyn tnh
mch mi 12 gi, hoc daptomycin 4-6 mg/kg cn nng ng TM 1 ln/ngy,
hoc teicoplanin 6mg/kg 1ln/ngy trong nhng ngy u, sau gim cn
3mg/kg TM hoc TB; hoc linezolid 600mg mi 12 gi tim mch, hoc ung
rifampicin 300mg ung 2 ln/ngy.
+ Nu d ng hoc khng p ng cc khng sinh trn: Clindamycin
6mg/kg 600-900mg tim mch mi 8 gi, hoc levofloxacin 750mg ung mi
24 gi rifampicin 300mg ung 2 ln/ngy, hoc acid fucidic 500mg tim mch
mi 8 gi kt hp vi rifampicin 300mg ung 2 ln/ngy.
- Trng hp do trc khun m xanh (P. aegurinosa): Cn phi hp ceftazidim
2g/ln x 2-3 ln/ ngy (hoc vi mezlocilin 3g tnh mch mi 4h) vi khng sinh
nhm aminoglycosid (nh gentamicin 5 mg/kg/ngy hoc amikacin
15mg/kg/ngy tim bp hoc pha truyn TM 1ln/ngy). Thi gian dng trong
khong 2 tun, sau dng khng sinh nhm fluoroquinolon nh ciprofloxacin
500 mg ung 2 ln/ngy n c hoc phi hp vi ceftazidim liu nh trn.
B Y t | VIM XNG TY NHIM KHUN 204
+ Cy mu c th dng tnh.
+ Chc ht m: Chc m hoc di hng dn ca siu m ly m xt
nghim:
T bo hc: Thy nhiu bch cu a nhn trung tnh thoi ha (t bo
m).
Cc xt nghim vi sinh: Soi ti, nhum Gram, nui cy, BK, PCR lao.
C th phn lp c vi khun qua soi trc tip hoc nui cy m.
- Chn on hnh nh
+ Siu m c: C th thy cc hnh nh c tng th tch, mt cu trc si
c, cc c cu trc siu m hn hp, p xe c.
+ X-quang quy c: Tn thng cc c chi: Chp chi c c tn thng
c th thy hnh nh vim xng mng xng kt hp. Tn thng c tht lng
chu: Vng ct sng tht lng c th thy r bng c tht lng chu, bng kh.
Hnh nh canxi ha ti vng p xe gi vi khun lao.
+ Chp ct lp vi tnh: c ch nh vi c tht lng chu cho php pht
hin sm tn thng vi nhy cao. Nu thy kh ti vng c, tc l c p
xe.
+ Cng hng t: Ch nh trong trng hp vim hoc p xe c chi
hoc c tht lng chu: Gim tn hiu trn T1,tng tn hiu trn T2 thnh khu
tr trn c.
c) Chn on xc nh
- Da vo lm sng (cc du hiu ti ch v ton thn)
- Xt nghim bilan nhim trng.
- Chn on hnh nh (siu m, chp ct lp vi tnh, hoc chp cng
hng t)
- Nui cy phn lp vi khun.
4. IU TR
a) Nguyn tc iu tr
- Dng khng sinh sm (ngay sau khi lm cc xt nghim vi sinh), liu
cao, ng tnh mch (sau c th chuyn ng ung), thi gian (4-6 tun).
La chn khng sinh da theo khng sinh .
- Khi cha c kt qu vi sinh, la chn khng sinh theo kinh nghim da
trn bnh cnh lm sng:
+ Khng sinh s dng u tin nn hng ti t cu vng. Nu nghi ng
t cu vng khng methicilin, xem xt s dng vancomycin.
B Y t | 215
B Y t | 216
+ Gentamicin tnh mch 4 6mg/kg cho liu u tin, liu tip theo da
vo thanh thi ca thn.
+ Lincomycin 600mg tnh mch mi 8 gi.
3.3. Ngoi khoa
- Loi b nhim khun. Khi nhit tr li bnh thng, tin hnh ct t
cung bn phn.
- i vi vim phc mc ton th: M lau ra bng, ct t cung bn
phn v dn lu bng.
4. D PHNG
- Ch cng tc v khun khi thm khm v th thut iu tr tch cc
cc nhim khun hu sn.
TI LIU THAM KHO
1. Therapeutic guidelines: Antibiotic. Therapeutic Guidelines Limited 2010. version14.
2. Hng dn iu tr tp II BYT 2006.
3. Trng i hc Y H ni: Bi ging sn ph khoa. NXB y hc 2002.
4. David E. Soper. Early recognition of serious infections in obstetrics and gynecology.
Clinical obstetrics and Gynecology. Vol 55, No 4, p858-63.
+ K thut Elisa.
+ Nui cy l tiu chun vng chn on Chlamydia.
- i vi N. gonorrhoeae:
+ Soi ti v nhum Gram thy song cu hnh ht c ph Gram-m nm
trong t bo bch cu.
+ Trng hp mn tnh khng tm thy song cu bng soi nhum th nui
cy trong mi trng Thaye Martin.
- i vi M. genitalium:
+ Chn on kh hn.
+ Bnh phm: dch thnh m o v nc tiu u dng.
+ Phng php chn on bng PCR.
d) iu tr:
- Nguyn nhn do Chlamydia:
+ Doxycyclin 100mg /12h x 10 ngy.
+ Hoc azithromycin 1g liu duy nht.
- Nguyn nhn do N. gonorrhoeae:
+ Ceftriaxon 500mg tnh mch liu duy nht.
+ Phi hp vi mt trong hai loi sau:
Hoc azithomycin 1g ung liu duy nht.
Hoc doxycyclin 100mg/12h x 10 ngy.
- Nguyn nhn do M. genitalium:
+ Azithromycin 250mg/24h x 5 ngy.
+ Hoc doxycyclin 100mg/12h x 7 ngy.
+ Hoc khi iu tr nh trn khng khi hn: moxifloxacin 400mg/24h x
10 ngy.
TI LIU THAM KHO
1. Therapeutic guidelines: Antibiotic. Therapeutic Guidelines Limited 2010. version14.
2. Hng dn iu tr tp II BYT 2006.
3. Trng i hc Y H ni: Bi ging sn ph khoa. NXB y hc 2002.
phn ng min dch hunh quang c trit ht. F.T.Aabs (Fluorescen Treponema
Antibody Absortion's Test), T.P.H.A (Treponema Pallidum Hemagglutination's
Assay).
4. IU TR
4.1. Nguyn tc
- iu tr sm v liu khi bnh, ngn chn ly lan, phng ti
pht v di chng.
- iu tr ng thi cho c bn tnh ca ngi bnhngi bnh.
- Penicilin l thuc c la chn, cho n nay cha c trng hp no
xon khun giang mai khng penicilin.
4.2. Penicilin
4.2.1 C ch tc dng
- Penicilin c tc dng dit xon khun
- Tc dng dit xon khun ch yu xy ra trong giai on xon khun
sinh sn, phn chia.
- Chu k sinh sn ca xon khun l 30 - 33h/ln. giang mai sm, xon
khun cng sinh sn v pht trin mnh th tc dng ca penicilin cng cao.
Ngc li, giang mai mun, nhp sinh sn v pht trin ca xon khun
chm th dng penicilin cng km hiu qu. V vy, cn ko di thi gian dng
penicilin hn.
- Nng c ch ti thiu l 0,03 v/ml huyt thanh. Nhng nng iu
tr phi l 0,07 - 0,2 v/ml huyt thanh. Nng cao ca penicilin khng c tc
dng dit xon khun m cn c ch s sinh sn ca xon khun nn ch loi
penicilin chm tiu l thch hp nht.
4.2.2 Phc iu tr: Ty theo bnh giang mai mi mc hay mc lu m p
dng phc thch hp.
a) iu tr giang mai I: p dng 1 trong 3 phc theo th t u tin:
- Benzathin penicilin G: 2.400.000 v tim bp su liu duy nht, chia
lm 2, mi bn mng 1.200.000 v.
- Hoc penicilin procain G: Tng liu 15.000.000 v. Mi ngy tim
1.000.000 v, chia 2 ln, sng 500.000 v, chiu 500.000 v.
- Hoc benzyl penicilin G ha tan trong nc. Tng liu 30.000.000 v.
Ngy tim 1.000.000 v chia lm nhiu ln c 2 - 3h tim 1 ln, mi ln
100.000 - 150.000 v.
b) iu tr giang mai II s pht, giang mai kn sm: p dng 1 trong 3 phc
theo th t u tin:
RPR
VDRL
TPI
FTA
FTAabs
TPHA
n v
TI LIU THAM KHO
4. Phm Vn Hin, Trnh Qun Hun, Nguyn Duy Hng v cs.(2003), X tr cc bnh ly
truyn qua ng tnh dc, nh xut bn y hc.
5. Sexually Transmitted Diseases guideline (2010) CDC Vol. 59/N0 RR-12, pp. 26-40
BNH LU
1. I CNG
- Bnh lu (Gonorrhea) l bnh ly truyn qua ng tnh dc thng
gp. Bnh do song cu khun Gram-m c tn l Neisseria gonorrhoeae gy
nn.
- Nhng nm gn y bnh lu c xu hng tng. Theo c tnh ca T
chc Y t Th gii (WHO) hng nm trn ton th gii c khong 62 triu ngi
bnhngi bnh lu/390 triu ngi bnhngi bnh mc cc bnh ly truyn
qua ng tnh dc.
- Bnh thng gp ngi tr tui, t l bnh thnh th nhiu hn nng
thn. Biu hin ch yu b phn sinh dc, nhng cng c th cc v tr khc
nh hng, hu mn. Bnh lu nam thng c triu chng, ph n thng
khng c triu chng hoc triu chng khng r rng.
- Bnh c th phi hp vi mt s tc nhn gy vim niu o khc, trong
thng gp nht l Chlamydia trachomatis v cc tc nhn khc nh trng
roi, Ureaplasma, Mycoplasma.
2. NGUYN NHN
a) Tc nhn gy bnh
- Song cu khun lu c Neisser tm ra nm 1879, c tn khoa hc l
Neisseria gonorrhoae. Song cu khun lu c c im:
+ Hnh ht c ph, sp xp thnh tng cp.
+ Bt mu Gram-m nm trong bch cu a nhn.
+ Di khong 1,6, rng 0,8, khong cch gia hai vi khun 0,1.
+ Nui cy trn mi trng thch mu hoc nc bng pht trin nhanh.
Hin nay thng nui cy trn mi trng Thayer-Martin v lm khng sinh .
+ Sc khng yu: ra khi c th ch tn ti mt vi gi.
b) Cch ly truyn
- Hu ht cc trng hp mc lu l do quan h tnh dc vi ngi b
bnh qua ng m o, hu mn v ng ming. Mt s t trng hp c th
mc lu do dng chung chu, khn hoc qua qun o nhim lu cu khun. M
mc lu, nu khng c iu tr c th gy vim kt mc mt do lu cho tr s
sinh khi sinh .
3. TRIU CHNG
3.1. Bnh lu nam gii
a) Lu cp:
B Y t | BNH LU 235
B Y t | BNH LU 236
hu mn. Biu hin lm sng: Ngi bnhNgi bnh mt rn, bun i tin
lin tc, lc u cn c phn sau ch ra cht nhy hoc khng.
- Lu mt: Lu mt tr s sinh thng xut hin sau 1 - 3 ngy. C
th b mt hoc c hai mt. Mt sng n khng m c, c rt nhiu m t mt
chy ra, kt mc, gic mc vim v c th lot. Lu mt ngi ln c th
ly do dng chung khn, chu ra mt vi ngi b nhim lu hoc do chnh
ngi bnhngi bnh gy ra khi i tiu m dnh vo tay ri di ln mt. Biu
hin: vim kt mc, gic mc c m, mt sng n.
3.4. Xt nghim:
- Nhum Gram thy song cu Gram-m trong v ngoi bch cu a nhn
trung tnh.
- Nui cy trn mi trng Thayer- Martin v lm khng sinh .
- PCR (Polymerase Chain Reaction).
- Cn lm cc xt nghim pht hin cc bnh khc phi hp nh nhim
Chlamydia, trng roi, giang mai, nhim HIV.
4. IU TR
4.1. Nguyn tc
- iu tr sm.
- iu tr ng phc .
- iu tr c bn tnh.
- Tun th ch iu tr: Khng quan h tnh dc, khng lm vic nng,
trnh thc khuya, khng ung ru bia v cht kch thch, khng lm th thut
tit niu trong thi gian iu tr.
- iu tr ng thi Chlamydia.
4.2. Phc
a) Lu cp
- S dng khng sinh:
+ Cefixim ung 400mg liu duy nht.
+ Hoc ceftriaxon 250mg tim liu duy nht.
+ Hoc spectinomycin 2g tim bp liu duy nht.
- iu tr ng thi Chlamydia vi cc thuc sau:
+ Azithromycin 1g liu duy nht.
+ Hoc doxycyclin 100mg x 2 ln/ngy x 7 ngy.
+ Hoc tetracyclin 500mg x 4 ln/ngy x 7 ngy.
B Y t | BNH LU 237
B Y t | BNH LU 238
BNH H CAM
1. I CNG
- H cam (Chancroid) l mt bnh nhim khun cp tnh, ly truyn qua
ng tnh dc. Biu hin c trng ca bnh l mt vt lot au ni vi khun
xm nhp, thng l vng sinh dc ngoi v vim hch bn m. Cn nguyn ca
bnh l trc khun Gram-m c tn l Haemophilus ducreyi. Bnh h cam c
ng yu t dch t hc trong ly truyn HIV, lm tng kh nng ly truyn HIV
t 5-9 ln hoc cao hn na.
- Bnh c trn ton cu, nhng gp nhiu cc nc ang pht trin, c
bit chu Phi. Vit Nam hin nay him gp. Nam b bnh nhiu hn n, vim
hch bch huyt cng hay gp nam. Ly truyn t ngi ny sang ngi khc
qua giao hp vi ngi c H. ducreyi vt lot.
2. NGUYN NHN
- Tc nhn gy bnh l trc khun Gram-m c tn l Haemophilus
ducreyi. Bnh ly qua tip xc trc tip, ch yu ly qua quan h tnh dc. Trc
khun h cam c th t ly nhim t thng tn ra vng da nim mc lnh nn
ngi bnhngi bnh thng c nhiu thng tn.
3. TRIU CHNG
a) Lm sng
- Thi gian bnh thng 3-10 ngy v khng c tin triu.
- Nam gii thng i khm cha v vt lot thng au hoc vim au
hch bn. Ph n triu chng thng khng r, biu hin tu thuc v tr sng
kh tr: au khi i tiu, au khi i i tin, chy mu trc trng, au khi giao
hp hoc ra kh h.
- Biu hin u tin l sn mm, xung quanh c qung . Sau khong 2448h tin trin thnh mn m ri trt v lot. Vt lot thng mm v au. B
vt lot r, si mn v khng cng. Nn vt lot ph bi dch tit m hoi t
mu vng hoc xm, di l t chc ht m, d chy mu. Thng c ph n
xung quanh tn thng. S lng vt lot c th ch c mt nhng thng nhiu
do t ly nhim, n thng b nhiu vt lot hn nam. Kch thc cc vt lot t
2-10mm, cc vt lot c th lin kt thnh mt vt lot ln hoc thnh hnh rn
b.
- Kh tr: Nam hay b vt lot bao qui u, rnh qui u, thn dng
vt. N c chc m h, mi ln, mi nh, tin nh m o, m vt, c t
cung, hu mn Cc v tr ngoi sinh dc nh v, ngn tay, i, nim mc
ming cng c th gp.
- Hch bn vim au thng mt bn v 1-2 tun sau khi thng tn
u tin xut hin. Hch sng , au, nng ri dn dn tr nn mm lng
B Y t | BNH H CAM 239
B Y t | 243
B Y t | 244
(Tuyn Zeis)
(Tuyn sn mi)
+ Tim tnh mch: thng tim tnh mch khng sinh iu tr vim ni nhn.
[2]
2. CC KHNG SINH THNG DNG TRONG NHN KHOA
2.1. Khng sinh nhm Beta-lactam
- Kh nng thm qua hng ro mu mt km. Tuy nhin, kh nng thm
tng mt b vim v khi ung cng probenecid.
- Khng sinh penicilin:
+ Ph tc dng: Ph khng khun rng, nhng hiu qu tt nht trn vi
khun Gram dng.
+ Khng bn vng trong dng dung dch v kh thm qua gic mc nn
khng c pha ch tra mt.
+ Hay gy d ng nn hin nay t dng. [2]
- Khng sinh cephalosporin:
+ Ph tc dng: tng t penicilin.
+ Khng c ch phm tra mt nhng cephalosporin c th c dng
iu tr lot gic mc do vi khun di dng thuc tra mt c pha ch theo
n (0,5%) t thuc tim khi cn thit.
+ Cefotaxim thm qua hng ro mu - mt tt hn so vi cc
cephalosporin khc. [3]
2.2. Cc Sulfonamid
- Ph tc dng: Khng sinh km khun, ph khng khun rng trn c vi
khun Gram dng v Gram m. Hiu qu tng khi phi hp vi trimethoprim.
- Dung dch tra mt sulfacetamid (10-30%) thm qua biu m gic mc
tt.
- Ch phm: sulfacetamid dng bo ch c c dung dch, m tra mt, n
c hoc phi hp vi corticoid. Do t l khng thuc cao v gy nhiu tc dng
khng mong mun khi tra mt (kch ng, ph hc mt,...) nn hin nay t s
dng. Hn na, n cn tng k vi cc thuc t tra mt nh procain v
tetracain. [2,3]
2.3. Cc Tetracyclin
- Ph tc dng: Ph rng, u th trn vi khun Gram m. Hin nay hiu
qu iu tr ca nhm ny gim mnh, t l khng thuc tng nn hu nh
khng cn c la chn iu tr nhim khun. Tuy nhin, tetracyclin vn
hiu qu trong iu tr v phng nga vim kt mc s sinh, phi hp ng
ung trong iu tr nhim Chlamydia ti mt v iu tr chc nng tuyn mi mt.
- Tetracyclin thm tt qua biu m gic mc khi tra mt.
B Y t | S DNG KHNG SINH TRONG NHN KHOA 249
- Ch phm: vin nn, nang 250mg; thuc m tra mt nng 1%. [2,3]
2.4. Cloramphenicol
- Ph tc dng: Rickettsia, Chlamydia, Mycoplasma... (P. aeruginosa khng
thuc ny)
- Cloramphenicol thm tt qua biu m gic mc khi tra mt, qua c
hng ro mu - mt khi dng ton thn. Ch nh dng ton thn ch p dng khi
nhim khun nng e do tnh mng m vi khun khng li ht cc thuc t c
khc.
- Ch phm: Ti mt, cloramphenicol c dng m, dung dch tra mt
0,4%, hiu qu cao trong iu tr nhim khun ngoi nhn cu. [2,3]
2.5. Cc Aminoglycosid: neomycin, gentamicin, tobramycin, amikacin...
- Ph tc dng: Ph rng, nhng tc dng mnh hn trn vi khun Gram
m.
- Km hp thu khi qua ng tiu ha nhng hp thu tt khi tim tnh
mch, tim bp. Khng d dng xm nhp hng ro mu mt nhng c th
dng tra mt dng nc, m hoc tim cnh nhn cu.
- c tnh cao cho thnh lc v tin nh nn hn ch s dng ton thn.
Khi tra ti mt trong thi gian di c th gy c vi biu m gic mc, trt biu
m dng m, chm lin biu m, thiu mu, ph kt mc.... Amikacin t c
hn so vi cc aminoglycosid khc.
- Cc ch phm:
+ Neomycin: dung dch, m tra mt, n c hoc phi hp khng sinh
polymyxin B hoc vi corticoid...
+ Gentamicin: ng tim 40mg/1ml, 80mg/2ml; dung dch hoc m tra
mt nng 0,3%; Trn lm sng i khi s dng gentamicin ng tim
pha ch thnh dung dch truyn ra ti mt cho nhng trng hp nhim
khun gic mc nng do trc khun m xanh.
+ Tobramycin: dung dch hoc m tra mt nng 0,3%, n c hoc
phi hp vi corticoid.
+ Amikacin: Khng c ch phm thuc tra mt trn th trng. Trn lm
sng, i khi s dng ng tim pha thnh dung dch tra mt nng 10 20mg/ml; Ch phm thuc tim dng tim ni nhn trong iu tr vim m ni
nhn do vi khun hoc lot gic mc do vi khun, phi hp vi khng sinh
penicilin khng penicilinase hoc cephalosporin hoc vancomycin. [2,3]
2.6. Cc Fluroquinolon: Norfloxacin, ofloxacin, pefloxacin, levofloxacin,
ciprofloxacin, enoxacin, lomefloxacin, temafloxacin, fleroxacin, tosufloxacin,...
- Ph tc dng: Ph rng, tc dng ln cc vi khun Gram dng v Gram
m.
B Y t | S DNG KHNG SINH TRONG NHN KHOA 250
+ Ch phm: dng tra mt phi hp vi khng sinh hoc khng vim khc
(neomycin, corticoid...) [2]
- Bacitracin:
+ Ph tc dng: Ch yu tc dng trn vi khun Gram dng.
+ Ch yu iu tr vim b mi
+ Ch phm: dng m tra mt, n c hoc phi hp vi polymyxin v
neomycin. [2]
TI LIU THAM KHO
1. B Y t (2006), Nhn khoa, Nh Xut bn Gio dc.
2. Nh Hn, Nhn khoa Tp 3 (2012), Nh Xut bn Y hc.
3. American Academy of Ophthalmology, Fundamentals and Principles of
Opthalmology, Section 2 (2004-2005).
4. Joseph Francis Duane, Duanes Ophthalmology, 2006 Edition.
5. Roger G. Finch, Antibiotic and Chemotherapy, 9th Edition.
VIM KT MC CP
1. I CNG
- Vim kt mc cp (Acute conjunctivitis) l tnh trng vim cp tnh ca
kt mc, thng do nhim khun (do virus, vi khun) hoc do d ng.
- Vim kt mc cp c nhiu hnh thi:
+ Vim kt mc cp tit t m do vi khun: y l hnh thi vim kt mc
dng nh ti cp.
+ Vim kt mc cp tit t mng do vi khun: l loi vim kt mc cp
tit t c mng ph trn din kt mc, c mu trng xm hoc trng ng.
+ Vim kt mc do virus: l vim kt mc c km nh, nhiu tit t v
hoc c gi mc, bnh thng km st nh v cc biu hin cm cm, c hch
trc tai, thng pht trin thnh dch.
2. NGUYN NHN
- Vim kt mc cp tit t m do vi khun: thng gp do lu cu
(Neisseria gonorrhoeae), him gp do no cu (Neisseria menigitidis).
- Vim kt mc cp tit t mng do vi khun: thng gp do vi khun
bch hu (C. diphtheria) v lin cu ( Streptococcus pyogene)
- Vim kt mc do virus: do Adeno virus, Entero virus ...
3. TRIU CHNG
3.1. Lm sng
a) Ti mt
- Bnh xut hin lc u mt mt, sau lan sang hai mt. Thi gian
bnh t vi gi n vi ngy.
- Vim kt mc tit t mng do vi khun:
+ Xut tit nhiu nht vo ngy th 5 ca bnh.
+ C th c mng tit t dai.
+ C th vim gic mc chm biu m.
- Vim kt mc do lu cu: m nhiu nht vo ngy th 5. Bnh din bin
rt nhanh:
+ Mi ph n.
+ Kt mc cng t, ph n mnh. C nhiu tit t m bn, hnh thnh rt
nhanh sau khi lau sch.
+ Nu khng iu tr kp thi gic mc b thm nhim rng, tin trin
thnh p xe gic mc v c th hoi t thng gic mc.
B Y t | VIM KT MC CP 253
b) Ton thn
- C th c hch trc tai
- St nh
3.2. Cn lm sng
- Nhum soi: Nhum Gram
- Nui cy v lm khng sinh
4. IU TR BNG KHNG SINH
4.1. Ti mt
- Bc mng hng ngy
- Ra mt lin tc bng nc mui sinh l 0,9 % loi tr tit t hoc
m.
- Trong nhng ngy u bnh din bin nhanh, tra khng sinh nhiu ln
trong ngy theo khng sinh hoc theo kt qu soi nhum vi khun. Trong
trng hp khng hoc cha c xt nghim nn chn khng sinh c ph rng
nh thuc nhm quinolon (ofloxacin, levofloxacin, ciprofloxacin,
moxifloxacin) hoc cc thuc phi hp nhiu loi khng sinh nh
gramicidin/neomycin sulfat/polymyxin B sulfat(15-30 pht/ln). Khi bnh
thuyn gim c th gim s ln tra mt.
- Thn trng khi dng corticoid: prednisolon acetat, fluorometholon tra 12 ln/ngy, 1 git/ ln.
- Dinh dng gic mc v nc mt nhn to.
4.2. Ton thn: (Ch dng trong bnh tin trin nng thng do lu cu, bch
hu). C th dng mt trong cc loi khng sinh sau khi bnh tin trin nng,
km theo triu chng ton thn.
- Cephalosprin th h 3: ceftriaxon, ceftazidim...
+ Ngi ln:
Nu gic mc cha lot: Liu duy nht 1 gram tim bp.
Nu gic mc b lot: 1 gram X 3 ln / ngy tim tnh mch.
+ Tr em: Liu duy nht 125mg tim bp hoc 25mg/kg cn nng 2-3
ln/ngy x 7 ngy tim bp.
- Fluoroquinolon (ciprofloxacin 0,5 gram hoc ofloxacin 0,4 gram): Ung
2 vin/ngy x 5 ngy. Chng ch nh dng cho tr em di 16 tui.
- Thuc nng cao th trng: Vitamin C, B1...
5. PHNG BNH
- iu tr bnh lu ng sinh dc (nu c).
B Y t | VIM KT MC CP 254
- V sinh v tra thuc st khun/ khng sinh cho tr s sinh ngay khi
ra.
- V khun trong sn khoa
- Tim phng y cc bnh theo ng qui nh ca tr.
- Nu b bnh cn iu tr tch cc trnh ly lan thnh dch.
B Y t | VIM KT MC CP 255
VIM KT MC DO LU CU
1. I CNG
Vim kt mc do lu cu (Gonococcal conjunctivitis) l mt bnh tin
trin nng n, c nguy c gy tn hi gic mc. y l loi bnh nhim khun
mt sinh dc, khi pht cp tnh, trong vng 12 n 48 gi. Bnh cn c c
bit quan tm bi nguy c tin trin nhanh ph hy gic mc dn n thng gic
mc v c th gy vim ni nhn.
2. NGUYN NHN
Tc nhn gy bnh l song cu hnh ht c ph (Neisseria gonorrhoeae) l
loi tc nhn nguy him, c c tnh mnh.
3. TRIU CHNG
a) Lm sng: Vim kt mc do lu cu khi pht rt rm r, vi cc biu hin
sau y:
- Mi sng n, ph kt mc, nh kt mc, xut hin hch trc tai.
- Xut tit tit m rt nhiu, chy tro ra khe mi, y l du hiu c trng
ca bnh.
- Lot gic mc c th xy ra trong vng mt vi gi, trung tm hoc
chu bin. Nhng lot ny c th kt ni li vi nhau thnh cc p xe hnh
nhn.
b) Cn lm sng
- Nhum soi tit t m kt mc s thy song cu khun Gram-m hnh ht
c ph.
- Nui cy trn mi trng thch mu v chocolate hoc mi trng
Thayer-Martin trong t m iu kin nhit 37oC trong 5 n 10% CO2.
4. IU TR BNG KHNG SINH
iu tr c hiu vi loi vi khun lu cu bao gm iu tr ton thn v
ti ch. iu tr ton thn bng Procain penixilin 1,5g tim bp mt ngy trong 3
ngy. Tr em dng 50mg/kg cn nng /ngy tim bp trong 3 ngy v tra ti ch
penixilin G c dng trong nhiu nm. Tuy nhin do tnh trng khng thuc
i vi cc loi beta lactam v nguy c phn ng thuc ca nhm penixilin, nn
s dng cc loi cc loi khng sinh thay th bao gm cc loi cephalosporin c
men beta-lactamase bn vng.
Cephalosporin th h 3: Ceftriaxone: ngi ln tim bp 1g mt liu duy
nht. Nu c tn thng gic mc hoc nguy c xm nhp vo gic mc th cn
phi nhp vin v iu tr ceftriaxone 1g tim tnh mch ngy 1 hoc hai ln,
thi gian ko di ty thuc vo p ng ca bnh (trung bnh l 7 ngy). Tr em
v tr s sinh : 25 mg/kg/ngy 1 ln.
B Y t | VIM KT MC DO LU CU 256
Cefotaxime liu cho ngi ln l 1g tim bp hoc tnh mch liu duy
nht. Liu cho tr em l 25mg/kg cn nng/ngy tim tnh mch hoc tim bp
(ti a l 1g). C th s dng mt liu duy nht nu khng thy c cc nguy c
pht tn bnh nh nhim khun huyt, hoc vim a khp, vim mng no.
Nu ngi bnhngi bnh d ng vi penicillin c th s dng
ciprofloxacin, 500 mg ung mt liu duy nht hoc ofloxacin 400mg ung mt
liu.
Ti mt:
Ra mt bng nc mui sinh l 0,9% hng gi cho n khi ht tit t.
Fluoroquinolon : dung dch ciprofloxacin 0,3% tra 2 gi mt ln,
Aminoglycosid: tobrex 0,3%, m bacitracin hoc m erythromycin.
Trong trng hp c tn thng gic mc tra ciprofloxacin 0,3%,
gentamicin 0,3% hoc tobramycin 0,3% mi gi mt ln.
Theo di hng ngy cho n khi bnh c tin trin tt, v cc triu chng
rt lui.
5. D PHNG
- Vim kt mc do lu cu hon ton c th phng c trnh cc
tn hi nng n gic mc. Phng php Crede (1881) dng argyrol 3% (Nitrat
bc) ngay sau khi sinh. C th dng m erythromycin v tetracyclin.
- iu tr bnh lu ng sinh dc nu c.
TI LIU THAM KHO
1. Harleys Pediatric Ophthalmology (1998), 4th edition.
2. Jack J Kanski, Clinical Ophthalmology (2008), third edition.
3. Myron Yanoff, Jay S. Duker, Ophthalmology (2004).
B Y t | VIM KT MC DO LU CU 257
BNH MT HT
1. I CNG
- Bnh mt ht (Trachoma) l mt bnh vim mn tnh ca kt mc v
gic mc. Tc nhn gy bnh l Chlammydia trachomatis. Trong giai on hot
tnh, bnh th hin c trng bng s c mt ca ht, km theo thm nhim ta
lan mch, ph i nh kt mc v s pht trin cc mch mu trn gic mc.
- Bnh thng xut hin la tui tr v ko di do b ti nhim.
- Bnh mt ht lin quan cht ch vi iu kin v sinh c nhn v mi
trng nn thng gp nhng vng nng thn ngho v v sinh km. Bnh
mt ht vn cn l nguyn nhn gy m la.
2. NGUYN NHN
Do vi khun: Chlamydia trachomatis: C nhiu type huyt thanh: A, B, C,
D, E, K, F, G, H, I, J.
- Chlamydia trachomatis type huyt thanh A, B hoc C: Ly truyn theo
ng t mt sang mt, ly truyn bnh cho ngi khc v gy tip nhim cho
ngi c bnh.
- Chlamydia trachomatis type huyt thanh D, E, K, F, G, H, I: Ly truyn
qua quan h tnh dc, ly t m sang tr s sinh
3. TRIU CHNG
a) Lm sng
- Tiu chun chn on bnh mt ht trn lm sng: C 4 tiu chun:
+ C ht trn kt mc sn mi trn. V tr: Vng trung tm (Ht vng gc:
khng c gi tr chn on, ht b trn sn: nghi ng)
+ So in hnh trn kt mc sn mi trn So c th l nhng on x
trng nh, hnh hoa kh hay hnh sao, so c th l nhng di di ct qua mch
mu.
+ Ht vng ra cc trn hoc di chng ht (lm ht).
+ Mng mu vng ra trn gic mc.
(*) Cn c 2 trong 4 tiu chun chn on. nhng vng mt ht nng, t
l cao ch cn 1 trong 4 tiu chun.
- Phn loi bnh mt ht theo T chc Y t th gii:
+ TF: vim mt ht-ht.
C t nht 5 ht trn kt mc sn mi trn.
ng knh ca ht t nht t 0,5 mm.
B Y t | BNH MT HT 260
+ Chng ch nh:
Ph n c thai, cho con b.
Tr di 1 tui v cn nng di 8 kg.
Ngi suy gan, suy thn nng.
5. D PHNG
Theo t chc y t th gii: d phng mt ht theo chin lc SAFE.
- S (Surgery): M qum sm, khng bin chng gy m.
- A (Antibiotic): iu tr khng sinh nhng trng hp mt ht hot tnh,
nhm tiu dit nhim khun v hn ch ly lan.
- F (Facial cleanliness): Ra mt hng ngy bng nc sch.
- E (Enviroment): Ci thin v sinh mi trng, cung cp nc sch.
B Y t | BNH MT HT 262
VIM T CHC HC MT
1. I CNG
Vim t chc hc mt (orbital cellulitis) l vim ca phn m mm trong
hc mt. Vim t chc hc mt gp c tr em v ngi ln. tr em di 5
tui th hay phi hp vi vim ng h hp trn. tr em trn 5 tui hay phi
hp vi vim xoang. ngi ln hay gp nhng ngi i tho ng, suy
gim min dch hay do d vt nm trong hc mt. Vim t chc hc mt c th
c chia thnh vim phn trc vch (preseptal) hay vim t chc trong hc
mt sau vch (postseptal). Vim trc vch c nhng du hiu nh sng nng
au phn m mm nhng vim khng lan n xng hc mt, th lc v vn
nhn thng bnh thng. Vim sau vch nh hng n th lc, c th lan vo
mng xng v xng hc mt. [1,3]
2. NGUYN NHN
a) Nguyn nhn
- Do vi khun thng gp l Staphylococcus aurreus (t cu vng),
Streptococcus pneumoniae, nhm Streptococcus anginosus/millieri (nhm lin
cu) hay Heamophilus influenzae type b (Hib) (lin cu tan huyt nhm b). Vi
khun Gram-m
- Do nm trong nhng trng hp s dng thuc c ch min dch,
corticosteroid ko di, suy gim min dch.
- Do virus.
- Do k sinh trng.
b) Cc yu t thun li nh:
- tr em hay gp do vim ng h hp trn, vim xoang.
- ngi ln hay gp nhng ngi i tho ng, suy gim min
dch.
- C th gp do nhng nguyn nhn lan truyn trc tip t nhng cu trc
nh nhn cu, mi v phn ph cn ca nhn cu cng nh cc xoang ln cn.
- Do chn thng xuyn lm tn thng vch hc mt, c bit nhng
chn thng c d vt hc mt.
- Nhng phu thut nh phu thut gim p hc mt, phu thut mi, phu
thut lc, ni nhn Vim t chc hc mt cng c th gp sau vim ni nhn
sau phu thut. [1]
3. TRIU CHNG
a) Lm sng
B Y t | VIM T CHC HC MT 263
VIM B MI DO VI KHUN
1. I CNG
Vim b mi do vi khun (Bacterial blepharitis) l nhim khun b mi gy
ra bi vi khun, gy ra cc biu hin kch thch ca cc b phn ngoi nhn cu.
2. NGUYN NHN
Thng gp do t cu (Staphylococcus).
3. TRIU CHNG
a) Lm sng:
Thng gp ngi tr, biu hin lm sng bao gm nga b mi, cm
gic d vt, bng rt, tit t dng vy cng ng quanh hng chn lng mi b
mi trc, c th lot nh b mi trc khi vy cng c ly i. C hin
tng gin mch ngoi vi ca b mi trc v sau do phn ng vim, bc lng
mi, rng lng, lng xiu nhiu mc , thng km theo kh mt ty thuc mc
nng v thi gian vim b mi.
Mt s trng hp c phi hp vim mn tnh b mi do vim tc tuyn
Meibomius: gin mch b mi na sau, b mi dy v l ng tuyn Meibomius
b y li ra sau.
b) Cn lm sng: nui cy bnh phm b mi thy c t cu.
4. IU TR
- Chm sc b mi hng ngy: cn duy tr ko di (t nht 1-2 thng)
+ Dng tm bng m tm dung dch du gi u ca tr s sinh pha long
ch dc b mi, ly sch vy bm, thc hin 2 ln/ngy
+ Bi m khng sinh vo 2 b mi sau khi lm sch: dng
cloramphenicol 1%, polymyxine B hoc fluoroquinolon, bi 2 ln/ ngy
- B sung nc mt nhn to cho cc ngi bnhngi bnh kh mt
(Systane, Refresh Tears)
- Vi trng hp c phn ng vim mnh b mi c th phi hp tra
thuc chng vim corticoid (prednisolon acetat, flumetholon, loteprenol), cn
lu gim liu v trnh dng ko di
- Trong trng hp vim mn tnh b mi do tc tuyn Meibomius, thng
hay phi hp trn c a bnh trng c (blepharitis associated with rosacea):
chm sc b mi hng ngy bng chm m v mt xa b mi, ung Doxycyclin
50-100 mg hng ngy (tr em >8 tui: 1,25-2,5 mg/kg cho n 50 mg, bnh
khng gp tr <8 tui), ko di 1-2 thng hoc di hn ph thuc p ng lm
sng.
5. PHNG BNH
B Y t | VIM B MI DO VI KHUN 271
VIM TI L
1. I CNG
Vim ti l (Dacryocystitis) l tnh trng vim mn tnh hoc cp tnh ti
ti l. y l bnh l thng gp trong nhn khoa, xy ra th pht sau tc ng l
mi bm sinh hoc mc phi.
2. NGUYN NHN
Tc nhn vi sinh vt thng gp gy vim ti l kh a dng. Cc vi sinh
vt c th gy vim ti l bao gm vi khun Gram-dng nh Staphylococus
epidermidis, Staphylococus aureus, Streptococus pneumoniae; vi khun Gramm nh: Pseudomonas aeruginosa, Hemophilus influenzae, Proteus, k c vi
khun k kh nh Propionibacterium acnes.
3. TRIU CHNG
a) Lm sng
- Vim ti l biu hin hnh thi mn tnh hoc c nhng t vim cp
tnh.
- Vim ti l mn tnh:
+ Chy nc mt thng xuyn, c th km chy m nhy.
+ Dnh mi mt do cc cht tit nhy.
+ Vng ti l c khi n, cng, n vo c m nhy tro ra gc trong mt.
+ Vim kt mc gc trong.
+ Bm l o: Nc tro qua l l i din c nhy m km theo.
- Vim ti l cp tnh
+ C tin s chy nc mt, hoc chy nc mt km nhy m.
+ au nhc vng ti l, c th au tng ln khi lic mt v phn ng vim
c th tc ng n c cho di. au c th lan ra na u cng bn, au tai
hoc au rng.
+ Vng ti l sng, nng, .
+ Ti l gin rng, lan ra pha di ngoi hoc mt phn pha trn.
+ Nu qu trnh nhim khun nng hn, gy p xe ti l.
+ Giai on mun hn, c th gy d m ra ngoi da. M nhy thot t ti
l ra ngoi qua l d ny.
+ Ton thn: Mt mi, st, c th c hch trc tai.
b) Cn lm sng
B Y t | VIM TI L 273
B Y t | VIM TI L 274
B Y t | VIM TI L 275
B Y t | 276
B Y t | 277
B Y t | 278
VIM MNG NO M
1. I CNG
- Vim mng no m (VMNM) l tnh trng nhim khun cp tnh ca
mng no do cn nguyn vi khun gy nn.
- Trn lm sng, bnh biu hin bng triu chng st v c hi chng
mng no, i khi c biu hin ca nhim khun khi im (ng vo). Hin
nay, vic iu tr VMNM vn cn phc tp v tin lng d dt.
2. NGUYN NHN
Cn nguyn hay gp tr em l Hemophilus influenzae typ b (Hib), ph
cu v no m cu, ngi trng thnh l ph cu, no m cu v lin cu.
Ngoi ra, cn ch cn nguyn Listeria monocytogenes c th gp tr s sinh
v ngi gi.
3. CHN ON
3.1. Lm sng
Bnh khi pht v din bin t vi gi n vi ngy, vi biu hin:
a) St
b) Hi chng mng no:
- C nng: Nhc u, nn vt, to bn (tr em thng tiu chy)
- Thc th: C mt hoc nhiu du hiu:
+ Gy cng.
+ Kernig (hoc brunzinski).
+ Tng cm gic (s nh sng - nm t th c sng).
+ Thay i thc (kch thch, ng g, l ln....).
+ Cc du hiu t gp hn: lit khu tr, co git, ph gai th, tng huyt p,
nhp tim chm (lin quan vi ph no nng).
c) Du hiu gi cn nguyn: Ban hoi t, chn thng hoc phu thut s no,
khuyt tt Tai Mi Hng.
d) Cc c a c bit nh tr s sinh, suy gim min dch, kit bch cu, c
bnh km theo, thng c bnh cnh lm sng nng hn.
3.2. Cn lm sng
a) Xt nghim mu: Cc ch s vim tng (nh bch cu, CRP v procalcitonin).
b) Dch no ty (DNT):
- Mu sc thng khng trong (m khi, thm ch c) v p lc tng.
B Y t | VIM MNG NO M 279
Bng II.19. Phc khng sinh kinh nghim khi cha c kt qu vi sinh
La tui
Cn nguyn thng gp
0 4 tun
tui
Vi khun ng rut,
S. agalactiae, Listeria.
1 thng 3
thng.
Ampicilin* +
Ceftriaxon (hoc
Cefotaxim)
Vancomycin +
Ceftriaxon (hoc
Cefotaxim)
3 thng 18
tui.
Ceftriaxon (hoc
Cefotaxim)
Vancomycin +
Ceftriaxon (hoc
Cefotaxim)
18 50 tui
Ceftriaxon (hoc
Cefotaxim)
Vancomycin +
Ceftriaxon (hoc
Cefotaxim)
Trn 50 tui.
Ceftriaxon (hoc
Cefotaxim)
Ampicilin* + Ceftriaxon
(hoc Cefotaxim)
Suy gim
min dch.
Chn
thng, phu
thut, d
DNT
Ceftazidim +
Vancomycin
Ceftazidim +
Vancomycin
Meropenem
Ch :
* chn Ampicilin khi nghi ng Listeria.
**Aminoglycosid (gentamicin hoc amikacin).
Bng II.20. Liu khng sinh khuyn co trn ngi bnhngi bnh vim mng
no c chc nng gan thn bnh thng
Thuc khng
sinh
828a
Tr em
Ngi ln
Amikacinb
30 mg/kg (8)
15 mg/kg (8)
Ampicilin
12 g (4)
Cefepim
6 g (8)
Cefotaxim
225-300mg/kg
8-12g (4-6)
Ceftazidim
6 g (8)
Ceftriaxon
4 g (1224)
Chloramphenicol
25 mg/kg (24)
50 mg/kg (1224)
46 g (6)c
Ciprofloxacind
800-1200 mg (8-12)
Gentamicinb
5 mg/kg (12)
5 mg/kg (8)
Meropenemd
6 g (8)
Oxacilin
75 mg/kg (812)
150200 mg/kg (6
8)
912 g (4)
Penicilin G
24 mU (4)
Rifampin
600 mg (24)
Tobramycinb
5 mg/kg (12)
5 mg/kg (8)
Vancomycinf
60 mg/kg (6)
3045 mg/kg (8
12)
(6-8)
Ch thch:
a
Tr s sinh non thng - nh cn (< 2kg) c khuyn co dng liu thp hn v khong cch di
hn
4.3. Theo di iu tr
- Khi c kt qu nhum Gram cn iu chnh ngay khng sinh ph hp:
+ Cu khun Gram-dng: Ceftriaxon hoc Cefotaxim + Vancomycin.
+ Cu khun Gram-m: Penicilin G.
+ Trc khun Gram-dng: Ampicilin + Aminoglycosid.
+ Trc khun Gram-m: Ceftriaxon + Aminoglycosid.
- Khi c kt qu cy: Thay i khng sinh theo khng sinh .
- Nu khng c kt qu cy, hoc lm sng khng ci thin cn xt
nghim li DNT sau 48 gi iu tr. DNT khng ci thin cn i sang phc
thay th.
- Hi chn ngoi: Nu c khuyt tt, bin chng (khi bnh n nh),
hoc chn thng.
4.4. Thi gian iu tr
- No m cu 7 ngy, Hib 10 ngy, ph cu 14 ngy, cc trc khun v vi
khun k kh Gram-m, lin cu, t cu l 3 tun.
- Hoc trung bnh: 10 14 ngy v ht st 3 ngy.
5. PHNG BNH
- Ha d phng: Cho ngi tip xc trc tip vi ngi bnh (chm sc).
+ Hib: Ung Rifampicin 20mg/kg/ngy (tr s sinh 10 mg/kg/ngy) x 4
ngy, hoc tim bp Ceftriaxon cho tr em 125 mg/ngy, ngi ln 250
mg/ngy trong 2 ngy.
+ No m cu: Rifampicin 10 mg/kg/ngy x 2 ngy, hoc tim bp
Ceftriaxon 125 mg cho tr em, ngi ln 250 mg mt ln duy nht.
Ch : Khng dng Rifampicin cho ph n c thai.
- Tim phng:
+ Vaccine Hib: tr < 1 tui: Tim 2 liu cch nhau 2 thng; 1 5 tui:
tim 1 liu.
+ No m cu nhm A v C: Tim trong vng ang c dch xy ra.
T VIT TT TRONG BI
VMNM
Vim mng no m
DNT
Dch no ty
ANC
B Y t | 285
B Y t | 286
Gram-dng:
gp
di
10%:
Enterococcus,
UPR
VK
Vi khun
VTBT
3. IU TR
Ty tng tc nhn gy bnh m vn la chn thuc iu tr c khc
nhau.
a) iu tr ngi bnhngi bnh nhim Chlamydia
- C th la chn mt trong cc thuc sau:
+ Doxycyclin 100 mg/ln, ung 2 ln/ngy, khong cch gia cc ln a
thuc 12 gi, thi gian dng thuc 1 tun.
+ Ofloxacin 300 mg/ln, ung 2 ln/ngy, khong cch gia cc ln a
thuc 12 gi, thi gian dng thuc 1 tun.
+ Erythromycin 500 mg/ln, ung 4 ln/ngy, khong cch gia cc ln
a thuc 6 gi, thi gian dng thuc 1 tun.
- iu tr cho c ngi cng quan h tnh dc v ngi bnhngi bnh.
b) iu tr ngi bnhngi bnh nhim Trichomonas
- Thuc la chn l metronidazol:
+ Metronidazol 500 mg/ln, ung 2 ln/ngy, khong cch gia cc ln
a thuc 12 gi, thi gian dng thuc 7 ngy.
- iu tr cho c ngi cng quan h tnh dc v ngi bnhngi bnh.
c) iu tr ngi bnhngi bnh vim niu o do nm
- Nm Candida albicans rt thng gp gy vim m o. Tuy nhin
vim niu o do nm t gp.
- Thuc iu tr chng nm c th la chn l:
+ Fluconazol vin 50 mg, 150 mg.
+ Itraconazol vin 100 mg
+ Ketoconazol vin 200 mg
- Cc thuc chng nm him khi gy d ng. Tc dng c vi gan, thn
c ghi nhn. V vy cn theo di chc nng gan, thn khi dng thuc.
d) iu tr vim niu o do cc vi khun thng thng:
- La chn iu tr tng t nh iu tr vim bng quang cp. Tt nht l
iu tr da vo khng sinh . Nu khng c kt qu cy vi khun: La chn
mt trong cc thuc trong nhm khng sinh fluoroquinolon, beta-lactam,
trimethoprim-sulfamethoxazol vi liu trnh ngn t 3 - 5 ngy.
- Cn gi v sinh b phn sinh dc ngoi v iu tr phi hp vim m
o.
e) iu tr vim niu o cp phi hp vi vim tin lit tuyn, vim tinh hon
B Y t | VIM NIU O CP KHNG DO LU 300
6. Grabe M., Bjerklund Johansen T.E., H Botto et al. Guidelines on Urological Infections.
European Association of Urology. 2012.
- Xt nghim nc tiu:
+ Bch cu niu dng tnh t (++) n (+++) ( 104 bch cu/ml), c
bch cu a nhn thoi ha.
+ Vi khun niu 105/ml nc tiu. Tuy nhin ch cn cy nc tiu khi
c nguyn nhn thun li, iu tr thng thng khng p ng, ti pht hoc
nam gii.
+ Khng c protein niu tr khi c i mu, i m i th.
- Xt nghim mu:
+ Thng khng cn xt nghim.
+ Bch cu mu thng khng cao.
3. IU TR
3.1. Nguyn tc iu tr:
- iu tr chng nhim khun.
- iu tr loi b nguyn nhn thun li.
- iu tr d phng ti pht.
3.2. iu tr c th:
a) Th vim bng quang cp thng thng:
C th dng mt trong nhng thuc sau:
- Trimethoprim sulfamethoxazol: vin 80/400 mg, ung 1 vin/ln, 2
ln/ngy cch nhau 12 gi trong 3 - 5 ngy.
- Cephalexin: vin 500 mg, ung 1 vin/ln, 2 ln/ngy cch nhau 12 gi
trong 5 ngy.
- Nitrofurantoin: vin 100 mg, ung 1 vin/ln, 2 ln/ngy cch nhau 12
gi trong 5 ngy.
- Amoxicilin-clavulanat: vin 500/125 mg, ung 1 vin/ln, 2 ln/ngy
cch nhau 12 gi trong 5 ngy.
- Nhm fluoroquinolon khng phi l la chn u tay tr khi iu tr cc
khng sinh khc tht bi. Thuc thng c chn l norfloxacin 400 mg,
ung mi ln 1 vin cch nhau 12 gi trong 3 - 5 ngy.
b) Vim bng quang cp ph n c thai:
C th dng mt trong nhng thuc sau:
- Cephalexin: Vin 500 mg, ung 1 vin/ln, 2 ln/ngy cch nhau 12 gi
trong 5 - 7 ngy.
6. Grabe M., Bjerklund Johansen T.E., H Botto et al. Guidelines on Urological Infections.
European Association of Urology. 2012.
B Y t | 305
B Y t | 306
B Y t | 307
B Y t | 308
Gram-dng
Escherichia coli
Klebsiella spp.
Staphylococcus aureus
Enterobacter
Enterococcus spp.
Pseudomonas aeruginosa
Acinetobacter spp.
Streptococcus pneumoniae
Proteus spp.
Streptococcus pyogenes
Stenotrophomonas maltophila
Listeria monocytogenes
b) Phc s dng khng sinh cho ngi bnh st gim bch cu ht trung tnh
c nguy c cao (theo khuyn co ca IDSA - Infectious Diseases Society of
America):
- C th khi u bng 1 trong cc thuc sau:
+ Ceftazidim: 2g mi 8 gi.
+ Cefepim: 2g mi 8 gi.
+ Piperacilin-tazobactam: 4,5g mi 6 gi.
+ Imipenem-cilastatin: 500mg mi 6 gi hoc 1g mi 8 gi.
+ Meropenem: 1g mi 8 gi.
- Hoc kt hp thm vi mt trong cc nhm:
+ Aminoglycosid: Amikacin, gentamicin, tobramycin (cn lu gim
liu i vi cc ngi bnh suy thn, liu c th cn c vo thanh thi
creatinin).
+ Flouroquinolon: Ciprofloxacin 400 mg mi 8 gi, levofloxacin 750 mg
mi 24 gi, moxifloxacin 400 mg mi 24 gi.
+ Vancomycin: 1g mi 12 gi (dng trong trng hp nhim khun da,
phn mm, chn catheter, vim phi, nhim khun huyt lin quan n vi khun
Gram-dng).
+ Teicoplanin: 400mg mi 12 gi cho trng hp nhim khun nng do
vi khun Gram-dng, c bit l t cu vng khng methicilin v
cephalosporin.
+ Colistin: 6.000.000 n v (tng ng 200mg colistin base) mi 8 gi
(i vi nhim khun nng e da tnh mng do vi khun Gram-m khng vi
nhm carbapenem).
c) Thi gian s dng khng sinh:
B Y t | SUY GIM MIN DCH (GIM BCH CU HT 311
TRUNG TNH V SAU GHP TY)
PH LC 1.
HNG DN X TR VIM PHI CNG NG TR EM
(Guidelines for the managment of community acquired pneumonia in
children)
1. Khuyn co 5.1: Chn on vim phi tr em
Tr b vim phi cng ng thng c st, th nhanh, kh th, ho, kh kh hoc
au ngc. Cc triu chng ny thay i theo tui (Khuyn co C). Tr >3 tui
th nhanh cng c gi tr chn on vim phi (Khuyn co B). Th nhanh
thng kt hp vi thiu oxy (Khuyn co B).
Tiu chun chn on lm sng vim phi cng ng l st, ho vi th nhanh
v/hoc rt lm lng ngc (Khuyn co C).
2. Khuyn co 5.2: X-quang ngc
Khng cn chp X-quang ngc thng quy chn on vim phi cng ng
(Khuyn co A). Tr vim phi nhng khng cn nhp vin iu tr th khng
cn chp X-quang ngc (Khuyn co A). nhng ni c iu kin th c th
chp phi thng cho tr vim phi cn nhp vin (Khuyn co C). Chp phi
nghing khng cn thc hin thng quy (Khuyn co B). Khng cn chp Xquang li theo di tr b vim phi cng ng khi tr khe mnh v khi
bnh. Nn chp X-quang li cho tr vim phi c hnh nh tn thng trn din
rng, vim phi dng hnh trn, xp phi hoc triu chng vn dai dng ko di
mc du iu tr ng (Khuyn co B).
3. Khuyn co 5.3: Tr vim phi c nhiu du hiu, triu chng biu hin
mc nng:
Nu tr c cc yu t nguy c v/ hoc mc cc bnh mn tnh km theo th cn
cho tr nhp vin (Khuyn co C). Tr c SpO2 < 92% cn phi nhp vin
(Khuyn co B). G c v ting th gim khi nghe phi l biu hin c bin
chng trn dch mng phi. V vy cn chuyn tr n bnh vin (Khuyn co
B).
Hng dn gia nh chm sc tr ti nh, c bit l cch pht hin cc du hiu
bnh nng ln kp thi a tr n bnh vin (Khuyn co C).
Tr vim phi iu tr ti cng ng hoc bnh vin u phi nh gi li nu
cc triu chng vn tn ti hoc khng p ng vi iu tr (Khuyn co B).
Nhng tr vim phi iu tr ti cng ng cn phi khm nh gi li sau 2
ngy hoc bt c lc no nu bnh nng hn hoc tr vn st dai dng hoc b
B Y t | PH LC 1. 313
NGHA
Mc I hay A
(Mnh)
Mc II hay B
(Trung bnh)
Mc III hay C
(Nh)
B Y t | 315
HNG DN X TR VIM PHI CNG NG TR
EM
PH LC 2.
LIU KHNG SINH TRONG D PHNG PHU THUT
Thuc
Cefazolin
Cefotetan
120 kg: 3 g
< 120 kg: 2 g
120 kg: 3 g
Mi 6 gi
Clindamycin
600 mg
Mi 6 gi
Ciprofloxacin
400 mg
Mi 8 gi
Gentamicin
5 mg/kg
Khng
Metronidazol
500 mg
Mi 12 gi
< 70 kg: 1 g
Vancomycin
Mi 12 gi
B Y t | PH LC 2. 316
PH LC 3.
LA CHN KHNG SINH D PHNG PHU THUT
Cc loi phu thut th thut
Khuyn co d
phng
Cefazolin
Ciprofloxacin HOC
gentamicin2
Cefazolin
Gentamicin2
Tn si
Cefazolin
Gentamicin2
Cefazolin
Clindamycin
Cefotetan
Clindamycin V
gentamicin2
[Cefazolin HOC
vancomycin] V
gentamicin2
[Clindamycin HOC
vancomycin] V
gentamicin2
Cefazolin
Vancomycin
Cefazolin V
vancomycin
Vancomycin
Cefazolin
Clindamycin HOC
vancomycin
Vancomycin
Cefazolin
Vancomycin
Cefazolin V
vancomycin
Vancomycin
B Y t | PH LC 3. 317
Cefazolin V
vancomycin n khi
ng ngc
Vancomycin V
ciprofloxacin n khi
ng ngc
Khng khuyn co d
phng
Khng khuyn co
d phng
Cefazolin
Clindamycin HOC
vancomycin
Cefotetan
Vancomycin +
gentamicin2
Cefazolin
Clindamycin
Cefotetan
Clindamycin
M hp s, t dn lu dch no ty, cy
bm di mc ty
Cefazolin
Clindamycin
Cefazolin
Clindamycin
Gn t sng
Cefazolin
Clindamycin HOC
vancomycin
Cefazolin V
vancomycin
Vancomycin
Ceftriaxone
Moxifloxacin 400mg
trong 60 pht
Khng khuyn co d
phng
Khng khuyn co
d phng
Cefazolin
Vancomycin
Cefazolin V
vancomycin
Vancomycin
Cefazolin
Clindamycin HOC
vancomycin
Ct ct chi di
Cefotetan
Clindamycin V
gentamicin2
Gn t sng
Cefazolin
Clindamycin HOC
vancomycin
Cefazolin V
Vancomycin
vancomycin
Cefazolin
Clindamycin
Cefotetan
Clindamycin
gentamicin2
Cefotetan
Clindamycin
gentamicin2
Ct gan
Cefotetan
Clindamycin
gentamicin2
Cefotetan
Clindamycin V
ciprofloxacin
Rut non
Cefotetan
Clindamycin V
gentamicin2
Cefazolin HOC
cefotetan
Clindamycin
gentamicin2
Cefotetan
Clindamycin V
gentamicin2
Cefotetan
Clindamycin V
gentamicin2
M thot v bn
Cefazolin
Clindamycin
Cefotetan
Clindamycin
gentamicin2
Ct tuyn v
Khng khuyn co d
phng
Khng khuyn co
d phng
Ct tuyn v c no vt hch
Cefazolin
Clindamycin V
gentamicin2
M Cesarean
Cefazolin
Clindamycin V
gentamicin2
Cefazolin HOC
cefotetan
Clindamycin V
gentamicin2
Cefotetan
Clindamycin V
gentamicin2
Cefazolin
Clindamycin
Khng khuyn co d
phng
Khng khuyn co
d phng
Cefazolin
Clindamycin
Cefotetan HOC
clindamycin
Clindamycin
i phu vng c
Cefazolin
Clindamycin
Cefazolin
Clindamycin
t/cy/tt c vt ghp m
Cefazolin
Clindamycin
To hnh mi
Khng d phng
HOC cefazolin
Khng d phng
HOC clindamycin
Cefotetan
Clindamycin V
ciprofloxacin
Cefazolin
Clindamycin
Ghp gan
Cefotetan
Clindamycin V
ciprofloxacin
Cefotetan
D ng Penicilin:
clindamycin V
gentamicin
Cefazolin
D ng Penicilin:
gentamicin
Cefazolin
D ng Penicilin:
clindamycin
Khng khuyn co d
phng
Cefazolin
D ng Penicilin:
clindamycin
D phng trong sinh thit tuyn tin lit da vo kt qu soi trc trng
Trng hp
iu tr d phng trc th
thut7
Nhy cm
Ciprofloxacin
Khng
Ciprofloxacin, nhy
cm TMP/SMX
Ciprofloxacin 750 mg ng
ung 2 gi trc th thut
ngi bnh c chc nng thn
bt k
Ciprofloxacin 500 mg ng
ung mi 12 gi sau th thut.
Nu mc lc cu thn < 30
ml/min khng cn dng liu sau
th thut.
TMP/SMX 160mg/800mg x 1
vin 1 gi trc th thut v 1
vin trc 3 gi
TMP/SMX 160mg/800mg x 1
vin ng ung mi 12 gi sau
th thut. Nu mc lc cu thn <
30 ml/min khng cn dng liu
sau th thut.
Khng
Cefazolin 2 g ng tnh mch Cefpodoxime 100 mg ng
Ciprofloxacin
v nhanh (3 5 pht) trong vng 1 ung 1 liu duy nht
TMP/SMX, nhy gi trc th thut
HOC
cm Cefazolin
cefdinir 300 mg ng ung 1
liu duy nht
Khng
Ciprofloxacin,
TMP/SMX,
Cefazolin
Nu c soi trc trng trc phu thut, xem D phng trong sinh thit tuyn tin lit da
vo kt qu soi trc trng
2
Phu thut ngc h, tip tc dng khng sinh d phng n khi ng ngc.
iu tr trc bng khng sinh c th c cn nhc cho ngi bnh vim phi tc nghn
mn tnh hoc tin s vim phi sau tc nghn ti pht.
6
Mch bch huyt hoc ngi bnh c da b hoi t trc khi t graft mch cn dng khng
sinh d phng l cefazolin.
7
PH LC 4
HNG DN TIM/TRUYN MT S LOI KHNG SINH
TT
Tim bp
Aztreonam
* chai truyn pha
sn
* bt pha tim
500mg, 1g, 2g
Azithromycin
bt pha tim
500mg
Ampicillin
bt pha tim
125mg,250mg,
500mg, 1g, 2g
Ampicillin
sulbactam
bt pha tim
1.5g hoc 3g
Pha 1g vi t
nht 3ml
NCPT/nc km
khun/NaCl
0.9%
6-10ml NCPT
Tc
Cch pha
3-5 pht
125 mg / 1ml;
250 mg/1ml;
500 mg /2ml; 1
g/4ml; 2 g/8 ml
NCPT
Ha tan 125mg,
250mg, 500mg
trong 5 mL
NCPT.
1g/7.4ml;
2g/14.8ml
NCPT hoc
NaCl 0.9%
10-15
pht
Ha tan: 500mg/5ml
NCPT, pha long:
100ml NaCl 0.9%
10-15
pht
Ha tan: 1.5g/3.2 ml
NCPT, pha long:
trong 50-100ml dung
mi tng hp
1.5g/3.2ml
NCPT hoc
lidocaine HCl
0.5 hoc 2%
1.5g/3.2ml
NCPT
Dung mi
tng hp
Ch
20-60 pht
NaCl 0.9%,
Gluc 5%, GlucNaCl,
Hartmanns,
Ringers
60 pht
NaCl 0.9%,
Gluc 5%,
Hartmanns.
Nn dng NaCl
0.9% [1]
NaCl 0.9%
15-30 pht
B Y t | PH LC 4 322
TT
Amoxicillin
bt pha tim
250mg, 500mg,
1g
Amoxicillin
clavulanate
bt pha tim
600mg, hoc
1.2g
Amikacin
ng dung dch
tim 50250mg/ml
Bleomycin
sulfate
bt pha tim 1530 UI
Cloxacillin
250mg, 500mg,
1g, 2g bt pha
tim
10
Clindamycin
ng tim 2-, 4-,
6ml
Tim bp
Ha tan 500
mg/2.5 mL; 1
g/4ml NCPT;
250mg/5ml
600mg/10 ml;
1.2g/20 ml
NCPT.
15UI/ 1ml-5ml
NCPT hoc
NaCl 0.9% hoc
nc km khun
500mg/1.7ml
NCPT
250mg/1.9ml
NCPT
* ch nn tim
bp liu
600mg
250mg/4.9ml
NCPT
500mg/4.8ml
NCPT
Dung mi
tng hp
Ch
NaCl 0.9%
3-4 pht
Ha tan: 250mg/5ml
NCPT
pha long: 50-100ml
NaCl 0.9%
3-4 pht
30-40 pht
NaCl 0.9%
2-3 pht
30-60 pht
NaCl 0.9%;
Ringer hoc
Ringer lactated
Bo qun c 2-80C
trong 24h [2]
NaCl 0.9%,
Gluc 5%,
Ringer lactate,
Hartmann's
n nh trong dung mi
NaCl 0.9% trong 24h
NaCl 0.9%
10 pht
30-60 pht
2-4 pht
Ha tan: 1g/3.4 ml
NCPT
pha long trong dung
mi tng hp
30-40 pht
10-60 pht,
tc khng
qu
30mg/pht
NaCl 0.9%
TT
Tim bp
11
Clarithromycin
l bt pha tim
500mg
12
Ciprofloxacin
chai truyn pha
sn 2mg/ml hoc
ng dung dch
10mg/ml
13
Chloramphenicol
1g bt pha tim
Ha tan trong
10ml NCPT
hoc Glu 5%
14
Cefuroxime
bt pha tim
250mg, 750mg,
1.5g
Liu 750mg
pha vi 3ml
NCPT (hn
dch) [2]
Ha tan 750mg/
6 n 10ml
NCPT [2]
15
Ceftriaxone
bt pha tim
250mg, 500mg,
1g, 2g
*Pha mi
250mg vi 1ml
lidocaine
*Liu >1g nn
c tim 2 v
tr khc nhau [2]
Ha tan 1g trong
10ml NCPT [2]
Dung mi
tng hp
Ch
60 pht [2]
60 pht
1 pht
10 pht [2]
3-5 pht
Ha tan: 750mg/ 6 n
10ml NCPT
Pha long: 50-100ml
NaCl 0.9% [2]
2-4 pht
[2]
Ha tan: 1g trong
10ml NCPT
Pha long: 50-100 ml
dung mi tng hp
[2]
TT
16
Ceftazidime
bt pha tim
500mg, 1g, 2g
17
Cefoxitin
bt pha tim 1g,
2g
18
Cefotetan
bt pha tim 1g,
2g
19
Cefotaxime
bt pha tim
500mg, 1g, 2g
20
Cefepime HCl
bt pha tim
500mg, 1g, 2g
Tim bp
Ha tan mi
500mg/ 1.5ml
NCPT, nc
km khun hoc
lidocain 1%
Ha tan mi
500mg/5ml
NCPT
1g/10ml dung
mi tng hp
2g/10 hoc 20ml
dung mi tng
hp
1g/2ml, 2g/3ml
NCPT, nc
km khun,
NaCl 0.9% hoc
lidocain 0.5-1%
ha tan mi
1g/10ml dung
mi tng hp
*Pha
500mg/2ml,
1g/3ml, 2g/5ml
NCPT
*Liu trn 2g
nn c tim
2 v tr khc
nhau
Ha tan
500mg/1.3ml,
1g/2.4ml NCPT,
nc km khun,
NaCl 0.9%, Glu
5%, Lidocaine
HCl 0.5-1%
10ml NCPT
Dung mi
tng hp
Ch
Khi ha tan, s to
thnh CO2, cn ch 1-2
pht loi ht CO2
trc khi s dng, s
dng ngay sau khi pha,
c th bo qun 2-80C
trong 24h
3-5 pht
Ha tan: 1g/10ml
NCPT
pha long: n
10mg/ml
3-5 pht
3-5 pht
20-60 pht
3-5 pht
30 pht
15-30 pht
TT
21
Cefazolin
bt pha tim
500mg, 1g
22
23
Doxycycline
hyclate
bt pha tim
100mg, 200mg
Daptomycin
bt pha tim
250mg, 500mg
24
Erythromycin
Bt pha tim
500mg, 1g
25
Fosfomycin
bt pha tim 1g
Tim bp
500mg/2ml
NCPT hoc
NaCl 0.9%;
1g/2.5ml NCPT
10ml NCPT
5ml NCPT
500mg/10ml
NaCl 0.9% [2]
Dung mi
tng hp
Ch
Truyn lin
tc
1-4h
NaCl 0.9%,
Ringer
3-5 pht
Ha tan: mi
100mg/10ml NCPT
Pha long: n nng
0.1-1mg/ml vi
dung mi tng hp
2 pht
[2]
Ha tan: mi 250mg/
5ml NaCl 0.9%
pha long: vi NaCl
0.9% n nng
20mg/ml
Ha tan: mi
500mg/10ml NCPT
Pha long: 100ml
NaCl 0.9% [2]
30 pht
20-60 pht
NaCl 0.9%,
Ringer lactate,
G5%
TT
26
Floxacillin
bt pha tim
250mg, 500mg,
1g
27
Gentamicin
ng dung dch
tim 40mg/ml
28
Imipenemcilastatin
bt pha tim
cha 250mg500mg mi hot
cht
29
30
Tim bp
250mg/1.5ml,
500mg/2ml,
1g/2.5ml NCPT
Liu 4ml nn
tim cc v tr
khc nhau
Ha tan mi
250mg/5ml
Dung mi
tng hp
Ch
30-60 pht
[2]; C th
truyn lin
tc[1]
NaCl 0.9%,
dextrose 5%
0.5-2h
NaCl 0.9%,
Gluc 5%, GlucNaCl,
Hartmanns [2]
3-4 pht
3-5 pht
[2]
250-500mg:
20-30 pht
[2]
30-60 pht
60 pht
500mg/2ml
Lidocain 1%
Kanamycin
ng dung dch
1g/3ml
Lincomycin
ng dung dch
300mg
Lincomycin
base/ml
TT
31
Levofloxacin
dch truyn pha
sn 5mg/ml
ng dung dch
25mg/ml
32
Metronidazole
dch truyn pha
sn 5mg/ml
33
Meropenem
bt pha tim
500mg, 1g
Tim bp
Dung mi
tng hp
Ch
60 pht cho
liu 500mg;
90 pht cho
liu 750mg
60 pht,
hoc truyn
tnh mch lin
tc
Ha tan mi
500mg/10ml
NCPT
3-5 pht
15-30 pht
NaCl 0.9%,
Glu 5%
TT
Tim bp
34
Oxacillin
bt pha tim 1g,
2g
1g/5.7ml v
2g/11.5ml
NCPT hoc
NaCl 0.45%0.9%
35
Ofloxacin
dch truyn pha
sn 2mg/ml
36
Polymyxin B
ng dung dch
500.000 UI/10ml
37
Piperacillin
bt pha tim 2g,
3g, 4g
38
Piperacillin tazobactam
Bt pha tim
2.5g hoc 4.5g
39
Benzylpenicillin
sodium
bt pha tim 600
mg (500.000 UI)
hoc 1.2 g
(1000.000 UI)
x
Thm 2ml
NCPT, NaCl
0.9% hoc
procain HCL
1%
Pha n nng
1g/2.5ml bng
NCPT, NaCl
0.9%, Glu5%NaCl 0.9%,
Lidocain HCl
0.5-1%
600mg/1.6ml
NCPT
* ch tim bp
cho liu di
1.2g [2]
10 pht
Dung mi
tng hp
Ch
200mg: 30
pht
400mg: 60
pht
60-90 pht
3-5 pht
20-30 pht
Glu 5%
Khng tim bp hn 2g
piperacillin cng 1 v
tr
3-5 pht
[2]
Qu trnh ha tan c th
mt n 10 pht, dung
dch hon nguyn nn
c b i sau 24h
nhit phng v sau
48h 20-80C
1g/5ml NCPT,
NaCl 0.9%,
nc km khun,
Glu 5%, Glu
5%-NaCl 0.9%
2.5g/10ml,
4.5g/20ml NCPT
hoc NaCl 0.9%
[2]
mi 600mg/5ml
NCPT hoc
NaCl 0.9% [2]
5 pht
[2]
30 pht
TT
40
Rifampicin
bt pha tim
600mg
Tim bp
Dung mi
tng hp
Ch
3h
Ha tan trong
NCPT: 4.2ml
to dung dch
200mg/ml,
3.2ml:
250mg/ml
1.8ml:
400mg/ml [2]
60-90 pht
NCPT
3-5 pht
[2]
41
Streptomycin bt
pha tim 1g, ng
dung dch tim
1g/2.5ml
42
Co-trimoxazole
ng dung dch
tim 10, 20,
30ml
43
Tobramycin
ng dung dch
40mg/ml
Rt ra liu thch
hp
44
Ticarcillin
clavulanat
bt pha tim
3.1g
20-60 pht
30 pht
TT
Tim bp
Dung mi
tng hp
Ch
45
Vancomycin
bt pha tim
500mg, 1g
46
Moxifloxacin
400mg/250ml
truyn trn 60
pht
Glu 5%
Tim
tnh
mch
chm 35 pht
50 n 200 mL NS hoc
D5W [4]
truyn 30 pht
n 2 ting
Truyn tnh
mch lin tc
sau khi tim
tnh mch 12h (1/2 liu:
tim tnh
mch, cn 1/2
liu: truyn
tnh mch lin
tc
47
48
Netilmicin
Colistin, l 150
mg
c th tim
Ha tan bng 2
ml NCPT
Ha tan bng 2
ml NCPT
3-5 pht
Truyn ngt
qung: 60
pht
Truyn lin
tc: 24h
Glu 5% [2];
NaCl 0.9%
NS, D5NS,
D5W, LR [4]
TT
49
50
Cefoperazone
Cefamandole
Sodium
Tim bp
tim bp su [3]
tim bp su [3]
Truyn tnh
mch gin
on khong
15-30 pht,
hoc lin tc
[3]
Truyn tnh
mch lin tc
hoc gin
on
Dung mi
tng hp
Ch