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(123doc - VN) - Huo-Ng-Da-N-Su-Du-Ng-Kha-Ng-Sinh-2015-Bo-Y-Te PDF
(123doc - VN) - Huo-Ng-Da-N-Su-Du-Ng-Kha-Ng-Sinh-2015-Bo-Y-Te PDF
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:
Nguyn Th Xuyn
B Y T
H NI - 2015
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
T TH K V BIN TP:
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
B Y t | DANH MC HNH V 10
T VIT TT TING ANH
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
5 Phenicol
6 Tetracyclin Th h 1
Th h 2
7 Peptid Glycopeptid
Polypetid
Lipopeptid
8 Quinolon Th h 1
Cc fluoroquinolon: Th h 2, 3, 4
9 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 6-
aminopenicilanic (vit tt l A6AP). Trong cc khng sinh nhm penicilin, ch
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
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 | 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
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.
Porin
Beta-lactamase
PBP H thng bm y ra
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.
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 antibiotic-
associated 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 | 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.
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).
T VIT TT TRONG BI
Penicilin 8,4% - -
Ampicilin 0 84,6 24,2
Cephalothin 14,5 64,3 6,8
Cefuroxime - 50,0 1,7
Erythromycin 64,6 13,2 17,3
Cefortaxim 0 2,6 4,9
Gentamycin - 35,1 8,3
Cotrimoxazole 62,9 88,6 65,8
Chloramphenicol 31,9 73,2 65,8
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
T VIT TT TRONG BI
NKQ Ni kh qun
1. Cunha BA (2010), Pneumonia Essentials 3nd Ed, Royal Oak, MI: Physicians Press, 111-
118.
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.
Vi sinh vt Yu t nguy c
H. influenzae, 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)
Moraxella catarrhalis,
S. pneumoniae
P. aeruginosa, iu tr bng corticoid, suy dinh dng, bnh phi (gin ph
Acinetobacter baumannii 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:
Imipenem 0,5 1g mi 6 gi, ti a 4g/ngy, truyn tnh mch trong 3-4 gi.
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).
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).
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.
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 | 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 beta-
lactam-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 1-
1,5g/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.
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 | 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 | 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, sng-
nng - . 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.
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.
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 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.
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:
T VIT TT TRONG BI
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.
T VIT TT TRONG BI
H.p Heliobacter pylori
PPI Proton pump inhibitor (Thuc c ch bm proton)
RBC Ranitidin bismuth citrate
Mc
Nh (I) Trung bnh (II) Nng (III)
Biu hin suy tng Khng Khng C
p ng iu tr ban u C 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.
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.
La chn s 1
Khng sinh
penicillin kt hp Ampicilin-sulbactam ng tnh mch (TM) 1,5-3 g/6 gi.
vi cht c ch beta-
lactamase c hot Piperacilin-tazobactam TM 4,5 g/6 gi.
ph rng
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 Ceftriaxon TM 2-4 g/1 ln/24 gi.
th h 3,4 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 | 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
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; MacGraw-
Hill/Appleton and Lange, 2001; p 160-168.
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 community-
acquired methicilin-resistant Staphylococcus aureus. Clin Infect Dis. Jun 1 2008;46 Suppl
5:S368-77.
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 | 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
T VIT TT TRONG BI
v n v
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.
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 24-
48h 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 | 243
B Y t | 244
Cc cu trc ca mt c lin quan n
cc bnh l nhim khun
(Tuyn Zeis)
(Tuyn sn mi)
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 1-
2 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.
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 | 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
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
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 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.
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)
Cefotaxim 100-150 mg/kg (8- 150-200 mg/kg (6- 225-300mg/kg 8-12g (4-6)
12) 8)
(6-8)
Ceftazidim 100-150 mg/kg (8- 150 mg/kg (8) 150 mg/kg (8) 6 g (8)
12)
Ceftriaxon 80100 mg/kg (12 4 g (1224)
24)
Chloramphenicol 25 mg/kg (24) 50 mg/kg (1224) 75100 mg/kg (6) 46 g (6)c
Gentamicinb 5 mg/kg (12) 7.5 mg/kg (8) 7.5 mg/kg (8) 5 mg/kg (8)
Oxacilin 75 mg/kg (812) 150200 mg/kg (6 200 mg/kg (6) 912 g (4)
8)
Penicilin G 0.15 mU/kg (812) 0.2 mU/kg (68) 0.3 mU/kg (46) 24 mU (4)
Vancomycinf 2030 mg/kg (812) 3045 mg/kg (68) 60 mg/kg (6) 3045 mg/kg (8
12)
Ch thch:
a
Tr s sinh non thng - nh cn (< 2kg) c khuyn co dng liu thp hn v khong cch di
hn
b
Cn gim st nng nh v nng y (nu c iu kin).
c
Vim mng no do ph cu c khuyn co dng liu cao hn.
d
Ch s dng khi cc khng sinh khc khng hiu qu.
e
Liu ti a trong ngy 600mg
f
Nng duy tr thp nht trong mu l 15-20 mg/ml (nu c iu kin)
g
Khng khuyn co s dng Meropenem cho tr di 3 thng tui.
T VIT TT TRONG BI
DNT Dch no ty
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 Gram-dng: t gp di 10%: Enterococcus,
Staphylococcus...
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.
T VIT TT TRONG BI
VK Vi khun
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.
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 | 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.
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 | 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 NGHA
BNG CHNG
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
B Y t | PH LC 2. 316
PH LC 3.
LA CHN KHNG SINH D PHNG PHU THUT
B Y t | PH LC 3. 317
Cefazolin V Vancomycin V
t cc dng c h tr tht (VAD) ngc
vancomycin n khi ciprofloxacin n khi
h
ng ngc ng ngc
Phu thut mch mu
Th thut mch cnh v mch cnh tay Khng khuyn co d Khng khuyn co
u khng t graft phng d phng
Th thut mch chi trn c t graft v Clindamycin HOC
Cefazolin
th thut mch chi di vancomycin
Th thut lin quan ng mch ch bng Vancomycin +
Cefotetan
hoc rch da vng bn gentamicin2
Phu thut lng ngc
Ct thy phi, ct phi, m ngc, ni soi
Cefazolin Clindamycin
lng ngc h tr video
Cc phu thut thc qun Cefotetan Clindamycin
Phu thut thn kinh
M hp s, t dn lu dch no ty, cy
Cefazolin Clindamycin
bm di mc ty
M cung sau t sng Cefazolin Clindamycin
Clindamycin HOC
Gn t sng Cefazolin
vancomycin
Gn t sng ngi bnh c t cu
Cefazolin V
vng khng methicillin (MRSA) xm Vancomycin
vancomycin
nhp/nhim khun
Moxifloxacin 400mg
Cc th thut qua xng bm Ceftriaxone
trong 60 pht
Phu thut chnh hnh
Cc phu thut sch vng bn tay, gi Khng khuyn co d Khng khuyn co
hoc bn chn, ni soi khp phng d phng
Thay khp ton b Cefazolin Vancomycin
Thay khp ton b ngi bnh c t
Cefazolin V
cu vng khng methicillin (MRSA) xm Vancomycin
vancomycin
nhp/nhim khun
Nn xng gy bn ngoi hoc c nh Clindamycin HOC
Cefazolin
bn trong vancomycin
Clindamycin V
Ct ct chi di Cefotetan
gentamicin2
Clindamycin HOC
Gn t sng Cefazolin
vancomycin
Gn t sng ngi bnh c t cu Cefazolin V Vancomycin
B Y t | PH LC 4 322
Tn hot cht - Dung mi
TT Tim bp Tim tnh mch Truyn tnh mch Ch
nng tng hp
Amoxicillin Ha tan: 250mg/5ml Lc mnh khi ha tan,
Ha tan 500
bt pha tim NCPT dng ngay sau khi pha,
5 mg/2.5 mL; 1 250mg/5ml 3-4 pht 30-60 pht NaCl 0.9%
250mg, 500mg, pha long: 50-100ml c th bo qun 2-80C
g/4ml NCPT;
1g NaCl 0.9% trong 24h [2]
Amoxicillin
Nn truyn trong vng
clavulanate 600mg/10 ml;
600mg/ 50ml NCPT 3-4h sau khi pha long
6 bt pha tim x 1.2g/20 ml 3-4 pht 30-40 pht NaCl 0.9%
hoc NaCl 0.9% 250C, bo qun c
600mg, hoc NCPT.
5oC trong 8h
1.2g
Ciprofloxacin
chai truyn pha Pha long trong dung Glu 5%, NaCl Dng ngay sau khi m,
12 sn 2mg/ml hoc x x x mi tng hp n 60 pht 0.9%, Ringer's, nu dng khng ht phi
ng dung dch 1mg-2mg/ml Hartmann's [2] b i
10mg/ml
Khng un nng ha
Imipenem- tan, ch phm tim bp:
cilastatin Ha tan: 10ml NaCl dng ngay trong vng 1h
250-500mg: NaCl 0.9%, Glu
bt pha tim 500mg/2ml 0.9% sau khi pha, dung dch
28 x x 20-30 pht 5%, NaCl- Glu,
cha 250mg- Lidocain 1% pha long: 100ml truyn: bo qun c
[2] Ringer, lactate
500mg mi hot NaCl 0.9% iu kin thng trong
cht 4h, iu kin 40C trong
24h
Lincomycin
ng dung dch
Pha long: 1g/100ml NaCl 0.9%, Glu
30 300mg * x x 60 pht
dung mi tng hp 5%
Lincomycin
base/ml
33 Meropenem x Ha tan mi 3-5 pht Pha dung dch tim 15-30 pht NaCl 0.9%, Dung dch sau khi pha
bt pha tim 500mg/10ml truyn bng cch ha Glu 5% nn c s dng ngay
500mg, 1g NCPT tan thuc meropenem lp tc. V mt n nh
trong dung dch tim l ha:
truyn NaCl 0.9%
- Dung dch tim pha
hoc dung dch tim
trong NCPT c th bo
truyn glucose
qun 25oC trong 3 gi,
(dextrose) 5% thu
nhit lnh (2-8oC)
c dung dch cui
trong 16 gi.
c nng t 1 n 20
mg/ml. - 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.
Tim
tnh
50 n 200 mL NS hoc truyn 30 pht Glu 5%, NaCl
47 Netilmicin c th tim mch D5W [4] n 2 ting 0.9%
chm 3-
5 pht
Truyn tnh
mch lin tc
sau khi tim Dung dch sau hon
Hon nguyn bng 2 tnh mch 1- nguyn nn bo qun
Colistin, l 150 Ha tan bng 2 Ha tan bng 2 ml NCPT sau pha 2h (1/2 liu: NS, D5NS, trong t lnh v cn
48 3-5 pht
mg ml NCPT ml NCPT long trong 50 ml tim tnh D5W, LR [4] c s dng trong 24
dung mi tng hp mch, cn 1/2 gi; hoc 8 gi nu
liu: truyn nhit phng (250C)
tnh mch lin
tc