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B Y T

CNG HA X HI CH NGHA VIT NAM


c lp - T do - Hnh phc

S: 708/Q-BYT

H Ni, ngy 02 thng 3 nm 2015

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

HNG DN S DNG KHNG SINH


(ban hnh km theo Quyt nh s 708/Q-BYT ngy 02/03/2015)

H NI - 2015

B Y t | BAN BIN SON 1

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

BAN BIN SON


GS.TS

Trn Qu

GS.TS

Hong Th Kim Huyn

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

Bch Quc Khnh

PGS.TS

Trn An

PGS.TS

Nguyn Gia Bnh

PGS.TS

inh Th Kim Dung

PGS.TS

Trng Thanh Hng

PGS.TS

Bi V Huy

PGS.TS

Nguyn Th Ngc Lan

PGS.TS

Th Liu

PGS.TS

o Vn Long

PGS.TS

on Mai Phng

PGS.TS

Nguyn Hu Su

PGS.TS

Phm Th Hng Thi

PGS.TS

Nguyn Th Vinh

B Y t | BAN BIN SON 2

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

Phan Thu Phng

TS.BS

Trn Qu Tng

TS.BS

L Th Dim Tuyt

TS.BS

L Th Kim Xun

TS.DS

Nguyn Th Lin Hng

TS.DS

Phm Th Thy Vn

TS.DS

V Th Thu Hng

Ths.BSCKII V B Quyt
BSCKII

Hunh Phan Phc Linh

Ths.DS

Cao Hng Thi

Ths.DS

Nguyn Hng Nga

Ths.BS

Lu Vn i

Ths.BS

Giang Thc Anh

Ths.BS

Bi Hi Bnh

Ths.BS

Nguyn ng Tun

Ths.BS

L Th Ngc Lan

Ths

V Quc t

Ths

Nguyn Th Thanh Huyn

Ths

on Th Phng Lan
B Y t | BAN BIN SON 3

Ths

T Th Diu Ngn

Ths

Nguyn Kim Th

BS

Thm Trng Khnh Vn

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

B Y t | BAN BIN SON 4

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

CHNG V. NHIM KHUN TIU HA....................................................................................171


Tiu chy do vi khun ............................................................................... 173
Dit Helicobacter pylori trong bnh l d dy t trng ............................ 178
Nhim khun ng mt ........................................................................... 181
p xe gan do vi khun............................................................................... 185
Vim ty cp c nhim khun ................................................................... 189
Vim phc mc .......................................................................................... 192
CHNG VI. NHIM KHUN C XNG KHP .........................................................197
Vim khp nhim khun ........................................................................... 199
Vim xng ty nhim khun ................................................................... 203
Vim c, p xe c nhim khun ................................................................ 206
Nhim khun ht t phi ............................................................................. 210
CHNG VII. NHIM KHUN SN PH KHOA V CC BNH LY TRUYN
QUA NG TNH DC.....................................................................................................................215
S dng khng sinh trong d phng sn khoa .......................................... 217
Nhim khun nng do sn khoa ................................................................ 219
Vim m o niu o do vi khun ........................................................ 222
Bnh giang mai .......................................................................................... 225
Bnh lu ..................................................................................................... 235
Bnh h cam .............................................................................................. 239
CHNG VIII. NHIM KHUN MT...........................................................................................243
Cc cu trc ca mt c lin quan n cc bnh l nhim khun ............. 245
S dng khng sinh trong nhn khoa ........................................................ 246
Vim kt mc cp ...................................................................................... 253
Vim kt mc do lu cu ........................................................................... 256
Vim gic mc do vi khun ....................................................................... 258
Bnh mt ht ............................................................................................. 260
Vim t chc hc mt ............................................................................... 263
Vim m ni nhn sau vt thng xuyn nhn cu .................................. 267
Vim b mi do vi khun ............................................................................ 271
Vim ti l ................................................................................................. 273
CHNG IX. VIM MNG NO ....................................................................................................277
Vim mng no m ................................................................................... 279
CHNG X. NHIM KHUN TIT NIU ...................................................................................285
Vim thn b thn cp ............................................................................... 287
Si thn tit niu nhim khun .................................................................. 293
Vim niu o cp khng do lu ............................................................... 299
Vim bng quang cp ................................................................................ 302
CHNG XI. S DNG KHNG SINH CHO NGI BNH SUY GIM MIN DCH
....................................................................................................................................307
Suy gim min dch (gim bch cu ht trung tnh v sau ghp ty) ....... 309
B Y t | MC LC 6

PH LC 1. HNG DN X TR VIM PHI CNG NG TR EM


........................................................................................................................... 313
PH LC 2. LIU KHNG SINH TRONG D PHNG PHU THUT... 316
PH LC 3. LA CHN KHNG SINH D PHNG PHU THUT ...... 317
PH LC 4. HNG DN TIM/TRUYN MT S LOI KHNG SINH
........................................................................................................................... 322

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

Bng II.17. im Balthazar nh gi mc nng trn CT ............................ 190


Bng II.18. Liu lng v cch dng khng sinh iu tr vim phc mc ....... 195
Bng II.19. Phc khng sinh kinh nghim khi cha c kt qu vi sinh ....... 281
Bng II.20. Liu khng sinh khuyn co trn ngi bnhngi bnh vim mng
no c chc nng gan thn bnh thng............................................................ 282
Bng II.21. Mt s chng vi khun thng gp ngi bnhngi bnh st
gim bch cu ht trung tnh ............................................................................. 311

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

T VIT TT TING ANH


A6AP

Acid 6-aminopenicilanic

A7AC

Acid 7-aminocephalosporanic

ADN

Deoxyribonucleic acid

ADR

Adverse drug reaction (Tc dng khng mong mun)

AFB

Acid Fast Bacillus (Nhum hunh quang tm vi khun khng


acid)

BK

Bacilie de Koch (Vi khun lao)

CFU

Colony forming unit (khun lc)

CK

Creatine kinase

CLSI

Clinical and Laboratory Standards Institute (Vin tiu chun


thc v lm sng v xt nghim)

CPIS

Clinical Pulmonary Infection Score (im nh gi nhim


khun phi trn lm sng)

CRP

C-reactive protein (Protein phn ng C)

CT

Computed tomography (Chp ct lp vi tnh)

ESBL

Extended spectrum beta-lactamase (Beta-lactamase ph


rng)

Hib

Heamophilus influenzae type b (Haemophilus influenzae


nhm B)

HIV

Human immunodeficiency virus

ICU

Intensive care unit

INR

International normalized ratio (T s bnh thng ha quc


t)

KPC

Klebsiella pneumoniae carbapenemase

MBC

Minimum Bactericidal Concentration (nng ti thiu cn


thit tiu dit vi khun)

MIC

Minimum Inhibitory Concentration (Nng c ch ti


thiu)

MDR

Multi-drug resistant (a khng)

MRI

Magnetic resonance imaging (Chp cng hng t)


B Y t | T VIT TT TING ANH 11

MRSA

Methicillin resistant Staphylococcus aureus (T cu khng


Methicilin)

MSSA

Methicillin sensitive Staphylococcus aureus (T cu nhy


cm vi Methicilin)

PAE

Post-Antibiotic Effect (Tc dng hu khng sinh)

PALE

Post-Antibiotic Leucocyt Enhancement Effect (Hiu qu


bch cu sau khng sinh)

PaCO2

p lc ring phn ca carbonic trong mu ng mch

PaO2

p lc ring phn ca oxy trong mu ng mch

PCR

Polymerase Chain Reaction (Phng php khuch i gen)

PD

Pharmacodynamics (Dc lc hc)

PDR

Pan-drug resistant (Ton khng)

PK

Pharmacokinetics (Dc ng hc)

SpO2

Saturation of Peripheral Oxygen ( bo ha oxy trong


mu)

TDM

Therapeutic Drug Monitoring (Theo di nng thuc trong


mu)

TMP-SMX

Trimethoprim/Sulfamethoxazole

WHO

World Health Organization (T chc Y t th gii)

B Y t | T VIT TT TING ANH 12

T VIT TT TING VIT


BV

Bnh vin

CTM

Cng thc mu

KC

Khuyn co

KSDP

Khng sinh d phng

NCPT

Nc ct pha tim

NK

Nhim khun

NKBV

Nhim khun bnh vin

NKN

Nhim khun nng

TB

Tim bp

TCV

T cu vng

TE

Tr em

TM

Tnh mch

TTT

Thi tm thu

VK

Vi khun

B Y t | T VIT TT TING VIT 13

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.

THAY MT BAN BIN SON


GS.TS. Trn Qu
B Y t | LI NI U 15

B Y t | 16

PHN I. I CNG V KHNG


SINH V VI KHUN HC

B Y t | 17

B Y t | 18

Chng I. i cng v khng sinh

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

CC NHM KHNG SINH V TC DNG


Cc nhm khng sinh c sp xp theo cu trc ho hc. Theo cch
phn loi ny, khng sinh c chia thnh cc nhm nh sau (Bng I.1):
Bng I.1. Phn loi khng sinh theo cu trc ha hc
TT
1

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

Cc nhm khng sinh khc


Sulfonamid
Oxazolidinon
5-nitroimidazol

1. KHNG SINH NHM BETA-LACTAM


Nhm beta-lactam l mt h khng sinh rt ln, bao gm cc khng sinh
c cu trc ha hc cha vng beta-lactam. Khi vng ny lin kt vi mt cu
trc vng khc s hnh thnh cc phn nhm ln tip theo: nhm penicilin,
nhm cephalosporin v cc beta-lactam khc.
1.1. Phn nhm penicilin
- Cc thuc khng sinh nhm penicilin u l dn xut ca acid 6aminopenicilanic (vit tt l A6AP). Trong cc khng sinh nhm penicilin, ch
B Y t | CC NHM KHNG SINH V TC DNG 22

c penicilin G l khng sinh t nhin, c chit xut t mi trng nui cy


Penicilium. Cc khng sinh cn li u l cc cht bn tng hp.
- S thay i nhm th trong cu trc ca penicilin bn tng hp dn n
s thay i tnh bn vng vi cc enzym penicilinase v beta-lactamase; thay
i ph khng khun cng nh hot tnh khng sinh trn cc chng vi khun gy
bnh.
- Da vo ph khng khun, c th tip tc phn loi cc khng sinh
nhm Penicilin thnh cc phn nhm vi ph khng khun tng ng nh sau:
+ Cc penicilin ph khng khun hp
+ Cc penicilin ph khng khun hp ng thi c tc dng trn t cu
+ Cc penicilin ph khng khun trung bnh
+ Cc penicilin ph khng khun rng ng thi c tc dng trn trc
khun m xanh.
- i din ca mi phn nhm v ph khng khun tng ng c trnh by
trong Bng I.2.
1.2. Phn nhm cephalosporin
- Cu trc ha hc ca cc khng sinh nhm cephalosporin u l dn
xut ca acid 7-aminocephalosporanic (vit tt l A7AC). Cc cephalosporin
khc nhau c hnh thnh bng phng php bn tng hp. S thay i cc
nhm th s dn n thay i c tnh v tc dng sinh hc ca thuc.
- Cc cephalosporin bn tng hp tip tc c chia thnh 4 th h. S
phn chia ny khng cn cn c trn cu trc ha hc m ch yu da vo ph
khng khun ca khng sinh. Xp theo th t t th h 1 n th h 4, hot tnh
trn vi khun Gram-dng gim dn v hot tnh trn vi khun Gram-m tng
dn. Ph khng khun ca mt s cephalosporin trong tng th h c trnh
by trong Bng I.3. Lu thm l tt c cc cephalosporin hu nh khng c tc
dng trn enterococci, Listeria monocytogenes, Legionella spp., S. aureus khng
methicilin, Xanthomonas maltophilia, v Acinetobacter spp.

B Y t | CC NHM KHNG SINH V TC DNG 23

Bng I.2. Phn nhm khng sinh Penicilin v ph khng khun


Tn thuc

Phn nhm

Cc penicilin ph khng Penicilin G


khun hp
Penicilin V
Methicilin
Cc penicilin ph khng Oxacilin
khun hp ng thi c Cloxacilin
tc dng trn t cu
Dicloxacilin

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

Cc penicilin ph khng Ampicilin


khun trung bnh
Amoxicilin

Carbenicilin
Cc penicilin ph khng
khun rng ng thi c
tc dng trn trc khun
m xanh

Ticarcilin

Mezlocilin
Piperacilin

Ph khng khun m rng hn so vi penicilin


G trn cc vi khun Gram-m nh Haemophilus
influenzae, E. coli, v Proteus mirabilis. Cc
thuc ny khng bn vng vi enzym betalactamase nn thng c phi hp vi cc
cht c ch beta-lactamase nh acid clavulanic
hay sulbactam.
Ph khng khun m rng hn trn cc chng vi
khun Gram-m nh Pseudomonas,
Enterobacter, Proteus spp. C hot tnh mnh
hn so vi ampicilin trn cu khun Gramdng v Listeria monocytogenes, km hn
piperacilin trn Pseudomonas.
C tc dng mnh trn cc chng Pseudomonas,
Klebsiella, v mt s chng vi khun Gram-m
khc. Piperacilin vn gi c hot tnh tng t
ampicilin trn t cu Gram-dng v Listeria
monocytogenes.

B Y t | CC NHM KHNG SINH V TC DNG 24

Bng I.3. Cc th h Cephalosporin v ph khng khun


Th h

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

Cephalosporin th h 4 c ph tc dng rng


hn so vi th h 3 v bn vng hn vi cc
beta-lactamase (nhng khng bn vi
Klebsiella pneumoniae carbapenemase
(KPC) nhm A). Thuc c hot tnh trn c
cc chng Gram-dng, Gram-m (bao gm
Enterobacteriaceae v Pseudomonas)

B Y t | CC NHM KHNG SINH V TC DNG 25

1.3. Cc beta-lactam khc


a) Nhm carbapenem
Nghin cu bin i cu trc ha hc ca penicilin v cephalosporin
to thnh mt nhm khng sinh beta-lactam mi, c ph khng khun rng, c
bit c hot tnh rt mnh trn vi khun Gram-m l khng sinh nhm
carbapenem. Tn thuc v ph tc dng ca mt s khng sinh trong nhm ny
c trnh by trong Bng I.4.
Bng I.4. Khng sinh carbapenem v ph tc dng
Ph tc dng

Tn khng sinh

Imipenem

Thuc c ph tc dng rt rng trn c vi khun hiu kh v k kh. Cc


chng vi khun nhy cm bao gm streptococci (k c ph cu khng
penicilin), enterococci (nhng khng bao gm E. faecium v cc chng
khng penicilin khng do sinh enzym beta-lactamase), Listeria. Mt vi
chng t cu khng methicilin c th nhy cm vi thuc, nhng phn
ln cc chng ny khng. Hot tnh rt mnh trn Enterobacteriaceae
(tr cc chng tit carbapenemase KPC). Tc dng c trn phn ln
cc chng Pseudomonas v Acinetobacter. Tc ng trn nhiu chng k
kh, bao gm c B. fragilis. Khng bn vng i vi men DHP-1 ti thn
nn cn phi hp cilastatin.

Meropenem

Ph tc dng tng t imipenem, c tc dng trn mt s chng Gram


(-) nh P. aeruginosa, k c khng imipenem.
Ph tc dng tng t imipenem v meropenem.

Doripenem

Ertapenem

Tc dng trn vi khun Gram-dng tng t imipenem, tt hn so vi


meropenem v ertapenem.
Ph tc dng tng t cc carbapenem nhng tc dng trn cc chng
Pseudomonas v Acinetobacter yu hn so vi cc thuc cng nhm.

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.

B Y t | CC NHM KHNG SINH V TC DNG 26

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

B Y t | CC NHM KHNG SINH V TC DNG 27

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

- Khng sinh nhm lincosamid c ph khng khun tng t nh khng


sinh nhm macrolid trn pneumococci, S. pyogenes, v viridans streptococci.
Thuc c tc dng trn S. aureus, nhng khng c hiu qu trn S. aureus khng
methicilin. Thuc cng khng c tc dng trn trc khun Gram-m hiu kh.
- Khc vi macrolid, khng sinh lincosamid c tc dng tt trn mt s
chng vi khun k kh, c bit l B. fragilis. Thuc c tc dng tng i tt
trn C. perfringens, nhng c tc dng khc nhau trn cc chng Clostridium
spp. khc.
- Cng khc vi macrolid, khng sinh nhm ny ch tc dng yu hoc
khng c tc dng trn cc chng vi khun khng in hnh nh M. pneumoniae
hay Chlamydia spp.
4.2. Tc dng khng mong mun (ADR):
Tc dng khng mong mun thng gp nht l gy a chy, thm ch
trm trng do bng pht Clostridium difficile, gy vim i trng gi mc c th
t vong. Vim gan, gim bch cu a nhn trung tnh cng gp nhng him v
c th hi phc.
5. KHNG SINH NHM PHENICOL
Nhm khng sinh ny bao gm hai thuc l cloramphenicol v
thiamphenicol, trong cloramphenicol l khng sinh t nhin, cn
thiamphenicol l khng sinh tng hp.
5.1. Ph khng khun
- Khng sinh nhm phenicol c ph khng khun rng, bao gm cc cu
khun Gram-dng, mt s vi khun Gram-m nh H. influenzae, N.
meningitidis, N. gonorrhoeae, Enterobacteriaceae (Escherichia coli, Klebsiella
pneumoniae, Salmonella, Shigella). Thuc c tc dng trn cc chng k kh
nh Clostridium spp., B. fragilis. Thuc cng c tc dng trn cc chng vi
khun khng in hnh nh Mycoplasma, Chlamydia, Rickettsia.
- Tuy nhin, do a vo s dng rt lu nn hin nay phn ln cc
chng vi khun gy bnh khng cc thuc nhm phenicol vi t l cao, thm
vo nhm thuc ny li c c tnh nghim trng trn to mu dn n hin
ti thuc khng cn c s dng ph bin trn lm sng.
5.2. Tc dng khng mong mun (ADR):
Tc dng ph gy bt sn tu dn n thiu mu trm trng gp vi
cloramphenicol. Hi chng xm (Grey-syndrome) gy tm ti, tru mch v c
th t vong, thng gp tr s sinh, nht l tr non. Hin khng sinh ny t
c s dng do nguy c gy bt sn tu c th gp mi mc liu; tuy him
gp nhng rt nguy him, d gy t vong.
6. KHNG SINH NHM CYCLIN

B Y t | CC NHM KHNG SINH V TC DNG 29

Cc thuc nhm ny gm c cc khng sinh t nhin v khng sinh bn


tng hp. Cc thuc thuc nhm bao gm: chlortetracyclin, oxytetracyclin,
demeclocyclin, methacyclin, doxycyclin, minocyclin.
6.1. Ph khng khun
- Cc khng sinh nhm cyclin c ph khng khun rng trn c cc vi
khun Gram-m v Gram-dng, c vi khun hiu kh v k kh. Thuc cng c
tc dng trn cc chng vi khun gy bnh khng in hnh nh Rickettsia,
Coxiella burnetii, Mycoplasma pneumoniae, Chlamydia spp., Legionella spp.,
Ureaplasma,Ngoi ra, thuc cng hiu qu trn mt s xon khun nh
Borrelia recurrentis, Borrelia burgdorferi (gy bnh Lyme), Treponema
pallidum (giang mai), Treponema pertenue.
- L khng sinh c a vo iu tr t rt lu, hin nay t l khng
tetracyclin ca vi khun gy bnh cng rt cao. Mt s cyclin s dng sau nh
doxycyclin hay minocyclin c th tc dng c trn mt s chng vi khun
khng vi tetracyclin.
6.2. Tc dng khng mong mun (ADR)
ADR c trng ca nhm l gn mnh vo xng v rng, gy chm pht
trin tr em, hng rng, bin mu rng; thng gp vi tr di 8 tui hoc do
ngi m dng trong thi k mang thai. Tc dng ph trn ng tiu ho gy
kch ng, lot thc qun (nu b ng thuc ti y), au bng, bun nn, nn,
a chy hay gp khi dng ng ung. c tnh trn thn hoc trn gan, gy
suy thn hoc vim gan, mt. Tng p lc ni s c th gp tr nh, c bit
nu dng phi hp vi vitamin A liu cao. Mn cm vi nh sng cng l ADR
phi lu tuy him gp.
7. KHNG SINH NHM PEPTID
Cc khng sinh thuc nhm ny c cu trc ha hc l cc peptid. Dng
trong lm sng hin nay c cc phn nhm:
- Glycopeptid (vancomycin, teicoplanin)
- Polypetid (polymyxin, colistin)
- Lipopeptid (daptomycin)
7.1. Khng sinh Glycopeptid
- Hin nay c hai khng sinh glycopeptid ang c s dng trn lm
sng l vancomycin v teicoplanin. y l hai khng sinh u c ngun gc t
nhin, c cu trc ha hc gn tng t nhau. Hai khng sinh ny c ph tc
dng cng tng t nhau, ch yu trn cc chng vi khun Gram-dng (S.
aureus, S. epidermidis, Bacillus spp., Corynebacterium spp); phn ln cc
chng Actinomyces v Clostridium nhy cm vi thuc. Thuc khng c tc
dng trn trc khun Gram-m v Mycobacteria. Trn lm sng, hai thuc ny
ch yu c s dng trong iu tr S. aureus khng methicilin.
B Y t | CC NHM KHNG SINH V TC DNG 30

- Tc dng khng mong mun (ADR)


+ Vancomycin: tc dng khng mong mun hay gp nht vi vancomycin
l vim tnh mch v phn ng gi d ng. Vi ADR gy vim tc tnh mch,
truyn thuc chm v pha long ng cch s gim bt ng k nguy c phn
ng ny. Phn ng gi d ng do vancomycin c kh nng gy c trc tip trn
t bo mast, dn n gii phng t histamin, dn n cc biu hin nh ban
d di: hi chng c (red-neck) hay ngi (red-man), tt huyt p, au v
co tht c. ADR khc cng cn lu vi vancomycin l c tnh trn tai v trn
thn, thng lin quan vi tng qu mc nng thuc trong mu. Ngoi ra
thuc c th gy ADR l biu hin ca qu mn nh phn ng phn v, st, rt
run, chng mt
+ Teicoplanin: tc dng khng mong mun chnh ca thuc l ban da,
thng gp hn khi dng vi liu cao. ADR khc bao gm phn ng qu mn,
st, gim bch cu trung tnh Thuc cng c c tnh trn tai nhng him gp.
7.2. Khng sinh Polypeptid
- Cc khng sinh c s dng trn lm sng thuc nhm ny bao gm
polymyxin B (hn hp ca polymyxin B1 v B2) v colistin (hay cn gi l
polymyxin E). Cc khng sinh ny u c ngun gc t nhin, c cu trc phn
t a peptid, vi trng lng phn t ln n khong 1000 dalton. Ph tc dng
ca hai thuc ny tng t nhau, ch tp trung trn trc khun Gram-m, bao
gm Enterobacter, E. coli, Klebsiella, Salmonella, Pasteurella, Bordetella, v
Shigella. Thuc cng c tc dng trn phn ln cc chng P.aeruginosa,
Acinetobacter.
- Cc thuc nhm ny c c tnh cao, c bit l c tnh trn thn, v
vy hin nay polymyxin ch dng ngoi, cn colistin ch c ch nh hn ch
trong mt s trng hp vi khun Gram-m a khng, khi khng dng c cc
khng sinh khc an ton hn.
- Tc dng khng mong mun (ADR)
Cc thuc nhm polypeptid khng c hp thu nu dng ngoi trn da
v nim mc nguyn vn, v vy khng gy ADR ton thn. Tuy nhin, thuc
vn c th gy mt s ADR dng qu mn khi dng ti ch. Khi dng ng
tim, thuc gy c ch dn truyn thn kinh c, vi cc biu hin nh yu c
hoc nguy him hn l ngng th. Cc ADR khc trn thn kinh khc bao gm
d cm, chng mt, ni lp. Cc thuc nhm ny u rt c vi thn, cn gim
st cht ch, c gng trnh dng cng vi cc thuc c thn khc nh khng
sinh aminoglycosid.
7.3. Khng sinh Lipopeptid
- Khng sinh nhm ny c s dng trn lm sng l daptomycin, y l
khng sinh t nhin chit xut t mi trng nui cy Streptomyces
roseosporus.
B Y t | CC NHM KHNG SINH V TC DNG 31

- Ph khng khun: thuc c tc dng trn vi khun Gram-dng hiu kh


v k kh nh staphylococci, streptococci, Enterococcus, Corynebacterium spp.,
Peptostreptococcus, Propionibacteria, Clostridium perfringensc bit, thuc
c tc dng trn cc chng vi khun khng vancomycin, tuy nhin MIC trong
cc trng hp ny cao hn so vi trn cc chng nhy cm vi vancomycin.
- Tc dng khng mong mun (ADR)
ADR c bn ca thuc ny l gy tn thng trn h c xng. c bo
co v cc trng hp tiu c vn, tuy him gp. Tng Creatin kinase (CK) c
th xy ra, nhng nu tng CK n thun thng khng cn dng thuc, tr khi
tng CK km theo cc biu hin khc ca bnh l c. Trong th nghim lm
sng pha 1 v pha 2, ghi nhn mt vi trng hp c biu hin ca bnh l
thn kinh c, tuy nhin khng gp ADR ny trong th nghim lm sng pha 3.
8. KHNG SINH NHM QUINOLON
8.1. Phn loi v ph khng khun
- Cc khng sinh nhm quinolon khng c ngun gc t nhin, ton b
c sn xut bng tng hp ha hc.
- Cc khng sinh trong cng nhm quinolon nhng c ph tc dng khng
hon ton ging nhau. Cn c vo ph khng khun, theo mt s ti liu,
quinolon tip tc c phn loi thnh cc th h nh tm tt trong Bng I.5.
8.2. Tc dng khng mong mun (ADR)
ADR c trng ca nhm l vim gn, t gn Asin; T l gp tai bin
tng nu s dng trn ngi bnhngi bnh suy gan v/hoc suy thn, ngi
cao tui hoc dng cng corticosteroid. Bin dng sn tip hp gp trn ng
vt non, do cng c th gp tr em tui pht trin nhng rt him. Tc dng
ph trn thn kinh trung ng, gy nhc u, kch ng, co git, ri lon tm
thn, hoang tng. Cc ADR ca nhm khng sinh ny tng t cc cyclin l
tc dng trn ng tiu ho, gy bun nn, nn, au bng, a chy hoc gy
suy gan, suy thn, mn cm vi nh sng.

B Y t | CC NHM KHNG SINH V TC DNG 32

Bng I.5. Cc th h khng sinh nhm quinolon v ph tc dng


Ph tc dng

Khng sinh quinolon


Th h 1
Acid Nalidixic

Tc dng mc trung bnh trn cc chng trc khun


Gram-m h Enterobacteriaceae.

Cinoxacin
Th h 2
Loi 1:

Cc khng sinh ny vn thuc nhm fluoroquinolon (cu


trc phn t c flo), tuy nhin ph khng khun cng ch
yu ch tp trung trn cc chng trc khun Gram-m h
Enterobacteriaceae.

Lomefloxacin
Norfloxacin
Enoxacin

Fluoroquinolon loi ny c ph khng khun m rng hn


loi 1 trn cc vi khun gy bnh khng in hnh.
Ciprofloxacin cn c tc dng trn P. aeruginosa. Khng c
tc dng trn ph cu v trn cc vi khun Gram-dng.

Loi 2:
Ofloxacin
Ciprofloxacin
Th h 3

Cc fluoroquinolon th h 3 vn c ph khng khun trn


Enterobacteriaceae, trn cc chng vi khun khng in
hnh. Khc vi th h 2, khng sinh th h 3 c tc dng trn
ph cu v mt s chng vi khun Gram-dng, v vy i
khi cn c gi l cc quinolon h hp.

Levofloxacin
Sparfloxacin
Gatifloxacin
Moxifloxacin
Th h 4

Khng sinh ny c hot ph rng, tc dng trn


Enterobacteriaceae, P. aeruginosa, vi khun khng in
hnh, S. aureus nhy cm vi methicilin, streptococci, vi
khun k kh.

Trovafloxacin

9. CC NHM KHNG SINH KHC


9.1. Nhm Co-trimoxazol
- Co-trimoxazol l dng thuc phi hp gia sulfamethoxazol vi
trimethoprim. Ph khng khun ca hai thnh phn ny tng t nhau v s
phi hp ny mang li tnh hip ng trn tc ng c ch tng hp acid folic
ca vi khun. Ph khng khun ca Co-trimoxazol kh rng trn nhiu vi khun
Gram-dng v Gram-m, tuy nhin Pseudomonas aeruginosa, Bacteroides
fragilis, v enterococci thng khng thuc. Thm vo , do a vo s dng
kh lu nn hin nay Co-trimoxazol b khng vi t l rt cao.
- Tc dng khng mong mun (ADR):
ADR c trng ca cc dn cht sulfonamid l cc phn ng d ng nh
my ay, nga, pht ban, hi chng Stevens-Johnson hoc Lyell vi cc ban
phng nc ton thn, c bit l lot hc t nhin (ming, b phn sinh dc,
hu mn) km theo cc triu chng ton thn trm trng nh tru tim mch, st
B Y t | CC NHM KHNG SINH V TC DNG 33

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.

B Y t | CC NHM KHNG SINH V TC DNG 34

C CH TC DNG CA KHNG SINH V PHI


HP KHNG SINH
1. C CH TC DNG CA KHNG SINH
Sau khi vo t bo, khng sinh c a ti ch tc ng 4 thnh phn
cu to c bn ca t bo (xem thm bi i cng v vi khun hc, phn
Cu to t bo vi khun) v pht huy tc dng: km hm s sinh trng & pht
trin hoc tiu dit vi khun, c bit c hiu qu cc vi khun ang sinh
trng v pht trin mnh (giai on 2/ log phase pht trin theo cp s nhn),
bng cch:
a) c ch sinh tng hp vch t bo vi khun: cc khng sinh nhm beta-lactam,
fosfomycin v vancomycin ngn cn sinh tng hp lp peptidoglycan nn khng
to c khung murein tc l vch khng c hnh thnh. T bo con sinh ra
khng c vch, va khng sinh sn c va d b tiu dit hoc b li gii, c
bit vi khun Gram-dng. Nh vy, nhng khng sinh ny c tc dng dit
khun nhng ch vi nhng t bo ang pht trin (degenerative bactericide).
b) Gy ri lon chc nng mng bo tng: chc nng c bit quan trng ca
mng bo tng l thm thu chn lc; khi b ri lon cc thnh phn (ion) bn
trong t bo b thot ra ngoi v nc t bn ngoi o t vo trong, dn ti cht,
v d polymyxin B, colistin. Vi c ch tc ng ny, polymyxin c tc dng
dit khun tuyt i (absolute bactericide), tc l git c t bo ang nhn ln v
c t bo trng thi ngh - khng nhn ln.
c) c ch sinh tng hp protein: tham gia sinh tng hp protein ngoi ribosom
cn c cc ARN thng tin v cc ARN vn chuyn. im tc ng l ribosom
70S ca vi khun: ti tiu phn 30S v d nh aminoglycosid (ni ARN thng
tin trt qua), tetracyclin (ni ARN vn chuyn mang acid amin ti) hoc ti
tiu phn 50S (ni acid amin lin kt to polypeptid) nh erythromycin,
cloramphenicol, clindamycin. Kt qu l cc phn t protein khng c hnh
thnh hoc c tng hp nhng khng c hot tnh sinh hc lm ngng tr qu
trnh sinh trng v pht trin.
d) c ch sinh tng hp acid nucleic: gm 3 cp :
- Ngn cn s sao chp ca ADN m to ADN con, v d do khng sinh
gn vo enzym gyrase lm ADN khng m c vng xon, nh nhm
quinolon.
- Ngn cn sinh tng hp ARN, v d do gn vo enzym ARNpolymerase nh rifampicin.
- c ch sinh tng hp cc cht chuyn ha cn thit cho t bo: qu trnh
sinh tng hp acid folic coenzym cn cho qu trnh tng hp cc purin &
pyrimidin (v mt s acid amin) b ngn cn bi sulfamid v trimethoprim.
B Y t | C CH TC DNG CA KHNG SINH V PHI 35
HP KHNG SINH

Nh vy, mi khng sinh ch tc ng ln mt v tr nht nh trong thnh


phn cu to, nh hng n mt khu nht nh trong cc phn ng sinh hc
khc nhau ca t bo vi khun, dn n ngng tr sinh trng v pht trin ca
t bo.
Nu vi khun khng b li gii hoc khng b nm bt (thc bo) v tiu
dit, th khi khng cn tc ng ca khng sinh (ngng thuc) vi khun s c th
hi phc/ sng tr li (reversible). Ch cn 1 t bo sng st, vi tc sinh sn
nhanh chng, sau vi gi s lng t bo vi khun khng th m c (v d
E. coli nu 20 pht 1 la th sau 5 gi: t 1 t bo m - ban u pht trin
thnh 215 t bo v sau 10 gi l 230 hn 1 t); s nguy him hn na nu t
bo sng st khng khng sinh.
2. PHI HP KHNG SINH
Trong thc t nng cao hiu qu iu tr, mt s trng hp cn thit
chng ta phi phi hp khng sinh.
a) C s l thuyt cho phi hp khng sinh l nhm mc ch:
- Lm gim kh nng xut hin chng khng: vi nhng khng do
t bin th phi hp khng sinh s lm gim xc sut xut hin mt t bin
kp. V d: xc sut t bin khng streptomycin l 10-7 v t bin khng
rifampicin l 10-9, th xc sut t bin khng c 2 khng sinh ny l 10-16.
y chnh l l do phi phi hp khng sinh trong iu tr lao v phong; ngoi ra
cn p dng cho mt s bnh phi iu tr ko di nh vim mng trong tim v
vim ty xng.
- iu tr nhim khun do nhiu loi vi khun gy ra, v d do c vi khun
hiu kh v k kh th phi hp beta-lactam vi metronidazol nh trng hp
vim phc mc, p xe no, p xe phi, mt s nhim khun ph khoa Nh vy
mi khng sinh dit mt loi vi khun, phi hp khng sinh s dit nhiu loi vi
khun hn.
- Lm tng kh nng dit khun: v d sulfamethoxazol & trimethoprim
(trong Co-trimoxazol) tc ng vo 2 im khc nhau trong qu trnh sinh tng
hp acid folic hoc cp phi hp kinh in beta-lactam (penicilin hoc
cephalosporin) vi aminoglycosid (gentamicin hoc tobramycin hay amikacin).
b) Kt qu ca phi hp khng sinh
Mi khng sinh u c t nhiu tc dng khng mong mun; khi phi hp
th nhng tc dng ph ny cng s cng li hoc tng ln. Khng nn hy vng
phi hp th h c liu lng tng thuc v c th dn n nguy c xut hin
vi khun khng khng sinh.
Phi hp khng sinh c th dn n tc dng cng (addition) hoc hip
ng (synergism) hoc i khng (antagonism) hay khng thay i
(indifference) so vi 1 thuc n l.
- Tc dng i khng: 2 m tc dng khng bng 1 thuc.
B Y t | C CH TC DNG CA KHNG SINH V PHI 36
HP KHNG SINH

+ Phi hp cc khng sinh c cng mt ch tc ng s c tc dng i


khng v chng y nhau ra khi ch, v d phi hp erythromycin vi
clindamycin (hoc lincomycin) v cloramphenicol.
+ Dng tetracyclin cng penicilin c th dn n tc dng i khng, v
penicilin c tc dng tt trn nhng t bo ang nhn ln, trong khi tetracyclin
li c ch s pht trin ca nhng t bo ny.
- Tc dng hip ng (n gin ha c th ni: 1+1 ln hn 2):
+ Trimethoprim v sulfamethoxazol c ch 2 chng khc nhau trn cng
mt con ng tng hp coenzym acid folic cn thit cho vi khun pht trin
nn 2 thuc ny c tc dng hip ng v c phi hp thnh mt sn phm
(Co-trimoxazol).
+ Cp phi hp kinh in: mt beta-lactam vi mt aminoglycosid cho
kt qu hip ng do beta-lactam lm mt vch to iu kin cho aminoglycosid
d dng xm nhp vo t bo v pht huy tc dng. V d phi hp piperacilin
vi aminoglycosid iu tr nhim khun nng do trc khun m xanh; penicilin
vi gentamicin nhm dit lin cu.
+ Phi hp penicilin vi mt cht c ch beta-lactamase gip cho
penicilin khng b phn hy v pht huy tc dng; v d phi hp amoxicilin vi
acid clavulanic hoc ampicilin vi sulbactam hay ticarcilin vi acid clavulanic.
Acid clavulanic hoc sulbactam n c khng c tc dng ca mt khng sinh,
nhng c i lc mnh vi beta-lactamase do plasmid ca t cu v nhiu trc
khun ng rut sinh ra.
+ Phi hp 2 khng sinh cng c ch sinh tng hp vch vi khun, nu
mi khng sinh tc ng vo mt protein gn penicilin (PBP) - enzym trong qu
trnh tng hp vch th s c tc dng hip ng; v d phi hp ampicilin (gn
PBP1) vi mecilinam (gn PBP2) hay ampicilin vi ticarcilin.
c) Ch dn chung cho phi hp khng sinh
- Phi hp khng sinh l cn thit cho mt s t trng hp nh iu tr
lao, phong, vim mng trong tim, Brucellosis.
- Ngoi ra, c th phi hp khng sinh cho nhng trng hp: bnh nng
m khng c chn on Vi sinh hoc khng ch c kt qu xt nghim; ngi
suy gim sc khng; nhim khun do nhiu loi vi khun khc nhau.
- Khi phi hp, cn dng liu v nn la chn nhng khng sinh c
tnh cht dc ng hc gn nhau hoc c tc dng hip ng. Tc dng khng
khun in vivo (trong c th) thay i ty theo s lng v tui (non - ang sinh
sn mnh hay gi) ca vi khun gy bnh cng nh cc thng s dc ng hc
ca cc khng sinh c dng phi hp.
- Mt s v d: nhim khun nng do t cu c th dng cc phi hp
khc nhau nh oxacilin (hoc flucloxacilin) vi acid fusidic hoc cephalosporin
th h 1 vi aminoglycosid hoc aminoglycosid vi clindamycin. Khi nhim vi
B Y t | C CH TC DNG CA KHNG SINH V PHI 37
HP KHNG SINH

khun k kh th dng metronidazol phi hp cha vim phc mc hay cc


nhim khun bng; nu nghi nhim vi khun k kh vng u v ng h
hp th dng cng clindamycin (khng sinh ny c tc dng tt trn c vi khun
Gram-dng v vi khun k kh).
- Quan st in vivo cho thy phn ln cc phi hp khng sinh c kt qu
khng khc bit (indifferent) so vi dng mt khng sinh, trong khi cc tc
dng khng mong mun do phi hp li thng gp hn; v vy cn thn trng
v gim st tt ngi bnh khi k n khng sinh.

B Y t | C CH TC DNG CA KHNG SINH V PHI 38


HP KHNG SINH

KHI NIM DC NG HC/DC LC HC


(PK/PD) V NG DNG
1. MT S KHI NIM LIN QUAN TI PK/PD CA KHNG SINH
Ch s lin kt c tnh dc ng hc (Pharmacokinetics) v dc lc
hc (Pharmacodynamics), k hiu l PK/PD, c p dng nng cao tnh
hiu qu v an ton khi s dng khng sinh. i vi cc khng sinh, cc nghin
cu trc y thng ch tp trung vo c tnh dc lc hc ngha l kh nng
c ch hoc tiu dit vi khun in vitro, t xc nh cc gi tr MIC/MBC nng ti thiu c ch hoc dit vi khun, lm c s cho la chn cc mc
liu. Cc gi tr MIC/MBC l cc ch s rt quan trng phn nh hot lc ca
khng sinh i vi vi khun nhng cc tr s ny n thun t nghin cu in
vitro, khng d on hot tnh y ca khng sinh trn lm sng. Hiu
qu khng khun trn lm sng ph thuc nhiu vo din bin nng thuc
trong c th ngi bnh tc l vo c tnh dc ng hc ca khng sinh. Cc
ch s PK/PD ca khng sinh c thit lp trn c s nng thuc trong
huyt tng (gi tr u vo ca dc ng hc) v nng c ch ti thiu (gi
tr u vo ca dc lc hc), nh phn nh chnh xc hn hiu qu ca
thuc in vivo, khc phc c hn ch trn.
Cc thng s xc nh hot tnh khng khun in vitro
a) MIC v MBC
- MIC (Minimum Inhibitory Concentration) l nng ti thiu ca
khng sinh c tc dng c ch s tng trng ca vi khun mc c th quan
st c; MBC (Minimum Bactericidal Concentration) l nng ti thiu cn
thit tiu dit vi khun. y l cc thng s ch yu c s dng xc
nh hot tnh khng khun in vitro i vi cc chng vi khun. Khi t l
MBC/MIC > 4, khng sinh c tc dng km khun, cn khi t l ny bng 1,
khng sinh c tc dng dit khun. Khng sinh km khun thng c s dng
trong nhng trng hp nhim khun nh v trung bnh, trn c a ngi
bnhngi bnh c sc khng. Cc nhm khng sinh c tc dng km
khun l: macrolid, tetracyclin, phenicol, lincosamid. Khng sinh dit khun
c dng cho cc nhim khun nng, trn nhng ngi bnhngi bnh yu,
suy gim min dch. Cc nhm khng sinh c tc dng dit khun l: betalactam, aminoglycosid, fluoroquinolon, 5-nitro-imidazol, co-trimoxazol.
- MIC v MBC c xc nh ngoi c th (in vitro) nn cc iu kin tc
ng ln vi khun c nhiu khc bit vi iu kin nhim khun trn lm sng,
v d:
+ iu kin nui cy vi khun in vitro thng l hiu kh, vi mi trng
lng c nng protein thp v pH 7,2 trong khi iu kin ti v tr nhim
khun trong c th li a phn l mi trng k kh, c pH acid v ti y thuc
c th dng lin kt vi protein ca t chc.
B Y t | KHI NIM DC NG HC/DC LC HC 39
(PK/PD) V NG DNG

+ Thi gian xc nh MIC v MBC l c nh k t khi m (thng l


t 18-24 gi) v nng khng sinh cng khng i trong sut qu trnh nui
cy trong khi nng ny bin i lin tc trong c th.
+ Mt vi khun a vo nui cy thng c nh mc 105 CFU/ml,
v thng khng ging vi mt vi khun m nhim khun (thng t 1081010 CFU/g m hoc m) v vic nui cy in vitro cng to ra s tng trng vi
khun theo hm m, khc vi iu kin nhim khun trn lm sng, ch yu l
vi khun khng tng sinh v thng phi hp vi tc dng hu khng sinh (postantibiotic effect = PAE) ngha l kh nng c ch s pht trin ca vi khun k
c khi khng cn khng sinh ti nhim khun.
Nh vy MIC v MBC xc nh in vitro n thun khng d on y
c hot tnh ca khng sinh trn lm sng, ni m hot tnh khng khun ph
thuc vo din bin nng thuc theo thi gian.
b) Tc dng hu khng sinh - PAE (Post-Antibiotic Effect):
- Tc dng hu khng sinh l mt thng s dc lc hc ca khng sinh.
n v ca PAE c tnh theo n v thi gian (gi hoc pht). PAE c th
c xc nh trong m hnh in vitro hoc in vivo. PAE in vitro l thut ng m
t tc dng c ch s tng sinh vi khun sau khi vi khun tip xc vi khng
sinh trong thi gian ngn. PAE in vitro phn nh thi gian cn thit vi khun
hi phc v s lng sau khi tip xc vi khng sinh v c chng minh bi
cc nghin cu in vitro s dng m hnh ng hc tng trng ca vi khun sau
khi loi b khng sinh. C ch ca PAE c th l: (1) vi khun b khng sinh
tc ng nhng ch b thng tn cu trc t bo v sau c th hi phc li
m khng b tiu dit; (2) khng sinh vn duy tr v tr gn hoc trong khoang
bo tng v (3) vi khun cn thi gian tng hp enzym mi trc khi tng
trng tr li.
- Nhc im ca nh gi PAE in vitro l gi tr ny c xc nh khi
khng c c ch phng v ca vt ch, do c nhng phng php xc nh
PAE in vivo trn m hnh nhim khun trn ng vt. Trn m hnh in vivo,
PAE phn nh s khc bit v thi gian mt lng vi khun tng thm 10 ln
nhm th (ng vt c iu tr) so vi thi gian tng ng ca nhm
chng, tnh t lc nng thuc huyt tng hoc m nhim khun gim
xung di MIC.
Trong phn ln cc trng hp, PAE in vivo ko di hn cc PAE in vitro
do c tc dng ca cc nng di MIC hoc c s tham gia ca bch cu v
nh vy PAE di hay ngn ph thuc vo c tnh ca khng sinh v loi vi
khun. Mt s loi khng sinh c th lm tng kh nng thc bo ca cc i
thc bo trong c th vt ch, lm cho vi khun d b tiu dit hn (cc
macrolid, penem, fluoroquinolon), iu ny cng lm tng PAE. c tnh ny
cn c gi l PALE (Post-Antibiotic Leucocyt Enhancement Effect). Chnh v
vy, PAE in vitro thng ngn hn PAE in vivo. Thc t th tt c cc khng
B Y t | KHI NIM DC NG HC/DC LC HC 40
(PK/PD) V NG DNG

sinh u c PAE nhng nu thi gian ko di khng ng k trong iu kin in


vitro v khng c li th v lin kt mnh vi protein huyt tng hoc khng
c PALE th PAE coi nh khng ng k. Theo c tnh dc lc hc ny,
khng sinh c chia lm 2 loi:
+ Loi khng c PAE hoc PAE rt ngn:
Tiu biu cho loi ny l cc khng sinh beta-lactam. Ngi ta cho rng
s d beta-lactam khng c PAE v c ch tc dng dit khun lin quan n s
bin dng v v v t bo vi khun, ch xy ra khi vi khun c tip xc vi
khng sinh.
+ Loi c PAE trung bnh hoc ko di:
Tiu biu cho loi c PAE di l cc khng sinh nhm aminoglycosid,
rifampicin, fluoroquinolon, glycopeptid, tetracyclin v imidazol. Mt s khng
sinh khc cng c c tnh ny l cc macrolid, carbapenem, lincosamid nhng
ngn hn. Vi aminoglycosid s d c PAE di l do c ch c ch tng hp
protein ca vi khun ko di to kh nng ngn cn ko di s pht trin tr li
ca vi khun sau khi khng cn tip xc vi khng sinh na. Vi mt s khng
sinh khc th PAE c c l nh c PALE hoc nh kh nng gn mnh vi
protein ti t chc hoc do phn b mnh t bo vi khun.
c) c tnh dit khun ca khng sinh
- y l c tnh c lin quan n nng thuc trong mu, theo
khng sinh c hai kiu tc dng chnh:
+ Kiu dit khun ph thuc nng (Concentration-dependent
bactericidal activity):
Vi loi ny, tc v mc dit khun ph thuc vo ln ca nng
khng sinh trong mu. Aminoglycosid, fluoroquinolon, daptomycin, ketolid,
metronidazol, amphotericin B c kiu dit khun ny.
+ Kiu dit khun ph thuc thi gian: (Time-dependent bactericidal
activity):
Vi loi ny, tc v mc dit khun ph thuc ch yu vo thi
gian vi khun tip xc vi khng sinh, t ph thuc vo ln ca nng
thuc trong mu. Kh nng dit khun t bo ha khi nng ln hn MIC
khong 4 ln; khi tng hn na nng , tc v mc dit khun tng
khng ng k. Nhm beta-lactam, macrolid, clindamycin, glycopeptid,
tetracyclin, linezolid c kiu dit khun thuc nhm ny.

B Y t | KHI NIM DC NG HC/DC LC HC 41


(PK/PD) V NG DNG

Bng I.6. Phn loi khng sinh lin quan n c tnh dc lc hc


Khng c PAE hoc PAE ngn

C PAE trung bnh hoc ko di


Aminosid

Cc Penicilin

Imidazol

Cc Cephalosporin

Fluoroquinolon

Monobactam (Aztreonam)

Glycopeptid
Macrolid
Tetracyclin
Carbapenem
Lincosamid

- Cc kiu dit khun khc nhau c gii thch nh Hnh I-1.

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

vi khun (PD). T cc nghin cu in vitro, c ba ch s PK/PD lin quan n tc


dng ca khng sinh, l:
+ T>MIC: thi gian nng khng sinh duy tr mc cao hn MIC.
+ Cpeak/MIC: T l gia nng nh ca khng sinh v MIC.
+ AUC0-24/MIC: T l din tch di ng cong nng - thi gian
trong 24 gi v MIC (Bng I.7).
Bng I.7. Phn loi khng sinh theo ch s PK/PD
Phn loi khng sinh

Nhm i din

Ch s PK/PD lin quan


n hiu qu

Khng sinh dit khun ph thuc thi Beta-lactam


gian v c tc dng hu khng sinh
ngn hoc khng c

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

Hnh I-2. Cc ch s PK/PD

- Trong nghin cu in vitro hoc in vivo trn ng vt, cc nhm khng


sinh c nghin cu nhiu nht v ln ca cc ch s PK/PD l nhm khng
sinh beta-lactam, fluoroquinolon v aminoglycosid.
+ Vi nhm khng sinh aminoglycosid:
Da trn cc nghin cu in vitro, hot tnh dit khun ti u ca nhm
khng sinh ny t c khi Cpeak/MIC khong 8-10.
+ Nhm beta-lactam:

B Y t | KHI NIM DC NG HC/DC LC HC 43


(PK/PD) V NG DNG

T>MIC l ch s d bo hiu qu iu tr ca nhiu khng sinh nhm


beta-lactam. Vi penicilin v cephalosporin, T>MIC cn chim 40-50% khong
cch a thuc. Vi carbapenem, tc dng km khun v tc dng dit khun
gn t ti a khi T>MIC ln lt l 20% v 40%.
+ Nhm fluoroquinolon: Ch s PK/PD lin quan vi hiu qu ca
fluoroquinolon l AUC0-24/MIC. ln ca ch s ny to ra hiu qu km
khun trn m hnh nhim khun trn ng vt l t 25-50, thay i i vi cc
chng gy bnh thng gp. Trn lm sng, gi tr AUC0-24/MIC ca khng sinh
nhm quinolon cho d bo hiu qu iu tr tt khc bit gia cc nghin cu v
thng trn 100-125 i vi cc nhim khun Gram-m v trn 30 i vi vi
khun Gram-dng. ng thi ch s Cpeak/MIC t 8-10 cng d bo hiu qu
iu tr tt vi nhm khng sinh ny.
b) ng dng ch s PK/PD thit k ch liu iu tr:
- T nhng khuyn co trn, ngi ta xut cc mc liu dng cho c
cc khng sinh c v mi, c bit c ch vi cc chng khng, khi cc mc
liu thng thng khng c hiu qu. ti u ha iu tr, tng kh nng t
ch s PK/PD khuyn co, trong mt s trng hp, phi thay i ch liu
ca khng sinh v s thay i ny c p dng ch yu cho nhng trng hp
sau:
+ Ngi bnhNgi bnh c thay i thng s dc ng hc ca khng
sinh (ngi bnhngi bnh khoa iu tr tch cc, ngi bnhngi bnh bng
nng, bo ph, tiu ng, ngi bnhngi bnh suy gan, suy thn, ngi gi,
tr s sinh v tr nh...). y l nhng trng hp c thay i dc ng hc
(PK) dn n thay i nng thuc trong mu. Lc ny vic hiu chnh liu
ca thuc s c tnh ton da vo cc cng thc hiu chnh theo thng s
dc ng hc ca c th ngi bnhngi bnh hoc da vo dc ng hc
qun th v cn gim st iu tr thng qua theo di nng thuc trong mu
(Therapeutic Drug Monitoring TDM).
+ Ngi bnhNgi bnh mc cc bnh l nhim khun nng do cc
chng vi khun khng thuc: nhim khun huyt do trc khun m xanh, vim
phi bnh vin do trc khun Gram-m, nhim khun trn ngi bnhngi
bnh c dng c nhn to.... Nhng trng hp ny MIC tng cao nn mc liu
dng thng thng khng p ng hiu qu iu tr, do cn tng liu. Vic
tng liu nhm t ch s PK/PD khuyn co.
- Cho n nay, cc phng php ti u ha ch liu nhm gia tng hiu
qu iu tr ca khng sinh, gia tng kh nng t c ch s PK/PD trong iu
kin c gia tng tnh khng ca cc nhm khng sinh c tp trung ch yu vo
2 nhm khng sinh beta-lactam v aminoglycosid.
c) ng dng ch s PK/PD ngn nga khng thuc:
- ngn nga t bin khng thuc quan trng l m bo nng
thuc trong mu ph hp c c Cpeak/MIC v AUC/MIC nh mong
B Y t | KHI NIM DC NG HC/DC LC HC 44
(PK/PD) V NG DNG

mun. Cc nghin cu cho thy cc gi tr PK/PD cn t c ngn nga


chng t bin thng cao hn gi tr t hiu qu iu tr.
- V AUC/MIC:
+ Khi nghin cu ch s AUC/MIC ca khng sinh nhm quinolon, mt
s nghin cu ch ra rng c th hn ch khng thuc bng cch tng ch s ny:
ch s AUC/MIC t gi tr 100 ngn chn t bin khng thuc, trong khi
nu ch s ny t 25-100 th c coi l nm trong ca s chn lc khng thuc.
Tuy nhin, mt nghin cu in vitro khc cho thy AUC/MIC l 52 s lm gia
tng chng khng, trong khi ch s ny t gi tr 157 th khng thy xut hin
chng khng.
+ Mt s nghin cu in vitro cng chng minh liu thp ko di ca
vancomycin vi AUC/MIC < 250 c lin quan n s pht trin khng ca
cc chng S. aureus nhm II khng c gen iu ha agr, tuy nhin liu 750mg
hoc 1g tng ng vi t s AUC/MIC l 382 hoc 510 khng cho thy s thay
i trong tnh khng ca chng t cu ny. D liu ny cng ch ra kh nng to
chng t bin do dng liu thp ko di vancomycin.
+ Tuy nhin gi tr AUC/MIC ngn nga chng khng cha thng nht
gia cc nghin cu v cn thm cc nghin cu lm sng khng nh gi tr
ny.
- V Cpeak/MIC:
+ Mt s nghin cu in vitro cho thy ch s Cpeak/MIC < 8 i vi cc
quinolon c coi l mt yu t nguy c gy pht trin cc chng vi khun
Gram-m khng khng sinh cn khi Cpeak/MIC >10 li c kh nng c ch
qun th t bin khng thuc v ngn nga t vong do pht trin chng khng
trong iu tr.
+ Cc nghin cu in vitro vi enoxacin v netilmicin cng cho thy nu
Cpeak/MIC < 8 c kh nng lm tng s chng vi khun t bin khng thuc.
+ Nh vy, cc nghin cu cho thy Cpeak/MIC thc s c vai tr tc
ng n khng thuc trong liu trnh iu tr. Tuy nhin, gi tr ti u ca ch
s ny rt khc bit gia cc nhm khng sinh v tu thuc vo tng cp khng
sinh vi khun. Do vy, cn thm cc nghin cu lm r mi lin quan ca
cc c ch khng khc nhau vi cc thng s ng hc ca thuc p dng ti
u cc m hnh dc lc hc trong lnh vc ny.

B Y t | KHI NIM DC NG HC/DC LC HC 45


(PK/PD) V NG DNG

CC NGUYN TC S DNG KHNG SINH


1. LA CHN KHNG SINH V LIU LNG
- La chn thuc khng sinh ph thuc hai yu t: ngi bnhngi bnh
v vi khun gy bnh. Yu t lin quan n ngi bnhngi bnh cn xem xt
bao gm: la tui, tin s d ng thuc, chc nng gan thn, tnh trng suy
gim min dch, mc nng ca bnh, bnh mc km, c a d ng Nu l
ph n: cn lu i tng ph n c thai, ang cho con b cn nhc li
ch/nguy c. V vi khun: loi vi khun, nhy cm vi khng sinh ca vi
khun. Cn cp nht tnh hnh khng khng sinh c la chn ph hp. Cn
lu cc bin php phi hp lm gim mt vi khun v tng nng
khng sinh ti nhim khun nh lm sch m, dn lu, loi b t chc hoi
t khi cn.
- Chnh sch k n khng sinh nhm gim t l pht sinh vi khun khng
thuc v t c tnh kinh t hp l trong iu tr. Vi nhng khng sinh mi,
ph rng, ch nh s phi hn ch cho nhng trng hp c bng chng l cc
khng sinh ang dng b khng.
- Liu dng ca khng sinh ph thuc nhiu yu t: tui ngi bnhngi
bnh, cn nng, chc nng gan thn, mc nng ca bnh. Do c im khc
bit v dc ng hc, liu lng cho tr em, c bit l tr s sinh v nh nhi
c hng dn ring theo tng chuyn lun. Liu lng trong cc ti liu hng
dn ch l gi ban u. Khng c liu chun cho cc trng hp nhim khun
nng. K n khng liu s dn n tht bi iu tr v tng t l vi khun
khng thuc. Ngc li, vi nhng khng sinh c c tnh cao, phm vi iu tr
hp (v d: cc aminoglycosid, polypeptide), phi bo m nng thuc trong
mu theo khuyn co trnh c tnh, do vy, vic gim st nng thuc
trong mu nn c trin khai.
2. S DNG KHNG SINH D PHNG
- Khng sinh d phng (KSDP) l vic s dng khng sinh trc khi xy
ra nhim khun nhm mc ch ngn nga hin tng ny.
- KSDP nhm gim tn xut nhim khun ti v tr hoc c quan c
phu thut, khng d phng nhim khun ton thn hoc v tr cch xa ni c
phu thut [10].
a) Ch nh s dng KSDP (Ph lc 2, 3):
- Phu thut c chia lm 4 loi: Phu thut sch, phu thut sch
nhim, phu thut nhim v phu thut bn (theo ph lc).
- KSDP c ch nh cho tt c cc can thip phu thut thuc phu thut
sch nhim.

B Y t | CC NGUYN TC S DNG KHNG SINH 46

-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

- Cephalosporins tim tnh mch trong 3 5 pht ngay trc th thut v


t nng cn thit da sau vi pht.
- Vancomycin v ciprofloxacin cn phi c dng trc MT GI v
HON THNH vic truyn trc khi bt u rch da.
- Clindamycin cn c truyn xong trc 10 20 pht.
- Gentamicin cn c dng 1 liu duy nht 5 mg/kg ti a ha s
thm vo m v gim thiu c tnh. Nu ngi bnhngi bnh lc mu hoc
ClCr < 20 ml/pht, dng liu 2 mg/kg.
- i vi phu thut m ly thai, KSDP c th dng trc khi rch da
hoc sau khi kp dy rn gim bin chng nhim khun m.
- B sung liu trong thi gian phu thut:
+ Trong phu thut tim ko di hn 4 gi, cn b sung thm mt liu
khng sinh.
+ Trong trng hp mt mu vi th tch trn 1500ml ngi ln, v trn
25ml/kg tr em, nn b sung liu KSDP sau khi b sung dch thay th.
g) Lu khi s dng KSDP:
- Khng dng khng sinh d phng cho cc nhim khun lin quan n
chm sc sau m v nhng nhim khun xy ra trong lc m.
- Nguy c khi s dng KSDP:
+ D ng thuc.
+ Sc phn v.
+ Tiu chy do khng sinh.
+ Nhim khun do vi khun Clostridium difficile.
+ Vi khun khng khng sinh.
+ Ly truyn vi khun a khng.
3. S DNG KHNG SINH IU TR THEO KINH NGHIM
- iu tr khng sinh theo kinh nghim khi cha c bng chng v vi khun
hc do khng c iu kin nui cy vi khun (do khng c Labo vi sinh, khng
th ly c bnh phm), hoc khi nui cy m khng pht hin c nhng
c bng chng lm sng r rt v nhim khun.
- Phc s dng khng sinh theo kinh nghim l la chn khng sinh c
ph hp nht gn vi hu ht cc tc nhn gy bnh hoc vi cc vi khun nguy
him c th gp trong tng loi nhim khun.
- Khng sinh phi c kh nng n c v tr nhim khun vi nng
hiu qu nhng khng gy c.
- Trc khi bt u iu tr, c gng ly mu bnh phm phn lp vi
khun trong nhng trng hp c th iu chnh li khng sinh ph hp hn.

B Y t | CC NGUYN TC S DNG KHNG SINH 48

- Nn p dng mi bin php pht hin nhanh vi khun khi c th (Xem


Chng II. i cng v vi khun hc) c c c s ng n trong la
chn khng sinh ngay t u.
- Nu khng c bng chng v vi khun sau 48 gi iu tr, cn nh gi li
lm sng trc khi quyt nh tip tc s dng khng sinh.
- Cn thng xuyn cp nht tnh hnh dch t v nhy cm ca vi khun
ti a phng la chn c khng sinh ph hp.
4. S DNG KHNG SINH KHI C BNG CHNG VI KHUN HC
- Nu c bng chng r rng v vi khun v kt qu ca khng sinh ,
khng sinh c la chn l khng sinh c hiu qu cao nht vi c tnh thp
nht v c ph tc dng hp nht gn vi cc tc nhn gy bnh c pht hin.
- u tin s dng khng sinh n c.
- Phi hp khng sinh ch cn thit nu:
+ Chng minh c nhim ng thi nhiu loi vi khun nn cn phi hp
mi ph tc dng (c bit nhng trng hp nghi ng c vi khun k kh
hoc vi khun ni bo).
+ Hoc khi gp vi khun khng thuc mnh, cn phi hp tng thm tc
dng.
+ Hoc khi iu tr ko di, cn phi hp gim nguy c khng thuc (v
d: iu tr lao, HIV).
5. LA CHN NG A THUC
- ng ung l ng dng c u tin v tnh tin dng, an ton v gi
thnh r. Cn lu la chn khng sinh c sinh kh dng cao v t b nh hng
bi
thc
n
(

B Y t | CC NGUYN TC S DNG KHNG SINH 49

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.

B Y t | CC NGUYN TC S DNG KHNG SINH 50

Bng I.8. Sinh kh dng ca mt s khng sinh ng ung


Sinh kh dng
(%)

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

Ghi ch: Gim hp thu

Khng nh hng hoc nh hng khng ng k

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

Nhng ni dung chnh trong cc nguyn tc trn c tm tt thnh nguyn tc


MINDME (Bng I.10).

B Y t | CC NGUYN TC S DNG KHNG SINH 52

Bng I.10. Nguyn tc MINDME trong s dng khng sinh


M

Microbiology guides wherever


possible

Theo ch dn vi khun hc bt k khi no c


th

Indication should be evidence-based

Ch nh phi cn c trn bng chng

Narrowest spectrum required

La chn ph hp nht cn thit

Dosage appropriate to the site and


type of infection

Liu lng ph hp vi loi nhim khun v


v tr nhim khun

Minimum duration of therapy

Thi gian iu tr ti thiu cho hiu qu

Ensure monotherapy in most situation Bo m n tr liu trong hu ht cc


trng hp

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.

B Y t | CC NGUYN TC S DNG KHNG SINH 53

10. Eugnie Bergogne-Brzin Pierre Dellamonica; (2004), Antibiothrapie en practique


clinique.
11. Network Scottish Intercollegiate Guidelines, Antibiotic prophylaxis in surgery. 2014

B Y t | CC NGUYN TC S DNG KHNG SINH 54

B Y t | CC NGUYN TC S DNG KHNG SINH 55

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

- Hiu kh bt buc (obligate aerobe): c oxy mi pht trin tt, v d trc


khun m xanh, phy khun t
- K kh bt buc (obligate anaerobe): ch pht trin c trong iu kin
hon ton hoc gn nh hon ton khng c oxy; thm ch gp oxy t do l cht,
v d trc khun un vn, hoi th sinh hi, Bacteroides
- Hiu k kh ty tin (facultative anaerobe): pht trin c c khi c hay
khng c oxy, v d cc trc khun ng rut (E. coli, thng hn, l) t
cu, lin cu
- Vi hiu kh (microaerophile): cn mt lng nh O2 v nhiu CO2 hn,
v d lu cu, ph cu, trc khun Haemophilus influenzae
2. CU TO T BO VI KHUN

Hnh I-3. S cu to t bo vi khun

- Bn thnh phn cu to quan trng t ngoi vo trong ca t bo vi


khun l:
+ Vch (cell wall): b khung murein ca vch l do peptidoglycan to
thnh. vi khun Gram-dng b khung ny gm nhiu lp peptidoglycan xp
ln nhau; Gram-m ch l 1 lp peptidoglycan nhng li c 1 mng ngoi
c cu to phc tp bao bc. Vch c nhim v: to hnh dng & bo v c hc
cho t bo v tham gia vo qu trnh sinh sn (nhn ln) ca t bo.
+ Mng bo tng (plasma membrane) c chc nng thm thu chn lc.
+ Bo tng vi rt nhiu ribosome l ni sinh tng hp protein - cc
enzym v thnh t thit yu cho qu trnh sinh trng v pht trin ca t bo.
+ Acid nucleic gm nhim sc th - vng nhn (ADN) v cc phn t
ADN ngoi nhn (plasmid); ADN cha mt m di truyn (gen) qui nh cc c
tnh ca t bo. Plasmid c th t truyn c cc gen ca n t t bo ny sang
t bo khc. ng lu l: trn nhim sc th v plasmid c th tn ti

B Y t | I CNG V VI KHUN HC 59

transposons gen nhy (on ADN c th nhy t nhim sc th vo plasmid


v ngc li hoc t plasmid ny sang plasmid khc).
- Bn thnh phn cu to c bn nu trn cng chnh l 4 v tr tc ng
ca thuc khng sinh trn t bo vi khun.
3. H VI KHUN C TH NGI BNH THNG
a) Vi h bnh thng ngi
- Khi nim:
+ Nhng qun th vi sinh vt c tr trn da v nim mc cc hc t nhin
ca c th ngi gi l vi h bnh thng (normal microflora normal
microbiota). Hu ht nhng qun th vi sinh vt l vi khun nn ngi ta cn
gi chng l h vi khun bnh thng (normal bacteriaflora).
+ Trn da v nim mc cc hc t nhin - khoang rng c tip xc vi
mi trng bn ngoi ca c th nh ming, mi, hng, m o, lun c rt
nhiu vi sinh vt c tr; n bao gm: nhng vi sinh vt c mt thng xuyn
(resident) ti v nhng vi sinh vt ch c mt thong qua (transient). Mt s
phn ca c th nh mu, dch no ty, cc m, cc c quan ni tng do cu
trc v hng ro min dch, iu kin bnh thng hon ton khng c vi sinh
vt.
- S lng: ty tng v tr trn c th m s lng v chng loi vi sinh
vt c khc nhau (Hnh I-4).
+ S lng cc loi v s lng c th ca tng loi vi khun thuc vi h
bnh thng ti mi a im thng khng c nhn nhn ng. Trong thc
t, v d da c ti 106/cm2; trong khoang ming c ti 109/ml nc bt; i
trng c ti 1011/gam phn kh v trong dch m o c ti 107/ml dch. S
lng vi khun trong t trng (duodenum) v hng trng (jejunum) c t hn, ch
khong <104/ml v ch yu l Streptococcus v Lactobacteria.
+ V s lng vi khun k kh so vi vi khun hiu kh: ch no vi
khun k kh cng nhiu hn. V d, t l vi khun k kh/vi khun hiu kh l
10/1 da, b phn sinh dc (ngoi), m o, ng tiu di; l 30/1 nim
mc ming v 100-1000/1 i trng.
+ Trong cuc sng chung, cc loi vi khun hiu kh s dng oxy to ra
mi trng vi kh hu thun li cho cc vi khun k kh; vi khun k kh pht
trin li cung cp cho vi khun hiu kh nhng sn phm chuyn ha cn thit,
to ra s hip ng vi sinh (microbial synergism). Bng nhiu c ch khc nhau,
trong iu kin bnh thng cc qun th vi sinh vt sinh sng v pht trin
trng thi cn bng sinh hc ti ni c tr (Hnh I-4).

B Y t | I CNG V VI KHUN HC 60

Hnh I-4. Vi h bnh thng c th ngi

b) Vai tr ca vi h bnh thng


- Nhng vi sinh vt lun c tr trn b mt ca c th l nhng vi sinh vt
hi sinh (commensal), chng khng hn c li v cng khng hn c hi. Chng
sinh sn nhiu hay t ph thuc vo nhiu yu t sinh l khc nhau nh nhit ,
m v mt s cht dinh dng hay c ch nht nh. Cho s sng ca c th
th khng quan trng, nhng mt s vng ca c th th vi h bnh thng
ng vai tr nht nh trong vic gi thng bng cho sc khe v chc nng
bnh thng ca c th.
- trong ng rut, cc thnh vin ca vi h sinh tng hp vitamin K v
h tr cho vic hp thu thc n. Trn nim mc v da, cc vi sinh vt c tr
thng xuyn c tc dng ngn cn s tn ti v xm ln ca vi sinh vt gy
bnh, c th do c ch cnh tranh sinh hc.
- bt k ni c tr no cng tn ti nhng vi sinh vt c th gy bnh
(facultative pathogen) khi c c hi, l khi mi trng thay i hoc do b
B Y t | I CNG V VI KHUN HC 61

chn thng v chng xm nhp c vo m hoc vo mu. V d, lin cu c


tr hng v ng h hp trn; nhng khi mt s lng ln vi khun vo mu
(do tn thng ti ch) c th gy bnh vim ni tm mc (endocarditis).
Bacteroides l c dn i trng th v hi, nhng nu chng xm nhp vo
bng hoc do chn thng chng cng cc vi khun khc xm nhp vo m s
gy nn nhng nhim khun c m v c th dn n nhim khun mu.
- Nh vy, cc vi sinh vt thuc vi h bnh thng cn c coi l nhng
tc nhn gy bnh c hi (opportunistic pathogens). Cn ch iu ny chn
khng sinh ph hp khi dng khng sinh d phng trong cc phu thut sch; v
d: t da, vi khun ng hng u c th gy nhim khun sau m l t cu
vng th ta chn cephalosporin th h 1; t ng tiu ha, thng l do cc trc
khun Gram-m (h Enterobacteriaceae) th chn cephalosporin th h 3.
- ng lu : mi mt iu tr bng khng sinh l mt ln tc ng vo s
cn bng ca vi h bnh thng: vi khun nhy cm b tiu dit, di p lc
chn lc, nhng vi sinh vt khng khng sinh (ang s dng) c gi li,
sinh sn mnh (qu sn) thay th nhng vi khun b tiu dit, lm mt cn
bng cho i sinh vt c th ngi. Mt cn bng trong vi h bnh thng cng
c th pht trin thnh bnh, v d ri lon tiu ha sau khi dng khng sinh ph
rng ng ung di ngy hoc vim i trng gi mc do Clostridium difficile
hoc b vim m o do nm sau khi t khng sinh khng khun di ngy.
Kt lun: ch dng thuc khng khun khi c nhim khun do vi khun
gy ra v phi gim st din bin ngi bnh trong qu trnh iu tr bng
khng sinh (khng ch theo di hiu qu dit vi khun gy bnh m cn c
nhng nh hng khng mong mun ca thuc ti c th & vi h bnh thng)!

B Y t | I CNG V VI KHUN HC 62

VAI TR CA VI SINH LM SNG VI


S DNG KHNG SINH HP L
I. MT S KHI NIM
Nhim khun nhim vi sinh vt, trong c nhim khun vn ang l
bnh hay gp nc ta. iu tr bnh nhim khun chng ta hin ang c rt
nhiu sn phm thuc khng khun (antibacterial antibiotics) trn th trng.
Nhm s dng khng sinh hp l cho tng ngi bnh bc s iu tr cn bit r
tc nhn/vi khun gy bnh l g v nhy cm ca chng vi khng sinh ra
sao c th la chn c loi thuc c tc dng tt nht trn vi khun gy
bnh v t gy tc dng khng mong mun nht cho ngi bnh .
Xt nghim Vi sinh y hc phc v cho chn on v iu tr ti cc bnh
vin, gi l Vi sinh lm sng. Khng nhng th, kt qu xt nghim Vi sinh cn
gip ch cho vic phng bnh, c bit quan trng l nhim khun bnh vin.
Khng sinh iu tr (antibiotic therapy) l a khng sinh vo c th nhm
dit vi khun gy bnh trong c th; nh vy xut hin mi quan h c tc dng
qua li ca 3 yu t: c th, vi khun v khng sinh.
- C th (kh nng chng ca c th; bao gm: h min dch dch th
v min dch t bo).
- Vi khun gy bnh (s lng, c lc v ng xm nhp).
- Khng sinh (ph tc dng, ng dc hc v dc lc hc).
iu tr mt ngi bnhngi bnh b nhim khun bng khng sinh
thnh cng hay tht bi u phi xem xt c 3 yu t trn.
Ngun gc vi sinh vt gy bnh: Vi sinh vt bao gm (theo ln gim
dn): ng vt nguyn sinh (protozoa) v d amp, nm (fungi) v d Candida
albicans, vi khun (bacteria) v d t cu, Escherichia coli, v virus (v d
si, cm, bi lit, ).
Vi khun gy bnh c th t bn ngoi/mi trng (nc, t/bi, khng
kh) xm nhp vo c th hoc t bn trong/chnh c th mnh, l h vi sinh
vt bnh thng (normal microflora) trn c th ngi (xem bi i cng v Vi
khun hc).
Xt nghim Vi sinh lm sng: Xt nghim Vi sinh phc v chn on
bnh nhim khun gm c 2 phng php: chn on trc tip (tm tc nhn// vi
khun gy bnh) v chn on gin tip (tm khng th trong huyt thanh ngi
bnh). Bi ny tp trung gii thiu phng php chn on trc tip.
Sau khi nui cy phn lp v xc nh/nh danh c vi khun gy bnh,
phng xt nghim (gi tt l Labo) Vi sinh s tin hnh tip k thut th nghim
nhy cm vi khng sinh (Antibiotic Susceptibility Test) gi tt l khng sinh
, nhm gip bc s chn c thuc thch hp nht cho iu tr.
B Y t | VAI TR CA VI SINH LM SNG VI 63
S DNG KHNG SINH HP L

II. CHN ON TRC TIP


1. Ly bnh phm
Ty tng bnh (c th l dch, m, mu, ) nhng phi m bo nguyn
tc 3 ng: ng lc, ng v tr v ng k thut v trng.
- ng lc (cha dng khng sinh, lc st cao, ) v ng v tr m
bo trong bnh phm c vi khun gy bnh.
- ng k thut v trng m bo bnh phm khng b nhim tp
khun, v d t da hoc mi trng lm sai lch kt qu xt nghim.
Lu : phi vn chuyn ngay n Labo Vi sinh hoc cy ngay vo mi
trng bo qun hay mi trng nui cy v cng vn chuyn sm ti phng xt
nghim, nhm gi cho vi khun sng.
2. Qui trnh xt nghim
a) Chn on nhanh
- Kinh in: nhum soi trc tip tm vi khun da vo hnh th, ln v
tnh cht bt mu cng nh cch sp xp ca chng, bng phng php nhum
Gram cho hu ht cc loi vi khun v nhum Ziehl-Neelsen cho cc vi khun
khng cn v acid, v d lao. Ring vi khun t, c th soi ti pht hin vi
khun da vo tnh cht di ng in hnh ca n.
- Hin i: nu c iu kin, c th p dng mt s k thut mi tm vi
khun, v d nhum hunh quang tm vi khun khng acid - AFB (acid fast
bacillus) da vo cht hunh quang gn vo v sp hoc da vo on ADN
c trng nh PCR (Polymerase Chain Reaction).
- u im ca phng php ny l nhanh c kt qu (sau khong 30 pht
n 2 gi) rt hu ch cho lm sng: iu tr kp thi, nhng nhc im l
khng chnh xc.
- Nhum soi c u im vt tri l n gin, r tin, d p dng cho mi
phng xt nghim nhng nhc im l khng chnh xc, v nhiu vi khun c
hnh dng & tnh cht bt mu ging nhau v khng bit nhy cm ca vi
khun vi khng sinh.
- Nhum soi trc tip cn c vai tr quan trng i vi Labo Vi sinh: gip
la chn mi trng nui cy& phn lp thch hp cho cng on xt nghim
tip theo.
- Kt qu nhum hunh quang hoc PCR tuy chnh xc hn nhng i hi
trang thit b hin i v sinh phm khng r tin.
b) Nui cy: gm 2 cng on
- Nui cy trong mi trng phn lp hoc tng sinh ty tng loi bnh
phm v vi khun cn tm c dng vi khun thun nht.

B Y t | VAI TR CA VI SINH LM SNG VI 64


S DNG KHNG SINH HP L

- Xc nh: nh danh vi khun gy bnh da vo cc c tnh sinh vt


ha hc v khng nguyn ca n.
c) Khng sinh
Khng sinh l k thut xc nh nhy cm ca vi khun vi khng
sinh in vitro.
Thc hin khng sinh nhm 2 mc ch: nh tnh v nh lng mc
nhy cm ca vi khun vi khng sinh, v th c 2 k thut da trn 2 nguyn
l khc nhau.
K thut khoanh giy khng sinh khuch tn nhm nh tnh: mi khoanh
giy thm mt loi khng sinh vi hm lng nht nh; chng s to ra cc
vng c ch c ng knh khc nhau sau khi nui cy vi khun. Da vo
ng knh ca vng c ch o c m xp loi S (nhy cm), I (trung gian)
hay R ( khng). WHO khuyn co tt c cc Labo Vi sinh p dng k thut
Kirby-Bauer c chun ha nhm t s ng nht v k thut v nu m
bo cht lng, kt qu khng sinh ca cc Labo khc nhau (k c trong nc
v nc ngoi) c th so snh c vi nhau, c tng hp v phn tch tm
ra c im v mc khng ca mi loi vi khun tng bnh vin/vng/
quc gia gip ch cho vic xy dng phc iu tr theo kinh nghim v cho
cng tc phng bnh.
K thut pha long khng sinh trong mi trng lng hoc c nhm nh
lng: xc nh nng khng sinh ti thiu c ch c s pht trin ca vi
khun (MIC Minimal Inhibitory Concentration) hoc nng khng sinh ti
thiu git cht vi khun (MBC Minimal Bactericidal Concentration).
u im ca phng php nui cy gm phn lp, nh danh vi khun &
khng sinh l kt qu chnh xc nhng nhc im l cn nhiu thi gian, v
d vi vi khun pht trin nhanh t mt s bnh phm c th sau 2 ngy c kt
qu xt nghim; nhng vi nhng vi khun pht trin chm (v d lao) hoc c
s lng t trong bnh phm (v d mu) hoc do ngi bnhngi bnh
dng khng sinh s cn nhiu ngy hn.
Cn nhiu thi gian chm c kt qu l l do lm cho bc s iu tr
km mn m vi Vi sinh lm sng, khi cha nh gi ng vai tr ca xt
nghim ny.
Tuy kt qu nui cy & khng sinh c th l chm vi chnh ngi
bnh y nhng l bng chng gip nh lm sng tch ly kinh nghim cho
vic iu tr nhng ngi bnhngi bnh tng t sau v c bit l n c
ngha quan trng cho cng tc phng bnh/phng dch, nht l nhim khun
bnh vin.
III. VAI TR CA VI SINH LM SNG VI S DNG KHNG SINH
HP L
Kt qu xt nghim Vi sinh gip:
B Y t | VAI TR CA VI SINH LM SNG VI 65
S DNG KHNG SINH HP L

1. iu tr trc tip tc nhn gy bnh cho tng ngi bnh.


Khi c kt qu xt nghim v vi khun gy bnh v khng sinh , bc s
iu tr s chn c thuc ph hp nht cho tng ngi bnh; ph hp nht
ngha l: thuc c tc dng tt trn vi khun m c t tc dng khng mong
mun nht cho ngi bnh .
2. Thng k, phn tch kt qu, tm ra:
- Vi khun gy bnh hay gp tng khoa, bnh vin, a phng.
- Mc nhy cm/ khng khng sinh ca tng loi vi khun tng
khoa, bnh vin, a phng, ton quc.
T kt qu thng k, phn tch chng ta c th a ra phc iu tr
kinh nghim khi cha hoc khng c kt qu xt nghim Vi sinh cho tng c s.
3. Gim st nhim khun bnh vin
- Pht hin vi sinh vt gy nhim khun bnh vin v mc khng
khng sinh ca chng c bin php phng nga ly lan cng nh s dng
khng sinh hp l (dit c vi khun gy bnh, t tc dng ph nht cho ngi
bnh, khng lm gia tng vi khun khng v khng gy ra s khng ca vi
khun).
- Pht hin dch, ng ly truyn
4. Cung cp d liu cho phng bnh
Theo di vi khun gy bnh truyn nhim, kt qu xt nghim Vi sinh cn
cung cp d liu quan trng v ngun ly, ng ly cho dch t hc v c s
cho nghin cu sn xut vaccine phng bnh.
Nh vy, mi bnh vin mun s dng khng sinh hp l, t hiu qu
iu tr cao v gim st nhim khun bnh vin th khng th khng c kt
qu xt nghim Vi sinh lm sng m bo cht lng.

B Y t | VAI TR CA VI SINH LM SNG VI 66


S DNG KHNG SINH HP L

S KHNG KHNG SINH CA VI KHUN


1. S KHNG KHNG SINH CA VI KHUN
a) Phn loi khng
- khng gi
+ khng gi l c biu hin l khng nhng khng phi l bn cht,
tc l khng do ngun gc di truyn. Khi vo trong c th, tc dng ca khng
sinh ph thuc vo ba yu t l khng sinh - ngi bnh - vi khun. khng
gi c th do mt trong ba yu t hoc c th kt hp hai hay thm ch c ba yu
t. V vy, nu vic iu tr bng khng sinh khng thnh cng, cn phi xem
xt s tht bi t c ba yu t ny.
Khng sinh

Ngi bnh

Vi khun

+ Do khng sinh: Do la chn khng sinh khng ng iu tr tc nhn


gy bnh, cch s dng khng ph hp v liu lng, ng dng, khong cch
gia cc ln dng, hoc do s dng khng sinh b km cht lng, mt hot
tnh
+ Do ngi bnh: Do h thng min dch b suy gim hoc do v tr
nhim khun hn ch khng sinh khuch tn ti .
+ Do vi khun: Do vi khun ang trng thi ngh, khng nhn ln,
khng chuyn ha nn khng chu tc dng ca khng sinh. V d khi vi khun
lao trong cc hang lao.
- khng tht: c 2 loi l khng t nhin v khng thu c.
+ khng t nhin do mt s loi vi khun khng chu tc dng ca mt
s khng sinh nht nh. V d Pseudomonas aeruginosa khng chu tc dng
ca penicilin G, Stapylococcus aureus khng chu tc dng ca colistin. Hoc vi
khun khng c vch nh Mycoplasma khng chu tc dng ca cc khng sinh
beta-lactam c ch sinh tng hp vch.
+ khng thu c do mt bin c di truyn l t bin hoc nhn c
gen khng mt vi khun ang t khng c gen khng tr thnh c gen
khng, ngha l ang nhy cm tr thnh c kh nng khng khng sinh.
Cc gen khng c th nm trn mt, mt s hoc tt c cc thnh phn di
truyn ca vi khun gm nhim sc th, plasmid v transposon.
b) C ch khng khng sinh
Gen khng lm g t bo vi khun khng chu tc dng ca khng
sinh?
B Y t | S KHNG KHNG SINH CA VI KHUN 67

- Lm gim tnh thm ca vch/mng ngoi v mng bo tng nn khng


sinh khng thm c vo t bo vi khun, v d khng tetracyclin, oxacilin
hoc lm mt kh nng vn chuyn qua mng nh khng streptomycin
hoc/v tng hot ng ca h thng bm (efflux) y khng sinh ra khi t bo.
- Thay i ch tc ng nn khng sinh khng gn c vo ch pht
huy tc dng, v d khng streptomycin, erythromycin do thay i ribosom;
thay i ch gn penicillin - penicillin binding proteins (PBPs) dn n
khng beta-lactam.
- Thay i con ng trao i cht do to ra isoenzym, khng c i lc
vi khng sinh na, v d khng sulfamid, trimethoprim.
- To ra enzym bin i cu trc phn t khng sinh (nh cc Ophosphotransferase, N-acetyltransferase bin i phn t aminoglycosid hoc
chloramphenicol acetyltransferase) hoc enzym ph hy cu trc phn t khng
sinh nh cc beta-lactamase.
Mt vi khun khng khng sinh khng phi do ch mt m thng l
do phi hp cc c ch ring r k trn. V d: trc khun Gram-m khng
beta-lactam l do sn sinh beta-lactamase (gm c beta-lactamase ph rng ESBL), thay i ch tc ng - PBPs, mt porin (tnh thm) v h thng bm
y khng sinh ra ngoi.
C hiu bit v c ch tc dng v c ch khng khng sinh ca vi
khun gy bnh, ta s chn c hoc/v phi hp khng sinh thch hp cho
tng ngi bnh, trnh quan im hon ton sai lm: khng trng con ny th
trng con khc.
Porin

Beta-lactamase

PBP

H thng bm y ra

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.

2. XU HNG KHNG KHNG SINH CA VI KHUN


- Gim st vi khun khng thuc c bin php phng nga s gia tng
khng l ht sc cn thit. Tuy nhin, m hnh bnh tt v xu hng khng
khng sinh ca vi khun c th thay i khc nhau gia cc quc gia, cc khu
vc, cc vng a l, thm ch khc nhau gia cc bnh vin v cc khoa iu
B Y t | S KHNG KHNG SINH CA VI KHUN 68

tr. V vy, mi a phng cn phi c c cc s liu v mc khng


khng sinh ca ring mnh.
- c s liu v mc khng khng sinh, cc c s phi c phng
xt nghim Vi sinh nui cy c vi khun v thc hin c k thut khng
sinh theo ti liu hng dn ca WHO (T chc y t th gii) v CLSI (Vin
chun thc v xt nghim v lm sng).
- c s liu m bo cht lng v ng tin cy, cc th nghim lun
phi c tin hnh ni kim hng ngy v ngoi kim nh k.
- Nu khng sinh c thc hin theo qui trnh chun, mi loi/ h vi
khun phi c th nghim vi nhng nhm/ th nhm khng sinh nht nh;
mi nhm/ th nhm th nghim vi mt s khng sinh i din, th xp loi
mc khng ca vi khun theo Clinical Microbiology and Infection (2012)
nh sau:
+ a khng MDR (Multi Drug Resistant) l khng nhy cm vi 1
khng sinh trong 3 nhm khng sinh c th; v d cc chng vi khun sinh
beta-lactamase ph rng ESBL (Extended Spectrum Beta-lactamase).
+ Khng m rng XDR (Extensively Drug Resistant) l khng nhy
cm vi 1 khng sinh ca tt c cc nhm nhng cn nhy cm vi 2 nhm
c th; v d A. baumannii ch cn nhy cm vi colistin.
+ Ton khng PDR (Pan-Drug Resistant) l khng nhy cm vi tt c
khng sinh ca tt c cc nhm c th.
Cc s liu nghin cu trong v ngoi nc cho thy: Vi khun ngy cng
c xu hng khng khng sinh nhanh hn, nhiu hn v khng ng thi
nhiu khng sinh mc cao.
2.1. Xu hng khng ca cc vi khun Gram-m
Hin nay vai tr gy bnh ca cc vi khun Gram-m ang chim u th
vi t l khong 70%. Cc vi khun Gram-m gy bnh thng gp l h
Enterobacteriaceae (E.coli, Klebsiella pneumoniae, ), A. baumannii, P.
aeruginosa. Cc vi khun ny c th sinh beta-lactamase ph rng (ESBL)
khng tt c cc khng sinh nhm beta-lactam tr carbapenem; nhng n nay
mt s chng c kh nng tit ra carbapenemase khng carbapenem, v d
NDM1 New Deli Metalo-beta-lactamase. Nhiu chng vi khun gy nhim
khun bnh vin l a khng MDR, thm ch mt s chng A. baumannii v
P. aeruginosa l khng m rng XDR hoc ton khng PDR.
2.2. Xu hng khng khng sinh ca cc vi khun Gram-dng
Cc vi khun Gram-dng gy bnh thng gp l S. aureus,
Enterococcus, S. pneumoniae. Hin nay S. aureus khng penicillin PRSA
(Penicillin Resistant S. aureus) khong 90%. T cu vng khng methicillin
MRSA (methicillin Resistant S. aureus) dao ng t 30-50%. MRSA khng
ton b nhm beta-lactam, k c carbapenem; vancomycin l khng sinh dng
B Y t | S KHNG KHNG SINH CA VI KHUN 69

iu tr MRSA. Cho n nay, cha pht hin S. aureus khng vancomycin,


tuy nhin nhiu nghin cu cho thy t l iu tr tht bi rt cao nu gi tr MIC
1mcg/ml do t cu vng trung gian d gen vancomycin hVISA
(heterogenous vancomycin intermediate S. aureus). hVISA c kiu hnh
khng vancomycin mc d MIC c th dao ng t 1-4 mcg/ml. Hin nay lin
cu ng rut khng vancomycin VRE (Vancomycin Resistant Enterococci)
c t l khng thp. Ph cu khng penicillin PRSP (Penicillin Resistant S.
pneumoniae) vi t l dao ng t 10-20%.
3. BIN PHP PHNG NGA
a) Tm quan trng ca phng nga khng khng sinh
- Trong khi s pht minh ra khng sinh mi trn th gii ngy cng gim
th mc khng khng sinh ngy cng gia tng, Vit Nam mc bo
ng. Nu khng c bin php phng nga khng, ko di tui th ca khng
sinh s dn n hu qu khn lng. Trong ngy sc khe th gii 7/4/2011, T
chc Y t th gii ra hnh ng chng khng thuc No action today, no
cure tomorrow - Khng hnh ng hm nay ngy mai s khng c thuc cha.
b) Nguyn nhn gy khng khng sinh tng cao
- C nhiu nguyn nhn gy nn tnh trng khng khng sinh, trong
vic lm dng khng sinh trong c ngnh y t v nng nghip l yu t quan
trng nht.
- Trong cng ng, ngi bnh c th mua v s dng khng sinh ty
m khng cn n ca bc s, dn n vic to ra nhng loi vi khun c sc
khng mnh.
- Ti cc bnh vin do s lng ngi bnh qu ng; nhiu ngi bnh
suy gim h thng min dch nng; nhiu thit b v k thut mi c p dng;
vi khun t cng ng tng khng; kim sot nhim khun, thc hnh cch
ly, s tun th cha hiu qu; tng s dng khng sinh d phng; tng iu tr
khng sinh cho nhiu loi vi khun theo kinh nghim; s dng khng sinh nhiu
theo vng theo thi gian.
- Vic s dng khng sinh khng hp l, khng hiu qu ang l vn
c phm vi nh hng rng khp mi cp chm sc y t, l nguyn nhn
lm tng ng k chi ph khm cha bnh, tin mua khng sinh lun chim
khong 50% kinh ph thuc ca cc bnh vin.
c) Bin php hn ch gia tng khng khng sinh
- C nhiu yu t gy nn tnh trng khng khng sinh. Trong , vic
s dng khng hp l khng sinh l yu t quan trng nht.
- Hn ch gia tng khng bng s dng khng sinh hp l
+ Ch s dng khng sinh khi tht s b bnh nhim khun. Khng iu tr
khng sinh khi khng c bnh nhim khun, ngay c khi ngi bnh yu cu.
B Y t | S KHNG KHNG SINH CA VI KHUN 70

+ 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 | S KHNG KHNG SINH CA VI KHUN 71

TI LIU THAM KHO


1. Atlas Ronald M. (1994), Chapter 1: Microorganisms and Microbiology; Chapter 13:
Nonspecific Host Defenses against microbial Infections: The immune Response in
Microorganisms in our World. Mosby Inc. St. Louis, Missouri, USA.
2. B y t (2007), Chng 1: i cng Vi sinh y hc trong Vi sinh vt y hc ; ch bin L
Huy Chnh. Nh xut bn y hc. H ni.
3. B y t (2008), K thut c bn v m bo cht lng xt nghim Vi sinh y hc, ch bin
inh Hu Dung. Nh xut bn y hc. H ni.
4. Clinical and Laboratory Standards Institute (2012), M02-A11 Performance Standards for
Antimicrobial Disk Susceptibility Tests; Approved Standard eleventh Edition. Wayne,
Pennsylvania, USA.
5. Clinical and Laboratory Standards Institute (2012), M07-A9 Methods for Dilution
Antimicrobial Susceptibility Tests for Bacteria that Grow aerobically; Approved Standard
ninth Edition. Wayne, Pennsylvania, USA.
6. Clinical and Laboratory Standards Institute (2014), M100-S24 Performance Standards for
Antimicrobial Susceptibility Testing; twenty fourth International Supplement. Wayne,
Pennsylvania, USA.
7. Magiorakos A. P., A. Srinivasan, R. B. Carey, Y. Carmeli, M. E. Falagas, C. G. Giske, S.
Harbarth, J. F. Hindler,G.Kahlmeter, B. Olsson-Liljequist, D. L. Paterson, L. B. Rice, J.
Stelling, M. J. Struelens, A. Vatopoulos, J. T. Weber and D. L. Monnet (2012), Multidrugresistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert
proposal for interim standard definitions for acquired resistance. Clin. Microbiol. Infect.,
18:268-281.
8. Livermore David M. and Paterson David L. (2006), Extended-Spectrum -lactamases in
Resistance. Current Medicine Group. London, UK.
9. Vandepitte J., J. Verhaegen, K. Engbaek, P. Rohner, P. Piot and C.C. Heuck (2003), Basic
Laboratory Procedures in Clinical Bacteriology 2nd Edition. WHO, Geneva.

B Y t | S KHNG KHNG SINH CA VI KHUN 72

B Y t | S KHNG KHNG SINH CA VI KHUN 73

PHN II. IU TR CC BNH


NHIM KHUN

B Y t | 74

B Y t | 75

Chng I. Nhim khun H Hp

B Y t | 76

B Y t | 77

VIM PH QUN CP NGI LN


1. I CNG
- Vim ph qun cp l tnh trng vim nhim cp tnh ca nim mc ph
qun ngi trc khng c tn thng. Khi khi khng li di chng.
Nguyn nhn thng do nhim virus, vi khun hoc c hai loi.
- y l bnh l nhim khun h hp thng gp nht trong thc hnh
lm sng. Nhiu trng hp vim ph qun cp t khi m khng cn iu tr.
- Vim ph qun cp cng thng lin quan nhiu ti tnh trng dng
khng sinh khng ph hp. Cn nguyn gy bnh thng gp nht l do virus,
tuy nhin, nhiu nghin cu nhn thy, c ti 70% s trng hp vim ph qun
cp c dng khng sinh.
2. CHN ON
- Ngi bnhNgi bnh thng khng c st.
- Ho khan hoc c th c khc m trng, mu xanh, mu vng, hoc c
nh m.
- Mt s t ngi bnhngi bnh c th c kh th.
- Hu ht cc biu hin lm sng ca vim ph qun cp thng ko di
chng 1 tun th ht, tuy nhin, ho c th ko di n 20 ngy [1].
- X-quang phi c t gi tr trong chn on xc nh vim ph qun cp.
Nn ch nh chp X-quang phi cho cc ngi bnhngi bnh khi c mt
trong cc du hiu: tui > 75 [1]; mch > 100 ln/ pht, th > 24 ln/ pht, hoc
nhit > 380C; hoc khm phi thy ran m, n, hi chng ng c [2,3].
3. CN NGUYN VI SINH
- Cc cn nguyn thng gp nht gy vim ph qun cp l virus:
influenza A v B, parainfluenza, corona virus (type 1-3), rhino virus, virus hp
bo h hp (respiratory syncytial virus), v metapneumo virus ngi; cc vi
khun in hnh: Streptococcus pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis; vi khun khng in hnh: Mycoplasma pneumoniae,
Chlamydophila pneumoniae. Trong , M. pneumoniae v C. pneumoniae
thng lin quan n vim ph qun cp ngi trc hon ton khe mnh
(Mc A).
- Mt s nguyn nhn khc:
+ Ht phi hi c: Khi thuc l, chlore, amoniac, acid, dung mi cng
nghip, hi c chin tranh.
+ Yu t d ng: Vim ph qun cp xy ra tr con ging nh cn hen
ph qun, vim ph qun cp cng hay xy ra trn ngi hen, my ay, ph
Quink.
B Y t | VIM PH QUN CP NGI LN 78

- Cc nguyn nhn thun li ca vim ph qun cp:


+ Thay i thi tit, nhim lnh t ngt.
+ C th suy mn, ci xng, suy dinh dng tr em, suy gim min
dch.
+ ng phi do suy tim.
+ Cc bnh ca phi nh lao phi v ung th phi.
+ Mi trng sng m thp nhiu khi bi.
4. IU TR
4.1. iu tr bng khng sinh
a) Khng sinh cho vim ph qun cp
- Hu ht cc trng hp vim ph qun cp khng cn dng khng sinh.
- Ch dng khng sinh cho nhng trng hp: (1) ci thin lm sng
chm, hoc khng ci thin; (2) ho khc m m, m mu vng, hoc mu
xanh, (3) ngi bnhngi bnh c km bnh tim, phi, thn, gan, thn kinh c,
suy gim min dch; (4) ngi bnhngi bnh > 65 tui c ho cp tnh km
thm 2 hoc nhiu hn cc du hiu sau; hoc ngi bnhngi bnh trn 80
tui km thm 1 hoc nhiu hn cc du hiu sau: nhp vin trong 1 nm trc;
c i tho ng typ 1 hoc typ 2; tin s suy tim sung huyt; hin ang dng
corticoid ung.
- Thiu bng chng v hiu qu ca iu tr khng sinh thng quy cho
vim ph qun cp.
b) La chn khng sinh no cho cc trng hp vim ph qun cp
- Nn chn khng sinh nhm macrolid, hoc doxycyclin cho nhng
trng hp vim ph qun cp ngi trc hon ton khe mnh; khng
sinh nhm beta-lactam phi hp vi cht c ch beta-lactamase hoc nhm
quinolon nn c la chn ban u trong iu tr cc trng hp vim ph
qun cp c tin s dng khng sinh trong vng 3 thng gn y, hoc vim ph
qun cp ngi c tui cao, c bnh mn tnh km theo.
- Khi hng ti cn
Chlamydophila pneumoniae:

nguyn

Mycoplasma

pneumoniae

hoc

+ Ngi bnhNgi bnh i khi c vim ph qun cp do M.


pneumoniae hoc C. pneumoniae. Hng ti chn on nhng cn nguyn ny
khi ngi bnhngi bnh c ho ko di v triu chng ng h hp trn in
hnh. Tuy nhin, im hn ch l thiu cc phng tin chn on thng
quy.
+ C hai tc nhn ny u nhy cm vi tetracyclin, macrolid, v
fluoroquinolon. Trong thc hnh lm sng, cc khng sinh ny thng ch c
khuyn co iu tr theo kinh nghim khi c nhng v dch bng pht.
B Y t | VIM PH QUN CP NGI LN 79

+ Influenza virus: Khng c thuc iu tr c hiu, trong trng hp


nng c th dng cc thuc c ch neuraminidase (oseltamivir hoc zanamivir).
t hiu qu ti u, thuc nn c dng ngay trong vng 48 gi k t khi
bt u c triu chng.
+ Thi gian dng khng sinh: thng 7-10 ngy.
Bng II.1. La chn khng sinh trong iu tr vim ph qun cp
Tnh hung lm sng

Khng sinh u tin

Khng sinh thay th

Vim ph qun cp ngi Macrolid, doxycyclin


hon ton khe mnh

Beta-lactam

Vim ph qun cp ngi c Beta-lactam phi hp vi


dng khng sinh trong vng 3 cht c ch beta-lactamase
thng gn y

Macrolid, doxycyclin

Vim ph qun cp ngi c Beta-lactam phi hp vi


bnh mn tnh
cht c ch beta-lactamase,
Quinolon

Macrolid, doxycyclin

4.2. Vai tr ca thuc gin ph qun trong vim ph qun cp


Ch dng thuc gin ph qun iu tr vim ph qun cp khi nghe phi
thy ran rt, ngy.
4.3. Cc iu tr triu chng khc
- Ngi bnhNgi bnh nn ung nhiu nc gip ci thin vic ho,
khc m.
- Khng c th nghim lm sng no ng h vic s dng thuc long
m.
- Khng hoc c rt t bng chng ng h vic s dng thuc gim ho
trong iu tr vim ph qun cp, do cc thuc gim ho thng lm gim vic
bi tit m, do vy lm chm s phc hi ca ngi bnhngi bnh.
- Khi iu tr ti u m ngi bnhngi bnh cn ho nhiu, cn lu
tnh trng co tht ph qun, hoc cn lu thm cc bnh l km theo nh tro
ngc d dy thc qun hoc bnh cha c chn on chnh xc.
5. PHNG BNH
- Loi b yu t kch thch: Khng ht thuc, trnh khi bi trong, ngoi
nh, mi trng nhim, gi m vo ma lnh.
- Tim vaccine phng cm, ph cu, c bit nhng trng hp c bnh
phi mn tnh, suy tim, ct lch, tui 65.
- iu tr cc nhim khun tai mi hng, rng hm mt, tnh trng suy
gim min dch.
- V sinh rng ming.
B Y t | VIM PH QUN CP NGI LN 80

TI LIU THAM KHO


1. Wenzel R.P, Fowler A.A 3rd. Clinical practice. Acute bronchitis. N Engl J Med 2006.
355:2125.
2. Eun-Hyung Lee F, Treanor J. Viral infection. Textbook of Respiratory Medicine 2010.
Saunders, 5th edition. 661-698.
3. Gonzales R, Bartlett J.G, Besser R.E, et al. Principles of appropriate antibiotic use for
treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001; 134:521.
4. Petersen I, Johnson A.M, Islam A, et al. Protective effect of antibiotics against serious
complications of common respiratory tract infections: retrospective cohort study with the UK
General Practice Research Database. BMJ 2007. 335:982.
5. Shehab N, Patel P.R, Srinivasan A, et al. Emergency department visits for antibioticassociated adverse events. Clin Infect Dis 2008. 47:735.
6. Smucny J, Fahey T, Becker L, et al. Antibiotics for acute bronchitis. Cochrane Database
Syst Rev 2004. CD000245.

B Y t | VIM PH QUN CP NGI LN 81

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

- Th tch ca thu phi c gin ph qun nh li.


- C cc sng nh ging hnh nh t ong, c th c sng vi mc nc
ngang kch thc thng khng qu 2 cm.
- Hnh nh vim phi ti din hng nm xung quanh khu vc gin ph
qun.
b) Chp ph qun cn quang
- C th thy ph qun gin hnh tr, hnh ti, hnh trng ht.
c) Soi ph qun
- Pht hin d vt, cc ph qun b gp khc, b cht hp, xc nh v tr
chy mu v ht dch ph qun tm vi khun.
d) Chp ct lp vi tnh: Lp mng, phn gii cao (tiu chun vng trong chn
on xc nh gin ph qun). Cc du hiu c th gp:
- ng knh trong ca ph qun ln hn ng mch i km.
- Cc ph qun khng nh dn - quy nh l khi mt ph qun trn mt
on di 2 cm c ng knh tng t ph qun phn chia ra ph qun .
- Cc ph qun cch mng phi thnh ngc di 1 cm.
- Cc ph qun i st vo mng phi trung tht.
- Thnh ph qun dy.
e) Cc xt nghim khc
- Cc xt nghim m tm vi khun, nm, trc khun khng cn, khng
toan.
- Lm in tm pht hin sm tm ph mn.
4. IU TR
4.1. iu tr ni khoa
- Dn lu m m ph qun: hng dn ngi bnhngi bnh cch ho
khc m v v rung lng ngc kt hp vi dn lu theo t th.
- iu tr khng sinh trong t cp tnh ca gin ph qun c bi nhim.
- iu tr triu chng:
+ Thuc gin ph qun khi nghe phi c ran rt, ngy.
+ Th oxy trong t cp khi c thiu oxy mu.
+ Ung nc, truyn dch lm long m.
+ iu tr ho mu: Theo mc ho ra mu nh, trung bnh, nng v rt
nng.
4.2. iu tr ngoi khoa: Ct thu phi hoc ct mt bn phi.
B Y t | GIN PH QUN 83

- Ch nh: Gin ph qun khu tr mt thy, mt bn phi (ch s FEV1 >


50%), ho mu nhiu ln, tc do khi u.
- Chng ch nh: Gin ph qun th lan to, c triu chng ca suy h
hp mn tnh.
4.3. iu tr khng sinh (t cp do nhim khun)
4.3.1. La chn khng sinh ban u cho t cp tnh ca gin ph qun dng
ng ung hay ng tim ty theo mc nhim khun, tnh hnh khng ca
vi khun ti a phng. Trng hp nhim khun nng phi dng phi hp
khng sinh, thay i khng sinh theo p ng lm sng v kt qu khng sinh
.
4.3.2. Thng dng phi hp nhm beta-lactam kt hp vi nhm
aminoglycosid hoc nhm quinolon:
a) Penicilin G 1 triu n v, liu 10 - 50 triu n v/ngy tu theo tnh trng v
cn nng ca ngi bnhngi bnh, pha truyn tnh mch chia 3 - 4 ln/ngy,
kt hp vi:
- 1 khng sinh nhm aminoglycosid:
+ Gentamicin 80mg: 3-5 mg/kg/ngy tim bp 1 ln hoc
+ Amikacin 500mg: 15 mg/kg/ngy pha truyn tnh mch trong 250ml
natri clorid 0,9%.
- Hoc kt hp vi 1 khng sinh nhm quinolon:
+ Levofloxacin 500mg 750mg/ngy truyn tnh mch, hoc
+ Moxifloxacin 400mg/ngy
+ Ciprofloxacin 800 mg/ngy
b) Nu nghi vi khun tit beta-lactamase, la chn cc khng sinh sau v kt
hp vi khng sinh nhm aminoglycosid nh mc a:
- Amoxicilin-clavulanat: 3-6g chia 3-6 ln/ngy, tim tnh mch, hoc
- Ampicilin-sulbactam:3-6g chia 3-6 ln/ngy, tim tnh mch.
c) Nu nghi vi khun Gram-m th dng cephalosporin th h 3 kt hp vi
khng sinh nhm aminoglycosid, la chn:
- Cefotaxim 3 - 6 g/ngy, chia 2 n 4 ln/ngy, hoc
- Ceftazidim 3 - 6 g/ngy, c 8 n 12 gi/ln
d) Nu ngi bnhngi bnh khc m m thi (vi khun k kh) th kt hp
nhm beta-lactam (vi thuc v liu nh mc a, b, c trn) vi metronidazol:
- Nhm amoxicilin-clanvulanat vi metronidazol liu 1- 1,5g chia 2-3
ln/ngy, truyn tnh mch, hoc
- Penicilin G + metronidazol 1-1,5g/ngy truyn tnh mch.
B Y t | GIN PH QUN 84

e) Nu do nhim khun mc phi bnh vin, khi cha c kt qu khng sinh :


- C th dng khng sinh:
+ Ceftazidim 3 - 6g chia 3 ln/ngy, hoc
+ Piperacilin-tazobactam 4,5g x 3 ln/ngy, hoc
+ Imipenem 2 - 4g chia 3-4 ln/ngy, hoc
+ Meropenem 3 - 6g chia 3-4 ln/ngy
- Kt hp khng sinh nhm aminoglycosid hoc quinolon, metronidazol
nh cc mc trn. iu chnh khng sinh theo din bin lm sng v kt qu
khng sinh .
f) Nu nghi ng do t cu:
- La chn:
+ Oxacilin 6 - 12g/ngy, hoc
+ Vancomycin 1-2 g/ngy
- Kt hp vi amikacin khi nghi do t cu khng thuc.
4.3.3 Thi gian dng khng sinh thng thng: 10 ngy n 2 tun. Nhng
trng hp gin ph qun nng, nhim vi khun khng thuc: Thng cn dng
khng sinh di ngy hn, hoc bi nhim do trc khun m xanh hoc t cu,
thi gian dng khng sinh c th ti 3 tun.
Ch xt nghim creatinin mu 2 ln trong mt tun i vi ngi bnhngi
bnh c s dng thuc nhm aminoglycosid, vancomycin pht hin tc dng
gy suy thn ca thuc, i hoc iu chnh liu nu c suy thn.
4.3.4 Nu c hi chng xoang ph qun (gin ph qun v vim a xoang mn
tnh): Ung erythromycin 10 mg/kg/ngy, chia 2 ln, ko di t 6-24 thng.
Khng dng ng thi vi cc thuc nhm xanthin (theophylin) do nguy c gy
ri lon nhp tim (xon nh).
4.3.5 Vi nhng trng hp thng xuyn ti pht cc t cp tnh (t 2 ln
tr ln trong 1 nm), c th cn nhc s dng phc khng sinh macrolid liu
thp (10mg/kg), di ngy.
5. D PHNG
- Khng ht thuc l, thuc lo, trnh mi trng c nhiu bi khi.
- V sinh rng ming, tai - mi - hng.
- iu tr trit cc nhim khun vng tai mi hng, rng ming, cc
bnh v ng h hp.
- Tim phng cm hng nm.
- iu tr sm lao s nhim tr em.
B Y t | GIN PH QUN 85

- 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

T CP BNH PHI TC NGHN MN TNH


1. I CNG
t cp bnh phi tc nghn mn tnh (BPTNMT) l mt tnh trng bnh
t giai on n nh tr nn xu i t ngt ngoi nhng bin i thng thng
hng ngy v i hi thay i cch iu tr thng quy ngi bnhngi bnh
c chn on BPTNMT.
2. CHN ON
a) Chn on xc nh
Ngi bnhNgi bnh c chn on bnh phi tc nghn mn tnh
t nhin xut hin mt trong ba triu chng theo phn loi ca Anthonisen
1987:
- Tng kh th.
- Tng s lng m.
- Thay i mu sc m: xanh, vng v m m.
b) Chn on phn loi t cp
- Type I (mc nng): Nu c y c ba triu chng.
- Type II (mc trung bnh): Nu c hai trong ba triu chng.
- Type III (mc nh): Nu c mt triu chng v km theo mt trong
cc triu chng ph sau: Triu chng nhim khun h hp trn trong vng 5
ngy trc , st khng do nguyn nhn khc, tng ho hoc kh kh hoc tng
nhp tim hay nhp th 20% so vi trng thi bnh thng.
c) Chn on nguyn nhn gy t cp
- Nguyn nhn trc tip thng gp nht gy t cp l nhim khun kh
ph qun phi cp do virus hoc vi khun (cc vi khun thng gp l
Streptococcus pneumoniae, Hemophilus influenzae v Moraxella catarrhalis).
- Cc nguyn nhn khc: Nhim lnh, bi nhim, khi, kh c.
- Khng r nguyn nhn: 1/3 cc trng hp.
3. IU TR
a) Khng sinh
- Ch nh dng khng sinh: Theo hng dn ca GOLD 2013, khuyn
co ch s dng khng sinh trong cc trng hp sau:
+ Ngi bnhNgi bnh typ I (Bng chng B).
+ Ngi bnhNgi bnh typ II (Bng chng C).

B Y t | T CP BNH PHI TC NGHN MN TNH 87

+ Ngi bnhNgi bnh cn thng kh nhn to (xm nhp hoc khng


xm nhp) (Bng chng B).
- Thi gian iu tr khng sinh: Thi gian dng khng sinh 5- 10 ngy,
(Bng chng D).
- La chn khng sinh theo mc nng ca t cp BPTNMT v cn
nhc trn tnh khng ca vi khun ti a phng. ng dng ca khng sinh
(ung hoc tnh mch) ty vo tnh trng ngi bnhngi bnh c ung c
khng v dc ng hc ca khng sinh. Cc phc kinh nghim c th s
dng nhau sau:
+ t cp mc nh: Beta-lactam phi hp vi cht c ch betalactamase (amoxicilin-clavulanat; ampicilin-sulbactam) 3g/ngy hoc cefuroxim
1,5g/ngy hoc moxifloxacin 400mg/ngy hoc levofloxacin 750mg/ngy.
+ t cp mc trung bnh: Cefotaxim 1g x 3 ln/ngy hoc ceftriaxon
1g x 3 ln/ngy v phi hp vi amikacin 15mg/kg/ngy hoc fluoroquinolon
(ciprofloxacin 1g/ngy ung, levofloxacin 500mg/ngy ung hoc truyn
TM...).
+ t cp mc nng v nguy kch: Dng kt hp khng sinh: nhm
cephalosporin th h 3 (ceftazidim 3g/ngy) hoc imipenem 50mg/kg/ngy kt
hp amikacin 15mg/kg/ngy hoc ciprofloxacin 800mg/ngy truyn TM chia 2
ln, levofloxacin 750mg/ngy truyn TM.
(Lu : Liu lng trn cn cn nhc iu chnh ph hp theo chc
nng thn ca ngi bnhngi bnh)
- Trong trng hp khng p ng (vn st, m vn vng, tnh trng kh
th khng ci thin...) cn phi cy m lm khng sinh .
b) iu tr t cp mc nh
- Cho iu tr v tng (nu cn) liu thuc gin ph qun phun ht
(ventolin, berodual, combivent) n 4 - 6 ln/ ngy.
- Dng thuc gin ph qun ng ung nu khng c thuc ng phun
ht: salbutamol 4 mg x 4 vin/ngy chia 4 ln hoc terbutalin 5 mg x 2
vin/ngy.
- Prednisolon ung 40 mg/ngy nu tnh trng khng ci thin sau 1 gi
k t lc tng cc loi thuc gin ph qun tc dng nhanh.
- S dng khng sinh cho t cp mc nh xin xem mc a pha trn.
c) iu tr t cp mc trung bnh
- Tip tc cc bin php iu tr nu trn. Theo di mch huyt p,
nhp th, SpO2.
- Th oxy 1-2 lt/pht sao cho SpO2 > 90% v th li kh mu sau 30 pht
nu c iu kin.
B Y t | T CP BNH PHI TC NGHN MN TNH 88

- Tng s ln xt hoc kh dung cc thuc gin ph qun ln 6 - 8 ln vi


cc thuc gin ph qun cng 2-adrenergic phi hp vi khng cholinergic
(albuterol/ipratropium, fenoterol/ipratropium).
- Nu khng p ng vi cc thuc kh dung th dng salbutamol,
terbutalin truyn tnh mch vi liu 0,5 2mg/gi, iu chnh liu thuc theo
p ng ca ngi bnhngi bnh. Truyn bng bm tim in hoc bu m
git.
- Methylprednisolon: 2 mg/kg/ngy tim tnh mch chia 2 ln.
- Nu ngi bnhngi bnh cha dng theophylin, khng c ri lon
nhp tim v khng c salbutamol hoc terbutalin th c th dng aminophylin
0,24g x 1 ng + 100 ml glucose 5% truyn tnh mch trong 30 pht, sau
chuyn sang liu duy tr. Tng liu theophylin khng qu 10mg/kg/24 gi.
Trong qu trnh iu tr bng theophylin cn lu du hiu ng c ca thuc:
bun nn, nn, ri lon nhp tim, co git, ri lon tri gic.
- Thng kh nhn to khng xm nhp (BiPAP) khi c t nht 2 tiu
chun sau:
+ Kh th va ti nng c co ko c h hp ph v h hp nghch thng.
+ Toan h hp nng (pH: 7,25 7,30) v PaCO2 45 65 mmHg.
+ Tn s th > 25.
- Nu sau 60 pht TKNTKXN, cc thng s PaCO2 tip tc tng v PaO2
tip tc gim hoc cc triu chng lm sng tip tc xu i th cn chuyn sang
thng kh nhn to xm nhp.
- Chng ch nh TKNTKXN:
+ Ngng th, ng g, ri lon thc, khng hp tc.
+ Ri lon huyt ng: tt huyt p, lon nhp tim, nhi mu c tim.
+ Nguy c ht phi dch d dy, m nhiu, dnh.
+ Mi phu thut rng hm mt hoc m d dy.
+ Bng, chn thng u, mt, bo ph qu nhiu.
- S dng khng sinh cho t cp mc trung bnh xin xem mc a
pha trn.
d) t cp bnh phi tc nghn mn tnh c suy h hp nng v nguy kch
- Th oxy qua gng knh oxy, gi SpO2 90% - 92%.
- Dng thuc gin ph qun ti ch:
+ Thuc cng 2 giao cm, kh dung qua mt n 5 mg (salbutamol,
terbutalin), nhc li tu theo tnh trng BN, c th kh dung nhiu ln.

B Y t | T CP BNH PHI TC NGHN MN TNH 89

+ Thuc khng cholinergic: Ipratropium (0,5 mg) kh dung qua mt n,


nhc li nu cn thit.
- Kt hp truyn tnh mch cc thuc cng 2 giao cm (salbutamol,
terbutalin).
+ Tc khi u 0,1 mg/kg/pht, iu chnh liu theo p ng ca
ngi bnhngi bnh (tng tc truyn 5 - 10 pht/ln cho ti khi c p
ng).
+ C th dng aminophylin 0,24g pha vi 100ml dch glucose 5%, truyn
trong 30-60 pht, sau truyn duy tr vi liu 0,5 mg/kg/gi.
- Methylprednisolon 2 mg/kg/24 gi tim tnh mch chia 2 ln.
Th my khng xm nhp
- Nu khng c chng ch nh.
- Thng la chn phng thc BiPAP:
+ Bt u vi IPAP = 8 - 10 cmH2O; EPAP = 4 - 5 cmH2O.
+ FiO2 iu chnh c SpO2 > 92%.
+ iu chnh thng s: Tng IPAP mi ln 2 cmH2O.
- Mc tiu: Ngi bnhNgi bnh d chu, tn s th < 30/pht, SpO2 >
92%, xt nghim khng c nhim toan h hp.
- Nu thng kh khng xm nhp khng hiu qu hoc c chng ch nh:
t ng ni kh qun v thng kh nhn to qua ng ni kh qun.
Th my xm nhp
- Phng thc: Nn ch nh thng kh nhn to h tr/iu khin th tch
+ Vt = 5 - 8 ml/kg.
+ I/E = 1/3.
+ Trigger 3-4 lt/pht.
+ FiO2 lc u t 100%, sau iu chnh theo oxy mu.
+ PEEP = 5 cmH2O hoc t bng 0,5 auto-PEEP.
- Cc thng s c iu chnh gi Pplat < 30 cmH2O, auto-PEEP
khng tng, SpO2 > 92%, pH mu trn 7,20. Duy tr tn s th khong 20
ln/pht bng thuc an thn.
- Trong trng hp ngi bnhngi bnh kh th nhiu, khng th theo
my, c th chuyn sang thng kh iu khin (th tch hoc p lc). Tuy nhin
vic dng an thn liu cao hoc gin c c th lm kh cai th my.
- nh gi tnh trng ngi bnhngi bnh hng ngy xem xt cai th
my khi cc yu t gy mt b c iu tr n nh.
B Y t | T CP BNH PHI TC NGHN MN TNH 90

- S dng khng sinh cho t cp mc nng v nguy kch xin xem


mc a pha trn.
Nu ngi bnhngi bnh suy h hp nguy kch
- Bp bng qua mt n vi oxy 100%.
- t ng ni kh qun, thng kh nhn to xm nhp.
- Ht m qua ni kh qun.
- Dng thuc gin ph qun truyn tnh mch.
- Tim tnh mch corticoid.
- Dng thuc khng sinh theo hng dn trong mc a trn.
T VIT TT TRONG BI
BiPAP

Bilevel Possitive Airway Pressure (Thng kh hai mc p lc dng)

BPTNMT

Bnh phi tc nghn mn tnh

EPAP

Expiratory Possitive Airway Pressure (p lc dng th ra)

FiO2

Fraction of inspired oxygen (nng oxy trong hn hp kh th vo)

IPAP

Inspiratory Possitive Airway Pressure (p lc dng ht vo)

PEEP

Positive end-expiratory pressure (p lc dng cui th th ra)

TKNTKXN

Thng kh nhn to khng xm nhp

TI LIU THAM KHO


1. Celli BR (2008), Update on the management of COPD, Chest, 133(6):1451-62.
2. Chronic Obstructive Pulmonary Disease (2010), The Washington Manual of Medical
Therapeutics (33rd ed), Lippincott Williams & Wilkins, 271-282.
3. Maclay JD, Rabinovich RA, MacNee W (2009), Update in chronic obstructive pulmonary
disease 2008, Am J Respir Crit Care Med, 179(7):533-41
4. Robert A. Wise (2008), Obstructive lung diseases, Fishmans Pulmonary Diseases and
Disorder (4th ed), McGraw-Hill, 749747.
5. Global Initiative for Chronic Obstructive Lung Disease (2013): Management of COPD
(Component 4: Manage Exacerbations), in: Global Strategy for Diagnosis, Management, and
Prevention
of
COPD
(Internet
version,
updated
2013).
Available
in http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html
Stoller J.K. (2010): Management of acute exacerbations of chronic obstructive pulmonary
disease. UpToDate online 18.3 [last updated: October 7, 2010], Available

B Y t | T CP BNH PHI TC NGHN MN TNH 91

in: http://www.uptodate.com/online/content/topic.do?topicKey=copd/8006&selectedTitle=1~
39&source=search_result.

B Y t | T CP BNH PHI TC NGHN MN TNH 92

VIM PHI MC PHI CNG NG


1. I CNG
- Vim phi mc phi cng ng (community acquired pneumonia) l
tnh trng nhim khun ca nhu m phi xy ra ngoi bnh vin, bao gm
vim ph nang, ng v ti ph nang, tiu ph qun tn hoc vim t chc k ca
phi.
- Tc nhn gy vim phi c th l cc vi khun, virus, k sinh trng,
nm, nhng khng phi do trc khun lao.
- T l mc chung ca Vim phi mc phi cng ng khong 5.166.11/1000 ngi trong nm v tng theo tui. Ma hay gp l ma ng. Nam
gp nhiu hn n. T vong do vim phi mc phi cng ng hay gp nhm
phi nhp vin iu tr, t l t vong chung ln ti 28% mi nm.
2. NGUYN NHN
- Nguyn nhn vim phi mc phi cng ng ty thuc tng vng a
l, nhng Streptococcus pneumoniae l nguyn nhn hay gp nht trn th gii.
- Vi khun: S. pneumoniae, H. influenzae, M. pneumoniae, C.
pneumoniae, Legionella,
Klebsiella pneumoniae, Escherichia coli,
Enterobacter,
Serratia spp., Proteus spp.,
v
Acinetobacter spp.,
Streptococcus nhm A, vi khun k kh, Neisseria meningitides, Francisella
tularensis (tularemia), C. burnetii (Q fever), v Bacillus anthracis.
- Virus: Influenza virus, Parainfluenza virus, respiratory syncytial virus,
Adenovirus, Human metapneumovirus, Severe acute respiratory syndrome
(SARS), coronavirus khc: Human coronavirus, HCoV-229E, HCoV-OC43,
Hantavirus, Avian influenza, Varicella.
- Nm: Cryptococcus spp., Histoplasma capsulatum, Coccidioides spp.,
Aspergillus spp., Pneumocystis jirovecii.
3. TRIU CHNG
3.1. Lm sng
a) Triu chng lm sng
- Khi pht t ngt vi st cao 39 - 400C, rt run.
- au ngc: Thng c, i khi l triu chng ni bt, au bn tn
thng.
- Ho mi xut hin, tng dn, lc u ho khan, v sau ho c m c, mu
vng, xanh hoc mu g st. C khi nn, chng bng, au bng.
- Kh th: Th nhanh, tm mi u chi.
- Khm:
B Y t | VIM PHI MC PHI CNG NG 93

+ Hi chng nhim khun: St cao, hi th hi, mi kh li bn.


+ Hi chng ng c phi, ran m, ran n bn tn thng.
+ Du hiu gi vim phi do ph cu: Mn Herpes mp, mi, cnh
mi
+ Trng hp c bit: Ngi nghin ru c th c l ln, tr con c co
git, ngi cao tui triu chng thng khng rm r, c khi bt u bng l
ln, m sng (t l t vong cao do suy h hp cp, h nhit ).
+ Th khng in hnh: Biu hin ho khan, nhc u, au c. Khm
thng khng r hi chng ng c; thy ri rc ran m, ran n. X-quang phi
tn thng khng in hnh (m khng ng u, gii hn khng r hnh thu).
b) Chn on mc nng: CURB 65
- C: Ri lon thc.
- U: Ure > 7mmol/L
- R: Tn s th 30 ln/ pht
- B: Huyt p:
+ Huyt p tm thu < 90mmHg
+ Hoc huyt p tm trng 60mmHg
- 65: Tui 65
nh gi: Mi biu hin trn c tnh 1 im, t nh gi mc nng ca
vim phi nh sau:
- Vim phi nh:

CURB65 = 0-1 im: C th iu tr ngoi tr.

- Vim phi trung bnh: CURB65 = 2 im: iu tr ti cc khoa ni.


- Vim phi nng:
tm h hp, ICU.

CURB65 = 3-5 im: iu tr ti khoa, trung

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

B Y t | VIM PHI MC PHI CNG NG 94

k, tn thng mi xut hin mt bn hoc c hai bn, c th km theo trn


dch mng phi.
4. IU TR
4.1. Nguyn tc chung
- X tr tu theo mc nng.
- iu tr triu chng.
- iu tr nguyn nhn: La chn khng sinh theo cn nguyn gy bnh,
nhng ban u thng theo kinh nghim lm sng, yu t dch t, mc nng
ca bnh, tui ngi bnhngi bnh, cc bnh km theo, cc tng tc, tc
dng ph ca thuc.
- Thi gian dng khng sinh: T 7 n 10 ngy nu do cc tc nhn gy
vim phi in hnh, 14 ngy nu do cc tc nhn khng in hnh, trc khun
m xanh.
4.2. iu tr
a) iu tr ngoi tr: CURB65: 0-1 im
- ngi bnhngi bnh khe mnh khng iu tr khng sinh trong
vng 3 thng gn y:
+ Amoxicilin 500 mg ung 3 ln/ngy. Hoc amoxicilin 500 mg tim tnh
mch 3 ln/ngy, nu ngi bnhngi bnh khng ung c.
+ Hoc macrolid: Erythromycin 2 g/ngy hoc clarithromycin 500 mg x
2 ln/ngy
+ Hoc doxycylin 200 mg/ngy sau dng 100 mg/ngy.
- ngi bnhngi bnh c bnh phi hp nh: Suy tim, suy h hp,
suy thn, suy gan, bnh tiu ng, bnh c tnh, nghin ru, suy gim min
dch hoc dng thuc c ch min dch hoc c iu tr khng sinh trong vng 3
thng gn y:
+ Fluoroquinolon (moxifloxacin (400mg/ngy), gemifloxacin (500
700mg/ngy), hoc levofloxacin (500-750mg/ngy).
+ Hoc kt hp mt Beta-lactam c tc dng trn ph cu{(Amoxicilin
liu cao (1g x 3 ln/ngy) hoc amoxicilin-clavulanat (1g x 3 ln/ngy), hoc
cefpodoxim (200mg 2 ln/ngy), hoc cefuroxim (500 mg x 2 ln/ngy)} vi
mt macrolid (azithromycin 500 mg/ngy trong ngy 1, tip theo 250/ngy
trong 4 ngy hoc clarithromycin 500mg 2 ln/ngy) (c th dng doxycyclin
thay th cho macrolid).
- khu vc c t l cao (125%) ph cu khng vi macrolid (MIC 16
mg/mL) ngi bnhngi bnh khng c bnh phi hp: S dng phc trn.

B Y t | VIM PHI MC PHI CNG NG 95

- m bo cn bng nc - in gii v thng bng kim - toan.


b) iu tr vim phi trung bnh: CURB65 = 2 im
- Khng sinh:
+ Amoxicilin 1g ung 3 ln/ngy phi hp vi clarithromycin 500mg
ung 2 ln/ngy.
+ Hoc nu ngi bnhngi bnh khng ung c: Amoxicilin 1g tim
tnh mch 3 ln/ngy hoc tim tnh mch benzylpenicilin (penicilin G) 1-2 triu
n v 4 ln/ngy kt hp vi clarithromycin 500 mg tim tnh mch 2 ln/ngy.
+ Hoc mt beta-lactam (cefotaxim (1g x 3 ln/ngy), ceftriaxone (1g x 2
ln/ngy), hoc ampicilin-sulbactam (1,2g x 3 ln/ngy) kt hp vi macrolid
hoc mt fluoroquinolon ng h hp. (Liu dng macrolid v quinolon ty
thuc vo thuc s dng).
+ Vi ngi bnhngi bnh d ng penicilin s dng mt fluoroquinolon
ng h hp v mt aztreonam. (Liu dng macrolid v quinolon ty thuc vo
thuc s dng).
+ Vi trng hp nghi do Pseudomonas: S dng khng sinh va c tc
dng vi ph cu v Pseudomonas: Cc beta-lactam nh piperacilin-tazobactam
(4,5g x 3 ln/ngy), cefepim (1g x 3 ln/ngy), imipenem (1gx 3 ln/ngy), hoc
meropenem (1g x 3 ln/ngy) kt hp vi:
Hoc ciprofloxacin (400mg) hoc levofloxacin (750 mg).
Hoc mt aminoglycosid (liu aminoglycosid ph thuc vo thuc s
dng) v azithromycin (0,5g/ngy).
Hoc vi mt aminoglycosid v mt fluoroquinolon c tc dng vi ph
cu (vi ngi bnhngi bnh d ng penicilin thay khng sinh nhm betalactam bng nhm aztreonam) (Liu dng cc thuc ph thuc vo thuc c
la chn).
+ Vi trng hp nghi do t cu vng khng methicilin xem xt thm
vancomycin (1g mi 12h) hoc linezolid (600mg/12 gi).
- m bo cn bng nc - in gii v thng bng kim - toan.
- Dng thuc h st khi nhit > 38,50C.
c) iu tr vim phi nng: CURB65 = 3-5 im
- Khng sinh
+ Amoxicilin-clavulanat 1-2g tim tnh mch 3 ln/ngy phi hp vi
clarithromycin 500 mg tim tnh mch 2 ln/ngy.
+ Hoc benzylpenicilin (penicilin G) 1- 2g tim tnh mch 4 ln/ngy kt
hp vi levofloxacin 500 mg ng tnh mch 2 ln/ngy hoc ciprofloxacin
400 mg ng tnh mch 2 ln/ngy.
B Y t | VIM PHI MC PHI CNG NG 96

+ Hoc cefuroxim 1,5g ng tnh mch 3 ln/ngy hoc cefotaxim 1g


ng tnh mch 3 ln/ngy hoc ceftriaxon 2 g ng tnh mch liu duy nht
kt hp vi clarithromycin 500 mg ng tnh mch 2 ln/ngy.
+ Nu nghi ng Legionella xem xt b sung levofloxacin (750mg/ngy)
+ Vi ngi bnhngi bnh d ng penicilin s dng mt fluoroquinolon
ng h hp v mt aztreonam (liu dng ty thuc thuc s dng)
+ Vi trng hp nghi do Pseudomonas: S dng khng sinh va c tc
dng vi ph cu v Pseudomonas: Beta-lactam (piperacilin- tazobactam (4,5g x
3ln/ngy), cefepim (1g x 3ln/ngy), imipenem (1g x 3ln/ngy), hoc
meropenem (1g x 3ln/ngy), kt hp vi:
Hoc ciprofloxacin (400mg) hoc levofloxacin (750 mg).
Hoc mt aminoglycosid v azithromycin (0,5g/ngy).
Hoc vi mt aminoglycosid v mt fluoroquinolon c tc dng vi ph
cu (vi ngi bnhngi bnh d ng penicilin thay khng sinh nhm betalactam bng nhm aztreonam ) (Liu dng cc thuc ph thuc vo thuc c
la chn).
+ Vi trng hp nghi do t cu vng khng methicilin xem xt thm
vancomycin (1g/12 gi) hoc linezolid (600mg/12 gi).
- Th oxy, thng kh nhn to nu cn, m bo huyt ng, iu tr cc
bin chng nu c.
d) iu tr mt s vim phi c bit (Phc iu tr cho ngi bnhngi
bnh nng khong 60 kg)
- Vim phi do Pseudomonas aeruginosa:
+ Ceftazidim 2g x 3ln/ngy + gentamicin hoc tobramycin hoc
amikacin vi liu thch hp.
+ Liu php thay th: Ciprofloxacin 500 mg x 2 ln/ngy + piperacilin 4g
x 3 ln/ngy + gentamicin hoc tobramycin hoc amikacin vi liu thch hp.
- Vim phi do Legionella:
+ Clarithromycin 0,5g x 2 ln/ngy rifampicin 0,6g x 1- 2ln/ngy x 14
21 ngy.
+ Hoc
moxifloxacin).

fluoroquinolon

(ciprofloxacin,

ofloxacin,

levofloxacin,

- Vim phi do t cu vng:


+ T cu vng nhy cm vi methicilin: Oxacilin 1g x 2 ln /ngy
rifampicin 0,6g x 1- 2 ln/ngy.
+ Vim phi do t cu vng khng vi methicilin: Vancomycin 1g x 2
ln/ngy.
B Y t | VIM PHI MC PHI CNG NG 97

- Vim phi do virus cm:


+ iu tr triu chng l chnh: H st, gim au.
+ Oseltamivir.
+ Dng khng sinh khi c biu hin bi nhim vi khun.
- Mt s vim phi khc:
+ Do nm: Dng mt s thuc chng nm nh: Amphotericin B,
itraconazol.
+ Pneumocystis carinii: Co-trimoxazol. Trong trng hp suy h hp:
Prednisolon (ung hoc tnh mch).
+ Do amp: Metronidazol.
5. PHNG BNH
- iu tr tt cc nhim khun tai mi hng, rng hm mt.
- Tim vaccine phng cm mi nm 1 ln, phng ph cu 5 nm 1 ln cho
nhng trng hp c bnh phi mn tnh, suy tim, tui trn 65 hoc ct lch.
- Loi b nhng yu t kch thch c hi: Thuc l, thuc lo.
- Gi m c, ngc trong ma lnh.
TI LIU THAM KHO
1. Armitage K, Woodhead M (2007), New guidelines for the management of adult
community-acquired pneumonia, Curr Opin Infect Dis, 20(2):170-6.
2. Cunha BA (2007), Severe Community-acquired Pneumonia in the Critical Care
Unit, Infectious Disease in Critical Care Medicine 2nd Ed, New York: Informa Healthcare,
157-168.
3. Cunha BA. Cunha BA (ed) (2008), Pneumonia Essentials 2nd Ed,
MI: Physicians Press, 55-63.
4. Thomas J. Marrie (2008), Community-acquired pneumonia,
Diseases and Disorder (4th ed), McGraw-Hill, 20972115.

Royal Oak,

Fishmans Pulmonary

5. Lionel A. Mandell, A Richard Ginfectious (2007). Diseases Society of


America/AmericanThoracic Society Consensus Guidelines on the Management of
Community-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S277.
6. Lim WS, Baudouin SV, George RC, et al (2009) BTS guidelines for the management of
community acquired pneumonia in adults: update 2009 Thorax; 64 Suppl 3:iii1.

B Y t | VIM PHI MC PHI CNG NG 98

S DNG KHNG SINH IU TR VIM PHI CNG


NG TR EM
1. I CNG
Vim phi cng ng hay cn gi l vim phi mc phi ti cng ng l
nhim khun cp tnh (di 14 ngy) gy tn thng nhu m phi, km theo cc
du hiu ho, kh th nhp th nhanh v rt lm lng ngc, u ngc... Cc triu
chng ny thay i theo tui (Khuyn co 5.1 Ph lc 1)
Vim phi cng ng tr em l bnh l ph bin c t l mc v t vong
cao, c bit l tr di 5 tui.
Theo thng k ca WHO (nm 2000) trung bnh mi tr mc 0,28
t/tr/nm.(9) (Bng II.2).
Bng II.2. T l mi mc VPC hng nm tr < 5 tui theo khu vc trn th
gii (WHO)
a d

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

Ty Thi Bnh Dng

133,05

0,22

29,07

Cc nc ang pht trin

523,31

0,29

151,76

Cc nc pht trin

81,61

0,05

4,08

Nh vy cc nc ang pht trin c t l mc cao gp 5 ln cc nc


pht trin.
Nu chn 15 nc c t l mc vim phi hng nm cao nht th ng
hng u l n , Trung Quc v Pakistan. Vit Nam ng th 9 (9) (Bng
II.3).
c tnh t vong do vim phi tr em < 5 tui trn th gii l 0,26
tr/1000 tr s sinh sng. Nh vy hng nm c khong 1,8 triu tr t vong do
vim phi (khng k vim phi s sinh: c tnh khong 300.000 tr s sinh
vim phi t vong hng nm) (15).
B Y t | S DNG KHNG SINH IU TR VIM PHI 99
CNG NG TR EM

Sau y l bng thng k 15 nc c t l mc v t vong do vim phi


cao nht (Bng II.3 v Bng II.4).
Bng II.3. 15 nc c s tr mc vim phi cao nht
Tn nc
n
Trung Quc
Pakistan
Bangladesh
Nigeria
Indonesia
Ethiopia
CHDCND Congo
Vit Nam
Philippines
Sudan
Afganistan
Tanzania
Myanma
Brazil

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

Bng II.4. 15 nc c s tr t vong do vim phi cao nht


Tn nc
n
Nigeria
CHDCND Congo
Ethiopia
Pakistan
Afganistan
Trung Quc
Bangladesh
Angola
Nigeria
Uganda
Tanzania
Mali
Kenya
Bunkina Faso

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

Vit Nam theo thng k ca cc c s y t vim phi l nguyn nhn


hng u m tr em n khm v iu tr ti cc bnh vin v cng l nguyn
nhn t vong hng u trong s t vong tr em.
Theo s liu bo co nm 2004 ca UNICEF v WHO th nc ta c
khong 7,9 triu tr < 5 tui v vi t l t vong chung l 23 th mi nm c
khong 38.000 tr t vong trong vim phi chim 12% trng hp. Nh vy
mi nm c khong 4500 tr < 5 tui t vong do vim phi (5).
B Y t | S DNG KHNG SINH IU TR VIM PHI 100
CNG NG TR EM

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

- Cn lu : m nhp th khi tr nm yn hoc lc ng, phi m trn 1


pht. i vi tr < 2 thng tui phi m 2 ln v tr nh th khng u, nu c
2 ln m m nhp th u 60 ln/pht th mi c gi tr.
- Rt lm lng ngc: L du hiu ca vim phi nng. pht hin du
hiu ny cn nhn vo phn di lng ngc (1/3 di) thy lng ngc lm vo
khi tr th vo. Nu ch phn mm gia cc xng sn hoc vng trn xng
n rt lm th cha phi rt lm lng ngc.
- tr < 2 thng tui nu ch rt lm nh th cha c gi tr v lng ngc
tr nh la tui ny cn mm, khi th bnh thng cng c th hi b rt lm.
V vy la tui ny khi rt lm lng ngc mnh (lm su v d nhn thy) mi
c gi tr chn on (8).
- Ran m nh ht: Nghe phi c ran m nh ht l du hiu ca vim phi
tuy nhin nhy thp so vi vim phi c xc nh bng hnh nh X-quang.
3.2. Hnh nh X-quang phi
Chp X-quang phi l phng php xc nh cc tn thng phi trong
c vim phi. Tuy nhin khng phi cc trng hp vim phi c chn
on trn lm sng no cng c du hiu tn thng trn phim X-quang phi
tng ng v ngc li. V vy khng nht thit cc trng hp vim phi cng
ng no cng cn chp X-quang phi m ch chp X-quang phi khi cn thit
(trng hp vim phi nng cn iu tr ti bnh vin) (Khuyn co 5.2 Ph
lc 1).
3.3. Cc xt nghim cn lm sng khc (nu c iu kin): Cy mu, cy dch
t hu, m, dch mng phi, dch kh ph qun qua ng ni kh qun, qua ni
soi ph qun tm vi khun gy bnh, lm khng sinh ; xt nghim PCR tm
nguyn nhn virus, nguyn nhn gy vim phi khng in hnh nh
M. pneumoniae, Chlamydia...
- Cc xt nghim ny ch c th lm c ti cc bnh vin c iu kin.
(Khuyn co 5.4 v khuyn co 5.5 Ph lc 1)
4. PHN LOI THEO MC NNG NH (THEO PHN LOI CA
TCYTTG)
4.1. Khng vim phi (Ho, cm lnh)
- Tr c cc du hiu sau:
+ Ho
+ Chy mi
+ Ngt mi
+ St hoc khng
- V khng c cc du hiu sau:
+ Th nhanh
+ Rt lm lng ngc
B Y t | S DNG KHNG SINH IU TR VIM PHI 102
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

B Y t | S DNG KHNG SINH IU TR VIM PHI 103


CNG NG TR EM

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

- Theo mc nng nh ca bnh


Cc trng hp vim phi nng v rt nng (suy h hp, sc, tm ti, b
b, khng ung c, ng li b kh nh thc, co git, hn m hoc tnh trng
suy dinh dng nng...thng l do cc vi khun Gram-m hoc t cu nhiu
hn l do ph cu v H. influenzae.
- Theo mc khng thuc
Mc khng khng sinh ty theo tng a phng, tng vng (thnh th
c t l khng khng sinh cao hn nng thn, bnh vin t l khng thuc
cao hn cng ng, ni lm dng s dng khng sinh c t l khng thuc
cao hn ni s dng khng sinh an ton v hp l...) (6).
Vit Nam tnh hnh khng khng sinh ca 3 vi khun thng gp gy
vim phi tr em (xem Bng II.5 ASTS 2003 2004).
Mc d nghin cu trong phng xt nghim th t l khng khng sinh ca
cc vi khun gy vim phi tr em l kh cao, nhng trong thc t lm sng
nghin cu y hc bng chng th mt s khng sinh nh penicilin, ampicilin,
gentamycin v chloramphenicol...vn c tc dng trong iu tr vim phi cng ng,
k c Co-trimoxazol (1,4). V vy cc thy thuc cn phn tch cc c im ni trn
la chn khng sinh ph hp.
Bng II.5. Tnh hnh khng khng sinh ca 3 vi khun thng gp gy vim phi
tr em
Khng sinh

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

5.3. Hng la chn khng sinh trong iu tr vim phi tr em


a) Vim phi tr s sinh v < 2 thng tui
- tr s sinh v di 2 thng tui, tt c cc trng hp vim phi u
l nng v phi a tr n bnh vin theo di v iu tr:
+ Benzyl penicilin 50mg/kg/ngy (TM) chia 4 ln hoc

B Y t | S DNG KHNG SINH IU TR VIM PHI 105


CNG NG TR EM

+ Ampicilin 100 150 mg/kg/ngy kt hp vi gentamycin 5-7,5


mg/kg/ngy (TB hoc TM) dng 1 ln trong ngy. Mt t iu tr t 5 -10
ngy.
- Trong trng hp vim phi rt nng c th dng:
+ Cefotaxim 100 150 mg/kg/ngy (tim TM) chia 3-4 ln trong ngy.
b) Vim phi tr 2 thng 5 tui
- Vim phi (khng nng)
Khng sinh ung vn m bo an ton v hiu qu trong iu tr vim
phi cng ng tr em k c mt s trng hp nng. (Khuyn co 5.8 Ph
lc 1). Lc u c th dng:
+ Co-trimoxazol 50mg/kg/ngy chia 2 ln (ung) ni vi khun S.
pneumoniae cha khng nhiu vi thuc ny.
+ Amoxycilin 45mg/kg/ngy (ung) chia lm 3 ln. Theo di 2 - 3 ngy
nu tnh trng bnh th tip tc iu tr t 5 7 ngy. Thi gian dng
khng sinh cho tr vim phi t nht l 5 ngy (Khuyn co 5.10 Ph lc 1).
Nu khng hoc nng thm th iu tr nh vim phi nng.
nhng ni tnh trng khng khng sinh ca vi khun S. pneumoniae cao
c th tng liu lng amoxycilin ln 75mg/kg/ngy hoc 90mg/kg/ngy chia 2
ln trong ngy.
+ Trng hp vi khun H. influenzae v B. catarrhalis sinh betalactamase cao c th thay th bng amoxicillin-clavulanat.
- Vim phi nng
+ Benzyl penicilin 50mg/kg/ln (TM) ngy dng 4-6 ln.
+ Ampicilin 100 - 150 mg/kg/ngy.
Theo di sau 2-3 ngy nu th tip tc iu tr 5 10 ngy. Nu
khng hoc nng thm th phi iu tr nh vim phi rt nng. Tr ang
c dng khng sinh ng tim iu tr vim phi cng ng c th
chuyn sang ng ung khi c bng chng bnh ci thin nhiu v tnh
trng chung tr c th dng thuc c theo ng ung (Khuyn co 5.9 Ph
lc 1).
- Vim phi rt nng
+ Benzyl penicilin 50mg/kg/ln (TM) ngy dng 4-6 ln phi hp vi
gentamycin 5 -7,5 mg/kg/ ngy (TB hoc TM) dng 1 ln trong ngy
+ Hoc chloramphenicol 100mg/kg/ngy (ti a khng qu 2g/ngy). Mt
t dng t 5- 10 ngy. Theo di sau 2-3 ngy nu th tip tc iu tr cho
7 -10 ngy hoc c th dng ampicilin 100 150mg/kg/ngy kt hp vi
gentamycin 5 -7,5 mg/kg/ ngy (TB hoc TM) dng 1 ln trong ngy.
B Y t | S DNG KHNG SINH IU TR VIM PHI 106
CNG NG TR EM

Nu khng hy i 2 cng thc trn cho nhau hoc dng cefuroxim 75


150 mg/kg/ ngy (TM) chia 3 ln (6).
- Nu nghi ng vim phi do t cu hy dng:
+ Oxacilin 100 mg/kg/ngy (TM hoc TB) chia 3-4 ln kt hp vi
gentamycin 5 -7,5 mg/kg/ ngy (TB hoc TM) dng 1 ln trong ngy.
+ Nu khng c oxacilin thay bng: Cephalothin 100mg/kg/ngy (TM
hoc TB) chia 3-4 ln kt hp vi gentamycin liu nh trn.
Nu t cu khng methicilin cao c th s dng:
+ Vancomycin 10mg/kg/ln ngy 4 ln (12) (Khuyn co 5.8 Ph lc 1).
c) Vim phi tr trn 5 tui
la tui ny nguyn nhn ch yu gy vim phi thng gp vn l S.
pneumoniae v H. influenzae. Sau l cc vi khun gy vim phi khng in
hnh l Mycoplasma pneumoniae, Chlamydia pneumoniae v Legionella
pneumophila...V vy c th dng cc khng sinh sau:
+ Benzyl penicilin: 50mg/kg/ln (TM) ngy 4-6 ln
+ Hoc cephalothin: 50 100 mg/kg/ngy (TM hoc TB) chia lm 3-4 ln
+ Hoc cefuroxim: 50 75 mg/kg/ngy (TM hoc TB) chia lm 3 ln
+ Hoc ceftriazon: 50 100 mg/kg/ngy (TM hoc TB) chia lm 1- 2 ln.
Nu ni c t l H. influenzae sinh beta-lactamase cao th c th thay th
bng amoxycilin-clavulanat hoc ampicilin-sulbactam (Unacin) TB hoc TM.
(6,12).
Nu l nguyn nhn do cc vi khun Mycoplasma, Chlamydia,
Legionella... gy vim phi khng in hnh c th dng:
+ Erythromycin: 40 -50 mg/kg/ngy chia 4 ln ung trong 10 ngy (13)
+ Hoc azithromycin: 10mg/kg/trong ngy u sau 5mg/kg trong 4
ngy tip theo. Trong mt s trng hp c th dng ti 7 10 ngy (11).
(Khuyn co 5.7 Ph lc 1)
6. PHNG BNH
- V sinh mi trng nh sch s.
- Trnh un bp than, gim khi bp, khi thuc l trong nh.
- Gim t l mang vi khun t hu, phng v iu tr kp thi cc trng
hp vim mi, hng, cm cm...
- Tng cng v sinh tay.
- Bo m tim vaccine phng bnh cho tr em theo chng trnh tim
chng. Cc vaccine cn thit phng cc bnh ng h hp tr em l
H. influenzae type b (Hib), ho g, ph cu, cm...
B Y t | S DNG KHNG SINH IU TR VIM PHI 107
CNG NG TR EM

TI LIU THAM KHO


1. Igor Rudan et al. Epidemiology and Etiology of childhood pneumoniae. Bulletin of the
World Health Organization Volum 86, Number 5, May 2008, 321-416
2. Nguyn Tin Dng, Hong Kim Huyn, Phan Qunh Lan. Nghin cu dch t hc v s
dng khng sinh trong iu tr vim phi tr em di 5 tui ti Khoa Nhi Bnh vin Bch
Mai. Y hc thc hnh s 391, 2000,tr 166-169
3. Trn Qu, N.T.Dng, N.V.Tim, Kiu Mnh Thng. Khng sinh trong iu tr vim phi
ti cng ng. K yu cng trnh nghin cu khoa hc Bnh vin Bch Mai (1991-1992) T1,
tr 113 119.
4. Trn Qu, Nguyn Tin Dng: c im lm sng v s dng khng sinh trong iu tr
vim phi tr 2 thng 1 tui. ti nhnh cp nh nc KY01-06 03B 1995.
5. UNICEF/WHO Pneumonia. The forgotten killer of the children - 2006
6. Cameron Grant Pneumonia acute in infants and children starship childrens health
clinical Guideline Reviewed September 2005.
7. Bristish Thoracic society of Standards of care committee. Bristish Thoracic society
Guidelines for the management of community acquired pneumonia in childhood. Thorax 2002
57 Suppl 1, i 124.
8. WHO Antibiotic in the treatment of acute respiratory infections in young children.
WHO/ARI 90 10
9. Nelson John D- Community acquired pneumonia in children guidelines for treatment.
Pediatr Infect. Dis.J.Volum 19 (3) March 2000 . 251- 253
10. Watanabe.K, Anh , Hng Ple T et al. Drug Resistant pneumococci in children with
acute lover respiratory infection in Vietnam. Pediatr. Int 2008 Aug 50 (4) 514, 8
11. Lee P.I, Wu M.H, Huang L.M, et al An open randomized comparative study of
clarithromycin and Erythromycin in the treatment of children with community acquired
pneumonia. J. Microbial. Immunol, Infect. 2008 Feb. 41 (1) 54-61
12. Kogan. R, Martinez MA, Rubila. L et al. Comparative randomized trial of azithromycin
versus erythromycin and amoxycilin for treatment of community acquired pneumonia in
children. Pediatr pulmonol 2003, Feb 35 (2) 91-8
13. Mc. Intosh. K, Community Acquired pneumonia in children N. Engl. J. Med. 2002,
346,429 -37
14. Harris M, Clark.J, Coote. N, et al Bristish Thoracic society standart of care commitee
Bristish Thoracic Society guidelines for the mannagement of community acquired pneumonia
in children update 2011- Thorax 2011 oct 66 Suppl 2ii 1-23.
15. Hazir T, Fox LM, Nisar YB et al. New outpatient short course home oral therapy for
severe pneumonia study group ambulatory short course high dose oral amoxicilin for
treatment of severe pneumonia in children a randomized equivalency. Lanet 2008 Jan 5, 371
(9606) 49 56
16. Nguyn Tin Dng Trn Qu, May Mya Sein, Nghin cu tc dng ca Cefuroxim
sodium tim v Cefuroxim acetyl ung trong iu tr vim phi mc phi ti cng ng tr
em. Y hc Vit Nam 1997, 7 (218) 21 -26

B Y t | S DNG KHNG SINH IU TR VIM PHI 108


CNG NG TR EM

17. Thanh Xun: Nghin cu c im lm sng v iu tr vim phi do vi khun khng


khng sinh tr em. Lun n tin s y hc nm 2000.
18. Anh , Hng Ple.T, Watanabe. K et al. Increased rate intense nasopharyngeal
bacterial colonization of Vietnamese children with radiological pneumonia. Tohoku.J.Exp.
Med 2007 Oct. 213 (2) 167 72.
19. Sinha. A, Levine.O, Knoll N.D, et al . Cost effecti veness of pneumonia conjugate
vaccination in the prevention of child mortality: an international economic analysis. Lancer
2007, 269, 359 69.
20. World Health Organization. The global burden of disease: 2004 update. Geneva, World
Health Organization 2008. Http://www.who.int/evidence/bod.
21. Hi lao v bnh phi Vit Nam. Hng dn x tr cc bnh nhim khun h hp di
khng do lao. Nh xut bn Y hc 2012. Trang 111-133.

B Y t | S DNG KHNG SINH IU TR VIM PHI 109


CNG NG TR EM

VIM PHI BNH VIN


1. I CNG
- Vim phi bnh vin (VPBV) bao gm cc khi nim: Vim phi mc
phi bnh vin (nosocomial pneumonia hoc hospital acquired pneumonia),
vim phi lin quan n chm sc y t (healthcare associated pneumonia ), vim
phi lin quan n th my (ventilation associated pneumonia).
- Vim phi bnh vin (VPBV) l tn thng nhim khun phi xut hin
sau khi ngi bnhngi bnh nhp vin t nht 48h m trc khng c biu
hin triu chng hoc bnh ti thi im nhp vin.
- Trng hp ngi bnhngi bnh c t ng ni kh qun (NKQ),
th my sau 48h xut hin vim phi c nh ngha l vim phi lin quan n
th my (VPTM).
- Vim phi lin quan n chm sc y t (VPCSYT), l loi vim phi
tin trin c th ti bnh vin hoc ngoi bnh vin, cc ngi bnhngi bnh
ch cn c tin s tip xc vi cc chm sc y t c nguy c mang vi khun
a khng thuc: Nm vin trong vng 90 ngy, nm iu tr ti cc trung tm
iu dng, chy thn nhn to ti nh, tip xc vi thnh vin trong gia nh c
cha vi khun a khng.
- Da theo nhiu khuyn co trn th gii, VPBV c chia ra 2 nhm
chnh:
+ Nhm I: VPBV khi pht sm <5 ngy v khng c yu t nguy c
nhim vi khun a khng (MDR).
+ Nhm II: VPBV khi pht mun 5 ngy v/hoc c yu t nguy c
nhim vi khun MDR.
2. NGUYN NHN
- Nguyn nhn gy bnh kh a dng, thng do nhiu loi vi khun v chng
hay kt hp vi nhau, him khi nguyn nhn la virus va nm nu ngi bnhngi
bnh khng b suy gim min dch. C hai nhm vi khun gy bnh thng gp .
Nhm gm cc vi khun Gram-m hiu khi khang nhiu thuc nh Pseudomonas
aeruginosa, Escherichia coli, Enterobacteriacae, Klebsiella pneumoniae v
Acinetobacter baumannii. Nhm MRSA (S. aureus khng methicilin), nhm vi
khun Gram-dng nh Staphylococcus aureus. Vim phi do S. aureus gp nhiu
hn bnh nhn bi ai thao ng, chn thng so nao, iu tr ti ICU. Ngoi ra,
mt s vi khun thuc cc chng streptococci, staphylococci coagulase (-),
Neisseria v Corynebacterium hi sinh vng ming hu cng c th gy bnh.
Nhng vi khun ny c th gy nhim khun trn cc ngi bnhngi bnh
thiu ht min dch, khi hng ro min dch b tn thng.

B Y t | VIM PHI BNH VIN 110

- 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

- Xem xt chin lc iu tr xung thang ngay sau khi c kt qu khng


sinh .
b) La chn khng sinh iu tr theo kinh nghim
- Khng sinh c th c la chn theo Bng II.6 v Bng II.7.
- Thi gian iu tr thng t 10 14 ngy, thi gian iu tr c th ko
di hn n 21 ngy nu nhim cc vi khun khng thuc nh: P. aeruginosa,
Acinetobacter sp., Stenotrophomonas maltophilia v MRSA hoc ngi
bnhngi bnh c triu chng ko di: St>380 c, cn m m, X-quang ci
thin chm
- Khi xc nh c cn nguyn gy bnh th iu tr theo khng sinh
.
- Nghi nhim vi khun a khng khi:
+ iu tr khng sinh trong vng 90 ngy trc
+ Nm vin 5 ngy
+ nhng ni c t l khng khng sinh cao trong cng ng hay trong
bnh vin
+ Vim phi lin quan n chm sc y t
- Vim phi mc phi bnh vin cn c iu tr ni tr ti cc bnh
vin tnh v bnh vin trung ng.
Bng II.6. La chn khng sinh iu tr theo kinh nghim
Phn loi
VPBV sm
(khng c
nguy c
nhim vi
khun khng
thuc)

Khng sinh u tin

Nguyn nhn chnh


S. pneumoniae,

Cephalosporin, th h III:

Streptococcus spp.,

Ceftriaxon 1-2 g mi 24h TM hoc

MSSA,

Cefotaxim 1-2 g mi 8h, TM

H.influenzae,

Hoc

E.coli,

Cephalosporin, th h IV:

Klebsiella spp.,

Cefepim 1-2 g mi 12h, TM

Enterobacter,

Hoc

Proteus spp.

Beta-lactam-cht c ch beta-lactamase

v Serratia spp.

(Piperacilin-tazobactam 4,5 g mi 8h TM)


Hoc
Fluoroquinolon:
Levofloxacin 750 mg mi 24h TM hoc
Moxifloxacin 400 mg mi 24h TM

VPBV mun
(c nguy c
nhim VK

S. pneumoniae,
Streptococcus spp., MSSA,

Cephalosporin, th h III: Ceftriaxon 1-2 g mi 24h


TM hoc
Cefotaxim 1-2 g mi 8h TM

B Y t | VIM PHI BNH VIN 112

Phn loi
a khng)
mc nh
v va

Khng sinh u tin

Nguyn nhn chnh


H. influenzae,

Hoc

E.coli

Cephalosporin, th h IV: Cefepim 1-2 g mi 8-12h,


TM

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

Vancomycin 1 g mi 12h, TM hoc linezolid 600 mg


mi 12h, TM (nu c hoc nghi ng MRSA)

S. pneumoniae,

Cephalosporin khng Pseudomonas

Streptococcus spp.

Ceftazidim 2g mi 8h hoc cefepim 1-2 g mi 8-12h,


TM

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)

B Y t | VIM PHI BNH VIN 113

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)

Vancomycin hoc teicoplanin

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

Carbapenem hoc piperacilintazobactam + aminoglycosid hoc


fluroquinolon (ciprofloxacin)

Polymyxin B hoc colistin

MDR Acinetobacter

Carbapenem phi hp vi colistin

Cefoperazon-sulbactam phi
hp vi colistin

Cc chng siu khng


thuc

Cc phi hp c th:

aminoglycosid

Carbapenem + ampicilin-sulbactam
Doxycyclin + amikacin
Colistin + rifampicin ampicilin-sulbactam

Ch : Khi s dng kt hp vi thuc nhm aminoglycosid cn theo di chc nng


thn ca ngi bnh 2 ln/ tun.

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.

B Y t | VIM PHI BNH VIN 114

- Nn ch nh thng kh nhn to khng xm nhp sm nhm hn ch cc


trng hp phi t ni kh qun, thng kh nhn to xm nhp nguyn nhn
hng u gy vim phi mc phi bnh vin.
- Nn t ni kh qun, ng thng d dy theo ng ming hn l ng
mi, nhm trnh nguy c vim xoang t c th gim nguy c vim phi bnh
vin.
- Nn ht lin tc dch h hng, trn thanh qun. Nn bm bng ng ni
kh qun khong 20 cm H2O ngn dch hu hng xung ng h hp di.
- Cn thn trng nc cc bnh cha nc ng trn ng ng th
trnh nc ng chy vo dy ng th qua vic kh dung thuc. m
bo dng c, nguyn tc v trng khi ht m qua ni kh qun hoc ng m kh
qun.
- C gng cai th my sm, gim ti thiu thi gian lu ng ni kh qun
v thng kh nhn to xm nhp.
- Ngi bnhNgi bnh nn c nm t th u cao (300- 450)
trnh nguy c sc phi dch ng tiu ha c bit nhng ngi bnhngi
bnh n qua ng thng d dy.
- V rung hng ngy i vi cc ngi bnhngi bnh phi nm lu.
- V sinh rng ming thng xuyn cho nhng ngi bnhngi bnh ri
lon thc, hn m, th my ko di.
T VIT TT TRONG BI
VPBV

Vim phi bnh vin

NKQ

Ni kh qun

VPTM

Vim phi lin quan n th my

VPCSYT

Vim phi lin quan n chm sc y t

TI LIU THAM KHO


1. Cunha BA (2010), Pneumonia Essentials 3nd Ed, Royal Oak, MI: Physicians Press, 111118.
2. Ferrer M, Liapikou A, Valencia M, et al (2010), Validation of the American Thoracic
Society-Infectious Diseases Society of America guidelines for hospital-acquired pneumonia in
the intensive care unit, Clin Infect Dis, 50(7):945.
3. Jean Chastre, Charles-Eduoard Luyt (2010), Ventilator-Associated Pneumonia, Murray
and Nadels Textbook of Respiratory Medicine (5th ed), Saunder.

B Y t | VIM PHI BNH VIN 115

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

B Y t | VIM PHI BNH VIN 116

VIM PHI LIN QUAN N TH MY


1. I CNG
nh ngha: Vim phi lin quan n th my (Ventilator Associated
Pneumonia - VAP), c nh ngha l nhim khun nhu m phi xy ra sau 48
gi k t khi ngi bnh c th my (qua ng ni kh qun, hoc canuyn m
kh qun), ngi bnh khng trong thi k bnh ti thi im bt u c th
my.
L bnh l nhim khun bnh vin rt thng gp trong khoa hi sc, vi
t l 8-10% ngi bnh iu tr ti khoa hi sc, v 27% trong s ngi bnh
c th my. T l t vong khong 20-50% theo nhiu nghin cu, thm ch c
th ti 70% khi nhim cc vi khun a khng.
Lm tng t l t vong, ko di thi gian th my, thi gian nm vin v
tng chi ph iu tr.
2. NGUYN NHN V CC YU T NGUY C
2.1. Nguyn nhn
- Cc vi sinh vt gy bnh rt thay i ph thuc vo c im ngi bnh
trong tng khoa hi sc, phng tin chn on, thi gian nm vin cng nh
thi gian nm iu tr ti khoa hi sc, qui trnh kim sot nhim khunv cc
chnh sch s dng khng sinh ti n v .
- Cc nguyn nhn hay gp trong vim phi lin quan n th my sm (<
5 ngy): T cu nhy methicilin, Streptococcus pneumoniae, Hemophilus
influenzae.
- Vim phi lin quan n th my mun ( 5 ngy): T cu khng
methicilin, P. aeruginosa, Acinetobacter baumannii, Stenotrophomonas
maltophilia.
- Ngi bnh dng khng sinh trc : T cu khng methicilin, P.
aeruginosa, Acinetobacter baumannii v cc vi khun Gram-m a khng khc.
Ngoi ra gn y nm l nguyn nhn rt ng ch gy vim phi bnh vin,
c bit nhng ngi bnh c c a suy gim min dch, s dng khng sinh
ph rng di ngy.
2.2. Cc yu t nguy c ca vim phi lin quan n th my
a) Yu t lin quan n ngi bnh
- Tui 60.
- Mc nng ca bnh.
- Suy tng.
- Dinh dng km hoc gim albumin mu.
B Y t | VIM PHI LIN QUAN N TH MY 117

- au bng thng v hoc c phu thut vng ngc.


- Hi chng suy h hp cp tin trin.
- Bnh phi mn tnh.
- Bnh l thn kinh c.
- Chn thng, bng.
- Hn m, suy gim thc.
- Ht phi lng th tch ln.
- C vi khun khu tr ng h hp trn.
- Vi khun khu tr d dy v pH dch v.
- Vim xoang.
b) Yu t lin quan n cc bin php can thip
- Thi gian th my.
- t li ni kh qun.
- Thay i h thng dy th thng xuyn.
- t ng thng d dy.
- Theo di thng xuyn p lc ni s.
- Dng thuc an thn, gin c.
- Dng thuc khng H2, thuc khng acid.
- Truyn > 4 n v mu.
- T th u, nm nga.
- Vn chuyn ra ngoi khoa hi sc.
c) Cc yu t khc
Ma: Ma thu, ma ng.
2.3. Yu t nguy c v cc vi sinh vt c bit

B Y t | VIM PHI LIN QUAN N TH MY 118

Bng II.8. Yu t nguy c v cc vi sinh vt c bit


Yu t nguy c

Vi sinh vt
H. influenzae,
Moraxella catarrhalis,

Bnh phi tc nghn mn tnh, vim phi lin quan n th


my t sm (xut hin sm < 5 ngy sau khi c th my)

S. pneumoniae
P. aeruginosa,
Acinetobacter baumannii

iu tr bng corticoid, suy dinh dng, bnh phi (gin ph


qun, x nang phi), vim phi lin quan n th my mun,
c dng khng sinh trc

T cu

Hn m, chn thng s no, phu thut thn kinh, i tho


ng, suy thn mn, cm

Vi khun k kh

Ht phi

Legionella

Ha tr liu, iu tr corticoid, bnh l c tnh, suy thn, gim


bch cu, ly nhim t h thng nc bnh vin

Aspergillus

iu tr bng corticoid, thuc c t bo, bnh phi tc nghn


mn tnh

Candida albicans

Suy gim min dch, thuc c t bo, s dng corticoid,


khng sinh ph rng di ngy, ngi bnh c lu cc ng
thng mch mu di ngy

Influenza virus

Ma ng, suy gim min dch, bnh l mn tnh tim n,


sng ni c dch cm lu hnh ...

Virus hp bo h hp

Suy gim min dch, bnh tim hoc phi mn tnh

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

- Gim oxy ha mu: nh gi da vo SpO2 ( bo ha oxy mch


ny), hoc ch s PaO2/FiO2 khi c kt qu kh mu ng mch.
4. IU TR BNG KHNG SINH
4.1. Nguyn tc la chn khng sinh
- Xem xt k cc yu t sau la chn khng sinh thch hp:
+ C a ngi bnh, cc yu t nguy c v bnh l km theo.
+ Cc khng sinh dng trc .
+ Mc tn thng phi.
+ Dch t hc, mc nhy cm ca cc chng vi khun ti tng khoa,
bnh vin.
+ Vim phi bnh vin sm hay mun.
- Khng sinh la chn theo kinh nghim cn c cho sm (tt nht sau
khi ly cc bnh phm nh dch ph qun, mu lm xt nghim vi sinh), ng
- liu, sau iu chnh theo p ng lm sng v kt qu xt nghim vi
sinh.
4.2. X tr ban u v vn chuyn cp cu
- Ngi bnh mc vim phi lin quan n th my thng ang c
iu tr ti cc c s Hi sc Cp cu. Trng hp ang c iu tr hoc
chm sc di ngy ti cc c s y t khc, ngi bnh cn c vn chuyn sm
v an ton n cc khoa Hi sc cp cu c iu tr v theo di st.
- Trc khi vn chuyn, cn ch nh sm khng sinh theo kinh nghim
liu u tin (da trn c a v nh hng s b trn lm sng). Ngoi ra,
ngi bnh phi c nh gi c th tnh trng h hp ch nh phng thc
th my ph hp.
- Trong qu trnh vn chuyn phi m bo mch, huyt p v tnh trng
h hp n nh (dch truyn, thng kh vi my th vn chuyn chuyn dng
hoc bp bng qua ng ni kh qun/canuyn m kh qun). Tn, liu v thi
gian s dng thuc khng sinh phi c ghi y trong tm tt bnh n
chuyn vin (hoc giy chuyn vin).
4.3. iu tr khng sinh ti bnh vin
a) Khng sinh iu tr vim phi bnh vin trong trng hp khng c nguy c
nhim vi khun a khng
- iu tr khng sinh kinh nghim vi: T cu nhy methicilin,
Streptococcus pneumoniae, Hemophilus influenzae, vi khun Gram-m ng
rut nhy vi khng sinh.
- La chn mt trong s cc khng sinh:
B Y t | VIM PHI LIN QUAN N TH MY 120

+ 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

- Thi gian iu tr ngn (khong 7-10 ngy): T cu, Hemophilus


influenzae.
- Thi gian iu tr di (t nht 14 21 ngy):
+ Tn thng nhiu thy.
+ C a suy dinh dng.
+ C tn thng dng , dng khoang.
+ Vim phi c hoi t do vi khun Gram-m.
+ Kt qu nh danh vi khun: P. aeruginosa, Acinetobacter spp.
4.4. Liu dng, ng dng c th ca mt s khng sinh
- Liu dng v ng dng c th ca mt s khng sinh c th hin
trong Bng II.9.

B Y t | VIM PHI LIN QUAN N TH MY 123

Bng II.9. Liu dng, ng dng c th ca mt s khng sinh


Loi khng sinh

Cch s dng

Ceftriaxon

1-2g x 1 ln/ngy, ti a 4g chia 2 ln/ngy. Dng ng tnh mch.

Cefepim

1-2g mi 8 gi, ti a 6g/ngy. Nhim khun e da tnh mng: 2g mi 8


gi. Dng ng tnh mch.

Ceftazidim

1-2g mi 8 gi. Dng ng tnh mch.

Ampicilin-sulbactam

1,5-3g mi 6 gi, dng ng tnh mch. Ti a 4,5g mi 6 gi.

Imipenem

0,5 1g mi 6 gi, ti a 4g/ngy, truyn tnh mch trong 3-4 gi.

Meropenem

0,5 1g mi 8 gi, ti a 2g mi 8 gi, ng tnh mch.

Piperacillin-tazobactam

4,5g mi 6 gi, truyn tnh mch.

Levofloxacin

750 mg/ngy, truyn tnh mch.

Moxifloxacin

400mg/ngy, truyn tnh mch.

Ciprofloxacin

400mg mi 8-12 gi, ti a 1200mg/ngy, truyn tnh mch.

Amikacin

Liu thng dng 15 20 mg/kg x 1 ln/ngy, truyn tnh mch. Nhim


khun nng c th tng n 28 mg/kg/ngy, phi gim st nng y (<
1g/ml).

Tobramycin

Liu thng dng 3 5 mg/kg x 1 ln/ngy, truyn tnh mch. Nhim


khun nng c th tng n 7 mg/kg, phi gim st nng y (<
1g/ml).

Gentamicin

Liu thng dng 3 5 mg/kg x 1 ln/ngy, truyn tnh mch. Nhim


khun nng c th tng n 7mg/kg, phi gim st nng y (< 1g/ml).

Linezolid

600mg x 2 ln/ngy, dng ng ung hoc ng tnh mch.

Teicoplanin

Liu dng: Khi u 400mg/12 gi x 3 liu u; liu duy tr 400mg/24 gi;


truyn tnh mch trong 30 pht

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

Liu u 400mg/ngy, sau duy tr 200mg/ngy, ng truyn, hoc


ung.

Itraconazol

200mg/12 gi trong 2 ngy u (4 liu), truyn tnh mch, sau


200mg/ngy trong 12 ngy, truyn trong 1 gi.

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.

B Y t | VIM PHI LIN QUAN N TH MY 124

Thuc khc: Colistin


- Ch nh trong vim phi lin quan n th my mun, c khng
nh hoc c nguy c nhim vi khun Gram-m a khng.
- Khng c s dng colistin n c, nn phi hp vi cc khng sinh
khc nh carbapenem, rifampicin, fluoroquinolon, k c khi vi khun
khng vi cc khng sinh ny bi v tc dng hip ng c chng minh.
- Phi dng liu np, dng 1 ln/ngy.
- Liu duy tr phi chia nhiu ln trong ngy, thng chia 2 3 ln/ngy.
- Liu dng c th cn cn c trn lm sng v MIC ca vi khun.
5. TIN LNG V BIN CHNG
5.1. Tin lng: Nng nu ngi bnh c nguy c nhim cc vi sinh vt a
khng thuc
- Ngi 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.
- Vim phi bnh vin mun ( 5 ngy).
- 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 bnh c bnh l suy gim min dch, hoc ang dng thuc gy
suy gim min dch.
5.2. Bin chng
- p xe phi.
- Hi chng suy h hp cp tin trin (ARDS - acute respiratory distress
syndrome).
- Vim m mng phi.
- Nhim khun huyt.
- Sc nhim khun.

B Y t | VIM PHI LIN QUAN N TH MY 125

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.

B Y t | VIM PHI LIN QUAN N TH MY 126

TI LIU THAM KHO


1. Nguyn Quc Anh, Ng Qu Chu. (2011), Vim phi lin quan n th my, Hng
dn chn on v iu tr bnh ni khoa. Nh xut bn Y hc, Tr. 96-9.
2. Nguyn Ngc Quang (2011), Nghin cu tnh hnh v hiu qu iu tr vim phi lin
quan n th my. Lun vn tt nghip bc s ni tr bnh vin. Trng i hc Y H Ni.
3. Bi Hng Giang (2013). Nghin cu c im vi khun v iu tr nhim khun bnh vin
ti khoa Hi sc tch cc, bnh vin Bch Mai nm 2012. Lun vn tt nghip Thc s Y
hc. Trng i hc Y H Ni.
4. Alp E, Voss A. (2006), Ventilator-associated pneumonia and infection control, Annals of
Clinical Microbiology and Antimicrobials, Pp. 5-7.
5. Antibiotic Essentials 2010. Physicians Press.
6. Australian Medicin Handbook. (2009), Anti-infectives.
7. Chastre J., Fagon J.Y. (2002), Ventilator-associated pneumonia, American Journal of
Respiratory and Critical Care Medicine, Vol 165 (7), Pp. 867-903.
8. Koenig S.M., Truwit J.D. (2006), Ventilator-associated pneumonia: Diagnosis, treatment
and prevention, Clinical Microbiology Review, Oct, Pp. 637-57.
9. Kollef M.H., Isakow W. (2012), Ventilator-associated pneumonia, The Washington
Manual of Critical Care. second edition.
10. Pelleg A.Y., Hooper D.C. (2010), Hospital Acquired- Infections due to gram-negative
bacteria, New England Journal Medicine (362), Pp. 1804-13.
11. The Sanford Guide to Antimicrobial Therapy 2010.
12. Therapeutic Guidelines Antibiotic 2010, Respiratory tract infections: pneumonia,
version 14, Melbourne.

B Y t | VIM PHI LIN QUAN N TH MY 127

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

kh, Streptococcus pneumoniae, Hemophilus influenzae. Mt s trng hp do


nm, k sinh trng (amp). Tuy nhin phi nhn mnh rng p xe phi thng l
tnh trng nhim nhiu loi vi khun cng lc (polymicrobial infections).
- Cn tm cc yu t thun li nh nghin ru, suy gim min dch do
HIV hoc cc thuc c ch min dch, tm cc nhim khun nguyn pht:
Rng hm mt, tai mi hng,
3. IU TR
3.1. iu tr ni khoa
3.1.1. iu tr khng sinh
a) Nguyn tc dng khng sinh:
- Dng khng sinh sm ngay khi c chn on.
- Phi hp t 2 khng sinh, theo ng tnh mch hoc tim bp.
- Nu m c mi thi dng khng sinh dit vi khun k kh:
Metronidazol 500mg x 2 l/ngy truyn tnh mch chia sng, ti.
- Liu cao ngay t u.
- S dng thuc ngay sau khi ly c bnh phm chn on vi sinh vt.
- Thay i khng sinh da theo din bin lm sng v khng sinh nu
c.
b) Thi gian iu tr khng sinh
- Thi gian dng khng sinh t nht 4 tun (c th ko di n 6 tun tu
theo lm sng v X-quang phi).
c) Cc loi khng sinh c th dng nh sau
- Penicilin G 10 - 50 triu n v tu theo tnh trng v cn nng ca
ngi bnhngi bnh (trong trng hp ngi bnhngi bnh khng c iu
kin chi tr s dng cc thuc khc), pha truyn tnh mch chia 3 - 4 ln
/ngy hoc amoxicilin-clavulanat hoc ampicilin-sulbactam, liu dng 3- 6
g/ngy, kt hp vi 1 khng sinh nhm aminoglycosid.
+ Gentamicin 3-5 mg/kg/ngy tim bp 1 ln hoc
+ Amikacin 15 mg/kg/ngy tim bp 1 ln hoc pha truyn tnh mch
trong 250ml dung dch natri clorid 0,9%.
- Nu nghi vi khun tit beta-lactamase th thay penicilin G bng
amoxicilin-clavulanat hoc ampicilin-sulbactam, liu dng 3- 6 g/ngy.
- Nu nghi ng p xe phi do vi khun Gram-m th dng cephalosporin
th h 3 nh cefotaxim 3 - 6 g/ngy hoc ceftazidim 3 - 6 g/ngy, kt hp vi
khng sinh nhm aminoglycosid vi liu tng t nh nu trn.
B Y t | P XE PHI 129

- 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

TRN M MNG PHI


1. I CNG
Trn m mng phi (empyema) l s tch t m trong khoang mng phi.
Bnh nu khng c chn on v iu tr sm s din bin xu hoc li di
chng nng cho ngi bnh.
2. NGUYN NHN
Bnh c th do nhiu nguyn nhn: Vim mng phi, vim phi, p xe
phi, phu thut lng ngc, chn thng ngc, p xe di honh (p xe gan,
vim phc mc khu tr...) v vo khoang mng phi hoc kt hp nhiu yu t
gy nn. Vi khun thng gp: Streptococcus pneumoniae, Staphylococcus
aureus, Escheria coli, Klebsiella pneumoniae, Haemophilus influenzae..., c th
do nm hoc amp.
3. TRIU CHNG
3.1. Lm sng
- Ngi bnh c th c tin s bnh trc : Vim phi, p xe phi hoc
phu thut lng ngc...
- St: t ngt st cao, dao ng. St nh ko di thng xy ra ngi
suy gim min dch hoc dng khng sinh.
- Ho khan hoc khc m, m.
- Kh th.
- au ngc bn tn thng.
- Thm khm: Hi chng nhim khun, thiu mu, du hiu mt nc: Da
kh, tiu t...
- Khm c th thy thnh ngc bn bnh l phng, km hoc khng di
ng, g c, rung thanh gim hoc mt, r ro ph nang gim.
- Chc thm d dch mng phi in hnh thy m, i khi c mu c,
vng, xanh hoc mu nu; mi thi (gi vi khun k kh) hoc khng.
3.2. Cn lm sng
- S lng bch cu mu ngoi vi tng, t l bch cu a nhn trung tnh
tng, CRP tng.
- Chp X-quang lng ngc: C hnh nh trn dch mng phi.
- Siu m khoang mng phi: Hnh nh trn dch, dch tng t trng, hnh
nh trn dch vi nhiu vch ngn.

B Y t | TRN M MNG PHI 132

- Chp ct lp vi tnh: gip xc nh r v tr, mc bnh, tn thng


nhu m phi, v tr v ng vo m mng phi c bit trong trng hp trn
m mng phi khu tr, a .
- Xt nghim dch mng phi: t bo hc (nhiu bch cu a nhn, thng
> 60%, c t bo thoi ho), vi khun hc (soi ti, nhum Gram, cy dch
mng phi tm vi khun gy bnh v lm khng sinh ).
- Cy mu tm vi khun gy bnh.
4. IU TR
4.1. Nguyn tc iu tr
- Mi trng hp chn on m mng phi phi c iu tr ni tr ti
bnh vin, cc khoa c iu kin t ng dn lu mng phi.
- Dn lu m sm, ht p lc m lin tc v ra mng phi hng ngy vi
Natri clorua 0,9%. Khi m c, dn lu km, hoc c hnh nh vch ha khoang
mng phi c ch nh bm streptokinase vo khoang mng phi.
- Khng sinh ng ton thn.
- iu tr triu chng: gim au, h st, m bo dinh dng, bi ph
nc in gii.
- Pht hin v iu tr cc nhim khun nguyn pht, cc bnh phi hp
nu c.
- C th ni soi can thip khoang mng phi sm gii phng m,
bm ra khoang mng phi, pht hin v x l l r ph qun - mng phi v c
th bc v mng phi qua ni soi.
- Vt l tr liu phc hi chc nng h hp sm.
4.2. iu tr khng sinh
a) Nguyn tc dng khng sinh
- Dng khng sinh theo kinh nghim ngay sau khi ly bnh phm chn
on vi sinh vt.
- Phi hp t 2 khng sinh tr ln, theo ng tnh mch hoc tim bp.
- Liu cao ngay t u.
- Thay i khng sinh da theo din bin lm sng v khng sinh nu
c.
- Thi gian dng khng sinh t 4 6 tun.
b) Cc loi khng sinh c th dng khi cha c kt qu xt nghim vi sinh vt v
khng sinh nh sau:

B Y t | TRN M MNG PHI 133

- Penicilin G 1 triu n v, liu 10 - 50 triu n v/ngy tu theo tnh


trng v cn nng ca ngi bnhngi bnh, pha truyn tnh mch chia 3 - 4
ln/ngy, kt hp vi 1 khng sinh nhm aminoglycosid:
+ Gentamicin 80mg: 3-5 mg/kg/ngy tim bp 1 ln
+ Hoc amikacin 500mg: 15 mg/kg/ngy tim bp 1 ln hoc pha truyn
tnh mch trong 250ml Natri clorid 0,9%.
Hoc kt hp vi 1 khng sinh nhm quinolon:
+ Levofloxacin 750mg/ngy truyn tnh mch.
+ Moxifloxacin 400mg/ngy.
+ Ciprofloxacin 800mg/ngy.
- Nu nghi vi khun tit beta-lactamase, la chn cc khng sinh sau v
kt hp vi khng sinh nhm aminoglycosid nh trn:
+ Amoxicilin-clavulanat: 3 6g/ngy, tim tnh mch chia 3-6 ln
+ Hoc ampicilin-sulbactam: 3- 6g/ngy, tim tnh mch chia 3-6 ln.
- Nu nghi ng do vi khun Gram-m th dng cephalosporin th h 3 kt
hp vi khng sinh nhm aminoglycosid, la chn:
+ Cefotaxim 3 - 6 g/ngy, tim tnh mch chia 3 n 6 ln
+ Hoc ceftazidim 3 - 6 g/ngy, tim tnh mch chia 3 n 6 ln.
- Nu nghi ng do vi khun k kh la chn kt hp khng sinh nhm
beta-lactam nh trn vi metronidazol hoc clindamycin:
+ Metronidazol liu 1- 1,5g/ngy, truyn tnh mch chia 2-3 ln/ngy
+ Hoc clindamycin 1,8g/ngy truyn tnh mch chia 3 ln.
- Nu trn m mng phi do nhim khun mc phi bnh vin, khi cha
c kt qu khng sinh c th dng khng sinh:
+ Ceftazidim 3-6g/ngy chia 3 - 6 ln
+ Hoc piperacilin-tazobactam 4,5g x 3 ln/ngy
+ Hoc imipenem 2-4g/ngy chia 4 ln/ngy
+ Hoc meropenem 3-6g/ngy chia 3-6 ln/ngy.
Kt hp khng sinh nhm aminoglycosid hoc quinolon, metronidazol vi
liu lng nh trn. iu chnh khng sinh theo din bin lm sng v kt qu
khng sinh .
- Nu nghi ng do t cu, la chn:
+ Oxacilin 6 - 12g/ngy
B Y t | TRN M MNG PHI 134

+ Hoc vancomycin 1-2 g/ngy.


Kt hp vi amikacin (15 mg/kg/ngy) khi nghi do t cu khng thuc.
- Nu do amp th dng metronidazol 1,5g/ngy, truyn tnh mch chia 3
ln mi 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 theo di tc dng ph
trn thn v iu chnh liu thuc khng sinh.
4.3. nh gi iu tr
- Tin trin tt: Ngi bnh ht st, lng m qua ng dn lu gim, tn
thng trn X-quang phi thuyn gim tip tc khng sinh cho 4 - 6 tun.
- Tin trin khng tt: Cn st, ng dn lu mng phi ra m ko di, Xquang phi khng ci thin thay khng sinh (da vo kt qu cy vi khun
m mng phi v khng sinh nu c), tm cc m khc trong khoang mng
phi cha c dn lu.
5. D PHNG
- iu tr tt cc nhim khun tai mi hng, rng hm mt.
- Tim vaccine phng cm mi nm 1 ln, phng ph cu 5 nm 1 ln cho
nhng trng hp c bnh phi mn tnh, suy tim, tui trn 65 hoc ct lch.
- Khng ht thuc l, thuc lo.
- Gi m c, ngc trong ma lnh.
TI LIU THAM KHO
1. Trn m mng phi. Hng dn chn on v iu tr bnh ni khoa. Nh xut bn y hc,
2011, 383-386.
2. Guidelines for antimicrobial usage. Cleverland Clinic, 2011-2012.
3. Sahn SA (2007). Diagnosis and management of parapneumonic effusions and
empyema, Clin Infect Dis, 45(11):1480-6.
4. Davies HE, Davies RJ, Davies CW. BTS Pleural Disease Guideline Group. Management of
pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax.
2010;65(Suppl 2):ii41ii53.
5. Ahmed AE, Yacoub TE. Empyema thoracis. Clin Med Insights Circ Respir Pulm Med.
2010 Jun 17;4:1-8.

B Y t | 135

B Y t | 136

Chng II. Nhim khun huyt v


sc nhim khun

B Y t | 137

B Y t | 138

NHIM KHUN HUYT V SC NHIM KHUN


1. I CNG
- Nhim khun huyt l mt bnh nhim khun cp tnh,gy ra do vi
khun lu hnh trong mu gy ra cc triu chng lm sng a dng, suy a tng,
sc nhim khun vi t l t vong rt cao (t 20 50%), trong sc nhim
khun l biu hin nng ca nhim khun huyt.
- Cc yu t nguy c:
+ Ngi gi, tr s sinh/ non.
+ Ngi s dng thuc c ch min dch, nh s dng corticoid ko di,
cc thuc chng thi ghp, hoc ang iu tr ha cht v tia x.
+ Ngi bnhNgi bnh c bnh l mn tnh, nh tiu ng,
HIV/AIDS, x gan, bnh van tim v tim bm sinh, bnh phi mn tnh, suy thn
mn.
+ Ngi bnhNgi bnh ct lch, nghin ru, c bnh mu c tnh,
gim bch cu ht.
+ Ngi bnhNgi bnh c t cc thit b hoc dng c xm nhp nh
inh ni ty, catheter, t ng ni kh qun
2. NGUYN NHN
- Nhim khun huyt do vi khun xm nhp trc tip vo mu hoc t cc
nhim khun m v c quan nh: da, m mm, c, xng khp, h hp, tiu
ha
- Cc vi khun thng gy nhim khun huyt
+ Mt s vi khun Gram-m gy nhim khun huyt thng gp: Vi
khun Gram-m ng rut h Enterobacteriacae: bao gm Salmonella,
Escherichia coli, Klebsiella, Serratia, v cc vi khun Enterobacter;
Pseudomonas aeruginosa; Burkholderia pseudomallei.
+ Mt s vi khun Gram-dng gy bnh thng gp: Streptococcus
pneumoniae, Staphylococcus aureus, Streptococcus suis
+ Cc vi khun k kh thng gp: Clostridium perfringens v Bacteroides
fragilis.
3. TRIU CHNG - CHN ON
3.1. Nhim khun huyt
- Chn on da trn triu chng lm sng v chn on xc nh da trn
kt qu cy mu.
a) Lm sng
B Y t | NHIM KHUN HUYT V SC NHIM KHUN 139

- St v cc triu chng ton thn.


+ St l triu chng rt thng gp, c th km theo rt run hoc khng.
Trong nhng trng hp nng, ngi bnhngi bnh c th h thn nhit.
+ Nhp tim nhanh, th nhanh, c th thay i tnh trng thc.
+ Ph, gan lch to.
- Triu chng nhim khun khi im:
+ Nhim khun tiu ha: p xe gan, vim ti mt, vim rut, vim i
trng, thng rut hay cc p xe khc.
+ Nhim khun sinh dc tit niu: Vim i b thn, p xe thn, si thn
c bin chng, p xe tuyn tin lit.
+ Nhim khun vng tiu khung: Vim phc mc vng tiu khung, p xe
bung trng-vi trng.
+ Nhim khun h hp di: Vim phi, vim m mng phi, p xe
phi
+ Nhim khun mch mu do cc ng truyn tnh mch, cc catheter
mch mu, thit b nhn to nhim khun.
+ Nhim khun tim mch: Vim ni tm mc nhim khun, p xe c tim,
p xe cnh van tim.
+ Cc nhim khun da v nim mc.
- Triu chng ri lon chc nng c quan: Suy gan, suy thn
- Bin chng: Sc nhim khun, suy a tng.
b) Xt nghim
- Cy mu dng tnh l tiu chun vng chn on nhim khun
huyt. Tuy nhin, cn lu l kt qu cy mu m tnh cng khng loi tr c
nhim khun huyt, c khong 60% nhim khun huyt c kt qu cy mu m
tnh.
Nn cy mu 02 ln (i vi c nui cy hiu kh v k kh) trc khi
iu tr khng sinh vi th tch mu ti thiu l 10 ml/mu. Tuy nhin trnh
vic ly bnh phm tr hon vic s dng khng sinh > 45 pht. Nu ly 2 mu
mu ng thi th cn ly 2 v tr khc nhau. Trong trng hp c catheter
mch mu t qu 48 gi, cn ly t nht mt mu bnh phm qua catheter
ny.
- Xt nghim huyt hc: S lng bch cu mu ngoi vi > 12 G/l hoc <
4 G/l hoc t l bch cu non > 10%, gim tiu cu (< 100 G/L), ri lon ng
mu (INR > 1.5 hoc aPTT > 60 giy)

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 140

- Xt nghim sinh ha: Gim oxy mu ng mch: PaO2/FIO2 < 300,


creatinin tng, tng bilirubin mu, tng men gan, protein phn ng C (CRP)
thng > 150 mg/l, tng procalcitonin > 1,5 ng/ml
- Cc xt nghim khc nh gi tn thng c quan theo v tr nhim
khun khi im nh xt nghim dch no ty, tng phn tch nc tiu, Xquang ngc, siu m
3.2. Sc nhim khun
- Chn on xc nh khi c tiu chun sau:
+ Nhim khun nng, ri lon chc nng cc c quan.
+ Tt huyt p (HA tm thu < 90 mmHg, HA trung bnh < 70 mmHg, HA
tm thu gim > 40 mmHg hoc huyt p gim di 2 ln lch chun so vi
gi tr bnh thng ca la tui ) v khng hi phc khi b dch hoc cn
phi dng thuc vn mch.
4. IU TR
4.1. iu tr khng sinh
4.1.1. Nguyn tc
- iu tr sm ngay trong gi u khi ngh n nhim khun huyt v sc
nhim khun sau khi cy mu.
- S dng liu php kinh nghim theo chin lc xung thang, khng sinh
ph rng bao ph c tc nhn gy bnh (phi hp khng sinh nu cn), khng
sinh thm tt vo t chc b bnh v s dng khng sinh theo khng sinh theo
hng khng sinh ph hp nhy cm vi vi khun gy bnh.
- u tin s dng khng sinh ng tnh mch.
4.1.2. Liu php khng sinh theo kinh nghim
a) i vi cc ngi bnhngi bnh cha xc nh c nhim khun trc
trn lm sng v khng c nguy c nhim khun bnh vin
- Vi ngi bnhngi bnh c p ng min dch bnh thng: Ty
thuc vo thng tin vi khun v nhy cm khng sinh ty tng n v c th la
chn sau y
+ S dng khng sinh ph rng ng tnh mch sm ngay trong gi u:
Phi hp mt khng sinh nhm penicilin ph rng (piperacilin-tazobactam) hoc
cephalosporin th h ba (ceftriaxon, cefotaxim, ceftazidim, cefoperazol...) hoc
th h bn (cefepim, cefpirom) phi hp vi mt khng sinh nhm quinolon
(ciprofloxacin, levofloxacin hoc moxifloxacin) hoc vi mt khng sinh nhm
aminoglycosid (amikacin, neltimicin...)

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 141

+ Nu nghi ng tc nhn gy bnh l S. aureus (t cu vng), cn nhc s


dng cc khng sinh chng t cu nh oxacilin, cloxacilin, cefazolin (khi nghi
ng nhim t cu vng nhy methicilin, MSSA) hoc vancomycin, teicoplanin
hoc daptomycin (i vi trng hp nghi nhim t cu khng methicilin,
MRSA).
+ Nu nghi ng tc nhn gy bnh l vi khun k kh, cn nhc s dng
metronidazol.
- Vi cc ngi bnhngi bnh c gim bch cu ht, suy gim min
dch.
+ Cn dng khng sinh ph rng ng tnh mch nu s lng bch cu
ht < 0,5 x 109/L hoc d on s gim < 0,5 x 109/L cc ngi bnhngi
bnh c s lng bch cu ht < 1 x 109/L.
+ Phi hp mt khng sinh nhm carbapenem (ertapenem, imipenemcilastatin, doripenem, meropenem) hoc khng sinh nhm penicilin ph rng
(piperacilin-tazobactam) vi mt khng sinh nhm quinolon (ciprofloxacin,
levofloxacin hoc moxifloxacin) hoc vi mt khng sinh nhm aminoglycosid
(amikacin, neltimicin).
+ Ty theo iu kin ca c s iu tr, c th s dng liu php khng
sinh theo kinh nghim nh phn a, mc 4.1.2.
+ Nu ngi bnhngi bnh vn st ko di ti 96 gi khi dng liu
php khng sinh kinh nghim ban u, cn tm kim cc nguyn nhn nhim
khun bnh vin v cn nhc b sung thuc khng nm ph hp.
b) i vi cc ngi bnhngi bnh cha xc nh c nhim khun khi
im nhng c yu t nguy c nhim khun bnh vin
- Cn da vo thng tin vi khun hc v nhy cm khng sinh ca tng
bnh vin la chn khng sinh kinh nghim cho ph hp:
+ C th phi hp mt khng sinh c tc dng chng P. aeruginosa nhm
carbapenem (imipenem-cilastatin, doripenem, meropenem) hoc khng sinh
nhm penicilin ph rng nh piperacilin-tazobactam vi mt khng sinh nhm
quinolon (ciprofloxacin, levofloxacin hoc moxifloxacin) hoc vi mt khng
sinh nhm aminoglycosid (amikacin, neltimicin) hoc vi fosfomycin. Ch
cn chnh liu cc khng sinh theo thanh thi creatinin.
+ Nu nghi ng tc nhn gy bnh l S. aureus (t cu vng) khng
methicilin (MRSA), cn cn nhc s dng thm vancomycin, teicoplanin hoc
daptomycin.
+ Nu nghi ng tc nhn vi khun Gram-m a khng (khng
carbapenem): Phi hp khng sinh nhm carbapenem c tc dng chng
A. baumanii v/hoc khng sinh nhm penicilin ph rng phi hp vi cc cht
B Y t | NHIM KHUN HUYT V SC NHIM KHUN 142

c ch beta-lactamase (piperacilin-tazobactam hoc ampicilin-sulbactam) vi


colistin tng tc dng hip ng.
c) i vi cc ngi bnhngi bnh c nhim khun ch im
- Khi cha xc nh c cn nguyn gy bnh, cn s dng khng sinh
theo kinh nghim. Khi c kt qu nui cy, chuyn dng khng sinh ph hp
nhy cm vi vi khun gy bnh khi c kt qu cy vi khun v khng sinh .
Cn chnh liu khng sinh theo thanh thi creatinin cc ngi bnhngi
bnh c suy thn.
- Nhim khun ng mt hay tiu ha:
+ Nhim khun gan mt: K. pneumoniae l vi khun chnh gy nhim
khun huyt v p xe gan Vit Nam. S dng khng sinh nhm cepalosporin
th h 3 hoc 4, hoc carbapenem (nu ngi bnhngi bnh c nguy c nhim
vi khun sinh beta-lactamase ph rng ESBL) phi hp vi mt khng sinh
nhm aminoglycosid (amikacin, neltimicin) hoc metronidazol khi nghi ng vi
khun k kh.
+ Nhim khun ng tiu ha: S dng khng sinh nhm cepalosporin th
h 3 hoc 4, hoc carbapenem hoc quinolon (ciprofloxacin) phi hp vi
metronidazol (khi nghi ng vi khun k kh).
- Nhim khun ng h hp:
+ Xem thm bi Vim phi mc phi cng ng v Vim phi lin quan
n th my.
- Nhim khun tim mch: Xem thm bi Vim ni tm mc nhim khun.
Nu nghi ng tc nhn gy bnh l S. aureus (t cu vng), cn nhc s dng
cc khng sinh chng t cu nh oxacilin, cloxacilin, cefazolin (i vi t cu
vng nhy methicilin, MSSA) hoc vancomycin, teicoplanin, daptomycin (i
vi trng hp t cu khng methicilin, MRSA) ng tnh mch.
- Nhim khun lin quan n cc dng c mch mu: Xem thm phn
nhim khun c yu t nguy c nhim khun bnh vin. Nu nghi ng do t cu
vng khng methicilin (MRSA), cn dng vancomycin, linezolid, teicoplanin
hoc daptomycin.
- Nhim khun sinh dc n gii: Dng ceftriaxon tnh mch 1gam hng
ngy phi hp vi azithromycin tnh mch 500mg hng ngy v metronidazol
1g/ngy. Nu nghi ng c lin quan n nhim khun bnh vin dng khng
sinh nhm carbapenem (imipenem-cilastatin, meropenem) hoc piperacilintazobactam phi hp vi azithromycin v metronidazol, nu nghi ng do vi
khun a khng thuc phi hp colistin.
- Nhim khun da: Tham kho phn s dng khng sinh cho nhim khun
da v m mm. Nu nghi ng tc nhn gy bnh l S. aureus (t cu vng), cn
B Y t | NHIM KHUN HUYT V SC NHIM KHUN 143

nhc s dng cc khng sinh chng t cu nh oxacilin, cloxacilin, cefazolin


(i vi t cu vng nhy methicilin, MSSA) hoc vancomycin, teicoplanin
hoc daptomycin (i vi trng hp t cu khng methicilin, MRSA). i
nhng ngi bnhngi bnh tn thng da (v d do bng), cn cn nhc nguy
c nhim khun bnh vin v s dng cc khng sinh c tc dng dit P.
aeruginosa.
4.1.3. La chn khng sinh da theo thng tin vi khun gy bnh
Khng sinh c la chn da trn thng tin v vi khun gy bnh c
th hin trong Bng II.10.

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 144

Bng II.10. La chn khng sinh theo kinh nghim


Vi khun

Khng sinh la chn

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)

Ertapenem 1g/ ln/ngy, truyn tnh


mch trong 3-4 gi

+ Ceftriaxone 2 g/ln, tim tnh


mch chm mi 12 gi/ln

Khng sinh thay th


Cc khng sinh cephalosporin th h
3 v 4 khc
Cc khng sinh nhm
fluoroquinolon
Imipenem-cilastatin 500 mg/ln,
truyn tnh mch mi 6 gi/ln
Meropenem 1g/ln, truyn tnh mch
8 gi/ln
Doripenem 500 mg/ln, truyn tnh
mch 8 gi/ln

Pseudomonas
aeruginosa

Ceftazidime 2 g/ln, tim tnh mch


chm mi 8 gi/ln

Burkholderia
pseudomallei

Ceftazidime 2 g/ln, tim tnh mch Imipenem-cilastatin 1g/ln, truyn


chm mi 8 gi/ln
tnh mch 8 gi/ln. Meropenem
1g/ln, ng tnh mch 8 gi/ln

Streptococcus
pneumoniae

Ceftriaxone 2 g/ln, tim tnh mch


chm mi 12 gi/ln

Ciprofloxacin x 400-1200 mg/ngy

Imipenem-cilastatin 1 g/ln, truyn


Cefepim 2 g/ln, tim tnh mch chm tnh mch mi 6-8 gi/ln
mi 8h /ln
Meropenem 1 g/ln, ng tnh
Piperacillin-tazobactam 4,5 g/ln,
mch mi 8 gi/ln
tim tnh mch mi 6 gi/ln

Cefotaxime 2 g/ln tim tnh mch


mi 6 gi/ln

Levofloxacin 750 mg/ngy


Vancomycin 1 g/ln, truyn tnh
mch cch mi 12 gi

Staphylococcus aureus
(nhy Methicilin)

Oxacilin 100-200 mg/kg/ngy chia


tim tnh mch chm cch 6 gi/ln

Vancomycin 1 g/ln truyn tnh


mch cch mi 12 gi

Staphylococcus aureus
(khng Methicilin)

Vancomycin 1 g/ln truyn tnh


mch cch mi 12 gi

Daptomycin 4-6 mg/kg/ngy

Streptococcus suis

Ampicilin: 2g/ln, tim tnh mch


mi 6 gi/ln. Tr em 200-250
mg/kg/ngy

Ceftriaxon: 2g/ln, tim tnh


mch12h/ln. Tr em
100mg/kg/ngy

Clostridium perfringens

Penicilin 3-4 triu n v tim tnh


mch cch 4 gi/ln

Clindamycin truyn tnh mch 6-9


g/ngy chia liu cch mi 8 gi/ln

Metronidazole truyn tnh mch


liu tn cng 15 mg/kg sau s
dng liu duy tr 7,5 mg/kg trong 1
gi cch mi 6 gi/ln
Bacteroides fragilis

Metronidazole truyn tnh mch


liu tn cng 15 mg/kg sau s
dng liu duy tr 7,5 mg/kg trong 1
gi cch mi 6 gi/ln

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 145

4.1.4. Cch dng c th cc loi khng sinh


Liu dng v cch dng ca mt s khng sinh c th hin trong Bng II.11.
Bng II.11. Liu dng - cch dng ca mt s khng sinh
Loi khng sinh

Cch s dng

Ceftriaxon

1-2g x 1 ln/ngy (hoc chia 2 liu), ti a 4g/ngy.

Cefepim

1-2g mi 12 gi, ti a 6g/ngy. Nhim khun e da tnh


mng: 2g mi 8-12 gi.

Ceftazidim

1-2g mi 8-12 gi.

Ampicilin-sulbactam

1,5-3g mi 6 gi, ng tnh mch.

Ertapenem

1g x 1 ln/ngy, truyn tnh mch trong 3-4 gi.

Imipenem

0,5g-1g mi 6 gi, ti a 4g/ngy, truyn tnh mch trong 3-4


gi.

Meropenem

1g mi 8 gi, ti a 2g mi 8 gi, ng tnh mch.

Piperacilin-tazobactam

4,5g mi 8 gi, truyn tnh mch.

Levofloxacin

500-750 mg/ngy, truyn tnh mch.

Moxifloxacin

400mg/ngy, truyn tnh mch.

Ciprofloxacin

400mg x 2 n 3 ln/ngy, ti a khng qu 1200mg/ngy,


truyn tnh mch.

Amikacin

16-24 mg/kg x 1ln/ngy, truyn tnh mch*.

Tobramycin

4-7mg/kg x 1ln/ngy, truyn tnh mch.

Gentamicin

4-7mg/kg x 1ln/ngy, truyn tnh mch.

Linezolid

600mg x 1 ln/ngy.

* Liu dng c th thay i ty theo kt qu theo di nng thuc trong mu (TDM)

4.2. X tr nhim khun khi im


- Dn lu p xe, dn lu mng phi, mng tim, dn lu ti mt, ly si
ng mt khi c tc mt
- Rt cc dng c/thit b y khoa l ng vo ca nhim khun nu c
ch nh.
4.3. iu tr h tr v hi sc
- phng v iu tr sc nhim khun.
- m bo h hp: m bo thng kh, th xy, t ng ni kh qun v
thng kh nhn to khi cn thit.
- iu chnh cn bng nc, in gii v thng bng kim toan.
- iu tr suy thn: Truyn dch, li tiu.
- Lc mu lin tc khi c ch nh.
B Y t | NHIM KHUN HUYT V SC NHIM KHUN 146

- iu tr xut huyt v ng mu ri rc trong lng mch.


- H st, dinh dng nng cao th trng.
- Chm sc v sinh, chng lot.
TI LIU THAM KHO
1. Dellinger, R.P., et al., Surviving Sepsis Campaign: international guidelines for
management of severe sepsis and septic shock, 2012. Intensive Care Med, 2013. 39(2): p.
165-228.
2. de Kraker, M.E., et al., The changing epidemiology of bacteraemias in Europe: trends from
the European Antimicrobial Resistance Surveillance System. Clin Microbiol Infect, 2013.
19(9): p. 860-8.
3. Martin, G.S., Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and
outcomes. Expert Rev Anti Infect Ther, 2012. 10(6): p. 701-6.
4. Marin H. Kollef and Scott T. Micek (2012), Severe septic and Septic shock, The
Washington Manual of Critical Care, 2rd Edition 2012, P 11-18.
5. The GARP Vietnam National Working Group, Situation Analysis Reports: Antibiotic use
and resistance in Vietnam. 2010.

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 147

B Y t | NHIM KHUN HUYT V SC NHIM KHUN 148

Chng III. Nhim khun tim mach

B Y t | 149

B Y t | THP TIM 150

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.

B Y t | THP TIM 151

- Ban vng (ban Besnier): Vng ban hng, xp thnh qung c ng


knh ca vin 1-2 mm, hay gp thn, mn sn, gc chi, khng c mt. Ban
mt i sau vi ngy.
- Ht Meynet: L nhng ht ni di da c ng knh khong 5-10 mm,
dnh trn nn xng (khuu, gi...) n khng au, xut hin cng vim khp v
vim tim, mt i sau vi tun.
- Suy tim (trong trng hp thp tim nng): Ngi bnhNgi bnh kh
th, ho khan, ph, gan to, tnh mch c ni, phi c ran m...
b) Cn lm sng
- Mu: CTM: Bch cu tng, mu lng tng; si huyt tng; Protein C
tng; Antistreptolysin O: Tng cao > 200 n v Todd. Tng nhiu sau nhim
lin cu beta tan huyt nhm A sau 2 tun, ko di 3-5 tun ri gim dn.
- in tm : Bloc nh - tht cp I hay gp. C th gp bloc nh - tht cp
II, III. Nhp nhanh xoang. Ngoi tm thu nh, ngoi tm thu tht...
- Chp tim phi: C th thy tim to, rn phi m...
- Siu m tim: Hnh nh HoHL, HoC, c th c dch mng tim...
4. IU TR THP TIM
a) Nguyn tc iu tr:
- iu tr triu chng; iu tr nguyn nhn; phng bnh.
b) iu tr c th:
- iu tr t thp tim: Ngh ngi, khng sinh, chng vim, iu tr triu
chng.
- Ngh ngi:
Bng II.12. Ngh ngi theo mc vim
STT

Mc

Ngh trn ging

i li trong phng

Khng vim tim

2 tun

2 tun

Vim tim, tim khng to

4 tun

4 tun

Vim tim, tim to

6 tun

6 tun

Vim tim, suy tim

Khi ht suy tim

3 thng

- Khng sinh iu tr bnh Thp tim:


+ Cn iu tr ngay, liu v thi gian dit c lin cu. Hin
nay, penicilin vn l thuc thng dng v c hiu qu nht, cha thy c s
khng penicilin ca lin cu, ng thi thuc c gi thnh thp v sn c trn th
trng thuc. Cc thuc khng sinh dng beta-lactam cng c hiu qu cao
trong iu tr lin cu. Khi b d ng vi penicilin c th dng erythromycin
(nhng c khong 10% lin cu khng erythromycin).
B Y t | THP TIM 152

+ Thuc v cch s dng trong iu tr bnh thp tim:


Bng II.13. Thuc v cch s dng trong iu tr bnh thp tim
STT

Liu lng

Khng sinh

Cch dng

Ghi ch

Benzathin
penicilin

<30 kg: 600.000 v.

Tim bp su
T 30 kg tr ln: 1.200.000 v. (tim mng) mt
ln duy nht.

Hiu qu
nht (>97%).

Penicilin V

< 30kg: 500mg/24 gi.

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%).

T 30kg tr ln: 1g/24 gi.


5

Erythromycin

< 30kg: 500 mg.


T 30 kg tr ln: 1g.

- Chng vim: Ty theo mc ca bnh


+ Vim a khp:
Aspirin 100 mg/kg/ngy x 6 ngy.
Aspirin 75 mg/kg/ngy x 2 tun.
+ Vim tim: Prednisolon 1-2 mg/kg/ngy x 2-3 tun, nu mu lng gim
th bt u gim liu 1-2 mg/tun.
- iu tr triu chng:
+ iu tr suy tim:
Tr tim: Digoxin 0,25mg/ngy;
Li tiu: Furosemid 40 mg x 1-2 vin/ngy (ch : b Kali).
+ Gin mch (thuc c ch men chuyn): Perindopril 4 mg x 1vin/ngy
hoc enalapril 5 mg x 1 vin/ngy hoc captopril 25 mg x 1 vin/ngy.
+ Ma vn: Phenobarpital: 16-32 mg/kg/ngy; haloperidol: 0,03 1
mg/kg/ngy; chlopromazin: 0,5 mg/kg/ngy.
5. PHNG BNH
- Phng thp ti pht hay phng thp cp II (cho ngi bnhngi bnh
c chn on b bnh thp tim). Theo khuyn co ca T chc y t Th
gii: hin nay vn cha c vaccine phng bnh Thp tim. c im ca vi
khun lin cu beta tan huyt nhm A l rt hay khng thuc nu dng mt loi
thuc ko di nhiu nm. Khuyn co ch dng 2 loi thuc phng bnh thp
tim ti pht l: penicilin (u tin s 1) v erythromycin (nu d ng vi
penicilin).

B Y t | THP TIM 153

- Benzathin penicilin (tim): 1.200.000 v cho ngi bnhngi bnh >


30 kg; 600.000 v cho ngi bnhngi bnh < 30 kg. Tim bp su (tim
mng), 28 ngy tim mt ln.
+ Hoc: Penicilin V (ung): 0,5 g/24 gi cho ngi bnhngi bnh < 30
kg; 1 g/24 gi cho ngi bnhngi bnh t 30 kg tr ln. Ung hng ngy.
+ Hoc: Erythromicin (ung): 0,5 g/24 gi cho ngi bnhngi bnh <
30 kg; 1 g/24 gi cho ngi bnhngi bnh t 30 kg tr ln. Ung hng ngy.
- Thi gian phng thp:
+ Thp tim cha c bin chng van tim: Phng thp tim ti pht t nht l
5 nm v t nht n nm 18 tui.
+ Thp tim c bin chng van tim: Phng thp tim ti pht ko di t nht
n nm 45 tui.
- Ch : Khi ang tim phng thp cp II, nn chuyn thuc tim thnh
thuc ung trong cc trng hp sau: Ngi bnhNgi bnh ang b suy tim
nng; ngi bnhngi bnh ang b mt bnh cp tnh khc nh: Hen ph
qun, vim ph qun, suy gan, suy thn...; ngi bnhngi bnh c ch nh
nong van, m sa van, m thay van...; ngi bnhngi bnh ang mang thai
(phng trng hp cp cu sc phn v do penicilin kh thnh cng).
TI LIU THAM KHO
1. Hng dn chn on v iu tr bnh Ni khoa. NXBYH, 2011.
2. Thp tim v bnh tim do thp, NXBYH, 2002
3. Therapeutic Antibiotic Guidelines 2010 version 14.

B Y t | THP TIM 154

VIM NI TM MC NHIM KHUN


1. NH NGHA
Vim ni tm mc bn cp nhim khun (infective endocarditis) l tnh
trng vim ni tm mc c lot v si, thng xy ra (nhng khng phi bt
buc) trn mt ni tm mc c tn thng bm sinh hoc mc phi t trc.
2. NGUYN NHN
- Trong a s trng hp, vi khun gy bnh l lin cu khun.
- Nhng loi vi khun v tc nhn gy bnh khc:
+ T cu khun: ng ch l hay gp trong nhng trng hp nhim
khun huyt do t cu sau no ph thai, cc tn thng thng hay gp van ba
l.
+ No m cu, ph cu, lu cu.
+ Trc khun Klebsiella pneumoniae, Salmonella, Brucella,
Corynebacterium, Vibrio foetus.
+ Cc loi nm Actynomyces, Candida albicans: Thng hay gy bnh
trn nhng c th suy gim min dch, tng c iu tr nhng liu php
khng sinh qu di. Tin lng ca nhng loi ny rt ti.
3. TRIU CHNG
3.1. Lm sng
- St dai dng trn 1 ngi bnhngi bnh c bnh tim.
- Lch to, mng tay khum, ngn tay di trng.
- Tuy nhin, trn thc t, c th chn on v iu tr sm ta nn ngh
n vim ni tm mc bn cp nhim khun trc mt ngi bnhngi bnh
tim c st dai dng trn 1 tun m khng c l do v cho cy mu ngay.
3.2. Cc xt nghim cn lm sng
a) Cy mu tm vi khun gy bnh
- Cn phi cy mu nhiu ln trc khi cho khng sinh.
- C gng cy mu khi ngi bnhngi bnh ang st v lc kh nng
dng tnh thng cao hn.
b) Cc xt nghim mu khc:
- Tc lng mu bao gi cng tng cao.
- Cng thc mu:
+ S lng hng cu thng gim nh.
+ S lng bch cu tng va, nht l bch cu a nhn trung tnh.
B Y t | VIM NI TM MC NHIM KHUN 155

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

+ Cefepim 6g/24h chia 3 ln tim TM chm x 6 tun.


+ Rifampin 900mg/24h chia 3 ln ung hoc ha vi Glucose 5% truyn
TM x 6 tun.
- Tr em (TE): Phi hp 4 loi khng sinh sau:
+ Cefepim 150mg/kg/24h chia 3 ln tim TM chm (TE> 2 thng).
+ Rifampin 20mg/kg/24h chia 3 ln ung hoc truyn TM (ha vi dung
dch Glucose 5%).
+ Vancomycin liu lng v ng dng nh trn.
+ Gentamicin liu lng v ng dng nh trn.
c) Vim ni tm mc nhim khun van nhn to xy ra > 1 nm sau phu thut
thay van tim: iu tr nh VNTM van t nhin, thi gian 6 tun.
4.3. iu tr khi c kt qu cy mu: phi hp khng sinh c hiu theo khng
sinh , thi gian iu tr l t 4 6 tun, ring vi aminosid thi gian iu tr
nn ngn nht nu c th (5 14 ngy) khng qu 14 ngy.
5. KHNG SINH PHNG BNH
5.1. Bnh tim c nguy c cao mc vim ni tm mc nhim khun:
- Van nhn to (van sinh hc, van c hc, homograffes).
- Tin s VNTMNK (ngay c khi khng c bnh tim).
- Bnh tim bm sinh tm: cha phu thut hoc phu thut tm thi.
- Shunt ch phi nhn to.
- Bnh van tim: h van ng mch ch, h van hai l, hp van ng mch
ch. Hp van hai l n thun him khi gp VNTMNK.
5.2. Bnh tim c nguy c:
- Sa van hai l c h van v dy van.
- Van ng mch ch hai l (Bicuspidie).
- Bnh tim bm sinh khng tm cha phu thut (tr thng lin nh).
- Bnh c tim tc nghn.
5.3. Khng sinh d phng cho cc th thut rng ming: ch 1 liu 30-60
pht trc th thut :
a) Khng d ng penicilin, ampicilin:
- ng ung: amoxicilin 2g (TE: 50 mg/kg).
- Khng ung c:
+ Ampicilin 2 g tim TM/TB (TE: 50 mg/kg tim TM/TB)

B Y t | VIM NI TM MC NHIM KHUN 157

+ Hoc cefazolin hoc ceftriaxon 1g tim TM/TB (TE: 50 mg/kg tim


TM/TB).
b) D ng vi penicilin hoc ampicilin:
- ng ung:
+ Cephalexin 2g (TE: 50 mg/kg), hoc thay bng cephalosporin th h 1/
th h 2 khc. Khng dng cephalosporin cho ngi bnhngi bnh c tin s
sc phn v, ph mch, my ay do penicilin/ampicilin
+ Hoc clindamycin 600 mg/ngy (TE > 1 thng: 20 mg/kg, ung trong
ba n)
+ Hoc azithromycin/clarithromycin 500mg (TE: 15 mg/kg).
- Khng ung c:
+ Cefazolin/ceftriaxon 1 g tim TM/TB (TE: 50 mg/kg)
+ Hoc clindamycin 600 mg tim TM/TB (TE >1 thng: 20 mg/kg, tim
TM/TB).
5.4. Khng sinh d phng cho cc th thut ng sinh dc-tit niu, tiu
ho, h hp: Ch 1 liu ngay trc th thut hoc khi gy t:
- Khng d ng penicilin: Ampicilin/amoxicilin 1g tim TM (TE:<5tui
250 mg; 5-10tui 500 mg) v gentamicin 1,5 mg/kg tim TM.
- D ng penicilin: Teicoplanin (tr tr s sinh) 400 mg tim TM (TE
<14tui: 6 mg/kg) v gentamicin 1,5 mg/kg tim TM.
5.5. Khng sinh d phng cho th thut t ng qua mi: ch 1 liu ngay
trc th thut hoc khi gy t:
- Khng d ng penicilin: Flucloxacilin 1g tim TM (TE<4 tui 50 mg/kg)
- D ng penicilin: Clindamycin 600 mg tim TM (50 mg TE<5 tui; 75
mg TE 5-10 tui ; 300 mg TE 10-16 tui).
TI LIU THAM KHO
1. Bnh hc ni khoa. Nh xut bn y hc 1990.
2. Ariel COHEN. Cardiologie et pathologie vasculaire, ESTEM-Med-line 1991.
3. Larry M. Baddour. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and
Management of Complication.
Circulation 2005;111;3167-3184.DOI:10.1161.
CIRCULATIONAHA 105.165563.
4. Walter Wilson. Prevention of Infective Endocarditis. Guidelines From the American Heart
Association. Circulation 2007; 116; 1736-1754; DOI: 10.1161.
CIRCULATIONAHA.106.183095.

B Y t | VIM NI TM MC NHIM KHUN 158

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

- Xt nghim m bnh hc: p xe nang lng, cu trc nang lng b


ph v, gia l t chc hoi t, xung quanh thm nhp nhiu cc t bo vim
ch yu l bch cu a nhn trung tnh.
- Nui cy m c t cu vng pht trin.
4. IU TR BNG KHNG SINH
- V sinh c nhn: Ra tay thng xuyn trnh t ly nhim ra cc vng
da khc bng x phng Lifebuoy, Septivon
- giai on sm cha c m: Trnh nn, kch thch vo tn thng.
- Giai on c m cn phu thut rch rng lm sch tn thng.
- Cn kt hp iu tr ti ch v khng sinh ton thn.
- Dung dch st khun: St khun ngy 2- 4 ln trong thi gian 10 -15
ngy. C th dng mt trong cc dung dch st khun sau:
+ Povidon-iodin 10%.
+ Hexamidin 0,1%.
+ Chlorhexidin 4%.
- Thuc khng sinh bi ti ch: Bi thuc ln tn thng sau khi st
khun, thi gian iu tr t 7-10 ngy. Dng mt trong cc thuc sau:
+ Kem hoc m acid fucidic 2%, bi 1- 2 ln ngy.
+ M Neomycin, bi 2- 3 ln/ngy.
+ Kem Silver sulfadiazin 1%, bi 1-2 ln/ngy.
+ M mupirocin 2% bi 3 ln/ngy.
+ Erythromycin 1-2 ln/ngy.
+ Clindamycin 1-2 ln/ngy.
- Khng sinh ton thn bng mt trong cc khng sinh sau:
+ Penicilin M (cloxacilin) 2g/ngy.
+ Amoxicilin-clavulanat.
Tr em 80 mg/kg/ngy chia 3 ln.
Ngi ln 1,5-2 g/ngy chia 2 ln.
+ Roxithromycin vin 150mg:
Tr em 5-8 mg/kg/ngy chia 2 ln.
Ngi ln 2 vin/ngy chia 2 ln.
+ Azithromycin 500 mg ngy u tin, sau 250 mg/ngy x 4 ngy.
+ Pristinamycin:
B Y t | NHT 162

Tr em 50 mg/kg/ngy, chia 2 ln.


Ngi ln 2-3 g/ngy, chia 2 ln.
+ Acid fucidic vin 250 mg.
Tr em liu 30-50 mg/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 sch s: ct mng tay, ra tay hng ngy.
- Trnh s dng cc sn phm gy kch ng da.
- Nng cao th trng.
TI LIU THAM KHO
1. Charles A Gropper, Karthik Krishnamurthy, (2010), Furunculosis, Treatment of skin
diseases, Saunders Elsevier, Third Edition pp. 262-263
2. Dega H. (2001), Folliculites, furoncles et anthrax staphylocoque dor, Thrapeutique
dermatologique, Mdecine-science Flammarion, pp.288-293
3. Noah Craft. (2012), Superficial cutaneous infections and pyodermas Fitzpatricks
Dermatology in general medecine Mc Graw Hill Eight Edition volume 2 pp. 2128- 2147.
4. Phm Thip, V Ngc Thy (2002). Thuc, bit dc v cch s dng, Nh xut bn y hc

B Y t | NHT 163

VIM NANG LNG


1. NH NGHA
Vim nang lng (Folliculitis) l tnh trng vim nng mt hoc nhiu
nang lng bt k vng da no tr lng bn tay v bn chn. Bnh gp bt k
la tui no, nht l thanh thiu nin v ngi tr.
2. NGUYN NHN
a) Nguyn nhn: Ch yu l t cu vng (S. aureus) v trc khun m xanh (P.
aeruginosa). Ngoi ra cn c th do cc nguyn nhn khc nh:
- Nm: Trichophyton rubrum hoc Malassezia filliculitis (Pityrosporum
filliculitis).
- Virus: Herpes simplex thng gy vim nang lng vng quanh ming.
- Vim nang lng khng do vi khun:
+ Pseudo-follicititis hay gp vng cm do co ru gy hin tng lng
chc tht.
+ Vim nang lng tng bch cu i toan thng gp nhng ngi suy
gim min dch.
+ Vim nang lng Decanvans hay gp vng da u gy rng tc vnh
vin.
+ Vim nang lng nhng ngi cng nhn tip xc vi du m nh th
lc du, th my, cng nhn xng du
b) Mt s yu t thun li
- Cc yu t ti ch:
+ Mc qun o qu cht.
+ Da m t.
+ Tng tit m hi.
+ Gi co.
+ Co ru.
+ Nh lng.
+ Cc thuc hoc m phm gy kch ng.
+ Dng thuc bi corticoid lu ngy.
- Ton thn:
+ Bo ph.
+ Tiu ng.
B Y t | VIM NANG LNG 164

+ Gim min dch bm sinh hay mc phi.


+ Suy thn, chy thn nhn to.
+ Thiu mu do thiu st i khi kt hp i vi nhng trng hp vim
nang lng mn tnh.
3. TRIU CHNG
a) Lm sng
- Tn thng c bn l nhng sn nh nang lng, trn c vy tit, khng
au. Vim nang lng c th xut hin bt k vng da no ca c th, tr
lng bn tay bn chn. V tr thng gp nht l u, mt, c, lng, mt ngoi
cnh tay, i, sinh dc, cng tay v cng chn... sau vi ngy tin trin, tn
thng c th khi khng li so. S lng tn thng nhiu hay t ty theo
tng trng hp. Hu ht cc trng hp ch c mt vi tn thng n c v
d dng b qua. Nhiu ngi bnhngi bnh c nhiu thng tn, ti pht
nhiu ln lm nh hng n sc khe v cht lng cuc sng.
- Mt s bin chng c th gp nh chm ha, hoc vim lan ta xung
pha di nang lng hnh thnh nht, vim m bo hoc nhim khun huyt.
b) Cn lm sng
- Nui cy vi khun c th thy vi khun t cu vng hoc trc khun m
xanh.
- Soi nm trc tip nhum Parker c th thy nm Malassezia.
4. IU TR
a) Loi b cc yu t thun li.
b) V sinh c nhn: ra tay thng xuyn trnh t ly nhim ra cc vng da
khc bng x phng Lifebouy, Septivon
c) Trnh co gi, kch thch vo tn thng.
d) i vi nhng trng hp nh, ch cn dng dung dch st khun kt hp vi
khng sinh bi ti ch.
- Dung dch st khun: c th dng mt trong cc dung dch st khun
sau:
+ Povidon-iodin 10%.
+ Hexamidin 0,1%.
+ Chlorhexidin 4%.
St khun ngy 2- 4 ln trong thi gian 10 -15 ngy.
- Thuc khng sinh bi ti ch: dng mt trong cc thuc sau:
+ Kem hoc m acid fucidic 2%, bi 1- 2 ln/ ngy.
B Y t | VIM NANG LNG 165

+ 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

B Y t | VIM NANG LNG 166

TI LIU THAM KHO


1. Dega H. (2001), Folliculites, furoncles et anthrax staphylocoque dor, Thrapeutique
dermatologique, Mdecine-science Flammarion, pp.288-293
2. Noah Craft. (2012), Superficial cutaneous infections and pyodermas Fitzpatricks
Dermatology in general medecine Mc Graw Hill Eight Edition volume 2 pp. 2128- 2147
3. Phm Thip, V Ngc Thy, (2002) Thuc, bit dc v cch s dng, Nh xut bn y hc
4. Rebecca Kleinerman, Robert Phleps,(2010), Folliculitis, Treatment of skin diseases,
Saunders Elsevier, Third Edition pp. 255-257.

B Y t | VIM NANG LNG 167

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

bit. nh lng protein trong dch chc ht t tn thng c gi tr chn on.


Trong vim tc tnh mch lng protein khong 5,5g/l, trong vim m t bo rt
cao, thng trn 10g/l. Ngoi ra, vim m t bo cn phn bit vi vim qung
l tnh trng nhim khun lp b vi biu hin l mng da , gii hn r, b
ni cao. Tuy nhin, i khi c hai bnh ny phi hp vi nhau rt kh phn bit.
b) Cn lm sng
- Nui cy bnh phm t dch t chc hoc vt trt lot. Ngoi ra, cy
mu hoc cc bnh phm t vt lot, nt, sang chn xa v tr tn thng cng
c gi tr xc nh nguyn nhn gy bnh. Tuy nhin, cc xt nghim nui
cy thng cho t l dng tnh khng cao, ch khong 1/5 trng hp c vi
khun mc. nh lng khng th khng lin cu trong mu c th c ngha
trong chn on hi cu.
- Cc xt nghim khc c th thy bch cu tng trong mu, mu lng
tng, procalcitonin tng trong mu.
4. IU TR
a) Cn ch nh khng sinh sm, ng v liu bng ng tim bp hoc tnh
mch i vi cc trng hp nng nht l nghi ng c nhim khun huyt, vim
khp, vim cn c. Khng sinh ng ung c th dng i vi nhng trng
hp nh. C th chn mt trong s cc phc khng sinh sau:
- Penicilin G vin 1 triu n v:
+ Tr em 100 000 UI/kg/ngy.
+ Ngi ln 3-4 triu n v/ngy.
+ Tim tnh mch mi 6 gi i vi nhng trng hp nng. Thi gian
iu tr t nht l 10 ngy.
- Amoxicilin-clavulanat:
+ Tr em 80mg/kg/ngy chia ba ln.
+ Ngi ln 1,5-2 g amoxicilin mi ngy chia ba ln.
+ Thi gian iu tr t nht l 10 ngy.
- Ceftriaxon:
+ Ngi ln v tr trn 12 tui: 1-2g x 1 ln/ngy, trng hp nng c th
tng n 4g/ln/ngy.
+ Tr di 12 tui: 20-80mg/kg x 1 ln/ngy.
+ Tim TM chm (ho 1g vi 10mL nc ct) hay truyn TM (ho 2g
trong 40mL dung dch khng cha Ca nh NaCl 0.9% hay Dextrose 5%).
+ Thi gian iu tr t nht l 10 ngy.
- Roxithromycin vin 150mg:
B Y t | VIM M BO 169

+ Tr em 5-8mg/kg/ngy chia 2 ln.


+ Ngi ln 2 vin/ngy chia 2 ln.
+ Thi gian iu tr t nht l 10 ngy.
b) Trng hp c vim tc tnh mch, cn kt hp vi thuc chng ng. Ngoi
khng sinh ton thn, cn tch cc nng cao th trng, cn bng nc, in
gii
c) Trng hp ti pht c th dng penicilin t 500mg n 2g/ ngy trong thi
gian lu hn phng ti pht.
TI LIU THAM KHO
1. Adam D Lipworth, Arturo P. Saadra et. Al. (2012). Non- necrotizing infections of the
dermis and subcutaneous fat. Cellulitis and erysipelas. Fitzpatricks Dermatology in general
medecine Mc Graw Hill Eight Edition volume 2 pp. 2169
2. Andrian HM Heagerty (2010), Cellulitis and erysipelas, Treatment of skin diseases,
Saunders Elsevier, Third Edition pp. 132-134
3. Bourgault Villada, Chosidow.O. (2001), Erysiple, Thrapeutique dermatologique,
Mdecine-science Flammarion, pp.235-237
4. Phm Thip, V Ngc Thy (2002) Thuc, bit dc v cch s dng, Nh xut bn y hc.

B Y t | 170

Chng V. Nhim khun tiu ha

B Y t | 171

B Y t | 172

TIU CHY DO VI KHUN


1. I CNG
- Tiu chy do vi khun l bnh thng gp mi la tui, lin quan mt
thit n v sinh an ton thc phm. Biu hin lm sng chung thng thy l:
st, nn, au bng, v tiu chy nhiu ln/ngy.
- Trng hp tiu chy nng c th gy mt nc hoc nhim khun
nhim c ton thn, dn ti t vong, c bit tr em v ngi gi.
2. CN NGUYN THNG GP
- Tiu chy do c t vi khun : Vibrio cholerae, E. coli, Clostridium
difficile, t cu.
- Tiu chy do bn thn vi khun (tiu chy xm nhp): Shigella,
Salmonella, E. coli, Campylobacter, Yersinia
3. CHN ON
Da vo lm sng v xt nghim.
a) Lm sng: Biu hin a dng ty thuc vo cn nguyn gy bnh.
- Nn v bun nn.
- Tiu chy nhiu ln, tnh cht phn ph thuc vo cn nguyn gy bnh:
+ Tiu chy do c t vi khun: Phn c nhiu nc, khng c bch cu
hoc hng cu trong phn.
+ Tiu chy do vi khun xm nhp: Phn thng c nhy, i khi c mu.
- Biu hin ton thn:
+ C th st hoc khng st.
+ Tnh trng nhim c: Mt mi, nhc u, c th c h huyt p.
+ Tnh trng mt nc.
b) Lm sng mt s cn nguyn thng gp:
- Tiu chy do l trc khun (hi chng l): St cao, au bng qun tng
cn, mt rn, i ngoi phn lng ln nhy mu.
- Tiu chy do t: Khi pht rt nhanh trong vng 24 gi, tiu chy d di
v lin tc 20-50 ln/ngy, phn ton nc nh nc vo go, khng st, khng
mt rn, khng au qun bng.
- Tiu chy do c t t cu: Thi gian bnh ngn 1-6 gi, bun nn,
nn, tiu chy nhiu nc nhng khng st.
- Tiu chy do E. coli:

B Y t | TIU CHY DO VI KHUN 173

+ 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

+TMP-SMX 0,96g x 2 ln/ngy x 5 ngy.


+ Doxycyclin 100 mg x 2 ln/ngy x 5 ngy.
b) Tiu chy do Clostridium difficile
- Thuc u tin: Metronidazol 250 mg (ung) mi 6 gi x 7-10 ngy.
- Thuc thay th: Vancomycin 250 mg (ung) mi 6 gi x 7-10 ngy.
c) Tiu chy do Shigella (l trc khun)
- Thuc u tin: Quinolon (ung hoc truyn TM) 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 (TM) 50-100 mg/kg/ngy x 5 ngy.
+ Hoc azithromycin (ung) 0,5 g/ngy x 3 ngy (u tin cho ph n c
thai) hoc azithromycin (ung) 10 mg/kg/ngy x 3 ngy (cho tr em <12 tui).
d) Tiu chy do thng hn (Salmonella typhi, paratyphi)
- Thuc u tin: Quinolon (ung hoc truyn) x 10-14 ngy (ngi ln
>12 tui):
+ Ciprofloxacin 0,5 g x 2 ln/ngy.
+ Hoc norfloxacin 0,4 g x 2 ln/ngy.
- Thuc thay th: Ceftriaxon (TM) 50-100 mg/kg/ln x 1 ln/ngy x 10-14
ngy.
e) Tiu chy do vi khun t
- Hin nay vi khun t khng li cc khng sinh thng thng, thuc
c la chn hin nay l:
- Nhm Quinolon (ung) x 3 ngy (ngi >12 tui):
+ Ciprofloxacin 0,5 g x 2 ln/ngy.
+ Hoc norfloxacin 0,4 g x 2 ln/ngy.
Hoc azithromycin (ung) 0,5 g/ngy x 3 ngy (u tin cho ph n c
thai) hoc azithromycin (ung) 10 mg/kg/ngy x 3 ngy (cho tr em <12 tui)
- Thuc thay th:
+ Erythromycin 1g/ngy ung chia 4 ln/ngy (tr em 40 mg/kg/ngy),
dng trong 3 ngy.
+ Hoc doxycyclin 300 mg liu duy nht (dng trong trng hp vi khun
cn nhy cm).
B Y t | TIU CHY DO VI KHUN 175

4.3. iu tr triu chng


a) nh gi v x tr tnh trng mt nc
- Phi nh gi ngay v kp thi x tr tnh trng mt nc khi ngi
bnhngi bnh n vin v song song vi vic tm cn nguyn gy bnh.
+ Ngi bnhNgi bnh mt nc I, ung c: b dch bng ng
ung, dng dung dch ORESOL.
+ Ngi bnhNgi bnh mt nc t II tr ln, khng ung c: b
dch bng ng tnh mch. Dung dch c la chn: Ringer Lactat hoc
Ringer Acetat. Ngoi ra: NaCl 0,9%, Glucose 5% vi t l 1:1.
b) iu tr h tr
- Gim co tht: Spasmaverin.
- Lm sn nim mc rut: dioctahedral smectit
- Khng lm dng cc thuc cm tiu chy nh loperamid.
5. PHNG BNH
- Tng cng v sinh an ton thc phm.
+ n chn, ung nc un si.
+ Ra tay trc khi n v sau khi i v sinh.
+ Ci thin h thng cp thot nc.
- iu tr d phng khi trong vng c dch.
T VIT TT TRONG BI
EIEC

Enteroinvassive E.coli (E.coli xm nhp)

EHEC

Enterohemorrhagic E.coli (E.coli gy xut huyt ng rut)

EPEC

Enteropathogenic E.coli (E.coli gy bnh)

ETEC

Enterotoxigenic E.coli (E.coli sinh c t rut)


TI LIU THAM KHO

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.

B Y t | TIU CHY DO VI KHUN 176

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.

B Y t | TIU CHY DO VI KHUN 177

DIT HELICOBACTER PYLORI TRONG BNH L D


DY T TRNG
1. I CNG
Vi khun Helicobacter pylori (H.p) t lu c pht hin sng ti lp
nhy ngay st lp biu m nim mc d dy. 60-90 % lot d dy t trng l do
H.p. T nm 2005 t chc y t th gii chnh thc xp H.p l nguyn nhn gy
ra ung th d dy. Vi khun H.p cn gy ra mt s bnh khc ti d dy nh
chng kh tiu chc nng. Ngoi ra H.p cn gy bnh ti ngoi c quan tiu
ha: nh bnh gim tiu cu tin pht.
2. CH NH DIT H.P TRONG BNH D DY T TRNG
- C nhim H.p gy ra cc bnh l d dy t trng:
+ Lot d dy.
+ Lot hnh t trng.
+ Chng kh tiu chc nng.
+ Ung th d dy phu thut hoc ct bt nim mc.
- D phng ung th d dy:
+ Nhng ngi c b, m, anh em rut b ung th d dy.
+ Khi u d dy: adenoma, polyp tng sn ct.
+ Vim teo ton b nim mc d dy.
+ Vim teo lan ht ton b nim mc thn v d dy.
+ Ngi c nhim H.p m qu lo lng v H.p gy ung th d dy.
3. CC PHNG PHP CHN ON NHIM H.P
- Test nhanh urease: Khi ni soi, nhy > 98% v c hiu 99%.
- Test th: S dng cacbon phng x C13, nhy 95% v c hiu
96%.
- Nui cy.
- M bnh hc: nhy > 95% v c hiu >95%.
- Khng th khng H.p trong huyt thanh.
- Xt nghim tm khng nguyn H.p trong phn.
- Trong thc tin lm sng ch dng test nhanh urease v test th chn
on v theo di iu tr nhim H.p. Nui cy vi khun dng lm khng sinh
trong trng hp khng khng sinh.

B Y t | DIT HELICOBACTER PYLORI TRONG BNH L 178


D DY T TRNG

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

- Amoxicilin 500mg x 2 vin x 2 ln/ngy.


d) Trng hp cc phc trn khng hiu qu cn nui cy vi khun v lm
khng sinh .
T VIT TT TRONG BI
H.p

Heliobacter pylori

PPI

Proton pump inhibitor (Thuc c ch bm proton)

RBC

Ranitidin bismuth citrate


TI LIU THAM KHO

1. P Malfertheiner, F Megraud, C OMorain, F Bazzoli, E El-Omar, D Graham, R Hunt, T


Rokkas, N Vakil,E J Kuipers, The European Helicobacter Study Group (EHSG). Current
concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus
Report. Gut 2007;56:772781.
2. Peter Malfertheiner, Francis Megraud, Colm A OMorain, John Atherton, Anthony T R
Axon, Franco Bazzoli, Gian Franco Gensini, Javier P Gisbert, David Y Graham,Theodore
Rokkas,Emad M El-Omar, Ernst J Kuipers, The European Helicobacter Study Group
(EHSG). Management of Helicobacter pylori infection the Maastricht IV/Florence Consensus
Report. Gut 2012;61:646 -664.
3. Wenming Wu, Yunsheng Yang, and Gang Sun. Review Article: Recent Insights into
Antibiotic Resistance in Helicobacter pylori Eradication. Gastroenterology Research and
Practice, Volume 2012 (2012).

B Y t | DIT HELICOBACTER PYLORI TRONG BNH L 180


D DY T TRNG

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)

Trung bnh (II)

Biu hin suy tng

Khng

Khng

p ng iu tr ban u

Khng

Khng

- iu tr ban u bao gm: Khng sinh v iu tr h tr


- Suy tng:
+ Tim mch: Huyt p tt phi dng thuc vn mch.
+ Thn kinh: Ri lon thc.
+ H hp: PaO2/FiO2 < 300.
+ Gan: Ch s INR > 1.5.
+ Thn: Creatinin > 2.0 mg/dl (>152mol/l).
+ Mu: Tiu cu <100.000 G/l.
4. IU TR BNG KHNG SINH
a) Nguyn tc
- Chn khng sinh bi tit tt vo ng mt.

B Y t | NHIM KHUN NG MT 182

- Phi hp vi khng sinh iu tr vi khun k kh khi c nhim khun


ng mt nng.
- 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.
- Tt nht l iu tr theo khng sinh , tuy nhin, trong khi ch kt qu
khng sinh c th iu tr theo kinh nghim.
- 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.
b) C th
- Cc la chn khng sinh trong nhim khun ng mt th hin trong
Bng II.15.
- Th nh: iu tr 5-7 ngy.
+ Hay dng loi ampicilin-sulbactam: tim TM 1,5- 3g/6 gi.
+ C th dng cc cephalosporin th h 1: Cefazolin hoc th h 2:
Cefmetazol, cefotiam, oxacephem (v d flomoxef) v th h 3.
- Th trung bnh v nng: iu tr 7-14 ngy, c th iu tr di hn ty
thuc vo p ng trn lm sng.
5. D PHNG
- iu tr si mt v nguyn nhn gy tc nghn ng mt.
- Ty giun nh k i vi trng hp do giun.

B Y t | NHIM KHUN NG MT 183

Bng II.15. Cc la chn khng sinh trong nhim khun ng mt


La chn s 1
Khng sinh penicillin kt hp vi Ampicilin-sulbactam TM 1,5-3g/6 gi.
cht c ch beta-lactamase c hot Piperacilin-tazobactam TM 4,5 g/6 gi.
ph rng
Aminoglycosid

Gentamicin TB hoc pha long tim tnh mch 80


mg/8 gi.
Amikacin TB hoc TM 5 mg/kg/8 gi.
Tobramycin TB hoc TM 1 mg/kg/8 gi.

Cc cephalosporin th h 3,4

Cefoperazon-sulbactam TM 2g/12 gi.


Ceftriaxon TM 2-4g/ 1 ln /24 gi.
Ceftazidim TM 1-2 g/12 gi.
Cefepim TM 1-2 g/12 gi.

Monobactam

Aztreonam 1-2 g/12 gi.

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

Ciprofloxacin 500mg ung hoc TM/12 gi.


Levofloxacin 500mg ung hoc TM/24 gi.
Moxifloxacin ung hoc TM 400 mg/24 gi.

Nu c nhim khun k kh dng mt trong 3 loi fluoroquinolon trn + metronidazol TM


500 mg/8 gi.
Carbapenem

Meropenem TM 1g/8 gi.


Imipenem-cilastatin TM 1-2 g/12 gi.
Doripenem TM 0,5g/8 gi.
TI LIU THAM KHO

1. Joseph S. Solomkin, John E. Mazuski, Ellen J. Baron, Robert G. Sawyer, Avery B.


Nathens, Joseph T. DiPiro,Timothy Buchman, E. Patchen Dellinger, John Jernigan, Sherwood
Gorbach, Anthony W. Chow, and John Bartlett. Guidelines for the Selection of Anti-infective
Agents for Complicated Intra-abdominal Infections. CID 2003:37 (15 October).
2. Atsushi Tanaka, Tadahiro Takada, Yoshifumi Kawarada, Yuji Nimura, Masahiro
Yoshida,Fumihiko Miura, Masahiko Hirota, Keita Wada, Toshihiko Mayumi, Harumi
Gomi,Joseph S. Solomkin, Steven M. Strasberg, Henry A. Pitt, Jacques Belghiti, Eduardo de
Santibanes, Robert Padbury, Miin-Fu Chen, Giulio Belli, Chen-Guo Ker, Serafin C. Hilvano,
Sheung-Tat Fan, and Kui-Hin Liau. Antimicrobial therapy for acute cholangitis: Tokyo
Guidelines. J Hepatobiliary Pancreat Surg (2007) 14:5967.
3. Massimo Sartelli. A focus on intra-abdominal infections. World Journal of Emergency
Surgery 2010, 5:9.

B Y t | NHIM KHUN NG MT 184

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.

B Y t | P XE GAN DO VI KHUN 186

Bng II.16. Cc la chn khng sinh trong p xe gan do vi khun


La chn s 1
Khng sinh
penicillin kt hp
vi cht c ch betalactamase c hot
ph rng

Ampicilin-sulbactam ng tnh mch (TM) 1,5-3 g/6 gi.


Piperacilin-tazobactam TM 4,5 g/6 gi.
Gentamicin tim bp (TB) hoc pha long tim tnh mch 80 mg/8
gi.

Aminoglycosid

Amikacin TB hoc TM 5 mg/kg/8 gi.


Tobramycin TB hoc TM 1 mg/kg/8 gi.
Cefoperazon-sulbactam TM 2g/12 gi.

Cc cephalosporin
th h 3,4

Ceftriaxon TM 2-4 g/1 ln/24 gi.


Ceftazidim TM 1-2 g/12 gi.
Cefepim TM 1-2g/12 gi.

Monobactam

Aztreonam 1-2 g/12 gi.

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

Ciprofloxacin 500mg ung hoc TM/12 gi.


Levofloxacin 500mg ung hoc TM/24 gi.
Moxifloxacin ung hoc TM 400 mg/24 gi.

Nu c nhim khun k kh dng mt trong 3 loi fluoroquinolon trn + metronidazol TM


500 mg/8 gi.
Carbapenem

Meropenem TM 1g/8 gi.


Imipenem-cilastatin TM 1-2 g/12 gi.
Doripenem TM 0,5 g/8 gi.

B Y t | P XE GAN DO VI KHUN 187

TI LIU THAM KHO


1. Joseph S. Solomkin, John E. Mazuski, Ellen J. Baron, Robert G. Sawyer, Avery B.
Nathens, Joseph T. DiPiro, Timothy Buchman, E. Patchen Dellinger, John Jernigan,
Sherwood Gorbach, Anthony W. Chow, and John Bartlett. Guidelines for the Selection of
Anti-infective Agents for Complicated Intra-abdominal Infections. CID 2003:37 (15 October).
2. Ajaz A Malik, Shams UL Bari, Khawaja Abdul Rouf, Khurshid Alam Wani. Pyogenic liver
abscess: Changing patterns in approach. World J Gastrointest Surg 2010 December 27;
2(12): 395-401.
3. Massimo Sartelli. A focus on intra-abdominal infections. World Journal of Emergency
Surgery 2010, 5:9.
4. Fung CP, Lin YT, Lin JC, Chen TL, Yeh KM, Chang FY, Chuang HC, Wu HS, Tseng CP,
Siu LK. Klebsiella pneumoniae in gastrointestinal tract and pyogenic liver abscess. Emerg
Infect Dis. 2012 Aug;18(8):1322-5.

B Y t | P XE GAN DO VI KHUN 188

VIM TY CP C NHIM KHUN


1. I CNG
Vim ty cp l tnh trng vim cp tnh ca nhu m ty. C th c nhng
bin chng nng v gy t l t vong cao. Vim ty cp c 2 th: th ph n v
vim ty cp hoi t, khong 1/3 s trng hp vim ty cp l th hoi t.
Vim ty cp nhim khun ch yu gp trong trng hp vim ty cp hoi t
nng hoc do giun v si mt.
2. NGUYN NHN
- Ru.
- Si mt.
- Ri lon chuyn ha: Tng triglycerid, tng canxi mu, vim ty cp do
di truyn.
- Sau chp mt ty ngc dng (ERCP).
- Lot hnh t trng.
- Cc nguyn nhn c tnh nh: u ty, u bng vater.
- Thuc: Steroid, sulfonamid, furosemid, thiazid.
- Nhim khun v k sinh trng: Giun, si, virus Coxsackievirus,
Mycoplasma pneumoniae, sn l gan nh.
- Ty phn chia (divisum), nang ng mt ch.
- Nguyn nhn hay gp nht gy vim ty l do ru v si mt. Vim ty
cp nhim khun hay gp nguyn nhn l do si mt v giun hoc vim ty cp
hoi t nng do cc nguyn nhn.
3. TRIU CHNG
a) Lm sng
- t ngt au bng d di ti vng thng v, au thng lan ra sau
lng.
- Bun nn, nn.
- St: St cao rt run.
- C th c a chy, hay gp trong trng hp vim ty nng.
- Trng hp nng c th biu hin c sc hoc suy cc tng: kh th,
mch nhanh huyt p tt, i t.
- Du hiu Grey Turner: Nhng mng bm tm trn da ti mng sn, gp
trong vim ty nng.

B Y t | VIM TY CP C NHIM KHUN 189

- Du hiu Cullen: Nhng mng bm tm trn da vng quanh rn, gp


trong vim ty nng.
- Trong vim ty c th c vng da do tc mt: Si, giun hoc do chn p
ca ty vo ng mt ch.
b) Cn lm sng
- Xt nghim:
+ Amylase mu tng, lipase mu tng.
+ Xt nghim cho thy c biu hin vim v nhim khun: bch cu tng
c bit a nhn trung tnh, CRP tng, Pro Calcitonin tng.
+ P02 gim, creatinin tng, canxi mu gim, ng mu tng, AST tng.
- Cy vi khun: Thy c vi khun t dch chc ht qua da di hng
dn ca siu m hoc C.T, hoc chc ht di siu m ni soi. i vi nhim
khun Gram-dng hay gp l t cu.
- Chn on hnh nh: Trn siu m thng kh quan st. Trn C.T hoc
cng hng t (MRI) thy ty ph n hoc hoi t, c th thy nguyn nhn nh
si ng mt ch, giun
Bng II.17. im Balthazar nh gi mc nng trn CT
Thang im
Balthazar

Ty trn C.T

im s

Mc hoi t
ca ty

im s

Bnh thng

Khng hoi t

Ty to ton b hoc tng phn

Hoi t 30%

Ty to v c dch quanh ty

Hoi t 30-50%

C mt dch duy nht

Hoi t > 50%

C t hai dch tr ln

4. IU TR BNG KHNG SINH


a) Nguyn tc
- Cy vi khun: Chc ht dch hoi t qua da di hng dn ca siu m
hoc C.T, hoc chc ht di siu m ni soi.
- Dn lu dch hoi t b nhim khun qua da hoc qua d dy, ch phu
thut trong trng hp cc bin php dn lu ny khng c hiu qu hoc khng
c kh nng tin hnh.
- iu tr nguyn nhn nhim khun do tc mt nh: si mt, giun chui
ng mt hoc ng ty.
- iu tr khng sinh d phng trong vim ty cp hoi t mc nhiu
(trn 30%) l vn ang cn bn lun.
b) C th
B Y t | VIM TY CP C NHIM KHUN 190

- Tt nht l da theo kt qu khng sinh . Trong khi ch kt qu khng


sinh c th dng :
+ Carbapenem: imipenem/cilastatin hoc meropenem tim TM 1g/8 gi.
+ Hoc ciprofloxacin 400mg TM/12 gi phi hp metronidazol 500mg
TM /8 gi.
TI LIU THAM KHO
1. Markus W. Buchler, Beat Gloor, Christophe A. Mu ller, Helmut Friess, Christian A.
Seiler, and Waldemar Uhl. Acute Necrotizing Pancreatitis: Treatment Strategy According to
the Status of Infection. ANNALS OF SURGERY, Vol. 232, No. 5, 619626.
2. UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute
pancreatitis. Gut 2005;54 (Suppl III):iii1iii9.
3. Peter A. Banks, Martin L. Freeman, and the Practice Parameters Committee of the
American College of Gastroenterology. Practice Guidelines in Acute Pancreatitis. Am J
Gastroenterol 2006;101:23792400.
4. Kun Jiang, Wei Huang, Xiao-Nan Yang, and Qing Xia. Present and future of prophylactic
antibiotics for severe acute pancreatitis.World J Gastroenterol. 2012 January 21; 18(3): 279
284.

B Y t | VIM TY CP C NHIM KHUN 191

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

B Y t | VIM PHC MC 192

- Vim phc mc tin pht do vi khun (Spontaneous bacterial peritonitis


SBP):
+ Thng xy ra ngi bnhngi bnh c trng do mc bnh gan
mn tnh.
+ Biu hin lm sng c th khc nhau t khng triu chng cho n
nhim khun nng cn cp cu ngay vi t l t vong cao.
+ Cc triu chng lm sng gm: St, rt run, bun nn, nn, c th c
cc triu chng suy gim chc nng gan (thay i thc, au bng, xut huyt
tiu ha...).
- Vim phc mc th pht:
+ Cc triu chng lm sng gm au bng, nn v bun nn, chng
bng, bng c co cng v c cm ng phc mc, km theo c st cao rt run,
du hiu nhim c. Trng hp nng hn c th c sc hoc ri lon thc.
3.2. Xt nghim
- S lng bch cu tng cao, t l a nhn trung tnh tng cao, CRP tng.
- S lng hng cu, hematocrit tng do hin tng c c mu, c th
gim do nhim c gy v hng cu.
- Ur v creatinin mu tng.
- in gii thay i.
- Siu m: thy dch trong lng rut, cc quai rut gin cha dch v hi.
Ngoi ra c th thy c cc nguyn nhn gy vim phc mc nh tnh trng
ca ng mt, thy ng nt v gan lch.
- Chp bng t th ng trn phim thng c th thy: M vng thp,
quai rut gin, thnh rut dy. Ngoi ra c th thy c cc du hiu c hiu
cho tng nguyn nhn gy vim phc mc nh lim hi di honh trong thng
lot d dy t trng, hnh mc nc, mc hi trong tc rut.
3.3. Chn on xc nh
- Chc dch bng l xt nghim quan trng chn on. i khi chc
ra c th thy m hoc dch mt c chy ra ty theo nguyn nhn gy vim
phc mc.
- Tng s lng bch cu trong dch mng bng (trn 500 t bo/mm3) v/
hoc s lng bch cu trung tnh trn 250 t bo/mm3.
- Soi v cy dch mng bng c th cho kt qu vi khun gy bnh.
4. IU TR
4.1.Vim phc mc nguyn pht

B Y t | VIM PHC MC 193

- iu tr khng sinh theo kinh nghim: Ceftriaxon hoc cefotaxim hoc


quinolon (moxifloxacin hoc levofloxacin).
- Nu nghi ng nhim E. coli hoc Klebsiella pneumoniae khng thuc c
th s dng mt trong cc thuc sau: doripenem, ertapenem, imipenem,
meropenem, ciprofloxacin, moxifloxacin.
- Khi c kt qu cy dch hoc cy mu dng tnh th iu tr theo khng
sinh .
- Thi gian iu tr t 5-14 ngy ty thuc p ng ca ngi bnhngi
bnh.
- iu tr h tr: Chc dch mng bng, truyn albumin tnh mch 1,5g/kg
trong 6h u sau l 1g/kg ngy th 3 (cho ngi bnhngi bnh x gan c
nhim khun dch c trng).
- iu tr d phng vim phc mc tin pht cc ngi bnhngi bnh
x gan ang c xut huyt tiu ha trn do tng p lc tnh mch ca hoc ngi
bnhngi bnh x gan c protein dch c chng thp (< 1g/dL).
+ D phng trn ngi bnhngi bnh x gan c xut huyt tiu ha
trn: dng trong 7 ngy mt trong cc thuc: Norfloxacin ung (400mg x 2
ln/ngy) nu BN ung c, bnh gan nh, hoc ciprofloxacin truyn tnh
mch (400mg x 2 ln/ngy) nu BN khng ung c hoc ceftriaxone ng
tnh mch (1g/ln/ngy) trn ngi bnhngi bnh x gan tin trin hoc ni
c t l khng quinolon cao.
+ Trn ngi bnhngi bnh c protein dch c trng thp (<1g/dL):
Dng di hn norfloxacin 400mg/ngy.
- iu tr d phng di hn vim phc mc c ch nh sau mt t
vim phc mc tin pht, chn u tin norfloxacin 400mg/ngy. Khng sinh
thay th: Ciprofloxacin ung 750 mg/tun hoc Co-trimoxazol 960mg/ngy.
4.2. Vim phc mc th pht
- C th s dng mt trong cc thuc sau: Ticarcilin-clavulanat hoc
piperacilin-tazobactam hoc ertapenem kt hp vi metronidazol.
- Trng hp nng c th dng imipenem hoc doripenem hoc
meropenem kt hp vi metronidazol.
- iu tr h tr: Dn lu p xe, phu thut li bng kt hp vi hi
sc ni khoa chng sc, th oxy, iu tr suy cc tng (nu c).
- Khi c kt qu cy dch bng hoc cy mu th iu tr theo khng sinh
.

B Y t | VIM PHC MC 194

Bng II.18. Liu lng v cch dng khng sinh iu tr vim phc mc
Tn khng sinh

Liu dng v cch s dng

Ciprofloxacin

Truyn TM 400mg, mi 12h

Levofloxacin

Truyn TM 750 mg, mi 24h

Moxifloxacin

Truyn TM 400 mg, mi 12-24h

Ceftriaxon

Tim TM 1-2g, mi 12h-24h

Cefotaxim

Tim TM 1-2g, mi 6-8h

Ertapenem

Truyn TM 1g, mi 24h

Piperacilin-tazobactam

Truyn TM 4,5g, mi 8h

Imipenem- cilastatin

Truyn TM 500 mg, mi 6h hoc 1g mi 8h

Meropenem

Tim/truyn TM 1g, mi 8h

Doripenem

Truyn TM 500 mg, mi 8h

Metronidazol

Truyn TM 500 mg, mi 8-12h


TI LIU THAM KHO

1. Cesar Alaniz, Randolph E. Regal. Spontaneous Bacterial Peritonitis. A Review of


Treatment Options. Pharmacy and Therapeutic. 2009 April; 34(4): 204210.
2. Bruce M Lo, Thomas E Herchline. Spontaneous Bacterial Peritonitis Organism-Specific
Therapy. http://emedicine.medscape.com/article/2014916-overview
3. Joseph S. Solomkin,1 John E. Mazuski,2 John S. Bradley et al. Diagnosis and Management
of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical
Infection Society and the Infectious Diseases Society of America. Clinical Infectious Diseases.
2010; 50:13364.
4. Beth Piraino, George R. Bailie, Judith Bernardini et al. Peritoneal dialysis-related
infections recommendations: 2005 Update. Peritoneal Dialysis International. Vol. 25, pp.
107131.
5. Dietmar H. Wittmann, Moshe Schein, Robert E. Condon. Management of Secondary
Peritonitis. Annals of Surgery. 1996, Vol. 224, No. 1, 10-18.
6. Jose Such, Bruce A. Runyon. Spontaneous Bacterial Peritonitis. Clinical Infectious
Diseases. 1998; 27:66976.
7. Bruce A. Runyon. Management of Adult Patients with Ascites Due to Cirrhosis: An
Update. Hepatology. 2009. Vol. 49, No. 6. 2087-2107.

B Y t | VIM PHC MC 195

B Y t | VIM PHC MC 196

Chng VI.
Nhim khun c xng khp

B Y t | 197

B Y t | 198

VIM KHP NHIM KHUN


1. I CNG
Vim khp nhim khun (septic arthritis) hay vim khp sinh m
(pyogenic/ suppurative arthritis) l vim khp do vi khun sinh m khng c
hiu (khng phi do lao, phong, nm, k sinh trng hay virus) gy nn.
2. NGUYN NHN
Phn lm hai nhm nguyn nhn chnh theo tc nhn gy bnh:
a) Vim khp nhim khun do lu cu (gonococcal bacterial/suppurative
arthritis): Lu cu khun (N. gonorrhoeae), chim ti 70-75% nhim khun
khp ngi ln di 40 tui.
b) Vim khp nhim khun khng do lu cu (nongonococcal
bacterial/suppurative arthritis): Nguyn nhn hay gp nht l do vi khun
Gram-dng c bit l t cu vng (50-70% trng hp), lin cu (20%), ph
cu... Vi khun Gram-m t gp hn (15-20%): E.coli, thng hn, trc khun
m xanh, Haemophilus influenzae; vi khun k kh chim khong 5% trng
hp. C khong 5-10% trng hp nhim ng thi nhiu loi vi khun, y l
loi nhim khun khp thng gp sau chn thng.
3. TRIU CHNG CHN ON
a) Lm sng
Thng xy ra cp tnh, gm hai bnh cnh vim khp nhim khun
khng phi do lu cu v do lu cu.
- Vim khp nhim khun khng do lu cu: thng xy ra mt khp
n c (90% trng hp), hay gp nht l khp gi.
+ Triu chng ti khp: Sng nng au, c th trn dch khp, co c,
hn ch vn ng.
+ Hi chng nhim khun: St, km rt run, mi kh li bn, hi th
hi.
- Nhim khun khp do lu cu: C hai bnh cnh lm sng trong nhim
khun do lu cu:
+ Hi chng nhim khun lu cu pht tn: St, rt run, ban v mn
m ngoi da cng cc triu chng vim khp, triu chng ti b phn sinh dc
nh i but, i rt, i mu - m Vim nhiu khp nh c tnh cht di
chuyn km vim bao hot dch - gn.
+ Vim khp thc s do lu cu: Thng tn thng mt khp n c
nh hng, gi, c tay, c chn vi triu chng sng nng au, c th trn
dch khp. C th km theo vim nhim ng tit niu, sinh dc nh i
but, i rt, i mu - m
B Y t | VIM KHP NHIM KHUN 199

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:

B Y t | VIM KHP NHIM KHUN 200

- 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

ciprofloxacin ung 500 mg hai ln /ngy; hoc spectinomycin 2g tim bp mi


12 gi /ngy trong 7 ngy.
- Khi nghi ng bi nhim Chlamydia trachomatis: Phi hp khng sinh
ung doxycyclin 100mg 2 ln/ngy hoc tetracyclin 500mg 4 ln/ngy hoc
erythromycin 500mg 4 ln/ ngy trong 7 ngy.
4.2.2 Cc bin php khc c th phi hp vi iu tr khng sinh
- Ht, dn lu khp khi c vim khp c dch m.
- Ni soi khp ra khp: Trong trng hp sau 5- 7 ngy iu tr ng
thuc kt hp ht, dn lu dch khp nhiu ln tht bi; hoc nhim khun khp
dch m c hay c vch ngn khng ht c dch khp.
- Phu thut m khp ly b t chc nhim khun khi km nhim khun
phn mm ln cn, nhim khun sn khp hay xng; nhim khun khp
nhn to (a s trng hp phi ly b khp nhn to, dng khng sinh ng
tnh mch t nht 4-6 tun, sau mi xem xt c lm li khp nhn to khc
hoc khng); nhim khun khp su kh ht nh khp hng; nhim khun
khp hng tr em (l bin php tt nht trnh tn thng lm h hi chm
xng i).
5. PHNG BNH
Thc hin v trng tuyt i khi lm cc th thut, phu thut tin hnh
ti khp. iu tr tt cc nhim khun ti cc c quan khc, c bit ti da, phn
mm v xng. i vi bnh lu phng bng cch thc hin hnh vi tnh dc an
ton.
TI LIU THAM KHO
1. L Ngc Trng, Khng Chin (ch bin); Vim khp m v vim khp do lu; Hng
dn iu tr, tp II: hng dn iu tr mt s bnh nhim khun thng gp; Nh xut bn Y
hc, 2006; trang 24-28.
2. Goldenberg D, Bacterial Arthritis, Textbook of Rheumatology, fourth Edition, Vol 2;
W.B Saunder Company, 2003; p 1449- 1466.
3. Goldenberg D, Sexton D; Septic arthritis in adults; Uptodate 19.3, 2011.
4. Hedstrom S, Lidgren L; Septic arthritis and osteomyelitis; Rheumatology 2th Edition,
Vol 2; Mosby, 2000; p 6/2.1- 6/2.10.
5. Madoff Lawrence; Infectious Arthritis; Harissons Principles of internal medicine 17th
Edition, Vol II; Mac Graw Hill, 2008, p2169-2175
6. Osmon DR, Steckelberg JM; Osteomyelitis, Infectious arthritis and Prosthetic- joint
infection; Current diagnosis and treatment in infectious diseases, 1th Edition; MacGrawHill/Appleton and Lange, 2001; p 160-168.

B Y t | VIM KHP NHIM KHUN 202

VIM XNG TY NHIM KHUN


1. I CNG
Vim xng ty (Osteomyelitis), hay cn gi l ct ty vim, l mt bnh
nhim khun ca xng (v hoc ty xng), c th l cp tnh hoc mn tnh,
do nhiu loi vi sinh vt gy nn, nhng thng gp nht l vi khun.
2. NGUYN NHN
a) Nguyn nhn
- Vi khun hay gp nht l t cu vng (Staphylococcus aureus).
- Cc vi khun thng gp khc bao gm lin cu tan huyt nhm B, cc
chng Pseudomonas, E. coli v cc trc khun ng rut khc v mt s loi
vi khun khc.
b) Yu t nguy c: Nhim khun da ko di, bnh tiu ng khng c kim
sot, mu lu thng km (x cng ng mch), cc yu t nguy c cho mu lu
thng km (huyt p cao, ht thuc l, cholesterol mu cao v bnh tiu ng),
suy gim min dch, khp gi, vic s dng thuc tim tnh mch, ung th.
c) Phn loi
- Vim xng ty cp: T ng mu v t ng k cn.
- Vim xng ty mn: Xy ra sau vim xng ty cp ng mu.
3. TRIU CHNG- CHN ON
a) Lm sng
- Vim xng ty ng mu: Biu hin hi chng vim (st, rt run, mt
mi). Biu hin au khng r rng, thng ch thy hi sng n ti vng au.
Mun hn thy c khi sng, nng, , au r, ging nh mt vim c, vng
khp ln cn sng n. Chc d c th thy m, nui cy vi khun thy a s l
t cu vng.
- Vim xng ty ng k cn: Sau m, sau gy xng h... t ngy th
4, 5 tr i, ngi bnhngi bnh tip tc st cao, rt run. au nhc ti gy
hoc ti vt thng, au ngy cng tng. Cng n, ty lan ta ti vt thng
hay vt m, chy m thi qua vt thng, vt m.
- Vim xng ty mn: Xy ra sau vim xng ty cp khng c iu
tr trit , bnh ti pht tng t vi c trng l l r v xng cht.
b) Cn lm sng
- Xt nghim mu: Trong vim xng ty cp thng c tng bch cu
(vim xng ty mn tnh bch cu mu thng bnh thng). Tc mu lng
v protein C phn ng (CRP) thng tng cao.
- X-quang: Hnh nh ph hy xng v phn ng mng xng. Tn
B Y t | VIM XNG TY NHIM KHUN 203

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

- Trng hp nhim nhiu vi khun (S. aureus, vi khun Gram-m,


P. aeruginosa) hay gp trong vim xng di sau ng inh ni ty:
Vancomycin 1g TM mi 12 gi phi hp ceftazidim 2g/ln x 2-3 ln/ ngy.
Hoc thay th bng linezolid 600mg (TM hoc ung) 2 ln/ngy phi hp
ceftazidim 2g/ln x 2-3 ln/ ngy.
- 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.
- Lu : Trng hp vim xng mn tnh, vim xng trn c a i
tho ng: cn thit c bng chng ca vi khun hc v khng sinh iu
tr.
b) Giai on sau: Ty theo p ng lm sng v kt qu khng sinh .
4.2.2. Cc bin php phi hp
- Bt ng: B bt c ch nh rng ri cho mi vim xng ty cp,
nhm phng gy xng bnh l v gip cho qu trnh chng ca c th tt
hn.
- Dinh dng: m bo ch n ung cht dinh dng.
- Phu thut: Rch rng tho m, loi b hoi t. Tin hnh c xng
n tn xng lnh (ch xng c r mu). Tho b cc vt cy ghp hoc thm
ch phi ct b chi ngn chn nhim khun lan rng thm. C th truyn
khng sinh ti ch. Lp y khuyt xng l iu cn thit v bt buc trong
phu thut iu tr vim xng.
5. D PHNG
Vim xng ty nu khng iu tr kp thi hoc iu tr khng y s
tin trin mn tnh rt kh iu tr dt bnh. V vy nhm phng chng vim
xng ty, vic qun l thch hp cc vt thng v chm sc y t kp thi cc
bnh nhim khun l rt cn thit v cn c tun th nghim ngt.
TI LIU THAM KHO
1. Chihara S, Segreti J. Osteomyelitis. Dis Mon. Jan 2010;56(1):5-31.
2. Calhoun JH, Manring MM. Adult osteomyelitis. Infect Dis Clin North Am.
2005;19(4):76586.
3. Aloui N, Nessib N, Jalel C, et al. [Acute osteomyelitis in children: early MRI diagnosis]. J
Radiol. Apr 2004;85(4 Pt 1):403-8.
4. Joseph M. Fritz, Jay R. Mc Donald. Osteomyelitis: Aproach to Diagnosis and Treatment.
Phys Sportsmed.2008; 36(1): nihpa 116823.

B Y t | VIM XNG TY NHIM KHUN 205

VIM C, P XE C NHIM KHUN


1. NH NGHA
Vim c nhim khun (Infectious myositis) l tn thng vim hoc p xe
ti c vn do vi khun gy nn.
2. NGUYN NHN
Vi khun gy bnh
- Nguyn nhn thng gp nht l t cu vng.
- Cc loi vi khun khc: Lin cu, lu cu, ph cu, no m cu,
Burkholderia pseudomallei, vi khun Gram-m v cc vi khun k kh khc.
3. TRIU CHNG CHN ON
a) Triu chng lm sng
- V tr tn thng: C th gp bt k v tr no.
- S lng: Thng mt c. nhng ngi bnhngi bnh nhim
khun huyt hoc c a suy gim min dch c th tn thng nhiu c.
- Vim c tht lng chu thng xy ra sau cc nhim khun ng tit
niu sinh dc hoc phu thut vng bng, thng do vi trng lao hoc do vi
trng sinh m. Trn lm sng, ngi bnhngi bnh thng au vng h
sn. Ngi bnhNgi bnh thng khng dui c chn bn c c b vim,
khm khp hng bnh thng.
- Tnh cht
+ Giai on u (1-2 tun u): Sng c, n chc, c th hoc au nh.
+ Giai on 2 (tun 2-4): C sng ty rt au, bng nhng khi n, chc
ht ra m.
+ Giai on 3: C th xut hin cc bin chng nh p xe xa, sc nhim
khun...
- Biu hin ton thn: Hi chng nhim khun thng r:
+ St cao 39- 40 C, st lin tc, dao ng.
+ Gy st, mt mi, mi kh, li bn.
b) Cc thm d cn lm sng
- Xt nghim
+ Xt nghim mu: T bo mu ngoi vi c th tng s lng bch cu,
tng t l bch cu on trung tnh; tng tc mu lng, tng CRP, tng
fibrinogen, tng globulin. Procalcitonin mu c th tng trong trng hp nhim
khun nng.
B Y t | VIM C, P XE C NHIM KHUN 206

+ 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 | VIM C, P XE C NHIM KHUN 207

+ Vi c a suy gim min dch, nn s dng khng sinh ph rng bao


trm trc khun Gram-m v vi khun k kh, chng hn vancomycin v mt
khng sinh nhm carbapenem hoc piperacilin-tazobactam. i vi vi khun k
kh, c th dng clindamycin.
- Kt hp chc ht dn lu m hoc phu thut dn lu m (giai on 2,
3).
- iu tr triu chng v nng cao th trng, chng sc nhim khun (nu
c).
b) iu tr c th
- 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.
- i vi t cu cn nhy cm vi methicilin:
+ Cefazolin 1g TM mi 8 gi x 2 tun.
+ Hoc levofloxacin 750mg TM mi 24 gi x 2 tun.
+ Hoc moxifloxacin 400mg TM mi 24 gi x 2 tun.
+ Hoc ampicilin-sulbactam 3g TM mi 6 gi x 2 tun.
Sau chuyn sang:
+ Cephalexin 500mg ung mi 6 gi x 2 tun.
+ Hoc iu tr phi hp clindamycin 300mg ung mi 6 gi x 2 tun
vi levofloxacin 750mg ung mi 24 gi x 2 tun hoc moxifloxacin
400mg ung mi 24 gi x 2 tun.
- Nu nghi ng t cu (Staphylococcus aureus) khng methicilin:
+ Vancomycin 1g TM mi 12 gi x 2 tun.
+ Hoc linezolid 600mg TM mi 12 gi x 2 tun.
+ Hoc daptomycin 4mg/kg TM mi 24 gi x 2 tun.
Sau chuyn sang:
+ Linezolid 600mg ung mi 12 gi x 2 tun.
+ Hoc minocyclin 100mg ung mi 12 gi x 2 tun.
- Nu nghi ng nhim Gram-dng khc:
+ Cefazolin TM 3g/ngy chia 3 ln trong 2-3 tun sau dng cephalexin
4g/ngy chia 4 ln (4-6 tun).
+ Hoc clindamycin TM 1800 mg/ngy, chia 3 ln trong 2-3 tun; sau
duy tr bng ung clindamycin 1800 mg/ngy, chia 3 ln trong 4-6 tun.

B Y t | VIM C, P XE C NHIM KHUN 208

+ Hoc lincomycin TM 1800 mg/ngy, chia 3 ln (2-3 tun); sau duy


tr bng ung lincomycin 1800 mg/ngy, chia 3 ln trong 4-6 tun.
- Nu nghi ng nhim lin cu (Streptococcus group A):
+ Penicilin G TM 2-4 triu IU mi 4-6 gi, sau chuyn sang penicilin V
ung.
+ Hoc ceftriaxon TM 1-2 g/24 gi.
- Nu nghi nhim khun trc khun m xanh 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).
- 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.
5. D PHNG
- m bo nguyn tc v trng khi lm th thut hoc tim chch.
- iu tr tt cc nhim ban u da nh mn nht, vt lot...
- Kim sot tt cc bnh l mn tnh nh i tho ng, cc bnh l t
min.
TI LIU THAM KHO
1. Nguyn Th Ngc Lan. Vim c do vi khun, Bnh hc c xng khp ni khoa, NXB
Gio dc Vit Nam, 2010: 239-246.
2. Acunha B. Antibiotic essentials 2008. Eighth edition- PhysicianS Press.
3. Gilbert DN, Modeellering RC, Eliopoulous GM, et al. The Sandford Guide to
Antimicrobial therapy 2011, 41st Edition
4. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.
5. Kroshinsky D, Grossman ME, Fox LP. Approach to the patient with presumed cellulitis.
Semin Cutan Med Surg. Sep 2007;26(3):168-78.
6. Stryjewski ME, Chambers HF. Skin and soft-tissue infections caused by communityacquired methicilin-resistant Staphylococcus aureus. Clin Infect Dis. Jun 1 2008;46 Suppl
5:S368-77.

B Y t | VIM C, P XE C NHIM KHUN 209

NHIM KHUN HT T PHI


1. I CNG
Nhim khun ht t phi (septic tophi) l mt trong nhng bin chng
him gp ca bnh gt mn tnh cc nc pht trin song li kh ph bin
Vit Nam do bnh thng c chn on mun, ngi bnhngi bnh khng
tun th iu tr. C ti gn 9% s ngi bnhngi bnh iu tr ni tr ti
khoa C-Xng-Khp Bnh vin Bch Mai trong khong thi gian 1991-2000
mc bnh gt, trong 85% giai on mn tnh, t l ht t phi v c th km
theo nhim khun kh cao. Do ht t phi cha tinh th urat nn khi v, rt kh
xc nh tnh trng nhim khun km theo nu ch xem xt v mt i th. V
vy, vic cy bnh phm v la chn khng sinh rt quan trng. Ngoi ra, vic
iu tr bnh gt km theo cng rt cn thit.
2. NGUYN NHN
Trong s 57 trng hp ht tophi v c xt nghim vi khun hc ti
khoa C Xng Khp bnh vin Bch Mai, ch c 44,4% s mu phn lp c
vi khun vi t l nhim khun nh sau: 75% l t cu vng (Staphylococcus
aureus), t l nhim E. coli, Klebsiella pneumoniae tng t nhau (12,5%).
3. TRIU CHNG - CHN ON
a) Lm sng
- Trn c s ngi bnhngi bnh b bnh gt mn tnh c ht t phi
nhng v tr d c xt nh bn chn, bn tay, lu ngy dn n lot v d, chy
dch, v ra, l ng cho vi khun xm nhp gy nhim khun ht t phi.
- Triu chng ti ch: Ht t phi d, v, chy ra cht dch mu trng c,
c th ln m mu vng c, khng mi hoc c mi hi.
- Cc khp ln cn c th sng, nng, , au biu hin mt cn gt cp
km theo.
- Hi chng nhim khun: St, km rt run, mi kh li bn, hi th hi.
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 chy ra t ht t phi: 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.
B Y t | NHIM KHUN HT T PHI 210

- Chn on hnh nh: Chp X-quang quy c, siu m khp, chp ct


lp vi tnh, chp cng hng t...
- Cn ch nguyn tc: Khi c biu hin sng nng au khp hoc
ht t phi ngi bnhngi bnh c chn on xc nh bnh gt th bao
gi cng phi lu c b nhim khun km theo hay khng.
4. IU TR
Do tnh trng nhim khun ht t phi khng ph bin cc nc pht
trin nn cc d liu v kinh nghim iu tr bnh rt hn ch. Ti bnh vin
Bch Mai, tt c cc vi khun phn lp c khng li khng sinh nhm lactam. Ngay c cc khng sinh thuc nhm c ch -lactamase cng b khng
t 75-100%. Cc khng sinh c th la chn thuc nhm glycopeptid
(vancomycin), quinolon (levofloxacin), oxacilin, lizonalid...
4.1. Nguyn tc iu tr
- Thc hin ngay cy mu, cy dch v t ht t phi, 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. Nn bt u bng t nht 1
khng sinh ng tnh mch, vi thi gian dng t 2-4 tun.
- Lun kt hp iu tr ti ch: Ra vt lot, thay bng, hoc chch rch
m rng, lm sch t chc nhim khun, can thip ngoi khoa khi cn thit.
4.2. iu tr c th
a) iu tr khng sinh:
- 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 nhim khun pht hin cu
khun Gram-dng: Cho oxacilin hoc nafcilin 2g mi 6 gi mt ln (8g/ngy),
hoc clindamycin ng tnh mch 2,4g/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.
- 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 v ht t phi 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):
B Y t | NHIM KHUN HT T PHI 211

+ 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 (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 ng tnh mch mi 4h trong 2 tun.
+ Nhim khun do H. influenzae v S. pneumoniae khng penicilin:
Ceftriaxon 1-2g mt ln/ngy, hoc cefotaxim 1g 3 ln/ngy trong 2 tun.
+ Phn ln cc nhim vi khun Gram-m ng rut: Khng sinh th h 2
hoc 3 dng ng tnh mch trong 3-4 tun, hoc thuc nhm fluoroquinolon
nh levofloxacin 500mg ng tnh mch hoc ung mi 24h.
+ Nu nhim khun trc khun m xanh cn phi hp ceftazidim (hoc
vi mezlocilin) vi khng sinh nhm aminoglycosid nh trn.
b) Cc bin php khc c th phi hp vi iu tr khng sinh:
- Ra sch vng tn thng ti ch bng nc mui sinh l hoc dung
dch iod pha long; sau c th p gc tm dung dch mui natri clorua 10%
va c tc dng chng nhim khun, va to iu kin mc t chc ht ti ch.
- Thc hin tiu phu thut rch rng tn thng, lm sch cc t chc
tinh th urt lng ng, ly b t chc nhim khun khi c km nhim khun
phn mm ln cn.
- Phu thut loi b t chc sn, xng khi c nhim khun sn khp hay
xng km theo.
- iu tr khng ch cn gt cp v khi cn gt cp n nh cho cc thuc
h acid uric mu, m bo h acid uric mu xung di 350 mol/l.
- Nng cao th trng.
5. D PHNG
- Phng v iu tr tt bnh gt, trnh bnh chuyn giai on mn tnh
c ht t phi hoc ht t phi to ra.
- Khi c ht t phi, c bit nhng v tr d c xt cn phng chng
nguy c lot bng cch i giy dp mm, trnh gy r, v; nu cn c th ct ht
t phi d phng nu to, d v hoc v tr hay c xt (bn, ngn chn).
- Thc hin v trng tuyt i khi lm cc th thut, phu thut tin hnh
gn v tr ht t phi. iu tr tt cc nhim khun ti cc c quan khc, c bit
ti da, phn mm v xng.

B Y t | NHIM KHUN HT T PHI 212

TI LIU THAM KHO


1. Trn Thu Giang, Nguyn Th Ngc Lan, Nguyn Th Ngc Mai. c im lm sng, cn
lm sng nhim khun ht t phi ngi bnhngi bnh gt ti khoa C Xng Khp bnh
vin Bch Mai. Tp ch Ni khoa Vit Nam, s thng 10/2013, trang 169-174.
2. Trn Thu Giang, Nguyn Th Ngc Lan, Nguyn Th Ngc Mai. Nhn xt thc trng iu
tr nhim khun ht t phi ngi bnhngi bnh gt ti khoa C Xng Khp bnh vin
Bch Mai. Tp ch Ni khoa Vit Nam, s thng 10/2013, trang 175-181.
3. K.H.Yu, S.F.Luo, L.B.Liou, Y.J.Wu, W.P.Tsai, J.Y.Chen, H.H.Ho, Concommitant septic
and gouty arthritis- an analysis of 30 cases. Rheumatology 2003; 42: 1062-1066.

B Y t | NHIM KHUN HT T PHI 213

B Y t | NHIM KHUN HT T PHI 214

Chng VII. Nhim khun sn ph


khoa v cc bnh ly truyn qua
ng tnh dc

B Y t | 215

B Y t | 216

S DNG KHNG SINH TRONG


D PHNG SN KHOA
1. I CNG
- Khng sinh d phng l s dng khng sinh phng trnh nhim
khun ti v tr phu thut. Khng sinh d phng cng c ngha l khc vi vic
s dng khng sinh iu tr sm cc nhim khun c.
- Ch nh: p dng cho cc th thut c nguy c r rng s nhim khun.
- Chng ch nh: Cc tn thng bn, cc bnh ni khoa khng c
kim sot, cc dp nt m khng ct lc c tt.
- Nguyn l ca khng sinh d phng trong m ly thai l lm gim s
lng vi khun hin din ti thi im phu thut v mc m h min dch c
th vt qua c. Cc th thut sn khoa hay gp thng ngy l: M ly thai,
th thut, kim sot t cung bng tay, vt rch tng sinh mn
2. CC TH THUT SN KHOA C CN NHC DNG KHNG
SINH
a) M ly thai
- Yu t nguy c quan trng nht i vi nhim khun hu sn l m ly
thai. M ly thai lm tng nguy c nng ln t 5 - 20 ln so vi ng m
o. Mt nghin cu ca CDC cho thy nhim khun vt m ly thai n 30
ngy sau m l 8,9%.
- Cc nhim khun sau m ly thai bao gm: vim nim mc t cung,
vim ng tit niu, nhim khun vt m. Vic s dng khng sinh d phng
c chng minh lm gim nguy c nhim khun cc ca m ly thai. Vic
dng khng sinh d phng cng c hiu qu nh vic dng khng sinh a liu
iu tr trn nhm ngi bnhngi bnh c la chn. Li ch khc ca khng
sinh d phng trong m ly thai l tit kim chi ph v rt ngn thi gian nm
vin.
- Nhiu tc gi la chn thi im tim sau khi kp dy rn v lo s khng
sinh vo mu ca tr s sinh c th gy ra mt s bt li. Nhng t c
nng khng sinh ti v tr vt m trc khi rch da th cn tim khng sinh d
phng trc 30 pht. Trong mt nghin cu i vi cefazolin cho thy tim
khng sinh trc khi rch da lm gim nguy c nhim khun cho m hn l sau
khi kp dy rn nhng khng c bt li cho thai.
- La chn khng sinh: Khng sinh c ph bao ph c cc chng
thng gp khi phu thut vng chu (lin cu, trc khun ng rut, t cu v
cc loi vi khun k kh).
b) th thut
B Y t | S DNG KHNG SINH TRONG 217
D PHNG SN KHOA

- Tng quan ca Cochrane 2004 cho thy khng c s khc bit v t l


vim nim mc t cung v thi gian nm vin gia nhm dng khng sinh d
phng v khng iu tr, khng c s d liu khuyn co dng khng sinh
d phng sau th thut.
c) Kim sot t cung
- WHO gi nn dng khng sinh d phng sau kim sot bung t cung
nhng khng c bng chng c th no v gi tr ca vic dng khng sinh d
phng cho cc trng hp ny.
d) Rch tng sinh mn III v IV
- Mt nghin cu th nghim ngu nhin cng b nm 2008 cho thy tim
tnh mch liu duy nht cefotetan, cefoxitin lm gim t l nhim khun vt
thng r rt (8% so vi 24%). Kt qu ny gi li ch ca vic dng khng
sinh d phng lm gim bin chng nhim khun vt thng.
- Liu ca khng sinh d phng i vi ngi bo ph: Vi ngi c BMI
> 35, dng liu khng sinh gp i so vi nhng ngi c BMI < 35.
3. S DNG KHNG SINH D PHNG
- i vi m ly thai: Cn pht hin v iu tr cc nhim khun m o
nh: Bacterial vaginosis, Chlamydia trc.
- Khng sinh cefazolin 1g tnh mch trc khi rch da 15 - 30 pht, ngi
nng 80kg th dng 2g cefazolin.
TI LIU THAM KHO
1. Therapeutic guidelines: Antibiotic. Therapeutic Guidelines Limited 2010. version14.
2. Hng dn iu tr tp II BYT 2006.
3. Julie Van Schalkwyk, el Antibiotic prophylaxis in obstetric procedure. SCOG Clinical
Practice Guideline. No 247, september 2010.

B Y t | S DNG KHNG SINH TRONG 218


D PHNG SN KHOA

NHIM TRNG NNG DO SN KHOA


1. I CNG
- Nhim khun hu sn l mt trong nm tai bin sn khoa nguy him
thng gp, c bit cc ni c trnh v c s vt cht yu km. S xut
hin ca khng sinh v s ra i cc dng v th h khng sinh mi gp phn
lm gim bt cc hu qu ca n. Tuy nhin cc nhim khun nng vn cn v
l nguyn nhn d dn n t vong m nu khng chn on v iu tr kp thi.
- Nguyn nhn ca cc nhim khun sn khoa gm: St rau, nhim khun
i, th thut trong t cung khng m bo v khun...
- Cc th thut sn khoa c th gy nhim khun nng nh: Sy thai, sau
, m ly thai.
- Vi khun gy bnh hay gp: E. coli, S. aureus, S. pyogenes,
C. perfungeus, C. seuclellii...
- Nhim khun hu sn c th gy ra cc tnh trng nhim khun nng bao
gm: Vim t cung ton b, nhim khun mu, vim phc mc...
2. TRIU CHNG
a) Vim t cung ton b
- L bin chng ca vim nim mc t cung hoc b sn dch.
- St cao, mt mi, kh chu.
- Sn dch t hoc khng c. Khi nn t cung c sn dch chy ra thi, en
(c bit ngy th 8, th 10).
- Nn t cung au.
- Tin trin thnh vim phc mc, nhim khun huyt.
b) Vim phc mc ton b
- Xy ra sau vim nim mc t cung, vim t cung ton b, vim phc
mc tiu khung hay vim phn ph.
- Thi gian: Sau hoc m 7 10 ngy.
- Ton thn: Du hiu nhim khun, nhim c.
- Nn, au khp bng: Tc rut hoc bn tc rut.
- a chy phn khm.
- Thc th: Bng chng, phn ng phc mc.
- Cn lm sng: X-quang bng khng chun b c hnh nh mc nc
hi.

B Y t | NHIM TRNG NNG DO SN KHOA 219

- Tin lng: Chn on v m sm th tin lng tt, nu m chm th


tin lng xu v c th t vong.
c) Nhim khun huyt
- Th pht sau nhim khun hu sn ch yu t vng rau bm t cung.
- Ton thn: St cao lin tc hoc dao ng hoc ko di, mt mi, suy
sp, l . C th sc, hn m, thiu niu, kh th, vng da.
- Sn dch hi, c mu v m. T cung to, co hi chm v n au.
- Gan lch to, bng chng
- Chn on xc nh: Cy mu (lc st cao), cy sn dch t bung t
cung, cy nc tiu.
- Hng cu gim, bch cu tng cao hoc gim.
- Tin lng nng, nguy c t vong cao.
3. IU TR
3.1. Nguyn tc
- Cy mu, cy sn dch v cy nc tiu trc khi iu tr khng sinh.
- Khng sinh phi hp ph rng khi cha c khng sinh . Nu c khng
sinh th iu tr theo khng sinh .
- B dch.
- S dng vn mch nu huyt p h khng phc hi sau khi b dch.
- Th oxy.
- Gii quyt nhim khun.
3.2. S dng khng sinh
a) Phi hp 3 loi khng sinh:
- Ceftriaxon 1g tnh mch/ 24 gi.
- Azithromycin 500mg tnh mch/ 24 gi.
- Metronidazol 500mg tnh mch/ 12 gi.
b) Nu d ng penicilin:
- Phi hp thuc:
+ Gentamicin tnh mch 4 6mg/kg cho liu u tin, liu tip theo da
vo thanh thi ca thn.
+ Clindamycin 600mg tnh mch/8 gi.
- Hoc phi hp thuc:

B Y t | NHIM TRNG NNG DO SN KHOA 220

+ 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.

B Y t | NHIM TRNG NNG DO SN KHOA 221

VIM M O NIU O DO VI KHUN


1. I CNG
- Vim m o (vaginitis) l bnh thng gp nht trong cc vim nhim
ng sinh dc ph n. Bnh tc ng nhiu n i sng v sinh hot ca
ngi ph n v li nhiu di chng v bin chng nh hng n kh nng
sinh sn v cc vn sc khe lu di. Do cu trc v gii phu niu o gn
vi m o nn cc tc nhn gy bnh t m o d xm nhp vo niu o v
gy vim niu o.
- Tc nhn gy vim m o - niu o c th c nhiu loi: vi khun, k
sinh trng v virus. Vim m o - niu o do vi khun thng gp nht l
N. gonorrhoeae sau l C. trachomatis v M. genitalism. Ngoi ra him gp
do tc nhn vi khun thng thng.
- C nhiu loi vi khun gy vim m o v cng to ra cc hnh thi
bnh khc nhau v cch chn on v iu tr cng khc nhau.
2. CC LOI VIM M O NIU O DO VI KHUN
2.1. Vim m o do tp khun
a) Tc nhn:
- Thng gp t cu vng gy bnh, E. coli, cc trc khun Gram-m, lin
cu tan huyt v cc vi khun ng rut.
- Hay gp ngi mn kinh hoc tr gi trc dy th hoc ph n b
ct hai bung trng.
b) Lm sng:
- m h vim, , nga, sung huyt.
- Kh h vng nh m, c th ln t mu.
- m o sung huyt, .
c) Cn lm sng: Xt nghim kh h:
- pH > 5
- Kh h nhiu bch cu a nhn.
- Nhum Gram khng thy tc nhn gy bnh c hiu.
- Cy kh h xc nh vi khun gy bnh.
d) iu tr:
- Nn xt nghim tm nguyn nhn v iu tr theo khng sinh .
2.2. Vim m o do Bacterial vaginosis
a) Tc nhn:
B Y t | VIM M O NIU O DO VI KHUN 222

- L loi vim m o do cc vi khun k kh: Mobiluncus, Mycoplasma


hominis, Bacteroide species, G. vagiralis.
b) Lm sng:
- Kh h nhiu, long mu trng hoc xm, mi hi kh chu c bit sau
giao hp.
- Nga v kh chu m h - m o.
c) Cn lm sng: soi ti kh h.
- pH m o > 4,5.
- Test sniff (+).
- Clue cells chim 20% t bo biu m m o.
d) iu tr:
- S dng cc khng sinh sau:
+ Metronidazol 400mg ung/12h x 07 ngy.
+ Hoc gel metronidazol 0,75% bi m o trc lc ng x 5 ngy.
+ Hoc gel clindamycin 2% bi m o trc lc ng x 7 ngy.
- Vi ph n c thai:
+ Clindamycin 300mg ung/12h x 7 ngy.
+ Hoc gel clindamycin 2% bi m o trc lc ng x 7 ngy.
2.3. Vim m o - niu o do Chlamydia, lu v M. genitalium
a) Tc nhn:
- Chlamydia.
- Lu (N. gonorrhoeae).
- M. genitalium.
b) Lm sng:
- Tit dch niu o.
- i but, i kh, ra mu.
- Nga rt m o, au khi giao hp, kh h nhiu v hi.
- Vim c t cung.
c) Cn lm sng: Bnh phm dch tit l niu o, c t cung.
- i vi Chlamydia:
+ Bng phn ng min dch chn on Chlamydia nhanh l n gin, r
tin, cho kt qu nhanh v chnh xc.
B Y t | VIM M O NIU O DO VI KHUN 223

+ 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.

B Y t | VIM M O NIU O DO VI KHUN 224

BNH GIANG MAI


1. I CNG
Bnh giang mai (Syphilis) l bnh ly truyn qua ng tnh dc do xon
khun nht, tn l Treponema pallidum gy nn. Bnh c th gy thng tn
da-nim mc v nhiu t chc, c quan ca c th nh c, xng khp, tim
mch v thn kinh. Bnh ly truyn ch yu qua quan h tnh dc v c th ly
truyn qua ng mu, ly truyn t m sang con. Bnh c th gy hu qu trm
trng nh giang mai thn kinh, giang mai tim mch, giang mai bm sinh.
1.1. Dch t hc bnh:
- Theo c tnh ca T chc Y t Th gii (WHO) hng nm khu vc
chu - Thi Bnh Dng c trn 35 triu trng hp mi mc cc nhim
khun ly truyn qua ng tnh dc (NTLQTD) trong giang mai chim
2%.
- Vit Nam: Thi k Php tm chim, bnh giang mai ng hng th 2
sau bnh lu. Sau 1954, min Bc bt u tin hnh cng cuc phng
chng bnh hoa liu, t l bnh gim mnh v n 1964 bnh c xu hng c
thanh ton. T 1965, do chin tranh, sinh hot x hi c nhiu xo trn v bin
ng nn cc bnh hoa liu li tng ln. c bit t nm 1975 sau khi gii phng
min Nam, thng nht t nc bnh tng r rt do s giao lu hai min. Theo
thng k hng nm, bnh giang mai chim khong 2 - 5% tng s NTLQTD.
1.2. Tc nhn gy bnh:
- Bnh gy nn do xon khun nht c tn khoa hc l Treponema
pallidum do hai nh khoa hc l Schaudinn v Hoffman tm ra nm 1905. y l
mt loi xon khun hnh l xo c t 6 - 14 vng xon, ng knh khng qu
0,5m, di t 6 - 15m. Xon khun c th c 3 kiu di ng: Di ng theo trc
dc gip xon khun tin hoc li, di ng qua li nh qu lc ng h v di
ng ln sng.
- Xon khun giang mai rt yu, ra ngoi c th ch sng c vi gi,
cht nhanh chng ni kh; ni m t c th sng c hai ngy. N c th
sng rt lu nhit lnh. 56oC cht trong vng 15 pht. Nhit thch hp
l 37oC. X phng v cc cht st khun c th dit c xon khun trong vi
pht.
1.3. Cch ly truyn:
- Xon khun xm nhp vo c th ngi lnh qua giao hp ng m
o, ng hu mn hoc ng ming. Ngoi ra bnh c th ly gin tip qua
cc dng, vt dng b nhim xon trng. Ly qua cc vt xc trn da nim
mc khi thy thuc tip xc m khng c bo him. Ly do truyn mu: truyn

B Y t | BNH GIANG MAI 225

mu hoc tim chch m bm kim tim khng v khun. Ly t m sang con,


thng sau thng th 3 ca thai k v gy bnh giang mai bm sinh.
1.4. Phn loi: c th chia bnh giang mai thnh hai loi.
a) Giang mai mc phi (acquired syphilis): Mc bnh do quan h tnh dc vi
ngi bnh, gm cc thi k sau:
- Giang mai mi v ly ( 2 nm), gm:
+ Giang mai thi k I: Thi gian bnh khong 3-4 tun v din bin
trong 2-3 thng.
+ Giang mai thi k II s pht v ti pht: Vi biu hin l o ban giang
mai, mng nim mc v sau c th xut hin nhng thng tn giang mai
thm nhim su hn vo da. Cc t pht xen k vi cc t n bnh. Thng
din bin trong 2 nm.
+ Giang mai kn sm: Cc thng tn giang mai bin mt, khng c triu
chng thc th v c nng. Thi gian thng trong vng hai nm u.
- Giang mai mun v khng ly (> 2 nm): Thng xut hin t nm th
ba tr i, gm cc giai on:
+ Giang mai kn mun: Trn da khng c thng tn, c th ko di vi
thng hay rt nhiu nm (c th 10 - 20 nm hoc lu hn). Ch pht hin bng
phn ng huyt thanh hoc c khi ra mt em b b giang mai bm sinh th
ngi m mi c pht hin ra mc bnh.
+ Giang mai thi k III: Xut hin c th hng chc nm sau mc bnh.
Thng tn n su vo t chc di da, nim mc; c quan vn ng (c,
xng, khp); ph tng nh tim mch v thn kinh.
b) Giang mai bm sinh (Congenital syphilis)
- Giang mai bm sinh sm: Xut hin trong hai nm u sau khi sinh. Cc
thng tn ging nh giang mai mc phi thi k II.
- Giang mai bm sinh mun: Xut hin t nm th 2 sau khi sinh. Thng
tn ging giang mai thi k III.
- Di chng ca giang mai bm sinh: Gm cc so, d hnh nh trn d,
trn do + mi tt to thnh yn nga, xng chy cong li kim, tam chng
Hutchinson (rng Hutchinson, ic nht thi, lc quy t) do thai nhi mc
giang mai t trong bo thai.
2. CC BIU HIN LM SNG
2.1. Giang mai thi k I
a) Sng (chancre)
- Thng tn n c, s lng thng ch c mt, xut hin ngay ti ni
xon khun xm nhp vo c th. Sng giang mai thng xut hin khong 3 - 4
B Y t | BNH GIANG MAI 226

tun (t 10 90 ngy) sau ly nhim. Sng c c im: L vt trt nng, ch


mt mt phn thng b, hnh trn hay bu dc, khng c b ni g ln hoc
lm xung, b mt bng phng, mu tht ti. Nn ca sng giang mai
thng rn, cng nh t ba, l c im quan trng gip phn bit cc vt
trt khc. Sng giang mai khng nga, khng au, khng c m, khng iu tr
cng t khi. Thng km theo vim hch vng ln cn. V tr khu tr: Sng
thng thy b phn sinh dc (> 90% cc trng hp).
+ n gii: Sng thng xut hin mi ln, mi b, mp sau m h, l
niu o, c t cung.
+ nam gii: Sng thng quy u, rnh quy u, thn dng vt,
ming so, dy hm, bu, xng mu, bn. Vi nhng ngi quan h tnh dc qua
hu mn, sng c th trc trng hoc quanh hu mn. Sng cn c th xut
hin mt s v tr khc nh: mi, li, amidan (do quan h ming - sinh dc),
khoeo chn, ngn tay (thng n h sinh), trn, v v.v
b) Hch:
- Vi ngy sau khi c sng b phn sinh dc, cc hch vng bn thng
b vim, hp thnh chm trong c mt hch to hn cc hch khc gi l
"hch cha". Hch rn, khng au, khng ha m, khng dnh vo nhau v vo
t chc xung quanh, di ng d.
- Nu khng c iu tr, 75% cc trng hp c sng s t khi sau 6 8 tun lm ngi bnh tng khi bnh. Tuy nhin, khi xon khun vn
tn ti trong c th v c th truyn bnh sang ngi khc. Nu c iu tr
ng v y th bnh c th khi hon ton giai on ny m khng chuyn
sang giai on tip theo.
2.2. Giang mai thi k II
- Thi k th II bt u khong 6 - 8 tun sau khi c sng. y l giai
on xon khun vo mu v i n tt c cc c quan trong c th nn thng
tn c tnh cht lan trn, n nng hi ht trn mt da, c rt nhiu xon khun
trn thng tn nn thi k ny rt ly, nguy him nhiu cho x hi hn l bn
thn ngi bnhngi bnh. Bnh tin trin thnh nhiu t, dai dng t 1 - 2
nm. Cc phn ng huyt thanh trong giai on ny dng tnh rt mnh.
- Giang mai thi k II c th chia thnh: giang mai thi k II s pht v
giang mai thi k II ti pht.
a) Giang mai II s pht: C cc triu chng sau
- o ban (Roseole): L nhng vt mu hng ti nh cnh o, bng
phng vi mt da, hnh bu dc, s lng c th t hoc nhiu. S mm, khng
thm nhim, khng nga, khng au. Khu tr ch yu hai bn mng sn,
mt, lng bn tay/chn. o ban xut hin da u gy rng tc. o ban tn
ti mt thi gian khng iu tr g cng mt i li vt nhim sc t loang l.
B Y t | BNH GIANG MAI 227

- Mng nim mc: L vt trt rt nng ca nim mc, khng c b, c th


nh bng ht hay ng xu. B mt thng trt t, i khi hi ni cao, sn
si hoc nt n ng vy tit, cha nhiu xon khun nn rt ly. V tr thng
gp cc nim mc mp, l mi, hu mn, m h, rnh quy u.
- Vt loang trng en: L nhng di tch cn li ca o ban, sn to thnh
cc vt loang trng en loang l. Nu thng tn tp trung c th gi l "vng
v n".
- Vim hch lan ta: C th thy hch bn, nch, c, di hm, rng
rc. Hch to nh khng u, khng au, khng dnh vo nhau. Trong hch c
nhiu xon khun.
- Nhc u: Thng hay xy ra v ban m.
- Rng tc: Rng u, lm tc b tha dn, cn gi l rng tc kiu "rng
tha".
b) Giang mai II ti pht
- Thi k ny bt u khong thng th 4 n thng 12 k t khi mc
giang mai I. Cc triu chng ca giang mai II s pht tn ti trong mt thi gian
ri li mt i cho d khng iu tr. Qua mt thi gian im lng li pht ra cc
thng tn da, nim mc. chnh l giang mai thi k II ti pht. S lng
thng tn t hn, nhng tn ti dai dng hn.
- Cc thng tn giang mai II ti pht: o ban ti pht vi t vt hn,
nhng kch thc mi vt li to hn, khu tr vo mt vng v hay sp xp thnh
hnh vng. Sn giang mai: Trn cc vng da khc nhau, xut hin nhng sn, ni
cao hn mt da, rn chc, mu hng, hnh bn cu, xung quanh c vin vy,
l cc sn giang mai. Cc sn giang mai rt a dng v hnh thi: sn dng
vy nn, dng trng c, dng thy u, dng lot Cc sn thng to hn bnh
thng, c chn b rng, b mt phng v t, c khi xp thnh vng xung
quanh hu mn, m h. Cc sn ny cha rt nhiu xon khun v rt ly c
gi l sn ph i hay sn si. lng bn tay, bn chn cc sn giang mai c b
mt phng, bong vy da hoc dy sng, bong vy theo hng ly tm nn thng
to thnh vin vy mng xung quanh, gi l "vin vy Biette".
- Biu hin khc ca giang mai thi k II: C th thy vim mng mt,
vim gan, vim hng khn ting, vim mng xng, au nhc xng c i v
m, vim thn, biu hin thn kinh (au, nhc u).
2.3. Giang mai thi k III
- Thi k ny thng bt u vo nm th 3 ca bnh. Ngy nay t gp
giang mai thi k III v ngi bnh thng c pht hin v iu tr sm bng
penicilin. thi k ny thng tn c tnh cht khu tr, mang tnh ph hy t
chc, gy nn nhng di chng khng hi phc, thm ch t vong cho ngi
bnhngi bnh. i vi x hi, thi k ny t nguy him v kh nng ly lan
trong cng ng b hn ch. Cc thng tn giang mai III:
B Y t | BNH GIANG MAI 228

+ o ban giang mai III: L nhng vt mu hng, sp xp thnh nhiu


vng cung, tin trin rt chm, t khi, khng li so.
+ C giang mai: Thng tn trung b, ni ln thnh hnh bn cu c
ng knh khong 5 - 20mm, ging nh ht xanh. Cc c c th ng ring
r hoc tp trung thnh m, nhng thng sp xp thnh hnh nhn, hnh cung
hoc vn vo. Cng c khi lot ra v ng vy tit en.
+ Gm giang mai (Gomme): Gm giang mai l thng tn c trng ca
giang mai thi k III. Gm l mt thng tn chc h b, tin trin qua 4 giai
on: Bt u l nhng cc trng di da s ging nh hch, dn dn cc cc
ny to ra, mm dn v v chy ra dch tnh ging nh nha cao su to thnh vt
lot v vt lot dn dn ln da non ri thnh so. Gm c th nhiu hoc t v c
th khu tr vo bt k ch no. V tr thng gp l mt, da u, mng, i, mt
ngoi phn trn cng chn, v.v nim mc, v tr thng thng l ming,
mi, vm ming, li, mi, hu
- Nu khng c iu tr cc thng tn ca giang mai III c th pht ra
lin tip ht ch ny n ch khc v dai dng hng nm. ng thi c th xm
nhp vo ph tng, khi v ra gy ph hy t chc, tn ph cho ngi bnhngi
bnh.
- Ngoi thng tn da/nim mc, giang mai thi k III cng thng khu
tr vo ph tng nh:
+ Tim mch: Gy phnh ng mch, h ng mch ch.
+ Mt: Vim cng mc, vim mng mt.
+ Thn kinh: Vim mng no cp. Gm mng no, ty sng gy t lit.
2.4. Giang mai bm sinh
Trc y quan nim l giang mai di truyn. Hin nay, ngi ta xc nh
giang mai khng phi l bnh di truyn m do m mc bnh giang mai ly cho
thai nhi. S ly truyn thng xy ra t thng th 4- 5 ca thai k, do mng rau
thai mng i, mu m d dng trao i vi mu thai nhi, nh vy xon khun
giang mai s xm nhp vo thai nhi qua rau thai ri gy bnh. Nh vy, ngi
cha khng th truyn bnh trc tip cho thai nhi c m phi thng qua bnh
giang mai ca ngi m. Ty theo mc nhim xon khun t ngi m vo
bo thai m c th xy ra cc trng hp sau: c th sy thai hoc thai cht lu,
tr non v c th t vong. Nu nhim xon khun nh hn na, em b mi
sinh ra trng c v bnh thng, sau vi ngy hoc 6 - 8 tun l thy xut hin
cc thng tn giang mai, khi gi l giang mai bm sinh sm. Giang mai
bm sinh c th xut hin mun hn khi tr trn 2 tui, khi 5 - 6 tui hoc ln
hn gi l giang mai bm sinh mun.
- Giang mai bm sinh sm: thng xut hin trong 2 nm u, nhng
thng gp nht vn l 3 thng u. Cc biu hin thng mang tnh cht ca
giang mai thi k th II mc phi ngi ln. C th c cc triu chng sau:
B Y t | BNH GIANG MAI 229

Phng nc lng bn tay/chn, thng gp hn l triu chng bong vy lng


bn tay, chn, s mi, kht kht mi, vim xng sn, gi lit Parrot: thng
trong 6 thng u ca tr sau sinh, c th gp chng vim xng sn cc
xng di vi cc biu hin: xng to, au cc u xng lm tr ngi vn ng
cc chi, v vy gi l "gi lit Parrot". Ton thn: Tr ra nh hn bnh
thng, da nhn nheo nh ng gi, bng to, tun hon bng h, gan to, lch to.
Tr c th st cn nhanh, cht bt thnh lnh.
- Giang mai bm sinh mun: Xut hin sau 3 - 4 nm hoc khi
trng thnh. Cc triu chng ca giang mai bm sinh mun thng mang tnh
cht ca giang mai thi k th III mc phi ngi ln. Cc triu chng thng
gp l: Vim gic mc k: thng xut hin lc dy th, bt u bng cc triu
chng nhc mt, s nh sng mt bn, v sau c hai bn. C th dn n m.
Lc quy t. ic c hai tai bt u t 10 tui, thng km theo vim gic mc
k. Cng c khi trn lm sng, ngi ta khng pht hin c cc du hiu ca
giang mai bm sinh sm, giang mai bm sinh mun m ch thy thng vm
ming, mi tt, trn d, xng chy li kim... y chnh l cc di chng ca
giang mai bm sinh do cc thng tn giang mai bo thai lin so li.
3. CHN ON GIANG MAI
3.1. Chn on xc nh
- Khai thc tin s.
- Lm sng: theo cc giai on.
- Xt nghim.
3.2. Cc xt nghim
a) Tm xon khun: cc thng tn nh sng, mng nim mc, sn hoc hch.
C th soi tm xon khun trn knh hin vi nn en thy xon khun giang mai
di dng l xo, di ng hoc nhum thm bc Fontana Tribondeau.
b) Cc phn ng huyt thanh
- Phn ng khng c hiu: Khng th l mt khng th khng Lipid
khng c hiu c tn l Reagin. RPR (Rapid Plasma Reagin), VDRL (Venereal
Disease Research Laboratory). Hin nay phn ng RPR hoc VDRL thng s
dng v cc u im:
+ Phn ng dng tnh sm.
+ K thut n gin nn c th s dng nh phn ng sng lc, lng ghp
khm sc khe hng lot.
+ L phn ng khng c hiu nhng c gi tr chn on.
- Cc phn ng c hiu: Khng nguyn l xon khun gy bnh giang
mai, khng th c hiu. T.P.I (Treponema Pallidum Immobilisation's Test):
phn ng bt ng xon khun. F.T.A (Fluorescent Treponema Antibody's Test):
B Y t | BNH GIANG MAI 230

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:

B Y t | BNH GIANG MAI 231

- Benzathin penicilin G: Tng liu 4.800.000 v tim bp su, trong 2


tun lin tip. Mi tun tim 2.400.000 v, 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.
* Nu d ng vi penicilin th thay th bng: tetracyclin 2g/ngy x 15
ngy hoc erythromycin 2g/ngy x 15 ngy.
c) iu tr giang mai II ti pht, ph n c thai, giang mai III, giang mai kn
mun, giang mai bm sinh mun ngi ln: p dng mt trong ba phc
theo th t u tin:
- Benzathin penicilin G: Tng liu 9.600.000 v, tim bp su trong 4
tun lin tip. Mi tun tim 2.400.000 v, chia lm 2, mi bn mng 1.200.000
v, hoc
- Penicilin Procain G: Tng liu 30.000.000 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.
* Nu ngi bnhngi bnh d ng vi penicilin c th thay th bng
tetracyclin 2 - 3g/ngy trong 15 - 20 ngy. Ph n c thai dng erythromycin 2 3 g/ngy trong 15 - 20 ngy.
d) iu tr giang mai bm sinh:
- i vi giang mai bm sinh sm (tr 2 tui)
+ Nu dch no ty bnh thng: Benzathin penicilin G 50.000 v/kg cn
nng, tim bp liu duy nht.
+ Nu dch no ty bt thng: Benzyl penicilin G 50.000 v/kg cn nng
tim tnh mch hoc tim bp 2 ln/ngy trong 10 ngy hoc procain penicilin G
50.000 v/kg cn nng tim bp trong 10 ngy.
- i vi giang mai mun (tr > 2 tui): Benzyl penicilin G 20.000 30.000 v/kg/ngy tim tnh mch hoc tim bp chia 2 ln, trong 14 ngy.
* Nu ngi bnhngi bnh d ng vi penicilin: Erythromycin 7,5 12,5mg/kg, ung 4 ln/ngy trong 30 ngy.
Lu :

B Y t | BNH GIANG MAI 232

- iu tr c hiu qu khi nh lng hiu gi khng th sau iu tr gim


xung.
- Xt nghim li RPR nn c tin hnh vo thng th 3, 6 v 12 sau khi
hon thnh iu tr.
- Phn ln cc trng hp giang mai c HIV s p ng tt vi phc
iu tr chun.
5. PHNG BNH
- Tuyn truyn, gio dc y t cho cng ng thy c nguyn nhn, cch
ly truyn, bin chng v cch phng bnh.
- Tp hun chuyn mn cho cc bc s a khoa, chuyn khoa da liu v
sn ph khoa khng ch n mc ti a lu mt tr s sinh.
- Hng dn tnh dc an ton: Chung thy mt v, mt chng. Tnh dc
khng xm nhp. S dng bao cao su khi quan h tnh dc: Dng ng cch v
thng xuyn, c bit cc i tng c nguy c cao nh gi mi dm, "khch
lng chi". Thc hin chng trnh 100% s dng bao cao su khi quan h tnh
dc vi i tng gi mi dm.
T VIT TT TRONG BI
NTLQTD

Nhim khun ly truyn qua ng tnh dc

RPR

Rapid Plasma Reagin

VDRL

Veneral Disease Research Laboratory

TPI

Treponema Pallidum Immobilisation's Test (phn ng bt ng xon khun)

FTA

Flourescent Treponema Antibody's Test (Phn ng min dch hunh quang


c trit ht)

FTAabs

Flourescent Treponema Antibody Absortion's Test

TPHA

Treponema Pallidum Hemagglutination's Assay

n v
TI LIU THAM KHO

1. Kenneth A.Katz. (2012) Fitzpatricks Dermatology in general medecine Mc Graw Hill


Eight Edition volume 2 pp. 2471-2492.
2. King K, Homes.P, Frederick Saprling et al. (2012), Sexually Transmetted Diseases, Mc
Graw Hill, Fourth Edition, pp. 627-545.
3. Miguel Sanchez,(2010), Syphilis, Treatment of skin diseases, Saunders Elsevier, Third
Edition pp. 730-735.

B Y t | BNH GIANG MAI 233

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

B Y t | BNH GIANG MAI 234

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

- bnh trung bnh 3 - 5 ngy, c th sm nht l 1 ngy, chm nht l 2


tun. Thi gian ny ngi bnh d khng c triu chng g nhng vn c kh
nng ly lan cho ngi khc.
- Triu chng lm sng:
+ Biu hin sm nht l cm gic kh chu dc niu o km i rt.
+ M c th t chy ra hoc i tiu ra m.
+ i but, i rt.
+ Ming so, quy u vim , c m chy ra t nhin hoc chy ra khi
vut dc t gc dng vt.
+ Ton thn: c th st, mt mi.
b) Lu mn tnh:
- Thng do lu cp khng c iu tr hoc iu tr khng ng. Biu
hin lm sng thng kh nhn bit lm ngi bnh khng bit mnh b bnh.
- C th thy cc triu chng sau:
+ C git m vo bui sng khi cha i tiu gi l "git m ban mai".
+ i but khng r rng. Ngi bnhNgi bnh c cm gic nng rt,
dm dt dc niu o.
+ i rt do vim niu o sau.
+ C th c cc bin chng nh vim mo tinh hon, vim tinh hon,
vim tuyn tin lit, vim ti tinh
3.2. Bnh lu n
a) Lu cp: Thi k bnh n thng ko di hn, trung bnh 5 - 7 ngy.
Biu hin lm sng thng m thm khng r rng. Khm b phn sinh dc
thy: M m h, l niu o vim c th c m chy ra, cc l tuyn
Skne, Bartholin . C t cung vim c m nhy mu vng hoc vng xanh.
b) Lu mn: Triu chng ngho nn. Ra "kh h" ging bt c vim nhim no
b phn sinh dc. Tuy nhin, c th a n nhiu bin chng nh: Vim
nim mc t cung, p xe phn ph, vim tc vi trng, vim vng h chu c
th gy v sinh, cha ngoi t cung.
3.3. Lu mt s v tr khc
- Lu hu hng: do quan h sinh dc - ming, biu hin lm sng l au
hng, nga hng. Khm thy hng , c m, vim hng cp hoc mn, c th
km gi mc.
- Lu hu mn - trc trng nam do quan h sinh dc - hu mn. n
gii c th do quan h tnh dc qua hu mn hoc do m chy t m h xung

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

+ Hoc erythromycin 500mg x 4 ln/ngy x 7 ngy.


+ Hoc clarithromycin 250mg x 2 ln/ngy x 7 ngy.
- Khng dng doxycyclin v tetracyclin cho ph n c thai v cho con b,
tr di 7 tui.
- iu tr bn tnh ging nh iu tr cho ngi bnhngi bnh
b) Lu mn
- C bin chng sinh dc tit niu: Ceftriaxon 1g/ngy x 5 - 7 ngy. Phi
hp vi iu tr Chlamydia nh phc trn.
- C bin chng nhim lu ton thn, vim mng no cn cho ngi
bnhngi bnh nm iu tr ni tr. Ceftriaxon 1 - 2 g/ngy. Tim bp hoc
tnh mch x 10 - 14 ngy. Phi hp vi iu tr Chlamydia nh phc trn.
- Lu mt tr s sinh: Ceftriaxon 50mg/kg tim bp liu duy nht, ti a
khng qu 125mg. Ra mt bng nc mui sinh l. iu tr lu cho b m.
Phng nga lu mt tr s sinh: ra sch mt tr ngay sau khi . Nh mt
bng dung dch nitrat bc 1%.
5. PHNG BNH
- Tuyn truyn, gio dc y t cho cng ng thy c nguyn nhn, cch
ly truyn, bin chng v cch phng bnh.
- Tp hun chuyn mn cho cc bc s a khoa, chuyn khoa da liu v
sn ph khoa khng ch n mc ti a lu mt tr s sinh.
- Hng dn tnh dc an ton: Chung thy mt v, mt chng. Tnh dc
khng xm nhp. S dng bao cao su khi quan h tnh dc: dng ng cch v
thng xuyn, c bit cc i tng c nguy c cao nh gi mi dm, "khch
lng chi". Thc hin chng trnh 100% s dng bao cao su khi quan h tnh
dc vi i tng gi mi dm.
TI LIU THAM KHO
1. King K, Homes.P, Frederick Saprling et al. (2012), Sexually Transmetted Diseases, Mc
Graw Hill, Fourth Edition.
2. Patrice Morel,(2010), Gonorrhea, Treatment of skin diseases, Saunders Elsevier, Third
Edition pp. 268-270
3. 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.
4. Sexually Transmetted Diseases guideline (2010) CDC Vol. 59/N0 RR-12, pp. 49-55.
5. Ted Rosen. (2012) Fitzpatricks Dermatology in general medecine Mc Graw Hill Eight
Edition volume 2 pp. 2514-2519.

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

nhng v v t nhin. M c snh nh kem, nam b nhiu hn n. T l ngi


bnhngi bnh b sng hch bn khong 1/3.
- Triu chng ton thn c th st nh, mt mi. Tuy vy, H. ducreyi
khng gy nhim khun ton thn hoc ly truyn sang cc c quan xa. Bi
nhim cc vi khun k kh c th gy lot hoi th v ph hu c quan sinh dc.
Trn nhng ngi bnhngi bnh HIV/AIDS th vt lot ln hn, lu lnh hn
v t b vim hch bch huyt nng nh ngi bnh thng.
- Bnh h cam khng thy gy bnh cho tr s sinh d ngi m ang b
bnh.
- Tin trin: Vt lot tin trin tt sau 1 tun iu tr, hch bn khi chm
hn. Do c mt t l nht nh (khong 10-15%) ngi bnhngi bnh ng
thi mc c giang mai, hoc herpes v h cam nn cn xt nghim huyt thanh
trong vng 3 thng. Cn xt nghim HIV cho ngi bnhngi bnh v ging
nh cc bnh c lot sinh dc, kh nng ly truyn HIV rt cao.
b) Xt nghim
- Bnh phm ly y vt lot.
+ Nhum Gram, trc khun bt mu Gram-m ging nh n c bi
nhng kh nhn bit do ln nhiu vi khun khc.
+ Nui cy trn mi trng thch giu dinh dng c hemoglobin v
huyt thanh. Vi khun mc sau 2-4 ngy, c th n 7 ngy.
+ PCR: l xt nghim mi c nhy v c hiu cao.
4. IU TR
- Hin nay, trc khun h cam khng li mt s thuc nh ampicilin,
sulfamid, chloramphenicol, tetracyclin, kanamycin, streptomycin, ciprofloxacin,
erythromycin v co-trimoxazol.
- Cc thuc c khuyn co iu tr hin nay:
+ Ceftriaxon 250mg tim bp liu duy nht.
+ Hoc azithromycin 1g liu duy nht.
+ Hoc spectinomycin 2g tim bp liu duy nht.
+ Hoc erythromycin 500mg ung 4 ln/ ngy trong 7 ngy.
- Bnh thng sau 2-3 ngy iu tr v khi sau khong 1 tun. Hch
bn sng thng khi chm hn, c th phi chc ht qua da lnh ht m
trong hch.
- Cc phc trn cng p dng iu tr cho ngi bnhngi bnh c
phi hp nhim HIV, tuy nhin thi gian iu tr thng lu hn v tht bi iu
tr c th xy ra vi tt c cc loi thuc.

B Y t | BNH H CAM 240

- Xt nghim HIV v giang mai cn c lm ngay, nu kt qu m tnh


cn cho xt nghim li sau 3 thng.
5. PHNG BNH
- Tuyn truyn, gio dc y t cho cng ng thy c nguyn nhn, cch
ly truyn, bin chng v cch phng bnh.
- Tp hun chuyn mn cho cc bc s a khoa, chuyn khoa da liu v
sn ph khoa khng ch n mc ti a lu mt tr s sinh.
- Hng dn tnh dc an ton: Chung thy mt v, mt chng. Tnh dc
khng xm nhp. S dng bao cao su khi quan h tnh dc: dng ng cch v
thng xuyn, c bit cc i tng c nguy c cao nh gi mi dm, "khch
lng chi". Thc hin chng trnh 100% s dng bao cao su khi quan h tnh
dc vi i tng gi mi dm.

TI LIU THAM KHO


1. King K, Homes.P, Frederick Saprling et al. (2012), Sexually Transmetted Diseases, Mc
Graw Hill, Fourth Edition.
2. Patricia A Henry, Glenn c Newell,(2010), Chancroid, Treatment of skin diseases, Saunders
Elsevier, Third Edition pp. 135-136
3. 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.
4. Sexually Transmetted Diseases guideline (2010) CDC Vol. 59/N0 RR-12, pp. 19-20
5. Stephan Lautenschlager. (2012) Fitzpatricks Dermatology in general medicine Mc Graw
Hill Eight Edition volume 2 pp. 2501- 2509.

B Y t | BNH H CAM 241

B Y t | BNH H CAM 242

Chng VIII. Nhim khun mt

B Y t | 243

B Y t | 244

Cc cu trc ca mt c lin quan n


cc bnh l nhim khun

(Tuyn Zeis)
(Tuyn sn mi)

Hnh II-1. Cc cu trc ca mt c lin quan n

B Y t | Cc cu trc ca mt c lin quan n 245


cc bnh l nhim khun

S DNG KHNG SINH TRONG NHN KHOA


Nhn chung, mi khuyn co p dng cho khng sinh ton thn cng p
dng cho khng sinh dng trong nhn khoa.
im khc bit khi s dng khng sinh trong nhn khoa so vi trong cc
bnh l khc ch yu lin quan n ng dng thuc. V iu m mi nh
nhn khoa u quan tm khi s dng khng sinh l c im ca khng sinh
trong mt v kh nng thm ca khng sinh vo cc t chc nhn cu.
1. NG DNG KHNG SINH TRONG NHN KHOA
Khuyn co chung v la chn ng dng khng sinh trong nhn khoa:
- u tin iu tr bng ng tra mt
- Ch khi iu tr bng ng tra mt km hiu qu, hoc i vi nhim
khun nng, cn phi hp thm phng php truyn ra ti mt, tim ti mt
hoc cc phng php iu tr ton thn. [1]
1.1. iu tr ti ch
iu tr ti ch bao gm: Tra thuc ti mt, tim ti mt, truyn ra ti
mt.
1.1.1. Tra thuc ti mt:
a) Ch nh: iu tr cc nhim khun ti mt.
b) u nhc im:
- u im:
+ Khng sinh tp trung ch yu ti mt, t hp thu vo tun hon nn hn
ch c tc dng ph ton thn.
+ Thun tin, d s dng, ngi bnh c th t s dng ti nh theo s
hng dn ca thy thuc.
- Nhc im:
+ Thuc nhanh chng b ra tri, c bit vi thuc tra mt dng lng.
+ Mt s khng sinh kh vt qua c hng ro sinh l tip cn t
chc b vim.
c) 2 dng thuc tra mt khng sinh thng gp:
- Thuc tra mt dng lng: phi dng nhiu ln trong ngy v khng nn
chp mt nhiu sau khi tra thuc. i vi thuc dng dch treo, khi s dng
phi lc u l thuc bo m cc thnh phn thuc c a vo mt.

B Y t | S DNG KHNG SINH TRONG NHN KHOA 246

- Thuc m: c thi gian tn ti mt di hn v kh nng thm qua gic


mc cao hn so vi thuc nc nn c th gim tn sut dng thuc, thng
c dng vo trc khi i ng. [1,2]
d) Cc khng sinh tan trong lipid (nh cloramphenicol, cc tetracyclin, cc
fluoroquinolon) d dng xm nhp biu m gic mc hn cc khng sinh tan
trong nc. [4]
e) Nu phi phi hp nhiu loi thuc tra mt th cn tra cc thuc dng lng
trc, thuc dng m sau. Cc thuc tra cch nhau t nht 5 pht trnh s ra
tri. [4]
1.1.2. Tim ti mt:
a) Ch nh
Phi hp vi ng tra mt nhm a lng khng sinh nhiu hn vo v
tr nhim khun trong mt.
b) u nhc im
- u im: c th t nng cao ca khng sinh ti v tr nhim khun.
- Nhc im: c th xy ra nhiu bin chng hn.
c) Cc phng php tim ti mt
- Tim di kt mc:
+ iu tr cc bnh phn trc ca nhn cu v cng c p dng khi
kt thc cuc m chng vim ni nhn. Mt s loi thuc khng thm c
vo nhn cu qua con ng tra mt, khi c tim di kt mc c th khuch
tn vo mt qua vng ra gic mc hoc cng mc.
+ Lng thuc dng tim di kt mc khong 0,25ml n 1ml.
- Tim cnh nhn cu:
+ Phng php ny c bit hu ch vi cc thuc t tan trong lipid (nh
penicilin), khng thm vo t chc nhn cu nu dng ng tra mt.
+ C th tim lidocain trc hoc cng lc vi tim khng sinh gim
kh chu cho ngi bnhngi bnh. Thuc t khng lm gim hot lc ca
thuc khng sinh.
- Tim trong tin phng: Dng trong nhng trng hp vim mng b
o nng, nhim khun ni nhn hoc trong phu thut. [1,2]
- Tim trong dch knh:
+ a thuc trc tip vo trong nhn cu iu tr nhim khun ni
nhn nng.

B Y t | S DNG KHNG SINH TRONG NHN KHOA 247

+ Lng thuc c dng rt nh (0,1 0,2ml), vi nng thp v nng


cao s rt c cho thy tinh th v vng mc (nng cho tng loi thuc
c da trn cc nghin cu lm sng c th)
+ C th tim lp li sau 48 72 gi, ty theo p ng lm sng. [2,5]
1.1.3. Phng php truyn ra ti mt
p dng cho mt s trng hp nhim khun nng (chng hn vim lot
gic mc do trc khun m xanh), a khng sinh vo mt c lin tc, ra
tri cc cht hoi t v vi khun gy bnh. [1]
1.2. iu tr ton thn (ung, tim bp, tim tnh mch...)
- Ch nh:
+ c p dng khi thuc tra km hiu qu, i vi cc nhim khun
nng hoc bnh mt c cn nguyn ton thn.
+ p dng i vi cc thuc c kh nng xm nhp tt qua hng ro
mu - mt khi dng ton thn.
+ iu tr cc cc nhim khun trong hc mt hoc phn ph ca mt (mi
mt, tuyn l v ng l mi) v hng ro mu - mt khng tn ti cc cu trc
ny, do cc khng sinh dng ton thn s d dng tip cn vi cc v tr vim.
- Nhc im:
+ Thuc vo mt rt t do b cn tr bi hng ro mu mt
+ Tc dng ph nhiu v nng hn so vi khi dng ng tra mt.
- Kh nng xm nhp ca thuc qua hng ro mu - mt ph thuc vo:
+ Kh nng tan trong lipid: Cc thuc d tan trong lipid d dng i qua c
hng ro mu - mt. V d: Cloramphenicol, d tan trong lipid, thm gp 20 ln so
vi penicilin, l thuc t tan trong lipid. Fluoroquinolon xm nhp tt qua hng ro
mu - mt.
+ Nng thuc lin kt vi protein huyt tng: Ch dng t do, thuc
mi i qua c hng ro mu mt. V d: Cc sulfonamid tan trong lipid nhng
kh nng xm nhp km do lin kt cao vi protein huyt tng (trn 90%). [3]
+ Tnh trng vim ca mt: mt nhim khun, hng ro mu mt b
ph v, cc khng sinh c th vo mt c d dng hn khi dng theo ng
ton thn. [5]
- iu tr ton thn bao gm:
+ ng ung
+ Tim bp: c dng khi c bnh l ti cc m mm hoc cc m c nhiu
mch nh tim khng sinh iu tr cc vim mi, hc mt, mng b o...

B Y t | S DNG KHNG SINH TRONG NHN KHOA 248

+ 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

- t gy c vi biu m gic mc hn so vi khng sinh aminoglycosid


(ngoi tr ciprofloxacin gy lng ng trng trn gic mc)
- Kh nng thm qua gic mc tt khi dng ng tra mt (nng
ofloxacin trong thy dch cao hn so vi cc thuc khc), kh nng xm nhp
qua hng ro mu mt tt khi dng ng ton thn.
- Ch phm: Trn th trng c lu hnh cc ch phm dung dch, m tra
mt ofloxacin 0,3%; dung dch tra mt ciprofloxacin 0,3%, levofloxacin 0,5%,
moxifloxacin 0,5%, gatifloxacin 0,3%... [2,3]
2.7. Cc macrolid
- Erythromycin
+ Ph tc dng: Ph rng nhng u th trn vi khun Gram dng, tu
tc nhn m c tc dng dit khun hoc km khun.
+ C th a thuc theo ng ung hoc tra mt song kh nng thm
qua hng ro mu mt km. Thng c ch nh iu tr cc nhim khun
mn tnh mi mt hoc dng thay th tetracyclin trong trng hp ngi
bnhngi bnh d ng vi tetracyclin hoc tr em, c bit c tc dng iu tr
trong bnh mt ht v vim kt mc do Chlamydia.
+ Ch phm: vin bao phim tan trong rut hoc dng ester ha, thuc m
tra mt. [2,3]
- Azithromycin:
+ iu tr mt ht ngi ln, vim kt mc do Chlamydia,...
+ Ch phm: Khng c ch phm dng tra mt. [2]
2.8. Cc khng sinh khc
- Vancomycin:
+ Ph tc dng: Hiu lc rt mnh trn vi khun Gram dng.
+ Dng iu tr cc nhim khun ngi bnhngi bnh b d ng hoc
khng p ng vi khng sinh nhm penicilin hoc cephalosporin v iu tr cc
t cu khng methicillin.
+ Ch phm: trn th trng khng c ch phm tra mt, trn lm sng,
i khi s dng thuc tim vancomycin pha thnh dung dch tra mt vi nng
50 mg/ml trong iu tr vim gic mc nhim khun, 5 mg/ml iu tr vim
kt mc mi mt do t cu nhy cm; bt pha tim 500mg, 1g. [2,3]
- Polymyxin B
+ Ph tc dng: l khng sinh dit khun, vi khun Gram m nhy cm
bao gm Enterobacter, Klebsiella, P. aeruginosa...
+ Dng tra mt hoc tim mt iu tr lot gic mc.
B Y t | S DNG KHNG SINH TRONG NHN KHOA 251

+ 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.

B Y t | S DNG KHNG SINH TRONG NHN KHOA 252

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

VIM GIC MC DO VI KHUN


1. NH NGHA
Vim gic mc do vi khun (bacterial keratitis) l hin tng thm nhim
t bo vim trn gic mc do vi khun, c th gy hoi t mt t chc gic mc.
y l mt nguyn nhn thng gp gy m lo.
2. NGUYN NHN
Cc loi vi khun thng gp gy vim lot gic mc:
- Vi khun Gram-dng: T cu (Staphylococcus aureus), ph cu
(Steptococcus pneumoniae), Staphylococcus epidermidis, Mycobacterium,
Nocardia
- Vi khun Gram-m: Trc khun m xanh (Pseudomonas aeruginosa),
Moraxella, Trc khun cm (Hemophilus influenzae)
3. TRIU CHNG
a) Lm sng
- Triu chng c nng:
+ au nhc mt, cm chi, s nh sng, chy nc mt.
+ Nhn m hn, c th ch cm nhn c nh sng.
- Triu chng thc th:
+ Kt mc cng t ra.
+ Trn gic mc c mt lot ranh gii khng r, y lot thng ph
mt lp hoi t bn. Khi nhum gic mc bng fluorescein 2% lot s bt mu
xanh, nu lot hoi t nhiu s c mu vng xanh.
+ Gic mc xung quanh lot b thm lu.
+ Mng mt cng c th b ph n, mt sc bng. ng t thng co nh,
c th dnh vo mt trc th thu tinh, tuy nhin kh quan st.
b) Cn lm sng
Ly bnh phm l cht no lot lm cc xt nghim sau:
- Soi ti: Thy c vi khun.
- Soi trc tip: Xc nh vi khun Gram-dng hay Gram-m.
- Nui cy vi khun: Xc nh c cc loi vi khun gy bnh: T cu,
lin cu, trc khun m xanh... Nu c iu kin c th kt hp lm khng sinh
xc nh khng sinh iu tr ph hp.

B Y t | VIM GIC MC DO VI KHUN 258

4. IU TR BNG KHNG SINH


a) Nguyn tc chung
- Cn phi tm c vi khun gy bnh v iu tr bng khng sinh nhy
cm vi loi vi khun (da vo khng sinh ), nu khng xc nh c loi
vi khun gy bnh cn phi dng khng sinh ph rng.
- iu tr bng thuc tra mt l chnh, c th kt hp vi dng ng ton
thn.
- Phi hp iu tr triu chng v bin chng.
b) iu tr c th
- Thuc tra mt:
+ Nu do vi khun Gram-m: Dng tobramycin, neomycin sulfat,
polymyxin B.
+ Nu do vi khun Gram-dng: Dng nhm fluoroquinolon th h 2
(ofloxacin) hoc th h 3 (levofloxacin) hoc th h 4 (moxifloxacin,
gatifloxacin). Nhm ny c ph khng khun rng nn c th dng iu tr c vi
khun Gram-m.
+ Cch dng: Ngy u c th tra mt lin tc cch nhau 30 pht, nhng
ngy sau tra mt 10 ln/ ngy.
- Thuc ung: C th dng mt trong cc loi khng sinh sau:
+ Cefuroxim acetil 250 mg ngy ung 2-3 vin chia 2 ln, trong 5-7 ngy.
+ Ofloxacin 0,2 g ngy ung 2 vin chia 2 ln, trong 5-7 ngy.
Trng hp nng c th dng phi hp 2 nhm thuc.
- Truyn ra mt lin tc trong nhng trng hp nng bng khng sinh +
ringerlactat: Thng dng: Gentamicin 80 mg x 2 ng pha vi 100 ml ringer
lactat truyn ra mt 1-2 ln/ngy.
5. D PHNG
- Lun gi gn mt sch s, trnh nhng chn thng vo mt.
- Khi b chn thng trn gic mc cn phi pht hin v iu tr kp thi
bng cc thuc st khun tra mt phng bin chng vim lot gic mc do vi
khun.
- Cn phi iu tr cc bnh mt l yu t thun li gy vim lot gic
mc: lng qum, lng xiu, h mi

B Y t | VIM GIC MC DO VI KHUN 259

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

+ TI: Vim mt ht mch-thm nhim.


Kt mc sn mi trn thm nhim, dy . Thm nhim che m trn na h
mch mu kt mc sn.
+ TS: So kt mc.
So trn kt mc, cc on x trng nh, di so, hnh sao, hnh mng
li.
+ TT: Qum, lng xiu.
C t nht mt lng mi c vo nhn cu hoc c bng chng ngi
bnhngi bnh mi nh lng xiu.
+ CO: So gic mc
So c trn gic mc che lp mt phn hay ton b ng t.
+ Giai on TF, TI: L giai on mt ht hot tnh, c kh nng ly lan.
+ Giai on TS, TT, CO: L giai on mt ht di chng.
b) Cn lm sng
- Chn on t bo hc: Chch ht hoc no nh kt mc sn mi trn
lm t bo hc c th thy:
+ CPH (+).
+ T bo lympho cc c (non, nh, gi).
+ i thc bo Leber.
+ Thoi ha ca t bo.
- Nui cy Chlamydia mt ht: C th nui cy Chlamydia trong ti lng
trng hoc cy vo cc t bo.
4. IU TR BNG KHNG SINH
- Ch dng trong giai on bnh mt ht hot tnh.
- Cn iu tr cho ngi bnhngi bnh v c gia nh ca ngi
bnhngi bnh b mt ht hot tnh.
- Thuc tra mt: Thuc m: M Tetracyclin 1% bui ti trc khi i ng
lin tc trong 6 tun.
- Thuc ung: Azithromycin: Ung 1 liu duy nht, ung 1 ln/nm, ung
1 ln mi ngy, ung 1 gi trc ba n hoc 2 gi sau khi n.
+ Liu lng:
Ngi ln trn 16 tui: 1 ln 1g (4 vin 0,25g)/nm x 2 nm.
Tr em t 1- 4 tui: 20mg/1 kg cn nng (ung thuc nc).
Tr em t 5-15 tui: 20mg/1kg cn nng (ung thuc vin).
B Y t | BNH MT HT 261

+ 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

- Xut hin au t ngt, au vng hc mt.


- au khi vn ng nhn cu, lic mt, au u, mt mi, st
- Mi ph.
- Ph kt mc v sung huyt kt mc.
- Li mt: Li mt c th li thng trc hoc khng thng trc.
- Song th.
- Sp mi.
- Hn ch vn nhn hoc lit vn nhn.
- Gim th lc nhiu mc khc nhau, nu vim gn nh hc mt c th
c gim th lc trm trng.
- C th c vim hc mc hoc vim th thn kinh.
- C th tng nhn p do chn p.
- Nhng triu chng h hp hay xoang.
b) Cn lm sng
- Chp XQ hoc chp CT: Hnh nh vim t chc hc mt, hnh nh vim
xoang. C th thy hnh nh vim xoang vi nhng xng v mng xng y
v pha hc mt.
- Hnh nh p-xe cnh mng xng: in hnh trn CT l hnh nh tn
thng cnh xoang m, c b xung quanh mm mi v c th c kh bn trong.
- Trong trng hp chn thng c th xc nh c d vt hc mt.
- Siu m: C gi tr trong mt s trng hp chn on xc nh v chn
on phn bit nh c vin dch quanh nhn cu.
- Cng thc mu: Bch cu a nhn trung tnh tng cao, CRP tng trong
nhim khun.
- Ly bnh phm hc mt hoc m p-xe lm xt nghim soi ti,
soi trc tip, nui cy vi khun chn on nguyn nhn v iu tr.
- Ly bnh phm xoang hay vng mi hng.
- Cy mu nu nghi ng hoc c nhim khun huyt.
4. IU TR BNG KHNG SINH
a) Nguyn tc chung:
- Phi iu tr cp cu vim t chc hc mt cp tnh phng bin
chng vim mng no, tc xoang hang v nhim khun huyt.
- Ngi bnhNgi bnh phi c iu tr cp cu tch cc.
B Y t | VIM T CHC HC MT 264

- iu tr theo khng sinh .


- Tm cc vim phi hp nh vim xoang, vim ng h hp trn
iu tr.
b) iu tr c th
- Khng sinh ng tnh mch liu cao, ph rng trong giai on sm v
khng sinh c hiu sau khi nui cy phn lp c vi khun.
- Trong thi gian ch i nui cy vi khun c th dng khng sinh ph
rng nh: [1,2,4]
+ Nhm cephalosporin th h 3: Cefotaxim 2g ( tr em: 50mg/kg cn
nng) ng tnh mch 3 ln/ ngy (8 ting 1 ln) hay ceftazidim 1g ( tr em
30-50 mg/kg cn nng) ng tnh mch 3 ln/ngy.
+ Hoc phi hp ceftriaxon 2g ( tr em: 50 mg/kg cn nng) ng tnh
mch/ngy phi hp vi di/flucloxacilin 2g (tr em: 50mg/kg cn nng) ng
tnh mch 4 ln/ngy (6 ting 1 ln)
+ Tip theo: Amoxicilin-clavulanat 875 + 125 mg (tr em: 22,5 + 3,2
mg/kg) ng ung, ngy 2 ln trong 10 ngy.
+ i vi nhng trng hp ngi bnhngi bnh b qu mn vi
penicilin hay nghi ng hoc nui cy c khng methicilin th cn hi chn vi
cc chuyn khoa nh ly, vi sinh.
+ Nhm glycopeptid (vancomycin) 1g truyn tnh mch chm 12h/ln.
tr em: 10 mg/kg truyn tnh mch chm 12h/ln.
- Khi xc nh c nguyn nhn v c nui cy vi khun v khng sinh
th iu tr theo nguyn nhn v theo khng sinh .
+ Chng vim: Steroid ng ung v ng tnh mch: Methyl
prednisolon 1mg/kg cn nng
+ iu tr phi hp nhng trng hp vim xoang, vim ng h hp,
i tho ng.
+ iu tr ngoi khoa: Khi xc nh c p-xe: Chch dn lu pxe v xoang vim. Nu do nguyn nhn chn thng c d vt hc mt phi ly
ht d vt.
5. D PHNG
- iu tr nhng vim nhim ca mi, vim phn trc vch phng lan vo
t chc hc mt.
- Phng nhng bnh nh h hp, vim xoang tr em. Khi tr mc bnh
cn c iu tr v theo di cn thn nhng bin chng khng xy ra.

B Y t | VIM T CHC HC MT 265

- Theo di v iu tr tt nhng ngi c bnh mn tnh nh i tho


ng, vim xoang, vim rng
- Khi c vim t chc hc mt phng cc bin chng xy ra.
TI LIU THAM KHO
1. Buchanan MA., Muen W, Heinz P., (2012) Management of periorbital and orbital
cellulitis, Paediatrics and Child Health, Volume 22, Issue 2, February 2012, Pages 72-77
2. Meara D.J (2012) Sinonasal Disease and Orbital Cellulitis in Children, Oral and
Maxillofacial Surgery Clinics of North America, Volume 24, Issue 3, August 2012, Pages
487-496.
3. Decock C, Claerhout I, Kestelyn P, Van Aken EH., (2010) Orbital cellulitis as
complication of endophthalmitis after cataract surgery . J Cataract Refract Surg.
Apr;36(4):673-5.
4. Jack Rootman., (2003) Diseases of the Orbit: A Multidisciplinary Approach Wolters
Kluwer Health: page 473.
5. Jimmy D . Bartlett, Siret D. Jaanus ., (2008) ., Clinical Ocular Pharmacology book.,
Elsevier Health Sciences: page 183.
6. Lee S., Yen MT., (2011) Management of preseptal and orbital cellulitis, Saudi Journal
of Ophthalmology, Volume 25, Issue 1, January-March 2011, Pages 21-29
7. Vairaktaris E, et al (2009) Orbital cellulitis, orbital subperiosteal and intraorbital
abscess. Report of three cases and review of the literature Journal of Cranio-Maxillofacial
Surgery, Volume 37, Issue 3, April 2009, Pages 132-136

B Y t | VIM T CHC HC MT 266

VIM M NI NHN SAU VT THNG XUYN


NHN CU
1. I CNG
Vim m ni nhn (VMNN) (Endophthalmitis due to penetrating ocular
trauma) l tnh trng vim ca cc khoang ni nhn (dch knh hay thy dch)
thng do nhim khun. Khi tnh trng vim khng ch dng cc cu trc ni
nhn m lan ra tt c cc lp v ca nhn cu gi l vim ton nhn.
2. NGUYN NHN
Tc nhn gy bnh qua vt thng xuyn nhn cu c th l vi khun, k
sinh trng, nm hay virus. Tc nhn gy bnh xm nhp qua vt thng nhn
cu h gy nn tnh trng VMNN.
3. TRIU CHNG
Ngi bnhNgi bnh c tin s b chn thng.
3.1. Lm sng:
au mt, au quanh vng h mt. Gim th lc nhanh. S nh sng, au
u, bun nn. Mi mt sng ph. Nhn cu c th li. Nhn p c th tng. Kt
mc ph n, cng t mnh. Gic mc ph, thm nhim vim, ta sau gic mc,
hoc p xe gic mc. Tin phng c Tyndall, xut tit hoc m. ng t gin km
hoc khng gin vi Atropin, mt phn x trc tip vi nh sng. Mt nh hng
ng t. Dch knh vn c, c m, hoc c bng kh. Vng mc c xut tit hay
hoi t. Ton thn c th st, mt mi
3.2. Cn lm sng:
- Xt nghim vi sinh: Ly bnh phm ni nhn bao gm thy dch hay dch
knh lm soi ti, soi trc tip, nui cy vi khun v khng sinh .
- Siu m: Siu m B cho php nh gi tnh trng dch knh vng mc,
xc nh s tn ti ca d vt ni nhn v gip cho vic theo di v iu tr bnh.
- Chp X-quang, chp CT scanner hc mt: gip xc nh d vt ni nhn.
4. IU TR BNG KHNG SINH
- iu tr VMNN sau vt thng xuyn nhn cu l s phi hp ca 3
khu: khng sinh, corticoid v ct dch knh.
- Khng sinh c ch nh ngay khi bt u nghi ng c VMNN. La
chn khng sinh theo khng sinh l tt nht nhng khng sinh ch c c
sau vi ngy (nu c th) dn ti vic iu tr mun. V vy thng bt u iu
tr vi khng sinh ph rng hay phi hp khng sinh. t c hiu qu iu
tr, khng sinh phi c kh nng thm tt vo bung dch knh vi nng tiu
B Y t | VIM M NI NHN SAU VT THNG 267
XUYN NHN CU

dit c mm bnh m khng gy c cho cc m ni nhn. ng dng: ton


thn (tim, ung), tim ni nhn, tim cnh nhn cu, tim di kt mc, tra ti
ch. Trong , tim khng sinh ni nhn l cch dng hiu qu nht.
4.1. Cc loi khng sinh dit vi khun
a) Vancomycin: tc dng tt trn cc vi khun Gram-dng.
- i vi ngi ln: Vancomycin tra ti ch: 50mg/ml, tra mt 1 gi/1
ln; tim ni nhn: 1mg/0,1ml; Tim di kt mc hoc tim cnh nhn cu: 25
mg/0,5 ml. Vancomycin liu ton thn: Truyn tnh mch chm liu duy nht
25mg/kg n 1,5g (TE<12 tui: 30mg/kg n 1,5g).
- i vi tr em: Vancomycin tra ti ch, tim ni nhn, tim di kt
mc hoc cnh nhn cu: Liu nh ngi ln. Vancomycin liu ton thn:
Truyn tnh mch chm TE<12 tui: 30mg/kg n 1,5g/ngy chia lm nhiu ln.
b) Ceftazidim: L khng sinh u tay tim ni nhn trn cc vi khun Gramm.
- i vi ngi ln: Ceftazidim tra ti ch: 50mg/ml, tra mt 1 gi/1 ln;
tim ni nhn: 2,25mg/0,1ml; Tim di kt mc hoc tim cnh nhn cu: 100
mg/0,5 ml. Ceftazidim liu ton thn: Truyn tnh mch chm 500mg, 1g hay 2g
c mi 12 gi.
- i vi tr em: Ceftazidim tra ti ch, tim ni nhn, tim di kt mc
hoc cnh nhn cu: Liu nh ngi ln. Ceftazidim liu ton thn: Liu thng
thng cho tr em trn 2 thng tui l 30-100mg/kg/ngy chia lm 2-3 ln.
c) Amikacin: L khng sinh thng c la chn th 2 sau ceftazidim tim
ni nhn chng li cc vi khun Gram-m, c bit l i vi cc chng khng
gentamicin v tobramycin. c bit, amikacin c tc dng tt trn trc khun
m xanh.
- i vi ngi ln: Amikacin tra ti ch: 8mg/ml, tra mt 1 gi/1 ln;
tim ni nhn: 0,4 mg/0,1ml; liu ton thn: truyn tnh mch chm
15mg/kg/ngy chia 2-3 ln trong ngy.
- i vi tr em (tr tr s sinh v tr non): Liu nh ngi ln.
d) Ciprofloxacin: Fluoroquinolon c tc dng trn Pseudomonas, lin cu, t
cu da v t cu khng methicilin v hu ht cc loi vi khun Gram-m khc
nhng khng c tc dng i vi cc loi vi khun k kh.
- i vi ngi ln: Ciprofloxacin tra ti ch 4 ln/ngy cho n 1 gi/ 1
ln. Ciprofloxacin liu ton thn: ung 500mg - 750 mg liu duy nht (TE:
20mg/kg n 750mg)
- i vi tr em: liu ton thn ung 20mg/kg/ngy n 750mg/ngy.
4.2. Cc loi khng sinh chng nm
B Y t | VIM M NI NHN SAU VT THNG 268
XUYN NHN CU

a) Khng sinh chng nm thuc nhm polyen: Amphotericin B. Thuc c tc


dng tt vi Candida, Cryptococcus v cc chng Aspergillus. Kh nng ngm
ni nhn ca thuc rt km khi thuc c dng theo ng ton thn.
- i vi ngi ln: Amphotericin B tim ni nhn vi liu 5-10 g.
- i vi tr em: Khng c ghi nhn.
b) Khng sinh chng nm thuc nhm Imidazol:
- Fluconazol: Thuc c tc dng tt chng Candida, Cryptococcus v cc
chng Aspergillus. Thm ni nhn tt khi dng ng ton thn.
+ i vi ngi ln: Liu tn cng 400 mg/ 1 ln/ 1 ngy. Liu duy tr
200 mg/1 ln/ ngy
+ i vi tr em: Liu tn cng 12 mg/ kg/ 1 ln/ 1 ngy. Liu duy tr
6mg/ kg/1 ln/ ngy.
Tng liu: khng vt qu 600 mg/ ngy.
- Ketoconazol: L khng sinh chng nm c tc dng chng li
Blastomyces, Dermatitidis, C. immitis, Candida v cc chng Fusarium. Bn
cnh thuc cng c mt vi tc ng chng li cc chng Aspergillus.
+ i vi ngi ln: Ung 200 mg - 400 mg/ ngy chia 1-2 ln.
+ i vi tr em: Di 2 tui: khng c ch nh. Trn 2 tui: 3,3-6,6
mg/kg/ngy chia 1-2 ln.
- Itraconazol:
+ i vi ngi ln: Liu ung 200mg 400mg/1 ln/ngy
+ i vi tr em: Khng c ghi nhn
- Voriconazol: c s dng iu tr ban u cho cc trng hp
nhim nm Aspergillus v cc trng hp nhim khun do Fusarium hoc
Scedosporium apiospermum.
+ i vi ngi ln: Liu tn cng: Truyn tnh mch chm trong vng 2
gi 6mg/kg/12 gi trong 24 gi u tin. Liu duy tr: Truyn tnh mch chm
trong vng 2 gi 4mg/kg/12 gi ri chuyn sang ung 200 mg/ 12 gi. i vi
ngi di 40kg, liu duy tr trung bnh l 100 mg - 150 mg/ 12 gi.
+ i vi tr em: Di 12 tui: Khng c ghi nhn. Trn 12 tui: Liu
nh ngi ln tuy cc s liu bo co cn rt hn ch.
5. D PHNG
Khu ng vt thng cng sm cng tt. S dng khng sinh liu cao,
ph rng ngay sau khi b chn thng. i vi cc vt thng c nguy c gy
VMNN cao nh ngi bnhngi bnh n mun sau 24 gi, c d vt ni nhn,
B Y t | VIM M NI NHN SAU VT THNG 269
XUYN NHN CU

c c v th thy tinh, vt thng ln hn 8mmc th tim khng sinh ni


nhn d phng.
TI LIU THAM KHO
1. Ferenc Kuhn, (2008), Ocular trauma. Chapter 2.17 : Endophthalmitis. Pages 437-448.
Springer.
2. Dave E. L., (2003), Ophthalmic care of the combat casualty. Chapter 17: Posttraumatic
endophthalmitis. Pages 281-290. Texbooks of military medicine. Published by the Office of
the surgeon general department of the army-United State of America.
3. Englander M., Chen T.C., Paschalis E.L., Miller J.W., Kim I.K., Intravitreal injections at
the Massachusetts Eye and Ear infirmary: analysis of treatment indications and postinjection
endophthalmitis rates. Br. J. Ophthalmol., Apr 2013; 97 (4), pages 460-465.
4. Faghihi H., Hajizadeh F., Esfahani M.R., et al., Posttraumatic endophthalmitis: Report No
2. Retina. (2012); 32 (1). Pages 146-151.

B Y t | VIM M NI NHN SAU VT THNG 270


XUYN NHN CU

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

Gi v sinh mi, trnh tip xc vi mi trng bi v nhim. Sau khi tip


xc vi mi trng bi bn nn tra ra mt bng dung dch NaCl 0,9%, lau sch
tit t v bi bm b mi v chn lng mi.

B Y t | VIM B MI DO VI KHUN 272

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

Thng thng, cc trng hp vim ti l c th c chn on d dng


da vo cc triu chng lm sng m khng cn n cc xt nghim chn on
khc. Tuy nhin trong mt s trng hp, chp phim ct lp vng ti l v hc
mt s cho thy r hnh nh ti l b vim hay u ti l.
4. IU TR BNG KHNG SINH
- iu tr bng khng sinh c p dng cho cc trng hp vim ti l
cp gii quyt tnh trng nhim khun cp tnh. Tt nht l ly m t ti l
nui cy, tm tc nhn gy bnh v dng khng sinh theo kt qu khng sinh .
Nu khng c khng sinh , c th dng cc khng sinh ph rng ti mt v
ton thn.
- Ti mt:
Tra khng sinh moxifloxacin nh mt 6 8 ln/ngy. C th dng cc
khng sinh quinolon khc nh gatifloxacin, levofloxacin.
- Ton thn:
+ Ung cefuroxim 500 1000mg/ngy ty theo mc vim nng hay
nh. Vi tr em, dng liu 15mg/kg cn nng, ung 2 ln/ngy, vi tng liu
khng qu 500mg/ngy.
+ C th dng: Amoxicilin-clavulanat: ngi ln ung 1 vin
500mg/125mg (amoxicilin-clavulanat) x 3 ln/ngy. Tr em dng liu 40 - 80
mg/kg/ngy, chia 3 ln/ngy.
+ Thi gian dng khng sinh t 7 -10 ngy ty theo mc p ng
khng sinh v mc nhim khun cp tnh.
- Cc iu tr phi hp: C th phi chch tho m ti l, gim ph n,
gim au.
- Sau khi qua t vim cp, bnh chuyn sang trng thi vim mn tnh.
iu tr cc trng hp vim ti l mn tnh, cn phi lm cho ng l
thng sang mi bng bm thng l o hoc m ni thng ti l mi. Nu khng
khi, cn phi ct ti l loi tr hon ton vim ti l mn tnh.
5. D PHNG
iu tr sm cc trng hp tc ng l mi l bin php c hiu qu
phng vim ti l mn. Cc trng hp vim ti l mn c iu tr sm th s
trnh c bin chng vim ti l cp.

B Y t | VIM TI L 274

TI LIU THAM KHO


1. Alain Ducasse, J.-P.Adenis, B.Fayet, J.-L.George, J.-M. Ruban (2006) Les voies
lacrymale", Masson.
2. Jeffrey Jay Hurwitz (1996); The Lacrimal System. Lippincott-Raven Publisher.
3. Jack J. Kanski, Clinical Ophthalmology (2008), Third edition.
4. J. Royer, J.P. Adenis, (1982), Lappareil lacrymal, Masson.
5. Jane Olver (2002) : Colour Atlas of Lacrimal Surgery. Elsevier.

B Y t | VIM TI L 275

B Y t | 276

Chng IX. Vim mng no

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

- S lng bch cu v t l bch cu trung tnh tng, c th c bch cu


a nhn thoi ha.
- Protein tng (>1g/l), Glucose < 2,2 mmol/l; Glucose DNT/mu < 0,3
mmol/l.
- Xc nh vi khun: Da vo nhum Gram (dng tnh 60 - 90%), cy,
PCR.
c) Xt nghim h tr chn on: XQ phi, chp CT v MRI s no, cy mu,
sinh ha mu v cc xt nghim khc ty thuc vo c a (bnh km theo...).
4. IU TR
4.1. Nguyn tc iu tr
- iu tr khng sinh kp thi theo phc kinh nghim v i khng sinh
thch hp khi c kt qu khng sinh .
- iu tr h tr tch cc.
- Pht hin v x tr sm cc bin chng.
4.2. iu tr ban u
- Khng sinh: Dng theo phc kinh nghim khi cha c kt qu vi sinh
(xem Bng II.19).
- Liu khng sinh: Khuyn co trn ngi bnhngi bnh vim mng
no c chc nng gan thn bnh thng (xem Bng II.20).
Ch :
+ H nhit: Bng paracetamol 15 mg/kg/ln, khng qu 60 mg/kg/ngy.
+ Dexamethason 0,6 mg/kg/ngy, tim 4 ngy (cng hoc trc khng
sinh 15 pht).
+ Chng ph no (Manitol 1g/kg/6gi, nm u cao 30o), b nc v
in gii.
+ Phng co git bng Barbituric 5 20 mg/kg/ngy (ung). Ct cn git
bng diazepam 0,1 mg/kg (pha vi 2ml NaCl 0.9%) tim TM n khi ngng
git.
+ Khng khuyn co dng meropenem cho tr di 3 thng tui.

B Y t | VIM MNG NO M 280

Bng II.19. Phc khng sinh kinh nghim khi cha c kt qu vi sinh
La tui

Cn nguyn thng gp

Khng sinh u tin

0 4 tun
tui

Vi khun ng rut,
S. agalactiae, Listeria.

Cefotaxim + Ampicilin Ampicilin* +


Aminoglycosid

1 thng 3
thng.

Hib, ph cu, no m cu,


S.agalactiae, E.coli, Listeria.

Ampicilin* +
Ceftriaxon (hoc
Cefotaxim)

Vancomycin +
Ceftriaxon (hoc
Cefotaxim)

3 thng 18
tui.

Hib, ph cu, no m cu.

Ceftriaxon (hoc
Cefotaxim)

Vancomycin +
Ceftriaxon (hoc
Cefotaxim)

18 50 tui

Ph cu, lin cu, no m cu

Ceftriaxon (hoc
Cefotaxim)

Vancomycin +
Ceftriaxon (hoc
Cefotaxim)

Trn 50 tui.

Ph cu, no m cu, Listeria,


k kh Gram-m

Ceftriaxon (hoc
Cefotaxim)

Ampicilin* + Ceftriaxon
(hoc Cefotaxim)

Suy gim
min dch.

Ph cu, no m cu, Listeria,


k kh Gram-m

Ampicilin + Ceftazidim Vancomycin +


Ampicilin* + Ceftazidim

Chn
thng, phu
thut, d
DNT

Ph cu, t cu, k kh Gramm

Ceftazidim +
Vancomycin

Khng sinh thay th

Ceftazidim +
Vancomycin
Meropenem

Ch :
* chn Ampicilin khi nghi ng Listeria.
**Aminoglycosid (gentamicin hoc amikacin).

B Y t | VIM MNG NO M 281

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

Tng liu hng ngy (gi cho mi liu)


Tr s sinh tnh theo ngy tui
07a

828a

Tr em

Ngi ln

Amikacinb

1520 mg/kg (12)

30 mg/kg (8)

2030 mg/kg (8)

15 mg/kg (8)

Ampicilin

150 mg/kg (8)

200 mg/kg (68)

300 mg/kg (6)

12 g (4)

Cefepim

150 mg/kg (8)

6 g (8)

Cefotaxim

100-150 mg/kg (812)

150-200 mg/kg (68)

225-300mg/kg

8-12g (4-6)

Ceftazidim

100-150 mg/kg (812)

150 mg/kg (8)

150 mg/kg (8)

6 g (8)

Ceftriaxon

80100 mg/kg (12


24)

4 g (1224)

Chloramphenicol

25 mg/kg (24)

50 mg/kg (1224)

75100 mg/kg (6)

46 g (6)c

Ciprofloxacind

800-1200 mg (8-12)

Gentamicinb

5 mg/kg (12)

7.5 mg/kg (8)

7.5 mg/kg (8)

5 mg/kg (8)

Meropenemd

30 120 mg/kg (8) g

6 g (8)

Oxacilin

75 mg/kg (812)

150200 mg/kg (6
8)

200 mg/kg (6)

912 g (4)

Penicilin G

0.15 mU/kg (812)

0.2 mU/kg (68)

0.3 mU/kg (46)

24 mU (4)

Rifampin

1020 mg/kg (12)

1020 mg/kg (12


24)e

600 mg (24)

Tobramycinb

5 mg/kg (12)

7.5 mg/kg (8)

7.5 mg/kg (8)

5 mg/kg (8)

Vancomycinf

2030 mg/kg (812)

3045 mg/kg (68)

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

Cn gim st nng nh v nng y (nu c iu kin).

Vim mng no do ph cu c khuyn co dng liu cao hn.

Ch s dng khi cc khng sinh khc khng hiu qu.

Liu ti a trong ngy 600mg

Nng duy tr thp nht trong mu l 15-20 mg/ml (nu c iu kin)

Khng khuyn co s dng Meropenem cho tr di 3 thng tui.

B Y t | VIM MNG NO M 282

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

B Y t | VIM MNG NO M 283

ANC

Absolute Neutrophil Count - ANC (s lng tuyt i ca bch cu ht


trung tnh)

MASSC Multinational Association for Supportive Care in Cancer


IDSA

Infectious Disease Society of America

B Y t | VIM MNG NO M 284

Chng X. Nhim khun tit niu

B Y t | 285

B Y t | 286

VIM THN B THN CP


1. I CNG
- Vim thn b thn cp (VTBT cp) l tnh trng nhim khun cp tnh
cc i thn, b thn, niu qun v nhu m thn hay cn gi l nhim khun
ng tit niu trn.
- Nhim khun cp tnh do vi khun gy nn theo ng ngc dng t
bng quang ln niu qun ri n i b thn, hoc do ng mu a n khi
c nhim khun huyt. Vi khun gy bnh thng gp l Gram-m...
2. NGUYN NHN
a) Vi khun gy bnh:
- Vi khun Gram-m: thng gp nht l E. coli (70- 80%), Klebsiella,
Proteus mirabilis, Enterobacter...
- Vi khun
Staphylococcus...

Gram-dng:

gp

di

10%:

Enterococcus,

b) Nguyn nhn thun li:


- Nhim khun tit niu ngc dng gp trong trng hp tro ngc
bng quang niu qun, sau khi soi bng quang niu qun, chp thn ngc
dng (UPR).
- Sau phu thut h tit niu.
- Tc nghn ng tit niu do si, khi u, hi chng ch ni, x sau
phc mc, hp b thn niu qun v c thai
- C vim khu tr: vim bng quang, vim tuyn tin lit, vim trc
trng, vim rut tha, vim phn ph...
3. CHN ON
a) Lm sng:
- Bnh thng xut hin t ngt vi nhng biu hin sau:
+ Hi chng nhim khun: st cao rt run, c th thnh cn 39 400C,
km theo au u v mt mi, mi kh li bn, c th mt nc do st cao.
Nu khng pht hin v iu tr kp thi s b sc nhim khun.
+ Hi chng bng quang cp: i but, i rt, i kh, i mu, i c,
i m l nhng du hiu sm trc khi c biu hin VTBT cp.
+ au: au hng lng, mng sn nhiu, c cm ng khi s vo, thng
au mt bn, him khi hai bn. C th xut hin cn au qun thn.
+ V hng lng (+): du hiu lm sng hay gp trong VTBT cp.
B Y t | VIM THN B THN CP 287

+ Chm thn bp bnh thn (+/-), c th s thy thn to.


b) Cn lm sng:
- Cng thc mu: s lng bch cu tng r rt, c bit tng bch cu a
nhn trung tnh.
- Cy mu cp: nu st cao > 39 40oC km theo rt run. Hay gp cc
trng hp nhim khun tit niu do vi khun Gram-m E. coli, t gp hn l
Enterobacter, Klebsiella, Proteus v Pseudomonas.
- Xt nghim nh gi chc nng thn (Mc lc cu thn) gip iu
chnh liu khng sinh ph hp.
- Protein niu <1g/24h.
- T bo niu: c t bo m, nhiu t bo bch cu, hng cu.
- Cy VK niu (+) 100 000 VK/ml nc tiu (gia dng), cng c khi
(-). Trng hp cn au khng in hnh, cn phi cy VK niu xc nh
chn on v c khng sinh cho iu tr.
- Siu m: pht hin d dng cc du hiu gin i b thn, gin niu
qun, hnh nh si thn tit niu, khi u chn p...l nguyn nhn gy VTBT
cp.
- Chp bng khng chun b: nu nghi ng c si thn tit niu.
- Chp niu tnh mch (UIV): tin hnh sau khi tnh trng st nhim
khun n nh tm kim nguyn nhn v v tr gy tc nghn ng tit
niu.
- Chp bng quang: tin hnh sau khi tnh trng nhim khun c gii
quyt nu nghi ng c tro ngc bng quang thn.
- Trong nhng trng hp kh, c th phi ch nh chp b thn ngc
dng, chp CT hoc MRI h thn tit niu tm nguyn nhn gy vim thn b
thn cp.
4. IU TR BNG KHNG SINH
4.1 Nguyn tc iu tr
- Nu st cao rt run cn iu tr ni tr, cc trng hp nh c th iu
tr v theo di ngoi tr. Cn cy vi khun niu, mu (nu c st cao) trc khi
bt u dng khng sinh. Trong khi ch i kt qu cy vi khun c th bt u
dng khng sinh ngay. Nu sau 3 - 5 ngy iu tr, triu chng lm sng khng
cn iu chnh khng sinh theo kt qu cy vi khun v khng sinh .
4.2 iu tr c th
a) Khng sinh ng ung

B Y t | VIM THN B THN CP 288

- Mt trong nhng thuc khng sinh c la chn u tin i vi


VTBT khng bin chng trong 7 14 ngy bng ng ung nu triu chng
khng nng:
+ Amoxicilin: 500 mg x 3 ln/ngy, ti a 6g/ngy.
+ Amoxicilin-clavulanat: 500/62,5 mg x 3 vin/ ngy, chia 3 ln.
+ Cephalosporin (th h 2, th h 3): Cefuroxim 250mg x 2 vin/ ngy,
chia 2 ln cch nhau 12h.
+ Trimethoprim sulfamethoxazol: 80/400 mg x 4 vin chia 2 ln cch
nhau 12 h.
+ Fluoroquinolon: nhm ny cn lu khng s dng cho ph n c thai
v ang cho con b, khng s dng cho tr em < 15 tui, cn gim liu ngi
bnhngi bnh suy thn. Thn trng vi ngi bnhngi bnh suy gan:
Ciprofloxacin 250mg 500 mg x 2 vin, chia 2 ln hoc
Norfloxacin 400mg x 2 vin chia 2 ln hoc
Ofloxacin 200mg x 2 vin chia 2 ln.
- Kt hp gim au chng co tht: drotaverin, hyoscin, metamizol..
- Ung nhiu nc hoc truyn dch m bo lng nc tiu nhiu
1500 - 2000 ml/24h.
- Nu tnh trng lm sng khng tin trin tt (hi chng nhim khun r,
vn st, tiu c, au, mt nc...) nn chuyn vo iu tr ni tr hoc ln
tuyn trn.
b) Khng sinh ng tim:
- Amoxicilin hoc ampicilin 1 g x 4 l/ ngy chia 4 ln tim tnh mch x
10 14 ngy.
- Hoc amoxicilin-clavulanat 875/125 mg x 2 ln/ngy tim TM.
- Hoc ampicilin-sulbactam 1500 mg x 4 ln/ ngy tim TM.
- Hoc cephalosporin (th h 2, th h 3): 10 14 ngy
+ Cefuroxim 750 mg x 3 ln/ngy tim TM.
+ Hoc cefotaxim 1g x 3 ln/ ngy tim TM.
+ Hoc ceftriaxon 1g 2g / ngy tim TM.
+ Hoc cefoperazon 1-2g x 2 ln/ngy tim TM.
Hoc:
- Imipenem-cilastatin 250 500 mg x 4 3 ln/ngy.
- Hoc meropenem 500 mg x 3 ln/ngy.
B Y t | VIM THN B THN CP 289

- Hoc ertapenem 1000 mg x 1 ln/ngy.


Hoc:
- Fluoroquinolon:
+ Ciprofloxacin 200 mg 400 mg x 2 ln/ngy.
+ Hoc levofloxacin 250 mg 750 mg x 1 ln/ngy.
i vi fluoroquinolon, c th truyn 3 ngy, sau chuyn sang ng
ung tip. Cn lu : Thuc c th gy ra ri lon tiu ha nh nn, bun nn
v khng c dng cho ph n c thai, tr em di 15 tui.
- Kt hp vi 1 thuc trong cc thuc trn vi aminoglycosid tim tnh
mch (TM) hoc tim bp (TB): Gentamicin hoc tobramicin 3 5 mg/kg/24h.
amikacin 15 mg/kg/24 gi. Thn trng vi ngi gi, cn gim 1/2 liu ngi
suy thn c mc lc cu thn di 30ml/ph.
- Nu cy nc tiu c trc khun Gram-m (-): Cephalosporin th h 3
hoc fluoroquinolon.
- Nu cy nc tiu c vi khun Gram-dng (+): Amoxicilin/ampcilin
1g x 6 ln/ngy tim TM. C th kt hp vi nhm aminoglycosid ngn chn
nguy c nhim vi khun ng rut trong khi ch i kt qu cy mu, nc
tiu v c khng sinh .
- Nu khng c bin chng, ht st, t ngy th 10 n ngy th 14
chuyn sang khng sinh ng ung. Khng sinh duy tr trong 3 tun k c khi
din bin lm sng c ci thin nhanh chng. Cn cy nc tiu kim tra
li sau 1 tun ngng thuc.
- Nu vn st, vi khun niu tn ti 48 gi n 72 gi, hoc tip tc c
du hiu nhim khun sau 3 ngy iu tr, cn tm kim tc nghn, nhim
khun lan rng hoc hnh thnh p xe thn. Siu m, chp ct lp (CT) thn c
th pht hin c v tr tc nghn v p xe quanh thn c ch nh ngoi
khoa dn lu.
4.3 Ngoi cc thuc khng sinh cn phi hp thm:
- B dch bng ng ung v/hoc ng truyn tnh mch: NaCl
0,9% hoc Ringer 5%, Glucose 5% m bo lng nc tiu > 50 ml/gi.
- Gim au, gin c trn khi au:
+ Phloroglucinol hydrat, trimethylphloroglucinol: vin ung - t, ng
tim x 4 ln/ngy .
+ Papaverin hydrochlorid vin ung, ng tim x 2-3 ln/ngy.
+ Tiemonium metylsulfat: vin ung, ng tim x 1 - 3 ln/ngy

B Y t | VIM THN B THN CP 290

4.4 Mt s trng hp khng in hnh:


- Cy vi khun khng mc: do tc nghn nc tiu hon ton vi khun
khng di chuyn c hoc dng khng sinh trc . Ch nh chp UIV
cp c th c t ra xc minh chn on.
- Din bin lm sng khng thun li mc d iu tr: tnh trng ton
thn khng ci thin hn, cha ct st c ch nh chp UIV cp xem xt iu
tr can thip ngoi khoa.
4.5 Mt s trng hp cn lu :
- VTBT cp ngi c thai:
+ Thng gp 3 thng cui.
+ Thn trng khi s dng thuc khng sinh. C th dng nhm sulfamid,
penicilin (amoxicilin).
+ Khng ch nh chp X-quang.
+ Trng hp i b thn gin km theo khng p ng thuc cn xem
xt chp UIV tm nguyn nhn gy tc nghn c gii v thn trng ch nh
ngoi khoa.
+ Mi thm d hnh thi khc ch tin hnh sau khi .
- VTBT cp ti pht nhiu ln:
+ Mi ln ti pht s lm bin dng i thn, ti pht nhiu ln s gy x
ha v teo nhu m thn.
+ Nn iu tr khng sinh ko di d phng ti pht v tm nguyn
nhn.
- VTBT cp v niu:
+ C th do tc nghn thn duy nht c chc nng hot ng hoc do
sc nhim khun.
+ C hai trng hp u rt nng v tin lng t vong cao.
+ Gii quyt nguyn nhn tc nghn l ch nh cp cu.
4.6 Theo di sau giai on iu tr:
- Nu p ng thuc tt v khng cn triu chng lm sng, cy vi khun
sau 5 ngy ngng thuc nu khng mc coi nh khi.
- Nu khng p ng tt, sau 2 tun iu tr cn thit: X-quang, cy li
nc tiu xt can thip si v p xe quanh thn nu c.
- Nu khng c bt thng h tit niu: iu tr li bng khng sinh khc
phi hp trong 2 tun.

B Y t | VIM THN B THN CP 291

- Nu ngi bnhngi bnh ti pht vi vi khun cng loi: tip tc iu


tr 6 tun.
4.7 iu tr d phng:
- Cn iu tr trit khi c nhim khun tit niu di.
- iu tr sm cc nguyn nhn gy nghim khun tit niu, gy tc nghn
ng tit niu.
- Ung nc hng ngy, khng nhn tiu.
T VIT TT TRONG BI
UIV

Chp niu tnh mch

UPR

Chp thn ngc dng

VK

Vi khun

VTBT

Vim thn b thn

TI LIU THAM KHO


1. Canbaz S, Peksen Y, Sunbul M et coll. Antibiotic prescribing and urinary tract infection.
Int J Antimicrob Agents 2002 ; 20: 407-11
2. Kawashima A, Sandler CM, Goldman SM. Imaging in acute renal infection. Brit J Urol
2000; 86 Suppl. 1:70-9
3. Krieger JN. Urinary tract infections: Whats new?. J Urol. 2002; 168: 23518
4. Pangon B, Chaplain C: Pylonphrite aigu: bactriologie et volution des rsistances.
Pathologie Biologie 2003; 51 : 5037
5. Urinary tract infectons: The Merck Manual eighteenth edition 2006:1968 1975
Recommendations.
6. Jurgen Floege, Richard J.Johnson, John Feehally. Comprehensive Clinical Nephrology
2010: 629- 640.

B Y t | VIM THN B THN CP 292

SI THN TIT NIU NHIM TRNG


Si thn tit niu kh thng gp, c pht hin ngy cng nhiu. T l
ngi bnhngi bnh suy thn do si cng kh cao. Si thn v niu qun
chim a s (90%), trong si canxi chim ch yu 80%, si uric chim 10
15%. Nam gii gp nhiu hn n, gp 3 ln. Ch n ung cha nhiu protein
ng vt, nhiu canxi, oxalat... l yu t nguy c to si.
1. NGUYN NHN
C nguyn nhn ti ch v nguyn nhn ton th.
a) Nguyn nhn ti ch: Yu t thun li cho tc nghn nc tiu
- Do bm sinh: Tro ngc bng quang niu qun, bnh l ch ni b
thn niu qun, ti tha h tit niu, thn mng nga, a nang
- Do mc phi: Cht hp i thn, hp niu qun, hp niu o, ph i
tuyn tin lit, bnh l c bng quang
b) Nguyn nhn ton th: Do cc ri lon chuyn ha gy ra si canxi, si uric,
si oxalat, si cystin. Mt s trng hp do nguyn nhn di truyn.
c) Do vi khun: Nhim khun tit niu do cc vi khun tit ra men Urease lm
phn hu ure to thnh amoniac, amoniac b phn hu s gy kim ho nc
tiu t d to thnh si (si Struvit).
2. CHN ON
2.1. Chn on xc nh
Chn on xc nh da vo tin s bnh, cc biu hin lm sng, xt
nghim sinh ha mu v nc tiu, cc thm d cn lm sng nh siu m, Xquang bng, UIV, CT scan, chp b thn ngc dng, xui dng.
a) Lm sng
- Khai thc tin s, din bin bnh, tin s gia nh...
- Triu chng ton thn:
St km rt run, c th st cao 39 400C trong vim thn - b thn cp,
c th sc nhim khun.
- Triu chng c nng: au l triu chng in hnh ca si thn tit niu
do si gy tc nghn v di chuyn. Hi bnh s pht hin:
+ au thn: au tht lng, au m vng tht lng (si thn).
+ au niu qun: Cn au qun thn lan xung di km du hiu v tiu
tin (si niu qun).

B Y t | SI THN TIT NIU NHIM TRNG 293

+ au bng quang: t gp, thng thnh cn km theo du hiu nhim


khun v ri lon tiu tin, c th lan xung niu o (si bng quang).
+ i mu: i th, vi th, thng km theo au.
+ Ri lon tiu tin: i but, rt, i m
+ Du hiu tc nghn: i kh ngt qung, tc, thn to nc.
- Triu chng thc th:
+ Chm thn, bp bnh thn +/-.
+ V hng lng +/-.
b) Cn lm sng
- Cng thc mu: Bch cu tng, ch yu a nhn tng.
- Protein niu: Protein niu < 1g/24h khi vim thn b thn cp.
- T bo niu: Hng cu niu, bch cu niu thng gp, c th thy cn
canxi, phosphat, urat
- Cy vi khun niu (+) khi c nhim khun. Thng gp E. coli, Proteus,
Klebsiella
- Siu m: Pht hin c si cn quang v khng cn quang v tr nhu
m thn, i b thn, niu qun 1/3 trn v 1/3 di. Pht hin c, tnh trng
si gy tc nghn, thn to (hnh nh nc, m b thn, niu qun gin, mu
cc b thn).
- Chp X-quang bng khng chun b: C th thy si cn quang h tit
niu.
- Chp UIV: Khng thc hin khi ang nhim khun nng, hoc khi c
suy thn cp.
- Chp ngc dng (UPR): Nu khng pht hin c nguyn nhn gy
nc thn cn chp UPR, nhng cnh bo nguy c gy nhim khun sau th
thut.
- Chp b thn xui dng: Tin hnh khi UPR khng thc hin c
ngi bnhngi bnh c nc b thn.
- Chp ct lp vi tnh CT: Phn bit si gy nhim khun p xe nhu m
thn, b thn hay khi u thn tit niu.
- Cy mu: Nu st cao > 380C km rt run, thng gp VK Gram-m
nh E. coli hoc Gram-dng.
2.2. Chn on phn bit: Mt s triu chng lm sng v cn lm sng c th
gp trong cc bnh khc.
- Phn bit i mu: Do si, khi u, lao tit niu, vim bng quang.
B Y t | SI THN TIT NIU NHIM TRNG 294

- Phn bit trn X-quang: Cn quang ngoi h thn tit niu, vi ha do


lao, gin i b thn do nguyn nhn khng phi do si tit niu.
- Phn bit bin chng: V niu v nhim khun tit niu do nguyn nhn
khc.
- Phn bit au: Do si thn tit niu, vim ti mt, rut tha, vim ty,
vim bung trng, nang bung trng.
3. IU TR
- Si thn - tit niu c th gy ra nhiu bin chng nh nhim khun tit
niu, vim thn b thn cp - mn, nng c th dn n nhim khun huyt; i
mu, v niu v suy thn cp.
- Nguyn tc iu tr:
+ iu tr triu chng.
+ iu tr trit .
3.1 iu tr triu chng bao gm:
- H st: Paracetamol 500mg x 1-2 vin/ ln khi st cao > 380C. Thn
trng c th gy suy gan cp do thuc.
- iu tr nhim khun tit niu (tiu but, rt, c th c): Khng sinh
ung:
+ Trimethoprim sulfamethoxazol: 80/400 mg x 4 vin chia 2 ln cch
nhau 12 h x 3 ngy, lu phn ng d ng chm.
+ Hoc nitrofurantoin 100 mg x 4 ln/ ngy x 7 ngy
+ Hoc amoxicilin: 250-500 mg x 3-6 vin/ ngy, chia 3 ln.
+ Amoxicilin-clavulanat: 500 mg x 3 vin/ ngy, chia 3 ln x 3 ngy. Nu
khng ung c v tnh trng nng c th chuyn ng tim TM: 1 g x 2 l/
ngy, chia 2 ln.
+ Hoc cephalexin 500mg x 4 vin chia 4 ln/ ngy x 10 ngy
- Gim au gin c trn khi c cn au qun thn:
+ Drotaverin 40mg x 3 vin/ ngy chia 3 ln ng ung.
+ Spasmaverin 40mg x 4 vin/ ngy ng ung, hoc x 4 ng/ngy
ng tim
3.2 iu tr khi c bin chng:
a) Thuc gim au:
- Phloroglucinol 40 mg x 4 vin/ ngy chia 3-4 ln khi au, ng ung,
hoc x 4 ng/ngy ng tim.
B Y t | SI THN TIT NIU NHIM TRNG 295

- Tiemonium 5mg x 1 ng/ ln nu cn au qun thn, ng tim.


b) Khng sinh:
- Amoxicilin hoc ampicilin 1 g x 4 l/ ngy chia 4 ln tim tnh mch x
10 14 ngy.
- Hoc cephalosporin (th h 2, th h 3): 10 14 ngy.
+ Cefuroxim 250mg x 2 ln/ngy ng ung, hoc cefuroxim ng
tim TM.
+ Hoc cefotaxim 1g x 3 ln/ngy tim TM.
+ Hoc ceftriaxon 1g /ngy tim TM.
Hoc:
- Fluoroquinolon ng ung: trong 3 7 ngy, c th ti 10 ngy
+ Ciprofloxacin 250mg 500 mg x 2 ln/ngy.
+ Hoc norfloxacin 400 mg x 2 ln/ngy.
+ Hoc ofloxacin 200mg x 2 ln/ngy.
C th truyn 3 ngy, sau chuyn sang ng ung tip.
Cn lu : Thuc c th gy ra ri lon tiu ha nh nn, bun nn v
khng c dng cho ph n c thai, tr em di 15 tui.
- Vim thn b thn cp (st cao rt run, bch cu mu cao, tiu but rt
c, au h thn, cy vi khun mu v niu dng tnh...): Xem bi Vim thn
b thn cp.
c) Cm mu khi c i mu ton bi:
- Transamin 500 mg x 2- 4 vin chia 2 ln ng ung, nu i mu nng
chuyn sang tim TM.
d) Truyn mu cp cu nu i mu nhiu gy tt huyt p.
e) iu tr suy thn cp: Nu v niu cn lc mu cp cu, khng tr hon khi
kali mu 6,5 mmol/l.
3.3 iu tr nguyn nhn: Gii phng tc v bn tc do si:
- Tn si:
+ Tn ngoi c th: Si < 2 cm b thn, on u v cui niu qun.
+ Tn si ni soi qua da: Nhiu si b thn.
+ Tn si ni soi laser: Qua ung ni soi bng quang - niu qun v b
thn.

B Y t | SI THN TIT NIU NHIM TRNG 296

- Ly si ni soi: Si nh niu qun on di, bng quang, niu


o.
- M ly si: Ch m m khi si to hoc si san h b thn. M ni soi
qua da, qua niu qun p dng nhiu cc nc.
4. TIN TRIN V BIN CHNG
Ty thuc vo kch thc, v tr ca si c th gp cc bin chng sau:
a) Bin chng c hc do si di chuyn:
- V niu suy thn cp: Tc nghn c 2 bn.
- V b thn hoc niu qun do nc: t gp.
b) Bin chng nhim khun: Vim thn b thn cp, mn, m b thn, hoi t
thn, hoi t nm thn, suy thn.
- Nhim khun ti nhu m thn: Vim thn b thn cp biu hin st cao,
au tht lng. Nguy c nhim khun huyt hoc lm hng thn do m b thn
nu khng iu tr kp thi.
- Nhim khun tit niu khng c biu hin ton thn: Si km theo
nhim khun tit niu, cy vi khun dng tnh, khng c st, khng c hi
chng bng quang cp.
5. D PHNG
- Vi bt k loi si no cng cn:
+ Ung nhiu nc, m bo lng nc tiu khong 1,5 n 2 lt/ngy.
+ iu tr cc t nhim khun, vim thn b thn.
- i vi si canxi:
+ Nc dng cho n ung t thnh phn canxi.
+ Hn ch n thc n c nhiu canxi.
+ Mt s thuc nh allopurinol iu tr ko di cn c theo di cn
thn.
- D phng si uric:
+ Duy tr pH niu kim.
+ Cho ung bicarbonat natri 5-10g/ngy.
+ Cho allopurinol 100-300 mg/ngy nu c tng axt uric mu.

B Y t | SI THN TIT NIU NHIM TRNG 297

TI LIU THAM KHO


1. Canbaz S, Peksen Y, Sunbul M et al. Antibiotic prescribing and urinary tract infection. Int
J Antimicrob Agents 2002
2. Krieger JN. Urinary tract infections: Whats new?. J Urol. 2002
3. Urinary tract infections: The Merck Manual eighteenth edition 2006
4. Jurgen Floege, Richard J.Johnson, John Feehally. Comprehensive Clinical Nephrology .
Elservier 2010 Four edition
5. M.Akimoto, E.Higashihara, H.Kumon et al. Treatment of urolithiasis Spinger 2001

B Y t | SI THN TIT NIU NHIM TRNG 298

VIM NIU O CP KHNG DO LU


Vim niu o cp c th do nguyn nhn nhim khun, k sinh trng,
virus hoc nguyn nhn c hc.
Vim niu o cp c th l tn thng n c hoc phi hp vi vim
bng quang, vim thn b thn, vim tin lit tuyn, vim tinh hon v mo tinh
hon.
1. NGUYN NHN
- Nguyn nhn vim niu o c chia lm hai nhm: Vim niu o do
lu v khng do lu.
- Cc nguyn nhn gy vim niu o khng do lu thng gp l:
+ Chlamydia trachomatis
+ Mycoplasma
+ Trichomonas vaginalis
+ Candida albicans
+ Herpes simplex virus
+ Streptococcus
+ Staphylococcus saprophyticus
+ Escherichia coli.
2. CHN ON XC NH
a) Lm sng
- Chn on xc nh c vim niu o d, ch yu da vo lm sng. Soi
v cy dch niu o bit loi vi khun, nm gip la chn khng sinh.
+ C tin s mi c quan h tnh dc t vi ngy n vi tun hoc
khng.
+ Xut hin chy m, dch niu o.
+ i but hoc nng rt khi i tiu.
b) Xt nghim
- Soi dch niu o: Nhiu bch cu, c th thy vi khun, nm.
- Cy dch niu o hoc nc tiu u bi: C vi khun, nm.
- i vi Chlamydia: Chn on xc nh c th da vo phn ng huyt
thanh dng tnh, v nui cy kh khn.

B Y t | VIM NIU O CP KHNG DO LU 299

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

Nhng tnh trng vim phi hp ny thng nng hn so vi vim niu


o cp thng thng. iu tr nh iu tr vim tin lit tuyn, vim tinh hon.
4. TIN LNG
Vim niu o cp thng khi hn nu c iu tr t sm v ng.
Nu khng c iu tr t sm c th dn ti vim bng quang hoc vim thn
b thn.
TI LIU THAM KHO
1. Bnh hc ni khoa tp 1, Nh xut bn Y hc. 2012.
2. Hng dn iu tr nhim khun ng tit niu Vit Nam, Hi thn hc Vit Nam, 2013.
3. Robert B. Taylor, Manual of Family Practice, Little Brown and Company, Boston
Massachusetts, 1997.
4. Massry & Glassocks. Text book of Nephrology. Fourth edition. Lippincott Williams &
Wilkins. 2002.
5. Therapeutic Guidelines Antibiotic. Version 14.
Melbourne. 2010.

Therapeutic Guidelines Limited,

6. Grabe M., Bjerklund Johansen T.E., H Botto et al. Guidelines on Urological Infections.
European Association of Urology. 2012.

B Y t | VIM NIU O CP KHNG DO LU 301

VIM BNG QUANG CP


Vim bng quang cp l tnh trng nhim khun cp tnh ti bng quang.
Biu hin lm sng thng c hi chng bng quang r vi i but, i rt, c
th c i mu, i m cui bi. Xt nghim nc tiu c bch cu niu v vi
khun niu. Bnh thng gp n vi t l n/nam = 9/1.
1. NGUYN NHN GY BNH
a) Cc loi vi khun thng gp:
Vi khun Gram-m chim khong 90%, vi khun Gram-dng chim
khong 10%. Thng gp l:
- Escherichia coli: 70 - 80% ngi bnhngi bnh.
- Proteus mirabilis: 10 - 15% ngi bnhngi bnh.
- Klebsiella: 5 - 10% ngi bnhngi bnh.
- Staphylococus saprophyticus: 5 - 10% ngi bnhngi bnh.
- Pseudomoras aeruginosa: 1 - 2% ngi bnhngi bnh.
- Staphylococus aureus: 1 - 2% ngi bnhngi bnh.
b) Nguyn nhn thun li:
- Ph i lnh tnh hoc u tuyn tin lit.
- Si, u bng quang.
- Hp niu o, hp bao qui u.
- i tho ng.
- C thai.
- t sonde dn lu bng quang hoc can thip bng quang, niu o.
2. CHN ON
2.1. Chn on xc nh: Da vo lm sng v cn lm sng.
a) Lm sng:
- C hi chng bng quang r vi i but, i rt, c th i mu, i m
cui bi.
- C th c au nh vng trn khp mu khi bng quang cng.
- i khi triu chng khng in hnh, ch c nng rt khi i tiu hoc i
rt.
- Thng khng st hoc ch st nh ( nhit < 38oC ).
b) Cn lm sng:
B Y t | VIM BNG QUANG CP 302

- 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.

B Y t | VIM BNG QUANG CP 303

- Nitrofurantoin: Vin 100 mg, ung 1 vin/ln, 2 ln/ngy trong 5 - 7


ngy.
- Amoxicilin-clavulanat: Vin 500/125 mg, ung 1 vin/ln, 2 ln/ngy
trong 5 - 7 ngy.
- Nu cy c vi khun niu (+), la chn theo khng sinh , vn cn ch
thuc chng ch nh ph n c thai.
c) Vim bng quang cp nam gii:
- iu quan trng l cn tm nguyn nhn lin quan nh vim tuyn tin lit,
vim tinh hon, mo tinh hon c la chn khng sinh v thi gian iu tr
cho thch hp. Khi cha r c nguyn nhn lin quan, thi gian dng thuc cng
nn ko di hn.
- iu tr thng thng nh sau:
+ Trimethoprim sulfamethoxazol: Vin 80/400 mg, ung 1 vin/ln, 2
ln/ngy trong 14 ngy.
+ Cephalexin: Vin 500 mg, ung 1 vin/ln, 2 ln/ngy trong 14 ngy.
+ Amoxicilin-clavulanat: Vin 500/125mg, ung 1 vin/ln, 2 ln/ngy
trong 14 ngy.
+ Nu pht hin c cc nguyn nhn nh: vim tuyn tin lit cp hoc
mn tnh s c phc iu tr ring.
d) iu tr vim bng quang cp c nguyn nhn thun li:
- Loi b cc nguyn nhn gy tc ng bi niu.
- Thi gian dng khng sinh nn ko di t 7 - 10 ngy.
) Ung nc:
Nn ung nc lng nc tiu t nht t > 1,5 lt/24 gi. Khng
nhn tiu qu 6 gi.
e) Tc dng ph v tng tc thuc:
- Nhm fluoroquinolon: Khng dng nhm quinolon cho ph n c thai,
cho con b, tr em di 15 tui, ngi c tin s co git v c tin s d ng vi
thuc. Thn trng dng pefloxacin ngi bnhngi bnh c suy gan nng.
- Nhm beta-lactam: Thuc c kh nng gy sc phn v nn chng ch
nh khi c tin s d ng vi penicilin hoc cc thuc trong nhm. Gim liu
khi mc lc cu thn < 30 ml/pht i vi nhng sn phm c acid clavulanic
v sulbactam.
- Nhm aminoglycosid: Thuc gy c vi thn v tai. V vy cn theo
di chc nng thn v gim liu khi c suy thn.
B Y t | VIM BNG QUANG CP 304

- Nhm sulfamid: Thuc t c tc dng ph. i khi c phn ng d ng


nng kiu hi chng Steven-Johnson, gim bch cu ht. Chng ch nh dng
thuc khi c suy gan, suy thn nng, ph n c thai, qu mn cm vi thuc.
4. TIN LNG
- i vi th vim bng quang cp thng thng: C tin lng tt, bnh
thng khi hn sau mt liu trnh khng sinh ngn ph hp. Tuy nhin vi
khun vn c kh nng ngc dng ln niu qun, b thn, thn gy vim thn,
b thn cp, mt tnh trng cp cu ni khoa. Bnh cng c th ti pht. Nu
vim ti pht t 4 ln tr ln trong 1 nm th cn c thi iu tr d phng.
Khi vim ko di hoc hay ti pht li nhiu so x c chn on l vim
bng quang mn tnh.
- i vi th vim bng quang cp c nguyn nhn thun li bin chng
th tin lng d dt hn. Bn cnh vic iu tr khng sinh chng nhim khun,
cn iu tr loi b nguyn nhn thun li nu c th iu tr c th mi c
tin lng tt. Liu php khng sinh chng nhim khun i hi di ngy hn.
TI LIU THAM KHO
1. Bnh hc ni khoa tp 1, Nh xut bn Y hc. 2012.
2. Hng dn iu tr nhim khun ng tit niu Vit Nam, Hi thn hc Vit Nam, 2013.
3. Robert B. Taylor, Manual of Family Practice, Little Brown and Company, Boston
Massachusetts, 1997.
4. Massry & Glassocks. Text book of Nephrology. Fourth edition. Lippincott Williams &
Wilkins. 2002.
5. Therapeutic Guidelines Antibiotic. Version 14.
Melbourne. 2010.

Therapeutic Guidelines Limited,

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

Chng XI. S dng khng sinh cho


ngi bnh suy gim min dch

B Y t | 307

B Y t | 308

SUY GIM MIN DCH (GIM BCH CU HT


TRUNG TNH V SAU GHP TY)
1. NH NGHA
- Ha tr liu v ghp t bo gc to mu cho ngi bnhngi bnh ung
th gy ra tnh trng gim bch cu ht trung tnh, lm tng nguy c nhim
khun nng nhng ngi bnhngi bnh ny. Mc cng nh thi gian
gim bch cu ht trung tnh ph thuc vo mnh ca phc ha tr liu.
Gim bch cu ht trung tnh su, ko di thng gp cc ngi bnhngi
bnh ghp t bo gc ng loi (giai on trc mc mnh ghp) v ngi bnh
l x mi (leukemia) cp iu tr ha cht phc tn cng.
- St: Khi nhit o ming ca ngi bnh > 38oC ti mt thi im
bt k hoc > 38oC lin tc t nht mt gi ng h.
- Gim bch cu ht trung tnh: S lng tuyt i ca bch cu ht trung
tnh (Absolute Neutrophil Count - ANC) < 500 t bo/l.
2. TRIU CHNG LM SNG
- nhng ngi bnh gim bch cu ht trung tnh, p ng vim thng
khng y , do tnh trng nhim khun nng c th ch biu hin bng cc
triu chng du hiu kn o.
- St c th l du hiu duy nht ca nhim khun trn cc ngi bnh
ny. t nht 50% ngi bnh st gim bch cu ht trung tnh c nhim khun
kn o hoc biu hin r trn lm sng. t nht 20% ngi bnh gim bch cu
ht trung tnh < 100 t bo/l b nhim khun huyt. Tnh trng nhim khun c
th tin trin rt nhanh, dn n tt huyt p v/hoc cc bin chng e da tnh
mng ngi bnh. Vic pht hin sm nhim khun ngi bnh gim bch cu
ht trung tnh v s dng khng sinh theo kinh nghim sm, thch hp l v
cng quan trng nhm trnh qu trnh tin trin thnh nhim khun nng v sc
nhim khun.
- Bch cu ht trung tnh gim cng nng th nguy c nhim khun cng
cao. Ngi bnh c ANC gim < 500 t bo/l c nguy c nhim khun cao hn
r rt so vi khi ANC < 1000 t bo/l, v khi ANC < 100 t bo/l th nguy c
nhim khun nng cao hn nhiu so vi ngi bnh c ANC < 500 t bo/l.
Thi gian gim bch cu ht trung tnh cng l mt yu t quan trng lin quan
cht ch vi tnh trng nhim khun nng. Nhng ngi bnh gim bch cu ht
trung tnh > 7 ngy c nguy c nhim khun cao hn nhiu nhm gim di 7
ngy.
- Trc mt ngi bnh c st gim bch cu ht trung tnh, cn thm
khm k cng cc c quan d b nhim khun: Ming, hng, thc qun, phi,
vng hu mn sinh dc, da v v tr ng vo ca catheter.
B Y t | SUY GIM MIN DCH (GIM BCH CU HT 309
TRUNG TNH V SAU GHP TY)

3. PHN TNG NGUY C


- Vic phn tng nguy c l cn thit, gip cho ngi bc s tin lng,
quyt nh bin php v thi gian iu tr thch hp.
- Nhm nguy c thp: Ngi bnh c ANC < 500 t bo/l trong thi
gian khng qu 7 ngy v khng c cc bnh l khc km theo hoc khng c
biu hin ri lon chc nng gan, thn.
- Nhm nguy c cao: Ngi bnh c 1 trong cc tiu chun sau:
+ Ngi bnh c ANC < 500 t bo/l ko di trn 7 ngy.
+ C bnh l khc km theo.
+ C ri lon chc nng gan, thn.
+ im MASSC < 21 im (Multinational Association for Supportive
Care in Cancer).
- Nhng ngi bnh thuc nhm nguy c cao bt buc phi c iu tr
khng sinh ng tnh mch v theo di st trong thi gian nm vin.
4. CC XT NGHIM CN THIT
- Cy mu khi st: Trc khi s dng khng sinh, cy t 2 v tr (1 v tr
tnh mch ngoi bin, 1 v tr t catheter nu c).
- Cy nc tiu, cy dch nu nghi ng ngun nhim khun.
- Tng phn tch t bo mu.
- Chc nng gan, thn, in gii .
- Thm d chn on hnh nh: Chp X-quang phi, chp ct lp vi tnh
nu cn.
5. IU TR KHNG SINH
a) Nguyn tc: Phi coi tnh trng nhim khun trn ngi bnh gim bch cu
ht trung tnh nh mt cp cu ni khoa. S dng khng sinh ph rng, liu cao
cng sm cng tt, l tng nht l trong vng 60 pht khi c du hiu st hoc
nhim khun (iu chnh liu theo chc nng gan thn). Mc tiu l phi bao
ph c hu ht cc tc nhn vi khun gy bnh. Khi c kt qu nui cy vi
khun, cn iu chnh khng sinh theo khng sinh .

B Y t | SUY GIM MIN DCH (GIM BCH CU HT 310


TRUNG TNH V SAU GHP TY)

Bng II.21. Mt s chng vi khun thng gp ngi bnh st gim bch cu


ht trung tnh
Gram-m

Gram-dng

Escherichia coli

Coagulase - negative staphylococci

Klebsiella spp.

Staphylococcus aureus

Enterobacter

Enterococcus spp.

Pseudomonas aeruginosa

Viridans group streptococci

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)

- Nu xc nh c nhim khun v nguyn nhn gy bnh: dng


khng sinh theo hng dn ring cho tng loi vi khun (v d nhim khun
huyt do E. coli cn dng khng sinh ti thiu 14 ngy). Nn tip tc cho khng
sinh n khi s lng bch cu ht trung tnh > 500 t bo/l.
- Nu khng xc nh c nhim khun v xt nghim vi khun hc
m tnh: dng khng sinh n khi ngi bnh ht st c ti thiu 48 gi v s
lng bch cu ht trung tnh tng > 500 t bo/l hoc chuyn sang ung d
phng bng flouroquinolon cho n khi c s hi phc ca ty xng.

B Y t | SUY GIM MIN DCH (GIM BCH CU HT 312


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

m lo lng nhiu v bnh ca tr (Khuyn co B). Tr ang c iu tr ti


bnh vin nu c cc biu hin nh: Tr vn st sau 48 gi, nhp th nhanh hn
hoc tr c tnh trng li b hoc kch thch hn cn phi thm khm nh gi li
ton din qu trnh chn on v iu tr (Khuyn co B).
4. Khuyn co 5.4: Chn on nguyn nhn vi sinh vt gy bnh cn phi thc
hin mi khi c th lm c trong mi trng hp tr khi khng c iu kin
nh trng hp iu tr ti cng ng.
Cc phng php chn on nguyn nhn bao gm: Cy mu, cy dch t hu,
m, dch mng phi, cy dch kh ph qun qua ng ni kh qun, soi ph qun
tm vi khun gy bnh, xt nghim PCR tm nguyn nhn virus gy bnh t
hu, m, huyt thanh chn on tm nguyn nhn vi khun khng in hnh
nh Mycoplasma pneumoniae v Chlamydia (Khuyn co C). Cc xt nghim
tm vi khun khng in hnh Mycoplasma pneumoniae v Chlamydia
pneumoniae ch thc hin khi nghi ng c nhim cc vi khun ny. Cc xt
nghim virus hc ch thc hin khi c dch c bit nghim trng nh H1N1,
H5N1... (Khuyn co C).
5. Khuyn co 5.5: Cc xt nghim cc cht phn ng pha cp khng c
dng phn bit gia vim phi do vi khun hay do virus v khng nn lm
thng quy (Khuyn co A). Xt nghim CRP khng c ch trong qun l vim
phi khng bin chng (Khuyn co A). Xt nghim cng thc mu, s lng
bch cu v cc cht phn ng pha cp nh CRP, PCT, ML cho cc trng
hp vim phi nng cn iu tr ni tr theo di din bin lm sng (Khuyn
co A).
6. Khuyn co 5.6: Cn phi iu tr khng sinh cho tt c cc tr c chn
on vim phi bi v khng th phn bit c trng hp no l vim phi do
vi khun hay do virus (Khuyn co C).
7. Khuyn co 5.7: Amoxicilin l thuc ung c chn ban u v thuc cn
tc dng tt vi cc tc nhn ch yu gy vim phi cng ng tr em, thuc
dung np tt v r. Cc thuc thay th c s dng l amoxicilin-clavulanat,
cefuroxim, cefaclor, erythromycin, azithromycin (Khuyn co B). C th cho
thm macrolid bt c tui no nu khng p ng vi iu tr ban u
(Khuyn co C) hoc nghi ng vim phi do Mycoplasma hoc Chlamydia hoc
trong trng hp bnh rt nng (Khuyn co C).
8. Khuyn co 5.8: Khng sinh ung an ton v hiu qu cho vim phi cng
ng tr em ngay c mt s trng hp nng (Khuyn co A). Khng sinh
tim dng cho cc trng hp c bin chng hoc c du hiu ca nhim khun
huyt hoc khng dung np (v d nn) hoc c vn v hp thu thuc qua
ng ung (Khuyn co A). Khng sinh ng tnh mch cho vim phi nng
gm amoxicilin, amoxicilin-clavulanat, ampicilin, penicilin, cefuroxim,
B Y t | 314
HNG DN X TR VIM PHI CNG NG TR
EM

cefotaxime, ceftriaxone, gentamycin hoc amikacin. Oxacilin kt hp


gentamycin dng cho cc trng hp vim phi nghi do S. aureus. Ch dng
vancomycin thay th khi c bng chng hoc nghi ng S. aureus khng li
oxacilin (Khuyn co C).
9. Khuyn co 5.9: Bnh nhi ang c dng khng sinh ng tnh mch
iu tr vim phi cng ng c th chuyn sang ng ung khi c cc bng
chng bnh ci thin nhiu v tnh trng chung ca tr c th dng thuc
c theo ng ung (Khuyn co C).
10. Khuyn co 5.10: Thi gian dng khng sinh cho tr vim phi t nht l 5
ngy.
11. Khuyn co 5.11: Nu tr vn st v tnh trng chung khng tt ln sau 48
gi iu tr cn phi khm nh gi li v chp X-quang phi pht hin cc
bin chng (Khuyn co C). Nu trn dch, trn kh mng phi mc t th
khng cn iu tr ngoi khoa. Nu trn dch nhiu v c suy h hp cn phi
dn lu mng phi (Khuyn co C).
12. Khuyn co 5.12: Liu php oxygen cn phi tin hnh khi SpO2 < 92%
(o khi ngi bnh th kh tri). Nu khng o c SpO2 th da vo tiu
chun th oxygen ca T chc y t th gii (Khuyn co B).
Ghi ch:
Ni dung khuyn co v cp khuyn co da trn nghin cu mc bng
chng (Evidence level) theo bng sau y:
MC GI TR
BNG CHNG

NGHA

Mc I hay A

Bng chng c c t nghin cu ngu nhin c i chng hay


tng quan h thng (systematic review of studies)

(Mnh)
Mc II hay B
(Trung bnh)
Mc III hay C
(Nh)

Bng chng c c t nghin cu khng chn ngu nhin (nghin


cu Cohort, nghin cu bnh chng, nghin cu loi ca)
Bng chng c c t nghin cu tng ca, k c nhng d liu v
nhy cm khng sinh m khng gn vi m t lm sng.

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

Liu thng dng

iu chnh liu trong th thut

< 120 kg: 2 g

Mi 4 gi (mi 2 gi i vi phu thut


tim)

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

71-99 kg: 1.25 g

Mi 12 gi

> 100 kg: 1.5 g

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

Khng sinh thay th


nu d ng
Penicillin

Cc phu thut, th thut tit niu


Sinh thit tuyn tin lit qua trc trng1

Cefazolin

Ciprofloxacin HOC
gentamicin2

Phu thut qua niu o (VD: Ct tuyn


tin lit qua niu o - TURP, ct u bng
quang qua niu o - TURBT, ni soi
niu qun, ni soi bng quang niu qun)

Cefazolin

Gentamicin2

Tn si

Cefazolin

Gentamicin2

Ct thn hoc ct b tuyn tin lit trit


cn

Cefazolin

Clindamycin

Ct bng quang trit cn; phu thut hi


trng; ct bng quang v tuyn tin lit
hoc ct bng quang, niu o, m o,
t cung v cc m thnh tiu khung.

Cefotetan

Clindamycin V
gentamicin2

Lin quan dng vt hoc cc phu thut


thay th b phn gi khc.

[Cefazolin HOC
vancomycin] V
gentamicin2

[Clindamycin HOC
vancomycin] V
gentamicin2

M xng c ng gia, ghp tim3

Cefazolin

Vancomycin

M xng c ng gia, ghp tim


ngi bnh tin s dng dng c h tr
tht (VAD) hoc c t cu vng khng
methicillin (MRSA) xm nhp/nhim
khun3

Cefazolin V
vancomycin

Vancomycin

t my to nhp hoc my kh rung tim


(ICD)

Cefazolin

Clindamycin HOC
vancomycin

Phu thut tim

t my to nhp hoc my kh rung tim


(ICD) ngi bnh c t cu vng khng Cefazolin V
methicillin (MRSA) xm nhp/nhim
vancomycin
khun

Vancomycin

t cc dng c h tr tht (VAD)

Cefazolin

Vancomycin

t cc dng c h tr tht (VAD)


ngi bnh c t cu vng khng
methicillin (MRSA) xm nhp/nhim
khun

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

Th thut mch cnh v mch cnh tay


u khng t graft

Khng khuyn co d
phng

Khng khuyn co
d phng

Th thut mch chi trn c t graft v


th thut mch chi di

Cefazolin

Clindamycin HOC
vancomycin

Th thut lin quan ng mch ch bng


hoc rch da vng bn

Cefotetan

Vancomycin +
gentamicin2

Ct thy phi, ct phi, m ngc, ni soi


lng ngc h tr video

Cefazolin

Clindamycin

Cc phu thut thc qun

Cefotetan

Clindamycin

M hp s, t dn lu dch no ty, cy
bm di mc ty

Cefazolin

Clindamycin

M cung sau t sng

Cefazolin

Clindamycin

Gn t sng

Cefazolin

Clindamycin HOC
vancomycin

Gn t sng ngi bnh c t cu


vng khng methicillin (MRSA) xm
nhp/nhim khun

Cefazolin V
vancomycin

Vancomycin

Cc th thut qua xng bm

Ceftriaxone

Moxifloxacin 400mg
trong 60 pht

Cc phu thut sch vng bn tay, gi


hoc bn chn, ni soi khp

Khng khuyn co d
phng

Khng khuyn co
d phng

Thay khp ton b

Cefazolin

Vancomycin

Thay khp ton b ngi bnh c t


cu vng khng methicillin (MRSA) xm
nhp/nhim khun

Cefazolin V
vancomycin

Vancomycin

Nn xng gy bn ngoi hoc c nh


bn trong

Cefazolin

Clindamycin HOC
vancomycin

Ct ct chi di

Cefotetan

Clindamycin V
gentamicin2

Gn t sng

Cefazolin

Clindamycin HOC
vancomycin

Gn t sng ngi bnh c t cu

Cefazolin V

Vancomycin

t cc dng c h tr tht (VAD) ngc


h
Phu thut mch mu

Phu thut lng ngc

Phu thut thn kinh

Phu thut chnh hnh

B Y t | LA CHN KHNG SINH D PHNG PHU 318


THUT

vng khng methicillin (MRSA) xm


nhp/nhim khun

vancomycin

M cung sau t sng

Cefazolin

Clindamycin

Th thut xm nhp vo ng tiu ha


trn, cu ni d dy, ct ty t trng, ct
thn kinh ph v chn lc cao, ni soi
cun y v Nissen

Cefotetan

Clindamycin
gentamicin2

Th thut ng mt (VD: ct ti mt,


m thong m rut)

Cefotetan

Clindamycin
gentamicin2

Ct gan

Cefotetan

Clindamycin
gentamicin2

Phu thut Whipple hoc ct ty

Cefotetan

Clindamycin V
ciprofloxacin

Rut non

Cefotetan

Clindamycin V
gentamicin2

M d dy ra da qua ni soi (PEG)

Cefazolin HOC
cefotetan

Clindamycin
gentamicin2

Ct rut tha (nu bin chng hoc hoi


t, iu tr nh vim phc mc th pht)

Cefotetan

Clindamycin V
gentamicin2

i trc trng, chn thng bng h

Cefotetan

Clindamycin V
gentamicin2

M thot v bn

Cefazolin

Clindamycin

Thot b bn c bin chng, m cp cu


hoc ti pht

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

Ct t cung (ng m o hoc bng)

Cefazolin HOC
cefotetan

Clindamycin V
gentamicin2

Phu thut ung th

Cefotetan

Clindamycin V
gentamicin2

Phu thut sa bng quang hoc sa trc


trng

Cefazolin

Clindamycin

Phu thut chung

Phu thut sn khoa

Phu thut vng u v mt

B Y t | LA CHN KHNG SINH D PHNG PHU 319


THUT

Ct tuyn mang tai, ct tuyn gip, ct


amydal

Khng khuyn co d
phng

Khng khuyn co
d phng

Phu thut to hnh c thay th cc b


phn

Cefazolin

Clindamycin

Ct VA, to hnh mi, phu thut gim


th tch khi u hoc gy xng hm di

Cefotetan HOC
clindamycin

Clindamycin

i phu vng c

Cefazolin

Clindamycin

Phu thut sch c yu t nguy c hoc


hn hp sch nhim bn

Cefazolin

Clindamycin

t/cy/tt c vt ghp m

Cefazolin

Clindamycin

To hnh mi

Khng d phng
HOC cefazolin

Khng d phng
HOC clindamycin

Ghp ty hoc ty/thn

Cefotetan

Clindamycin V
ciprofloxacin

Ghp thn/ngi cho sng

Cefazolin

Clindamycin

Ghp gan

Cefotetan

Clindamycin V
ciprofloxacin

Cefotetan

D ng Penicilin:
clindamycin V
gentamicin

Phu thut to hnh

Phu thut ghp tng vng bng

Th thut X quang can thip


ng mt/ng tiu ha; nt ha
cht/ct gan di da (tin s phu
thut/t dng c ng mt; m thng
manh trng.

Nt ha cht; gy tc ng mch trong u


Khng khuyn co d
x t cung; ct gan/thn/phi qua da5; nt
phng
d dng mch6
Th thut tit niu (tr ct thn)

Cefazolin

D ng Penicilin:
gentamicin

Chp/gy tc mch bch huyt

Cefazolin

D ng Penicilin:
clindamycin

t ng thng (VD: tnh mch trung


tm); th thut can thip ng/tnh mch.

Khng khuyn co d
phng

t bung tim cy di da (VD


Mediport)

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

La chn khng sinh ng


ung sau th thut8

B Y t | LA CHN KHNG SINH D PHNG PHU 320


THUT

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

Gentamicin 5 mg/kg ng tnh Khng cn thm liu v


mch 1 liu duy nht trong 30- gentamicin v ceftriaxone duy tr
60 pht
mc kh dng trong 24 gi
HOC
ceftriaxone 1 g ng tnh
mch trong 30 pht nu nhy
cm

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

Khng k thm liu gentamicin sau phu thut d phng.

Phu thut ngc h, tip tc dng khng sinh d phng n khi ng ngc.

Cc khuyn co a ra dnh cho cc ngi bnh khng c d liu xc ng v vi sinh c th


gi tnh trng khng thuc;
5

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

Mi liu cho chc nng thn bt k

SCIP khng yu cu khng sinh sau th thut.

B Y t | LA CHN KHNG SINH D PHNG PHU 321


THUT

PH LC 4
HNG DN TIM/TRUYN MT S LOI KHNG SINH
TT

Tn hot cht nng

Tim bp

Tim tnh mch


Cch pha

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

Pha 1g vi 50ml dung


mi tng hp
* Ha tan trong 3ml
NCPT, pha long
trong dung mi tng
hp (nng khng
vt qu 2%)

Ha tan trong 4.8ml


NCPT, pha long: vi
dung mi tng hp
n nng 1-2mg/ml

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

Khi pha, cn lc mnh


ngay lp tc; Dung dch
Aztreonam c nng
>2%, phi s dng ngay
tr khi hon nguyn/ pha
long bng NCPT v
NaCl 0.9%

60 pht

NaCl 0.9%,
Gluc 5%,
Hartmanns.

Dung dch sau khi pha


n nh 24 gi nhit
phng (250C) v 7 ngy
trong t lnh

30-60 pht [2]

Nn dng NaCl
0.9% [1]

Dung dch pha nn s


dng ngay, c th bo
qun 2-80C trong 24h
[2]

NaCl 0.9%

Tim bp: ngay trong


vng 1h sau pha, tim
tnh mch: trong vng 8h
sau pha, pha long ngay
sau khi ha tan

Truyn tnh mch


Tc

15-30 pht

B Y t | PH LC 4 322

TT

Tn hot cht nng

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

Tim tnh mch

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

15UI/ 5ml NaCl


0.9%

500mg/1.7ml
NCPT
250mg/1.9ml
NCPT

* ch nn tim
bp liu
600mg

250mg/4.9ml
NCPT
500mg/4.8ml
NCPT

Truyn tnh mch

Dung mi
tng hp

Ch

NaCl 0.9%

Lc mnh khi ha tan,


dng ngay sau khi pha,
c th bo qun 2-80C
trong 24h [2]

3-4 pht

Ha tan: 250mg/5ml
NCPT
pha long: 50-100ml
NaCl 0.9%

3-4 pht

600mg/ 50ml NCPT


hoc NaCl 0.9%

30-40 pht

NaCl 0.9%

Nn truyn trong vng


3-4h sau khi pha long
250C, bo qun c
5oC trong 8h

2-3 pht

Pha long dung dch


cha 500mg/ 100ml 200ml dung mi tng
hp

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%

Lc k khi pha; Dung


dch sau hon nguyn
(125 -250 mg/ml) n
nh trong 24 gi nhit
phng (25oC);
Dung dch truyn sau
pha long n nng
1-2mg/ml n nh trong
vng 12h nhit
di 25oC

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

Liu < 900mg: pha


long/ 50ml dung mi
tng hp
*liu 900mg: 100ml
dung mi tng hp

10-60 pht,
tc khng
qu
30mg/pht

NaCl 0.9%

Dng ngay sau khi pha,


bo qun c 2-8oC
trong 24h; C th truyn
lin tc 0,751,25mg/pht [1]

B Y t | HNG DN TIM/TRUYN MT S LOI 323


KHNG SINH

TT

Tn hot cht nng

Tim bp

Tim tnh mch

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]

Truyn tnh mch

Dung mi
tng hp

Ch

Ha tan: 10ml NCPT


pha long: 250ml
NaCl 0.9% (hoc dung
mi tng hp n
nng 2mg/ml) [2]

60 pht [2]

NaCl 0.9%, Glu


5%, NaCl- Glu,
Ringer, lactate

S dng ngay sau khi


m hoc pha long;
Dung dch truyn, sau
pha long (2mg/ml), nn
s dng trong vng 6 gi
bo qun nhit
phng (250C) hoc 2448 gi nu bo qun
di 50C [1]

Pha long trong dung


mi tng hp n
1mg-2mg/ml

60 pht

Glu 5%, NaCl


0.9%, Ringer's,
Hartmann's [2]

Dng ngay sau khi m,


nu dng khng ht phi
b i

1 pht

Ha tan: 9.2ml NCPT,


NaCl 0.9%, Glu 5%
Pha long: 100ml
NaCl 0.9% [2]

10 pht [2]

Glu 5%, NaCl


0.9%,
Ringer's,
Hartmann's [2]

Dung dch pha truyn c


th bo qun nhit
phng trong 24h [2]

3-5 pht

Ha tan: 750mg/ 6 n
10ml NCPT
Pha long: 50-100ml
NaCl 0.9% [2]

15-60 pht [1]


30 pht [2]

Glu 5%, NaCl


0.9%,
Ringer's, NaClGlu, Hartmann's
[2]

S dng ngay sau khi


m hoc pha long, c
th bo qun 2-80C
trong 24h [2]

2-4 pht
[2]

Ha tan: 1g trong
10ml NCPT
Pha long: 50-100 ml
dung mi tng hp
[2]

15-30 pht [1]


30 pht [2]

Glu 5%, NaCl


0.9%, NaClGlu, Ringer's,
Hartmann's [2]

S dng ngay sau khi


m hoc pha long, c
th bo qun 2-80C
trong 24h [2]

B Y t | HNG DN TIM/TRUYN MT S LOI 324


KHNG SINH

TT

Tn hot cht nng

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

Tim tnh mch

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

Truyn tnh mch

Dung mi
tng hp

Ch

Glu 5%, NaCl


0.9%, Ringer
lactate

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

Pha long dung dch


hon nguyn trong 50100ml dung mi tng
hp

Glu 5%, NaCl


0.9%, NaClGlu, Ringer's,
Hartmann's [2]

3-5 pht

Pha long dung dch


hon nguyn trong 50100ml NaCl 0.9%, Glu
5%

20-60 pht

Glu 5%, Ringer


lactate, NaCl
0.9%

dung dch c nng


10-40mg/ml bo qun
c trong 24h iu
kin thng v 96h
trong t lnh

3-5 pht

Ha tan: 4ml NCPT


pha long: 50-100ml
Glu 5% hoc NaCl
0.9% [2]

20-60 pht [2]

Glu 5%, NaCl


0.9%

S dng ngay sau khi


m hoc pha long, c
th bo qun 2-80C
trong 24h [2]

Pha long dung dch


hon nguyn trong
dung mi tng hp

30 pht

Glu 5%, NaCl


0.9%, Glu-NaCl
[2]

Dung dch sau khi pha


long bo qun c
nhit phng trong 24h
hoc bo qun lnh trong
1 tun

15-30 pht

B Y t | HNG DN TIM/TRUYN MT S LOI 325


KHNG SINH

TT

Tn hot cht nng

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

Tim tnh mch

5ml NCPT

500mg/10ml
NaCl 0.9% [2]

Dung mi
tng hp

Ch

Truyn lin
tc

Glu 5%, NaCl


0.9%, Ringer
lactate

dung dch sau khi pha


bo qun c nhit
phng trong 24h hoc
bo qun lnh trong 10
ngy

1-4h

NaCl 0.9%, Glu


5%, Ringer
lactate,
G5%/Ringer
lactate

Dung dch pha truyn c


th bo qun 2-80C,
trnh nh sng trong 72h
hoc n nh trong 48
gi nhit phng
(250C); Qu trnh truyn
cn hon tt trong 12h

NaCl 0.9%, Glu


5%, Ringer

Sau khi ha tan tim


tnh mch, yn trong
khong 10 pht to
dung dch trong sut,
Dung dch ha tan
hoc pha long c th
bo qun iu kin
thng trong 12h v bo
qun t lnh trong 40h

NaCl 0.9%,
Ringer

*Ha tan ngay sau khi


cho NCPT vo ng
thuc, dung dch pha
c th bo qun nhit
phng trong 24h hoc
2-150C trong 14 ngy

Truyn tnh mch

3-5 pht

Pha long dung dch


hon nguyn trong 50100 ml dung mi
tng hp

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]

Pha long dung dch


hon nguyn vi t
nht 250ml dung mi
tng hp

30 pht

20-60 pht

NaCl 0.9%,
Ringer lactate,
G5%

B Y t | HNG DN TIM/TRUYN MT S LOI 326


KHNG SINH

TT

Tn hot cht nng

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

Tim tnh mch

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%

Tim trong vng 30 pht


sau khi ha tan, c th
bo qun trong t lnh
trong 24h

0.5-2h

NaCl 0.9%,
Gluc 5%, GlucNaCl,
Hartmanns [2]

Dng ngay sau khi pha,


c th bo qun 2-80C
trong 24h; dung dch sau
pha long n nh trong
24h nhit phng
(250C)[1]
Khng un nng ha
tan, ch phm tim bp:
dng ngay trong vng 1h
sau khi pha, dung dch
truyn: bo qun c
iu kin thng trong
4h, iu kin 40C trong
24h

Truyn tnh mch

3-4 pht

3-5 pht
[2]

Pha long dung dch


hon nguyn trong
dung mi tng hp,
thng dng 100ml
NaCl 0.9% [2]

Pha long: 50-200ml


NaCl 0.9% hoc Glu
5%

Ha tan: 10ml NaCl


0.9%
pha long: 100ml
NaCl 0.9%

250-500mg:
20-30 pht
[2]

NaCl 0.9%, Glu


5%, NaCl- Glu,
Ringer, lactate

Pha long: NaCl 0.9%


hoc Glu 5% n nng
2.5-5mg/ml

30-60 pht

NaCl 0.9%, Glu


5%

Pha long: 1g/100ml


dung mi tng hp

60 pht

NaCl 0.9%, Glu


5%

500mg/2ml
Lidocain 1%

Kanamycin
ng dung dch
1g/3ml

Lincomycin
ng dung dch
300mg
Lincomycin
base/ml

B Y t | HNG DN TIM/TRUYN MT S LOI 327


KHNG SINH

TT

Tn hot cht nng

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

Tim tnh mch

Truyn tnh mch

Dung mi
tng hp

Ch

* Dch truyn pha sn


* Pha long vi dung
mi thch hp n
5mg/ml

60 pht cho
liu 500mg;
90 pht cho
liu 750mg

NaCl 0.9%, Glu


5%

Dng ngay sau khi m,


nu khng dng ht phi
b phn cn li i; Dung
dch sau pha long
5mg/ml n nh trong
vng 72 gi nhit
=<25oC hoc 14 ngy
50C [1]

60 pht,
hoc truyn
tnh mch lin
tc

NaCl 0.9%, Glu


5%, NaCl- Glu
[2]

Khng bo qun lnh


trnh kt tinh, dng ngay
sau khi m, nu khng
dng ht phi b i

Khng cn pha long

Ha tan mi
500mg/10ml
NCPT

3-5 pht

Pha dung dch tim


truyn bng cch ha
tan thuc meropenem
trong dung dch tim
truyn NaCl 0.9%
hoc dung dch tim
truyn glucose
(dextrose) 5% thu
c dung dch cui
c nng t 1 n 20
mg/ml.

15-30 pht

NaCl 0.9%,
Glu 5%

Dung dch sau khi pha


nn c s dng ngay
lp tc. V mt n nh
l ha:
- Dung dch tim pha
trong NCPT c th bo
qun 25oC trong 3 gi,
nhit lnh (2-8oC)
trong 16 gi.
- Dung dch tim truyn
pha trong NaCl 0.9% c
th bo qun 25oC
trong 3h, nhit lnh
(2-8oC) trong 24h.
- Dung dch tim truyn
pha trong Glucose
(dextrose) 5% nn c
s dng ngay lp tc.
Khng nn trn vi cc
thuc khc.

B Y t | HNG DN TIM/TRUYN MT S LOI 328


KHNG SINH

TT

Tn hot cht nng

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]

Tim tnh mch


Pha mi 1g trong
10ml NCPT
hoc NaCl
0.45%-0.9%

Truyn tnh mch

10 pht

Pha long trong dung


mi tng hp n
0.5-40mg/ml

Dung mi
tng hp

Ch

NaCl 0.9%, Glu


5%

Dung dch hon nguyn


n nh trong 3 ngy
iu kin thng v 1
tun trong t lnh

NaCl 0.9%, Glu


5%

Dng ngay sau khi m,


nu dng khng ht phi
b i

Khng cn pha long

200mg: 30
pht
400mg: 60
pht

Pha long: 300-500ml


Glu 5%

60-90 pht

NaCl 0.9%, Glu


5%, Ringer

Dung dch hon nguyn


nn c b i sau 72h

3-5 pht

Pha long dung dch


hon nguyn trong t
nht 50ml dung mi
tng hp

20-30 pht

Glu 5%

Khng tim bp hn 2g
piperacillin cng 1 v
tr

3-5 pht
[2]

Pha long dung dch


hon nguyn trong t
nht 50ml dung mi
tng hp

Glu 5%, NaCl


0.9%, Ringer
lactate

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

NaCl 0.9%, Glu


5%, Ringer
lactacte

Dung dch hon nguyn


n nh t 3-7 ngy
trong t lnh, dch pha
truyn n nh 24h
nhit phng
S dng ngay sau khi
pha [2]

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]

Pha long dung dch


hon nguyn trong
100ml NaCl 0.9% [2]

30 pht

30-60 pht [2]

B Y t | HNG DN TIM/TRUYN MT S LOI 329


KHNG SINH

TT

Tn hot cht nng

40

Rifampicin
bt pha tim
600mg

Tim bp

Tim tnh mch

Truyn tnh mch

Dung mi
tng hp

Ch

3h

NaCl 0.9%, Glu


5% [2]

Dung dch hon nguyn


n nh trong 24h
nhit phng
Dch truyn pha nn
s dng ngay [2]

Ha tan: 10ml NCPT


Pha long: 500ml Glu
5% hoc NaCl 0.9%

Ha tan trong
NCPT: 4.2ml
to dung dch
200mg/ml,
3.2ml:
250mg/ml
1.8ml:
400mg/ml [2]

NaCl 0.9%, Glu


5% [2]

Dung dch hon nguyn


c th bo qun nhit
phng trong 24h [2]

Pha long mi 5ml


trong 125 ml Glu 5%
c th trong 75ml Glu
5% nu phi hn ch
dch truyn

60-90 pht

NCPT

S dng ngay sau khi


pha [2]

3-5 pht
[2]

Pha long: 50-100ml


NaCl 0.9%, Glu 5%
[2]

Glu 5%, NaCl


0.9%, Glu-NaCl

Dng ngay sau khi m,


c th bo qun 2-80C
trong 24h [2]

Ha tan: 13ml NCPT


hoc NaCl 0.9%
Pha long: n nng
Ticarcillin 10100mg/ml trong dung
mi tng hp

Glu 5%, NaCl


0.9%
[2]

Dung dch hon nguyn


n nh nhit phng
trong 6h v 40C trong
72 gi

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

B Y t | HNG DN TIM/TRUYN MT S LOI 330


KHNG SINH

TT

Tn hot cht nng

Tim bp

Tim tnh mch

Truyn tnh mch

Dung mi
tng hp

Ch

S dng ngay sau khi


pha, c th bo qun 280C trong 24h [2]

45

Vancomycin
bt pha tim
500mg, 1g

Truyn ngt qung:


ha tan: mi
500mg/10ml NCPT,
pha long: mi 500mg
trong 100ml NaCl
0.9% hoc Glu 5%
Truyn lin tc: pha
thuc vi nng 2,55 mg/ml trong NaCl
0.9% hoc Glu 5%

46

Moxifloxacin
400mg/250ml

Khng cn pha long

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

Glu 5%, NaCl


0.9%

Hon nguyn bng 2


ml NCPT sau pha
long trong 50 ml
dung mi tng hp

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]

Dung dch sau hon


nguyn nn bo qun
trong t lnh v cn
c s dng trong 24
gi; hoc 8 gi nu
nhit phng (250C)

B Y t | HNG DN TIM/TRUYN MT S LOI 331


KHNG SINH

TT

49

50

Tn hot cht nng

Cefoperazone

Cefamandole
Sodium

Tim bp

tim bp su [3]

tim bp su [3]

Tim tnh mch

Truyn tnh mch

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

NaCl 0,9%, Glu


5%, Ringer
lactate

Khi nng ha tan


vt qu 333mg/ml, cn
lc mnh v lu. Dung
dch pha n nh
trong 24h nhit
phng v trong 5 ngy
nu bo qun trong t
lnh [3]
cc nng 2mg hay
20mg/ml, cefamandol n
nh v mt vt l trong
24h nhit phng
hoc 96h 5C trong
dung dch v khun [3]

Ti liu tham kho:


[1] Handbook on injectable drugs;
[2] Injectable drugs guide
[3] Dc th quc gia
[4] Micromedex
Ch thch:
X ng dng khng khuyn co s dng
* dng trc tip

B Y t | HNG DN TIM/TRUYN MT S LOI 332


KHNG SINH

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