Nhiém tring ngogi khoa - Khdng sinh trong phiiu thujt - GS. TS. Nguyén Cong Minh. 1 NHIEM TRUNG NGOAI KHOA sU DUNG KHANG SINH TRONG PHAU THUAT GS. TS. BS. NGUYEN CONG MINH PHAN 1. NHIEM TRUNG NGOAI KHOA DINH NGHIA NHIEM TRUNG Nhigm tring durge xée dinh khi c6 lp duge vi tring tir mét t6 chite (hay mgt co quan) tring tai ché thudng két hp véi hign tuong viém nhu sung, néng, do, dau. Hau hét nhiém tring déu c6 hdi chimg (HC) dap tng viém toan than (SIRS) khi c6 2 trong cdc déu ching sau:°74"") 9 > 38°C hay <36°C tim> 90 lin/phiit o. Nhip thé > 20 Lin/phut hay PaCO2 < 32mmHg © Bach cdu > 12.000/ml hay < 4.000/ml. Negoai nguyén nhan nhiém tring, HC dip dng viém toin_thin (SIRS: systemic inflammatory response $) ciing thubng gp trén cic BN ngoai khoa nhu: da thwong, bang, viém tuy, ung thu, phan img dich truyén...!"9) Nhigm tring (sepsis) 18 tinh trang viém nhiém do vi tring, siéu vi, vi nam, ho&c ky sinh tring gay ra, cé biéu hién toan than (HC dap tmg vigm toan than). tb) ‘*Nhigm tring nang (severe sepsis) 18 tinh trang nhigm tring va bit dau 6 suy ede co quan (do gidim tudi mau m6) nh ~ Thiby nigu-Creatnine > 2ma% (€®i hoi hoi se le truyén)s - Huyét ap tudt (ddi hoi phai str dung vén mach)... #Séc nhiém tring (septic shock) la nhigm tring ning c6 suy ‘tuan hoan cap (hu; thu < 90mm Hg) bat chdp héi sire truyén dich va khéng cd nguyén nhan khdc. Séc nhi&m tring chiém 40% céc loai nhiém tring ning, dua tir vong lén dén 60-80%"! NHIEM TRUNG NGOAI KHOA Trude day cde tée gid sir dung thudt ngtt *N/ tring vét_mé (Surgical Wound Infection), nay duge hiéu rong va thay | bang *Nhiém trig do phdu thudt (SSI: Surgical Site Infection) la nhiém tring do kip m6 gay ra (do phu thuat), durge theo dot trong vong 30 ngay (hoac trong vong 1 nam, déi véi cuge mé cé manh ghép nhan tao).!"* *Nhiém tring ngoai khoa (Surgical Infection) mang ¥ nghia bao quét hon, 1a tit cd nhiém tring lién quan dén ngogi khoa.!*78! Quan diém ci: nhiém tring ngoai khoa la loai nhiém tring ddi héi phai can thiép ngoai nhu: *Nhiém tring trong 6 bung (VPM, ap xe tén luu); *Nhiém tring da va mé mem, Quan diém hign nay: nhigm tring ngogi khoa la tinh trang nhiém ep aal al tate ip phdu thudt hoa 1a héu qua (bién chimg) cla phau thuat.°5) chimg bao gm tat cd cdc nhiém tring lién quan dén cue mé, ké ca nhiém tring isin vién 67"Nhiém tring ngogi khoa - Khiing sink trong phéu thudt - GS. TS. Nguyén Cong Minh. 2 KHA NANG DU PHONG ‘Tat ca cdc nhiém tring nguy hiém va tén kém déu c6 thé trénh duge nhé ede phurong thie ddy phong ap dung dng loat. Béi vi khéng 6 mt phuong thire don 18 nao mang Igi dy phong hiéu qua") Nguyén tc phong chéng nhiém tring do phdu thuat la: ~ Quy trinh chudn bj tién phdu, nguyén téc v6 tring va KS dy phong ding quy cach: Rifa tay bang xa phéng la tét nhét.©78!51 Ria tay nhanh bing gel cdn sdt trio ig cling higu qua, ngoai trir Clostridium difficile (phai ding xa phng va nuéc sach)_678!'5) ~ Han ché cdc éng dan luu va céc éng théng ngi mach, Rit cang sém cang tét, néu myc dich da dat duge: ong théng ludn do ép lye tinh mach trung tém khéng duge Iu gitt mot ché qua 24 gid,!678!51 - Thao tée thii thugt phai nhe nhang, cm mau ky, khong dé lai khoang tréng va luén tuéi dung dich mudi dang truong 4m Ién cac té chiie phai phoi bay léu trong lie mé, ~ Sir dung khéng sinh diéu tri va khdng sinh dy phéng theo kinh nghigm hod theo khang sinh dé khéng nén chi dinh rong rai, hau trénh tinh trang da khéng nhu hién nay. KHA NANG CHONG DO CUA KY CHU G dong vat hitu nhi, I6p biéu bi cia da va lép niém mac (cia dudng hé hdp, tiéu héa, nigu - sinh duc) ludn duge bao vg trude sy tan cong cua vi tring, ké cd céc vi tring thudng trdi céng sinh tai day (vi tring chi: micro flora). Hang rao bao vé nay sé khong, con higu gua néu bj tdn thuong (sang chan-bim dap - duéi téc dung cia vat ly hay hod hoo) 63891 - G da: mé hdi va qué xtie véi cfc tée nhan ‘inh bong tréc da ty nhién 1a mt hinh thite bao vé co thé khi tip it I¥ (vi dy tia tir ngoai cua dnh nang...). 6 dudng hd : dam duge tiét ra sé gitr mot lugng Ién vi tring, dé rdi duge ting xudt ra ngoai nhé céc té bao long chuyén. O duéng hé hp dudi, cdc dai thyc bao tai phé nang sé tiéu digt dan céc vi tring xudt hign tai chd. Khi kha ning chong dé nay bi suy gidm, viém phé quan va viém phdi dé xay ra"9) ~ Cac vi tring cng sinh trong dudng nigu-sinh duc, dudng mat, éng tuy va phan ho hép tan khOng gay bénh, trir phi cdc hang rao chéng dé bj t6n thong (nhwr ung thu, viém, sdi hay vat la) hoe sang chin (do dat dng théng hoc viém phéi hit).!©") ~ C6 v6 s6 vi triing trong dudng tiéu héa, ma da sé 6 hd hong va tryc trang. 'ai sao c6 nhieu vi tring tai hau hong, nhung khong gay bénh dung tiéu hod ? Boi vi s6 vi tring dy khi qua da day sé bj pH toan tiéu digt hoc lam yéu di. Bat ctr bénh ly ho&c sy lam dung thudc nao kim kiém héa méi trudng da day déu 6 thé khién cdc vi tring nay phat trién, gay bénh. Mac khéc, su ér dong, thoi gian lu lai lau va ndng d6 oxy kém trong dai trang, sé gidp cdc vi tring phét trién manh. Cé mot digu may min dic bigt la trong ede truéng hop vigm phic mae do thing tang réng, ede vi tring niy Iai hign hotu rét it.) Khi vi tring vao cdc khoang ty nhién (khoang mang phdi hay 6 bung), dudi tic dung. cia co ché vat IY, lactoferrin (céc protein duge tiét ra) sé thu ldy yéu t6 ting trung sit ciia vi tring, ngin chan sy vi tring phat trién. Trén tong thé, fibrinogen trong dich xuat ti&t (dich viém) cdm gitr mot long l6n vi tring, duéi téc dung cia men polymerase. Hoat dong lén xudng cita co hoanh tgo co ché hut, dua vi triing vé sat mat dudi hoanh, tich ty, Khu trd lai thanh 4p xe dudi hoanh. Két hgp véi hign twong ligt rut khu tra va Vai trd bao vé cia mac néi... tgo thanh bite tung thinh che boc Iai, gidip gidi han mize 49 nhiém tring, khéng cho lan rong (4p xe khu trd).!6!3)N tring ngogi khoa - Khdng sinh trong phéu thudt - GS. TS. Nguyén Cong Minh. 3 - Vi tring chi phat trién trong céc méi tring thudin Igi nhur: *Céc té chife thodi héa, hoai tl; *C6 sy hign dign cla cdc vat la, manh xuong chét hose *Mé dap nat do chén thuong. 6") CAC YEU T6 ANH HUONG DEN SUC DE KHANG CUA KY CHU + Tudi va gidi tinh, : ee ~ Cc BN cao tudi (& 65 tudi) c6 nguy co nhigm tring nhigu nhdt. ~ Mac di trong thyre nghigm, Androgens cé tc dung tic ché min dich va céc nghién ctru trén thi cfing cho thay: sau chan thuong, thi dye cé ty 1 nhiém tring va tir vong cao hon tha i lai, cdc céng trinh nghién ctu ee Bnuol thi nam nif: nguy co nhiém tring va tinh trang nding khong khdc biét c6 y nghta.! * Kiém soat duéng huyét trong qua trinh chu phau (trong va sau ma). Cac cOng trinh nghién eu gan day cho thay: ing duing huvét gay céin tré chite nding ctia bach edu, do 46 phai kiem sodt chic ché duéng huyet trong giai dogn chu phau. ‘Thong ké ciing cho théy: ty 1g nhiém tring vét mo va nhiém tring bgnh vign gia ting trén cdc BN chu phdu cé dutng huyét cao, khéng kiém sodt duge (ké ca ngudi c6 hoge khong 06 tigu duong). Dac biét trong céc phdu thuat tim qua during mo ite, di huyét trung binh (> 200mg/dL) kéo dai suot ngiy thir 1 sau mé, thi nguy co nhiém tring ting gap 4 lan (mé tim hay khéng mé tim). Cac cBng trinh truée day cho thay: truyén Insulin gitr duong huyét < 110 mg/L gitip gidm 40% tir vong BN sau mo (vi gidm 70% ti vong BN mé tim), ké ca viém phi cOng dong va suy da tang. Chai y: gid ‘rj ciia vic str dung ligu phap insulin tich cyc (intensive insulin) lim gidm nguy co tr vong 6 ¥ nghifa, bat ké BN cé tigu dutng hay khong. Tuy nhién, véi ligu phap insulin tich cuc, néu dudng huyét thap kéo dai (< 60mg/dL) thi nguy co tir vong lai tang. Hang loat cdc nghién ciru gan day cho thay tét nhat 1a duy tri duéng huyét & mite 140-180 mg/dL.6"* © Cée ydu t6 lam ting nguy co nhiém trig trong qué trinh hai sic. Cae nghién ecru gin day cling cho thay cng dung ctia liéu phdp thé: oxy liéu cao va lam dm vét md gitip lam giém ty 1g nhigm tring vét m6, Trong mot edng trinh khée cho tha lam 4m noi mé 30 phi truéc khi phdu thudt khién ty 18 nhiém trang cdn 5% thay vi 14% nhur tragedy." Do a6 trong moi tinh hung hoi ste, NB te ho hp voi nding db oxy ding dii s& giém han nhi&m tring céc cuge mé phién.!°75 3) * Bat cir nguyén nhin nao lam thiéu oxy dén cdc mé (tissue hypoxia) do ri loan hogt dong cia vi tuan hodn (mét mau, dich - méu khéng duge lam am trude khi truyén, suy hé hap cp, bénh tim mach...) déu gia ting nguy co nhiém tring sau mé.675) - Van dé truyén mau Truyén méu dé ciru sng ngn nhan da thong, nan nhén mat mau cp, nhung Iai lam gia tang nguy co nhiém tring trén nhig BN nay.(6"*! ‘Voi mau gitt lanh lau trong ngan hang (nhu 4% néi trén) sé lam gidm cée phosphate ning lugng cao, din téi_bién dang héng cdu, két hop véi hign tong co mach gay r6i togn vi tun hodn (gp trén nhiing BN da thuong, BN nhiém tring nding) Khién oxy tigw thy dén cdc m6 gidm, lim gia ting t6n throng tang, gay suy da tang.! ~ Ha than mhiét do teuyén mot long Ién dich hoc ché phim mau khéng duge suoi dm; Hoje do sy thodt - mat dich: *Trong cuge mé vao cée khoang Ién ty nhién cia co thé (m6 ngye, md byng), hoe *Trong da throng... dan dén hign tong co mach. ChinhNhiém tring ngogi khoa - Khéng sinh trong phéiu thugt - GS. TS. Nguyén Cong Minh. 4 hign tugng co mach lam gidm luu lugng vi tuan hoan (gidm twéi mau dén cdc mé), gay gidm hoat déng cita hé mién dich. Tir dé gia ting nguy co nhiém tring va tir vong,°"*) © Hoi site voi dung dich keo hay dung dich tinh thé. Quan diém tragedy, truyén nhieu dung dich keo t6t hon dung dich tinh thé. Hign nay, thiéu gi thi truyén cdi dy.! © Van dé sic dung Corticoids trong BN séc nhiém tring. 6 thp nién 1980, ngudi ta sir dung corticoid Ii BN bj sc nhiém tring tgi céc phong sin s6c dc bigt déu tiém An tinh trang suy thugng than. Do vay, trén cée BN roi vao séc nhiém tring ma khong dé dip ing voi thudc van éi thdp (100 me/ 8gia).!" PHAN 2. KHANG SINH DU’ PHONG Khang sinh la cdc héa chat duge tiét ra bdi ede loai thyc vat, vi nam, hoac duge téng hgp... ¢6 tac dung ngiin cl v6i hai phuong thie: ngin sy ting truéng cia vi tring g. (khang tring hay kiém khudn: bacteriostatic drugs); Tham cl la diét trimg (bactericidal drugs).!*) Cé hai phuong thie sir dung khang sinh (KS): “KS digu tri” va “KS du phone” Khéng sinh dieu tri da hinh thanh va phét trign tir khi lich sir c6 khang sinh. Chi dinh str dung KS diu tj theo kinh nghigm hoke dya trén két qua khang sinh 46." Khang sinh dy phdng phat trién thyc su tir nm 1961: ban du Ia penicillins nay thay bing cac thé h¢ cephalosporins va céc logi KS khac. Myc dich cia KS dy phing kim giim nguy co nhiém tring ng 10a." sinh vat, dugc trich tinh tir su phat trién ca vi tring a khang sinh khéng tring -6 thé tigu diét ching, goi nay, khai nigm dy phng duge mo rng (truse-m 3 chan thuomg, 8 gia {ing higu qua cia KS diéu trj sau mé va van dé khang thudc nira.!”*! KS dy phong duge sir dung tnuée mot phiu thust, theo sau m6t chin thug e6 fc sip tiép xtc v6i mét nguén nhiém di duge xée dinh trude € em 6 bénh tim bam sinh, bat bude str dung KS dy phéng truéc Khi nhé ring dé phong chéng bién chimg viém ndi tam mac nhiém tring... Y NIEM CO BAN TRONG DU PHONG KHANG KHUAN Dur phing la sir dung tat ca cde phuong phap dé lim gidm di lwong vi Khudn 6 nguén géc ngoai sink (phéu thuét vién, moi trudng vi dung cy phong mé); ngudn ede ndi sinh (bgnh nhén), bao gdm tat ca cde phuong thite héa hoc, vat ly... 48 phong tran nhiém tring ngoai khoa. O day, ching ta t§p trung chi yéu vao KS dy phdng trong phéu thuat. Theo dinh nghia, KS dy phong bao gbm viée sir dung KS trudc khi bit diu cuge phdu thugt hoc thi thudt hdu lim giém di lugng vi tring xm nhap vio cée mé hode ede khoang tu nhién cia eg thé. KS duge chon Iya tly theo kha nang khang cée vi tring hign dign tai phau trudng. Y nghia dy phong duge sir dung giéi han trude hod trong lic mo. Do 6, KS du phdng chi ding mot ligu day nha, tir phi cue mé phe tap hoi kéo dai.) sir dung KS dy phong kéo dai s@ gia ting ty Ié nhiém tring bénh vign va guy co da khang, cy thé Ia viém phdi va nl ing dng théng ludn ngi mach (catheter).Nhiém tring ngoai khoa - Khang sinh trong phéu thujit - GS. TS. Nguyén Cong Minh. 5 CHUAN B] TIEN PHAU VA NGUYEN TAC VO KHUAN 1. Sue lay nhiém i phéu trong vign sir dung KS dy phong nbu la mot khi giéi chéng nhigm tring ta phdu trudng. Nhiéu nghién ctu tién edu chuyén sau cho thay van dé nhiém tring trong Tie m khong thé trinh khdi cho di 6 chun bj KY. Trén thu 6 ede phuong thie vO tring trong lic mé chi lim gidm chir kh6ng loai trir hodn toan nhiém tring: parang ~Do ludn khéng khi bj nhiém len vio khi nhan vién y té di chuyén trong phong md, ~ Da va hoi thé tir mai thé cia ¢ kip trong phong mé. ~ Sy lan nhiém tir nude rita - Nguén lay nhiém tir yéu t5 du Do dé vée sir dung KS dy phong li o6 ¥ nghié # Nhiéu céng trinh nghién ecu da chting minh gid tri cla KS dyr phong. Howard") khao sit trén 20,000 phu thu trong 5 nim gin day, cho théy chi con 1,9% nhigm ting néu ding KS dy phing, so véi 4,9% khéng ding.” + Nady nay vei cée nghién ctu dich té chuyén sdu da dinh danh 16 durge ofc logi vi tring tirmoi trudng ldy nhiém, tir d6 dinh hudng gidp ta chon KS dy phong,"” Cée vi tring thydng tré céng sinh (vi tring chi: microflora) trén da ci i va ca phdu thuat vign, sé tin céng hing rio chéng dé cia BN néu 6 co hoi (chén thuong, bing hodc thao tée eft khdu - gay sang chdn bam dap t6 chite trong tic mé).°"8) Vi thé, chai nia ban-cing tay nhén vign kip mo, sit tring da ciia BN noi tién hanh phdu thuat, vo tring dung cy phau thuat 1a diéu bit bude.) 2. Sét tring da (skin antisepsis): v6i chlorhexidine-alcohol (0,5% dén 4%) cho higu qua tt hon la iodine-aleohol (kinh dién). Béi vi chlorhexidine-aleohol khOng bi miu va huyét tuong bat hoat. Cac ky thugt sat tring da tir trung tam danh ving ra ngoai vi tot hon la tir ngoai bién danh ving vao trung tm. Cé tac gid dé xudt phuong phap tim BN trude mé v6i chlorhexidine, nhung chua thay higu qua r6.'°" 3. Lim sach long noi vét mo Cudn bj da bing phuong phép lim sgch long qua eft (sir dung t6ng do tia Long 16t hon li cao ling 6 dién), Va tot nhét la cat ngay truée khi rach da. Néw ute rach sat bo Tong thi khéng can phai kim sach long (TD: mé bat con hign nay).!°"9 NGUYEN TAC VA PHUONG THUC SU DUNG. KS DU PHONG 1. Bén nguyén tic chon KS dye phong: Bs 1. KS phi an toan, dung nap tt, dat ndng d9 cao - kiém sodt duge cfc 6 c6 nguy eo nhigm triing, it dc hai cho co thé (nhwr dj img, suy than...) 2. KS c6 quang phé thich hgp véi vi tring cn digt. 3. Gid thanh ré va khong phai la loai KS manh (danh cho KS didu tr. 4. Tiém mgch mt ligu duy nhat la ly tuéng, trong vong 1 gig true mé va 06 tée dung trong mot thai gian ngin (khong qua 24gid, hoe khong qué 48 gid véi cuge mé tim). + Trong hau hét ede cude pha thudt, KS dy phong tt nhét vin la cephalosporins thé he thir nhit (Cefazolin 1g), hole cephalosporins thé h thi hai (cefoxitin 2g), Lieu t6i da 142 g cho nhitng BN trén 80 kg") * Cée tic gia khuyén han ché sir dung nhém Aminoglicoside nhu gentamicin lim KS dy phdng. Nhém nay chi tac dung khi dat ndng 46 dinh trong huyeét tuong (KS phy thude 1g d6), do dé phai ding ligu cao va diing mt lan trong ngiy (do tic dung dc thén,Nhiém trimg ngogi khoa - Khdng sinh trong phdu thuit - GS. TS. Nguyén Cong Minh. 6 nén phai cn nhc)", Trai Iai, nhém Glycopeptides nhur vancomycin téc dung higu qua éu liéu dat néng 49 161 thigu duy tri MIC (KS phy thude thai gian), phai truyén 1g vancomycine kéo dai trong 60 phiit. + V6i cde nguyén tic trén, ho Quinolones ho’ Carbapenems sé la KS khong duge chon, mic dit Ertapenem va Qui lones 14 KS rat t6t cho céc phdu thuat dai tring (khéng ché duge pseudomonas).°7") Dac bigt, Quinolones ngdm vio nhu mé phdi tét hon céc logi Penicillins.(") « Khéng nén sir dung KS dy phong mt ech bira bai sau khi ding da hole kéo dai nhiéu ngay, hau trénh: nguy co khéng thuéc, lam gia ting hén loan cdc vi tring dudng rudt nhu Clostridiun difficile, chin han.!!!) © Voi BN via duge didu trj KS true mé, thuéng khong cin KS dur phong.!"!) 2. Cate tring hop cé nguy co nhiém tring cao clin KS dw phong © Mé cdp cizu, nhit la cdc truéng hop cé sc chan thuong.!") * Bénh nhén cé co dia ~ BN ung thu. - BN tiéu dudng, suy gidm min dich mic phai (HIV/AIDS). BN dang ding corticoid hay thuéc tre ché mién dich. BN qué béo hay qué gay.©781 ~ BN cao tudi (trén 70),!") * Cic cuge mé sach, khéng cin KS dy phong, trir phi: ~ Céc phdu thuat phai sir dung céc sin pham nha tao (thay van tim, va ghép véi protese, tay alu Moore 6 xuong dui, xuyén dinh n9i tity); Hoge du kién cuge md béc tach nhiéu...!°7*: ~ Cie phdu thuat sach phin mém ving diu mat cd, thutng khong can KS dur phong, trir phi cé cit xuong (nhur mé so, mé xuong tic), hose phdu thuat béc néi mac DM canh 67810) * Cac cugc mé kéo dai trén 4 gid.!"3) * Voi cae phdu thudt mé mém (nh mé thodt vi mé tuyén vii khong tao hinh) thi KS dy phong cdn dang ban cai, mac di trong cée nghién ett phan tich da bién, sir dung KS dy phéng trong phdu thugt dogn nhii ung thu dat higu qua.!57*) + Ngdm manh ghép trong KS la diéu khéng chdp nhan.{678:131 3. Thoi gian sit dung KS dye phon, ‘Nhiéu nghién ciru thyc nghiém feu hing dinh: mgt khi mé cia co thé bj “phoi nhiém” thi KS du phong chi cn mot thdi gian han hep dé phat huy tac dung. Do 46 phai thue ign KS dy phng truée khi rach da.) Sy cham tr sé lam gidm tac dung clla KS dy phdng, nghia la chi can tir 3 dén 4 gig sau khi vi tring xm nhiip vio ede 16 chit, thi KS dir phong that su khéng cdn gid tj nia. KS phai hién dign sin sing trong m6, dé dap ting voi sy lay nhiém xay ra,09.'21327) * Voi KS dy phong, nén diing m6t ligu tén cong, tiém mach 30-60 phat true khi rach da va nén cham ditt sau dé, khong nhét thiét phai gan sat lic mé (riéng vancomycin hay Suormuinolones, 6 thé sir dung 2 gid truée mé, do thai gian truyén tinh mach kéo ai) L102 - Trong mé bit con, nén ding KS dy phong tiém mach 30 phi nj Khi dé néng d§ KS trong mau sé cao dit khéng ché nhiém tring.!' ~ Vide tiép tue KS dy phong cho dén khi rit din luu la khéng ding, * Néu cuge mé khéng qué 4 gid: sir dung mét ligu duy nhat. ay true khi sé nhau. syNhiém tring ngogi khoa - Khang sinh trong phéiu thugt - GS. TS. Nguyén Cong Minh. 7 # Lidu KS sé phai dugc lap Iai (tng liéu) néu: = Cude mé kéo dai qua 4 gio. = Cudc mé kéo dai g4p déi thi gian ban hay. Chin han Cefazolin va Cefoxitin c6 thi gian ban huy ngan (ti. <2 gid). Cefazolin sé 6 tic dung trong mdi 2-5 gid; Cefor méi 2-3 gid; Cefuroxime mi 3-4 gid, Ampicillin/sulbactam mdi 2-4 gid; Vancomyci mOi 6-12 gids Clidamycin méi 3-6 git’ va Metronidazole mdi 6-8 giv... Do d6, phai lap Bu sau 3 hoge 4 gid, "92526271 cudc mé mat mau hode phai sir dyng tudn hoan ngoai co thé") KHANG SINH DU’ PHONG TRONG PHAU THUAT BUNG Cée nhiém tring tai ché hau hét la do cdc cdu trang gram duong, vi thé, KS dy phong cho cae phéu thuat dudng tigu héa vi gan mt 1a cephalosporin thé hé I. Chi ding clindamycin khi BN bi di ting vdi penicillins. Néw can dy phong cA cdc vi tring hey Kh gram dm, thi nén ding cephalosporin thé hg II hoe diing cephalosporin thé he I két hop véi metronidazole, Vancomycin chi ding dy phng véi tu cdu vang dé khang methicillin (trén 20% tu cdu vang dé khang methicilin gay nhiém tring tai ché).©') Phiu thuat da day, ta trang Thong thung, céc vi triing di qua da day sé bi khéng ché béi nding d@ acid trong da diy va sur luu thong t6t qua rudt. Bat cir ly do gi lm gidm nong d9 acid da day (thude kkhdng thy thé Ha, ife ché bom proton), thing da day ta tring, xuét huyét da day, ung thu dg day, gidm nhu ddng da day... hofic do i tré sau mé cit da mot s6 vi tring sé phat trin (E. coli, Klebsiella, Proteus), nghia li nguy co nhiém tring tang lén. Bigu ny thumg xay ra 6 bénh nhén béo phi, ng eao tub, suy gidm min dich hoge ung thu." Cae trudng hgp trén nén sir dung KS dur phong true md. © Khong can sir dung KS dy phong, néu phdu thuat khong vao duéng tiéu héa. Phau thudt dai trang Phau thudt dai trang 1a phdu thuat sach, dy phong tdt nhét duge ching minh la KS dy phong dudng rut. Chuan bj dai tring bang dudng uéng Neomycin va Erythromycin cé Ui thap nign 1970... ngay nay khéng con ding nia (do nguy eo gia ting Clostridium difficile duémg ruét).") © Véi cic phdu thuat dai trang phai cdn than, nhat la voi phan & phan cudi dai trang nén ly sach di cing, nhiéu cing t6t. Ngay nay, chi cn udng nude sach tir 12-24 gid trudc mé dai trang, uéng thudc tay nhe (saline laxative hodc propylethylen glycol) két hop véi udng nhiéu nude dé tay ‘Sach vi tring trong dudng rugt la du. Gan day, chit trrong khong a thut thao trude m6.) Vi tring trong dai trang ¢6 ca loai hiéu khi lén ky khi, véi mat dé rét cao (10"" trong 1g phan). Vi tring ky khi nhiéu gdp 1000 lan vi trang khi. Bacteroides (vi tring ky khi) va E. coli (vi trang hiéu khi) gp nhigu nhdt. Ngoai ra cdn cé cde trye tring dudng rudt khéc nhu Klebsiella, Enterobacter. Trén céc BN bj ung thy nim lau, Pseudomonas vi Staphylococcus, e6 thé ld nguyén nhan gay nhigm tring kéo dai sau md. Dy phéng trong loai phdu thuat dai tryc trang phai thoa man ba digu kign sau: ~ Han ché mét d6 vi tring 6 dai trang qua thut tho, keém theo KS duimg udng. ~ Khing sinh phai dat néng 49 cao trong huyét thank eiing nhu 6 thanh dai trang. - Khang sinh phéi hgp dé kiém soat durge cd vi tring hiéu khi va ky khi.Nhiém tring ngogi khoa - Khéng sinh trong phau thug - GS. TS. Nguyén Cong Minh. 8 Vi da sé vi tring gram am trong rudt khang véi cephalosporins thé hé I, do dé trong chudn bj dai tring, phai ding KS ong truéc (dé khéng ché cdc vi tring hiéu khi va ky khi nhur Neomycin + Metronidazole).!""! Sau d6, méi str dung mot liéu KS dy phong tiém mach thudng quy trudc mé nhu (cefoxitin, cefotetan, hodc Ampicillin-sulbactam) theo truéng phdi Bic My da khién ty 18 nhiém tring giam chi con 4%!) Vi vay cho BN uéng thude tay nhe két hop véi udng nhiéu nude sach 2 ngay truée va uéng metronidazol 750mg chia kim 3 lan két hgp véi 3g neomycin chia lam 3 lan mdi ngay, trong 2 ngay. Can luu y vai trd ciia Metronidazol tac dong rét khde nhau gitta Amibe ky sinh va ring. Véi amibe, metronidazol ngin chin duéng chuyén hoa tao ning lurong, véi vi triing chat nay de ché men topoisomerase do 46 vi tring khéng thé nhdn bin DNA. Phdu thugt cit rugt thira viém: c6 thé ding cefoxitin (2g) tiém mach 30 phut truée mé, ‘Néu vim rudt thira da v8, tiép tue duéi dang KS diéu tri: cefoxitin (cephalosporein thé hg Il) cling véi metronidazol 500mg, truyén tinh mach cham (20 phiit) 8 gid mot lan,!!) Phau thuat dung © M6 phién cit tii mat ngi soi Li mé sach, khong can KS dur phdng, trit phi chuyén sang md més, hoe BN c6 nguy co cao (trén 70 tudi, tiéu dudng hode phai dat stent dying * Ceftriaxone (cephalosporein thé hé I) higu qua trén vi tring gram am va vi trang gram duong, lé mét KS duy nhat cé théi gian ban huy kéo dai trong mau (gan 8 gid), do dé chi ding mét hogc hai liéu trong ngay.!!0) KHANG SINH DY PHONG TRONG PHAU THUAT NGYC Cephalosporins thé hg thir I ding du sé rét higu qua trong viée ngan ngira nhiém tring tir ngoai da, Sit dung cephalosporins thé he thir II sé gidm di cc bién chimg mi mang phéi, viém phdi sau mé va ngin ngira nhiém tring vét md ngue.!20 KS dy phong duge Khuyén céo la cephazolin (1g) hoe cephalothin (1 - 2g), tigm tinh mach. Neu e6 dj ing véi penicilin, nén chuyén thanh clindamycin (600mg).!U3.'92324) ‘Chon KS dy phong trong ph4u thuat ngye Ngoai nguén lay nhiém tir mdi trudng, mam vi tring trong, chat tiét phé quan thuong 1a Hemophillus influenzae va Staphylococcus aureus. Do dé:l'32!2324) © Néu khéng cat phdi hodic nhu mé phéi, van a8 dur phang chi cén la nhiém tring tir ngoai da ciia thanh ngye lay nhiém: ty cdu vang!?2324), © Néu BN bj viém phé quan, phai diéu tri noi voi KS diing di truée khi mé két hop véi vat ly hé hap. Va néu phdu thudt pham dén nhu mé phéi, phai chit ¥ dén vi trang thudng tri cOng sinh (vi tring chi) hign hitu trong cy phé quin - phdi. KS dur phong nhu thuéng quy.3) Negtiy nay KS dy phong trong phdu thugt ngye thong dung nhur cefazolin, cephalothin (thé hg 1) hoc cefuroxime (thé hé II phé rong chéng vi tring gram am). Co ché nhiém tring trong phdu thuat ngye * Clic phéu thugt vao ngue Phéiu thudt mé Trong phau thud ohiém nhiéu nhat. mé xuong tfc, nhigu nghién ctru gin day cho thay day la giai doan layNid tring ngogi khoa - Khéng sink trong pha thug - GS. TS. Nguyén Cong Minh. 9 ~ Cuge mé céng Idu, ty 18 nhim tring cang cao. ~ BN béo phi va BN c6 bénh co dia s® lim gia ting nguy co nhiém tring xuong (re sau mé. Phai tim rita sach ving ngye trude xuong te BN va v6 tring ky ving nay truéc mo, = 5 thugt déng xuong ste cling tham gia gay nhiém tring. Nhiém tring xuong ite gia ting trén cdc BN ma xuong te durge ding khéng ving (2 hoe 3 mdi). Chinh sur “abit hit - khéng én dinh” nay ella hai manh tre méi khdu sé to nén mot 4p lye Am, hat vi tring, ngoai yéu t6 gay phan (mg viém do vi sang chan lién tue trong céc ett dng cla BN sau mé. C6 truimg hgp Ap xe sau chd md xuong tte do phé cdu (deep pneumococcal abcess) xy ra trong vong 3 théng sau mé. Tuy nhién néu chudn bj can than trude, trong va sau mé, sé han ché tdi da bién ching nay.l""42!) Bit cif phdu thuat mé te nao cfing can KS dy phong. Céic phdiu thudt mo ngue cit co nhiéu hoac lam dap nét nhiéu Isp co ngye 1d yéu 16 thuan Igi gidp vi tring phat trién tang sinh va tiét nhiéu doe +6 quan trong, tao vong ludn quan trong nhiém tring vét mé. Ngoai ra, cdn c6 sy lan nhiém cia cdc tap tring eng sinh (normal flora) tir ede phé quan vita durge edt di Do 46, tt nhét la ding cephalothine dy phong va ting cudng KS diéu tr trong suét thoi ky chu phau.!") Phéu thudt can thigp noi tang Phdu thudt jc thay) van tim tim va mac ir dung KS dy phéng trong mét phdu thuat dic bigt nhu phu thudt tim hé thay van tim la bat budc, dé tranh bién ching viém néi tim mac.""'* = Cée nghién cfu gin day cho thay ring chinh yéu t6 “vat la” trong cdc thit thudt ndi mach déu 1a cde yéu t6 thuan Igi cho nhiém tring. - Vai trd cita du triing huyét (bacteremia) ciing la van dé duge dat ra cho vige sit dyng KS dy phong!?, = Cefazolin (vancomycin)* nén duge ding truée va trong mo, Phd thudt edt nhu mé phéi Trén thy té, boi vi mim bénh thudng tir phé quan (trong dich phé quan) chi yéu li Hemophilus influenzae va Staphylococcus aureus, va cae nghién ciru gan day cho thdy cefazolin van la KS dy phong cé téc dung t6t nha. !!21241 Phu thudt dt méy tao nhip Negay nay, thi thudt nay cé ty 1¢ nhiém tring thép"”), tuy nhién 1a phdu thugt ¢6 vét la, nén sir dung KS dy phong. Céc truéng hop ¢é co dia nhiém tring nh BN tiéu duéng hode nguy co nhiém tring cao, thi KS dy phong nén ap dung thudng qui. «© Trong céc cuge mé cép cieu, nhat 1a cde truéng hop chén thyong nang cé dp phi, vet throng ngue 7417241 ‘Vi vét thuong thdu ngye ma tién Iuong kha ning nhiém tring c6 thé lan manh, ding clindamycine 300mg/ mdi 6 gid trong 5 ngiy sé gidm ro bién ching mi mang phdi. (Huéng KS didu tr).27Nhiém tring ngogi khoa - Khdng sinh trong phéu thufit - GS. TS. Nguyén Cong Minh, 10 KHANG SINH DY’ PHONG TREN NAN NHAN CHAN THUONG Tai sao phi ding KS dy phong cho cae BN chan thuong hoje da throng * Céc nan nhan vét thong hé hoe da thuong, ngoai anh huéng cia méi trudmg lay nhiém tai hign truéng (bén ngoai) cdn c6 thé cé vo céc tang (bén trong) co thé théng qua_céc 18 ty nhién nh dudng tiéu hod, hé hap, tiét nigu-sinh duc khién tinh trang nhiém tring gia ting.(*14!71 © Trén thyc té, sdc kéo dai, xit Ij khing thich dang, tit vong cao vi * Séc, truéc mit Ia suy tuan hoan cdp; + Sau 1a cdc rdi logn chuyén héa tai cae mo: = Khign cdc t6 chite mau, kém dudng,... tao thugn Igi cho vi tring phat trién. Sy co mgch trong sdc sé kim gim mite ngdm khang sinh vao céc t6 chitc. Dic bigt, 48-72 gid sau chan thuong, hign tugng viém sé lan rng, kim thay déi thé tich khuyét tin cla khang sinh tai céc m6. Chinh roi loan huyét dng sé lam giam tac dung cla khéng sinh dy phong.”*4) vj 1é dé, quan diém nén ting ligu Khang sinh trén nhimg bénh nhén chan thuong durge nl iéu dong thugn, Nén sir dung KS dy phong ngay lic so ctu ban dau, ing ligu sau dé va tiép tye chuyén thanh KS diéu tri... cho dén khi tinh trang séc én dinh 74!) Nghia 1a tign lugng nhiém tring ning c6 thé tro thanh trim trong, néu 6 séc mét mau kéo dai.” ~ Tang nguy co't6n thuong céc tang (han ché sit dung aminoglicosides). MEE) ~ Ging nih ring KS hi edt dung higu qua khi cdc véthuong phn mém duge xt i 161.4 Chon KS dy phong két hyp véi KS diéu trj tren BN da thong Ngay sau khi so’ ciru va cép ciru ban dau, néu nhan thy nguy co nhiém tring cao, nén sit dung ngay KS dy phéng, tét nhét 1a logi cephalosporin thé hé thir I (cefazolin). Néu nan nhan dj tig véi ho beta-lactam, ding clindamycine. Buéng sit dung khang sinh higu qua nhat la duéng tinh mach.7*!71 Su chon Iya KS cling tity thudc vi tri co thé va mdi trudng lay nhiém: ~ Vi tn thong ngoai da thi khong can ding khang sinh. ~ V6i ton thuong dung tigu héa: dé khéng ché vi tring yém khi va Gram am, nén din cephalosporin thé hé thir II nhu: cephotetan hode cefoxitin. Dé phdng nan nhin d& khang véi ho beta-lactam, thi ding két hgp Clindamycin va Gentalin hoe Astreonam, ~ Néu c6 gy xuong hd: mic di ct Igc va tudi ria sach nhung ching nhiém tring cao va nguy hiém, phai ding KS (dy phéng lin didu tri) cephalosporins thé hé thit L ~ VT ving dau mat cé c6 tan sudt nhiém tring thdp. Tén thong dau 19 mang nao, chiy dich nfo tly va mé nao sé cé nguy co nhiém tring cao. Mac dii c6 nhiéu y kién khéc nhau, nhung kinh nghigm cia cdc chuyén gia ngoai than kinh, ding KS loai beta- ‘sea (oer in) 14 t6t nhdt, vi thude ngém qua “hang rao mgch ndo tiy” higu qua nit” ~ Véi BN c6 vét thuong théu bung, dy phong Cefoxitin 1 g la di nhung néu tang tng, nén ding cephalosporin the he thi It va ding lign tue trong 24 gi hon sé gy hai nhiéu hon Igi cho di e6 vé dai trang). ~ Chan thuong m6 mém cé nguy co nhiém tring rat cao, nhung khéng cé nghta la phai kéo dai thoi gian sir dung KS dy phong. ~ Mii mang phoi la bién chimg dang sg. Khang sinh dy phong trong ving 24 gid sau chin thuong ¢6 dn Iwu mang phéi (trin méu hode tran khi mang phdi) v6i cephalosporinsNhiém tring ngoqi khoa - Khang sinh trong phéu thugt - GS. TS. Nguyén Cong Minh. 11 \goai Khoa chan thuong EAST (Eastern Association for thé hé thir nhat duge hiép hdi (7,826.27) the Surgery of Trauma) khuyén céo. ~ Ligu khang sinh dyr phong qui uéc: cefazolin 1 g, cefoxitin 1-2 g (thé hé thir 11) 674) ~ Chi y, sit dung KS lau dai trén cdc BN nay khéng nhing kh6ng thé ngan chin duoc nhiém tring tir ede khoang ty nhién cia co thé, ma cdn dé dn dén khang thudc°7*") TOM TAT KET HOP KS DY PHONG VA KS DIEU TR] HIEN NAY # Mé sach hoa toan: cefazolin. Néu e6 dj tmg voi ho PNC, thay bang vancomycin) - ding trudc va trong mé.!** © Mé sach nhung cé kha nding ity nhiém = Cudc mé 6 lign quan dén dau-cd, dudng tiéu ha, gan mat, Cefazolin (ho&c clindamycin cho dau va c6). ~ Cudc mé lién quan dén am dao, cit tir cung qua ng bung: Cefazolin hoc cefoxitin hot cefotetan - ding truée va trong = Cudc mé sach nhung c6 nguy co lay nhiém cao phdu thuat nigu sinh due: Fluoroquinolone - ding truée va trong mé. = Cudc mé sach trén dai truc trang, cét ruét thira: Fefoxitin hoi fefotetan - dig truéc va trong mé. © Cudc mé do (cé vo tang): Cefoxitin hoc cefotetan + gentamycin. Clindamycin + gentamycin Ding trusc va ting curdng thém 3-5 ngay sau mé. © Cudc mé do (do chan thong): Cefazolin - Ding truéc va ting cudng thém 3-5 ngay sau chan thuon, mé bat con, mé cét tir ung: 3.67808) PHAN 3: KHANG SINH DIEU TRI CHAN DOAN NHIEM TRUNG SAU MO ‘Dinh gid sét va kha nding nhiém tring t BN cé vét thuong phan mém, chin han, mic di: khéng s6t, nhung 6 huyét 4p tut, tim nhanh, lo mo, kém theo TC hé hép, thiéu niéu, lactic acidosis, BC ting hoic BC giam, BC da nhan trung tinh non (nghiéng trdi), tiéu cdu thap... goi y mOt tinh trang nhiém tring sip xy ra, ngudi thay thudc nén di én gé tring va chudn bj chon Iya KS theo kinh nghiém va kién thite sin c6. Chi ¥ la cac logi nhiém tring nang, de doa tinh mang thudng la loai nhiém tring ma céc BN thudng 6 biéu hign nhigt 46 thdp hog nhiét 49 binh thug, nhat 1a trén cde BN cao tudi, suy da phi tang hose bénh ac tinh.) BN nim & phong sin sée de bigt ma nhigt d6 Ién trén 38.3 46 C ( 101° F) 1a. c6 trigu ching s6t, phai di tim nguyén nhén nhiém tring. Voi nhiing BN suy giém mién dich, nhiét a6 thp hon cling phai duge cha y.6'9) Chin doan nguyén nan sét sau m6 # Sét xudt hign trong vong 72 gid dau sau mé:6")Nhiém tring ngogi khoa - Khéng sinh trong phdu thugs - GS. TS. Nguyén Cong Minh, 12 Trong giai doan nay, BN thudng cé sét va hdu hét déu khong do nhiém tring, + Ham hép sét (s6t nhe < 39°C) thuéng do phan img tai chd nhu: tan thuong mé mém, bim dap noi thao tac hoge ty méu (gay thiéu mau hog hogi tt md). Chén ép khoang va udn van 1a hai bién chimg v6 cling hiém gp gay sét trong thoi ky hau phdu.'6!9) + Sit kéo dai (39°C) cé thé do: ~ Tang than nhigt 4c tinh (malignant hyperthermia: r6i loan tng chuyén hod ca co van, tng tiéu thy dét chay ATP trong té bao. Lam sang biéu hién sét, ting CPK: creatinine phosphokinase trong méu. Thuéng egp nhét 1a trén nhing BN dang ding corticasteroid). Dic bigt, lign quan dén tén thong nhiéu md mém va tu méu Jan rong." ~ Viém phdi hit hoe xep phéi do tie nghén dam rai sau mé: qué trinh din dén nhiém tring (vim phéi). ~ Hodc li mét nhiém tring cé tir trude khéng phat hién nhur (nhiém tring dudng mat tigp dién sau mé mét, nhiém tring tiéu sau phdu thuat hé niéu),!3441 * Sét xudt hign 3-4 ngay sau mé, phai loai trir cdc nguén géc nhiém tring (ngoai cac nguyén nhan tén tai néu trén). Chi ¥ sét khong do nhiém tring trong giai doan nay nhw: huyét khdi tinh mach sau, bién chimg thuyén tic phdi, suy than - phan img dich truyén, phan Ung truyén mau hay phan img thudc va hign tong thai ghép cp, Nguyén nhan giy sot thuéng gap nhat trong giai doan nay la: vigm phéi, nhiém tring tiéu, viém tc tinh mach sau, md trong 6 byng va phan img thude,® ~ Ding trude mét BN vita chém sét sau mé véi bach edu tang, ma chua tim duge nguyén han cu thé, phai Adi ky bénh sit, dénh gid ky cdc vj tri vet md, noi dat dan luu, ‘ong thong luén n6i mach va tién hanh cdc xé¢ nghiém can thiéy !6!.'4.320) ~ Sét do thude it khi duge xée dinh trén BN sau mé va phai loai trir truée. Chit ¥ mot vai ogi thuée gay hign tuong viém tai noi tiém truyén (viém tinh mach, phan ting viém m6 mém) nhu Amphotericin B, Erythromycin va Potassium chloride... Chit ¥ m@t sé KS nhu Vancomycine, B-lactams, thuéc chéng déng kinh (phenytoin)...c6 thé gay sét.[63) X quang phi dugc tién hank fe quy trén nhiing BN thé may sau mé c6 sét, két hop véi lim sing (nghe phéi, nhip hé hap va khi méu dng mach). Cha y nhigm tring bénh vign trudc mé véi phé cau tring hay Hemophulus influenza") Téng phan tich nuéc tiéu hodc cdy nwée tiéu nén tién hanh trén nhimg BN cé sét, dic bigt BN 6 bénh sir chan thong hé nigu, vi nhiém tring tiéu thuéng xay ra trén nhimg BN nay.{643:922) ‘Siéu dm doppler dé logi trie huyét khéi tink mach sau @ chan sau md ‘Trén m6t BN nim Iéu: theo doi nhigt d trong ngay, c6 thé sm t hign benh viem tie ‘TM sau. Viém tic TM séu ma khéng sét la mét diéu hiém gap." (Cay mau: voi BN s6t sau mé ma da loai trir tat ca nguyén nan thi nén tién hanh cdy mu, Két qua cdy mau tir DM va TM khéng khéc nhau. Nén tién hanh cdy mau lay tir 2 dén 3 diém khac nhau dé c6 mét chimg cit chide chén: vi tring tim thay gidng nhau 1a nguyén nhan chinh. Boi vi vi tring ¢6 thé 06 & trén da (ch3 Lay mau) hoge do du tring huyét (bacteremia) hoe nhiém ndm mau (fungemia) tir éng. thdng ludn ndi mach.!*!3)Nhidm tring ngogi khoa - Khdng sink trong phdu thugt - GS. TS. Nguyén Cong Minh. 13 CAC LOAI NHIEM TRUNG THUONG GAP ihiém tring vét mo Chi xudt hign ti ngay thir 3 sau m6. Néu chi Ia bién ching nhiém tring vét md, phai oft méi chi dé thodt uu mii néu c6 va cdy mii - lam KS dd. Théng thuong mii sé giém va vet mé sé khé hoain toan sau 48 gid didu tr} KS thich hop.!6!2"9) 2. Nhiém tring khae sau md Nhiém tring do phdu thuat, viém phdi, nhiém tring tiéu thudng gap nat") - Nhigm fring tiu do qué trinh dat théng tiéu - luu gift ldu, ho&c do thi thudt gay sang. chan! = Nhigm tring do dat éng théng ludn ni mach (catheter), do Iuu catheter lau trong long ng mgch hoge tinh mach...thu’mg khéng ¢6 triéu chimg, chi 6 bach cau ting cao, cay mau lay ra noi dat éng c6 thé phat hign vi tring. Néu thdy mi hod dich tiét ra tai noi dat dng, phai rit catheter ngay. Néu phan lép duge ede vi tring it dc lye nhu: Staphyllococcus epidermidis (chiém ty 1g cao 50-60%), nén ding KS digu tr (nhur da ké trén) tir 14-21 ngay.619) 3. Vim phéi bénh vign Thuimg xay ra 48-72 gid sau khi nhép vign hoc sau m6, hoe do d3t n9i khé quan - the méy Iau. Thudng tir vong cao, nhat Ia trén cde BN suy kiét, bénh phdi man tinh hose BN cao tui. + Viém phéi do thé may thudng gap nhét. Vi tring thudng gap la: S. aureus, H. influenzae va S. pneumococeus. + Vim phdt hit dé thank gp xe phdi thu’mg la nhtng t6n thuong ning, sir dung KS don thudn sé kém higu qua. 4, Nhiém tring eae eo quan trong bung hike mage Con goi la nhiém tring 6 bung, chia lim hai dang: - Viém phic mac nguyén phdt do vi tring tn céng qua duéng mau (hematogenous) do nnguén nhiém tir xa. Thuong xdy ra trén BN ¢6 bang bung hoc dang thm phan phic mae (suy than). Céc trudmg hgp nay khéng cin mé. Choe dich 6 bung cho thay e6 hon 100 bgch cdu /ImL va nén nhudm gram tim vi tring. Cay c6 thé thay E. coli, K. pneumonia, pneumococci, streptococci... KS digu trj theo KS dé tir 14-21 nga theo rit tat cd cdc éng dan lu, cde Sng thdm phan...) , kem - Viém phiie mac thit phit do ve thing tang réng... nhu viém phic mec rudt thia, thing Tot da day, vo tdi thita. Phai phdu thuat cit bé phan t6 chire bénb, lay sach mo vat la va mé hogi tt, kém theo KS true tiép véi vi tring hiéu va ky khi. Phai sir dung KS két hop hoe KS quang phd rOng. Sir dyng KS tiém mgch trude, va xuéng thang, chuyén sang KS uéng khi nu d6ng ru6t hoat dng tr Ia. Néu nguyén nhn nhiém tring doe kiém soat, tir vong chi chiém 5-6%, Nguge Iai, tir suat lén trén 40%!) *Viém phic mac sau md - Ap xe trong 6 bung: cdc truéng hgp buc hoje db migng néi tiéu hoa duge khu tri k ~ YPM kéo dai thuéng pip tn ede BN gidm mign dich, Di sir dung KS ding di, t suit van cao, trén 50%."Nhiém tring ngoqi khoa - Khéng sinh trong phdu thu@t - GS. TS. Nguyén Cong Minh. 14 Vi tring thudng la Enterococcus faecalis, Staphylococcus epidermidis, Candida albican va Pseudomonas aeruginosa.'*"3) ‘V6i ap xe trong bung, phai dan luu thoat mi. Ngay nay nho CT scan, c6 thé din luu qua da. Ap xe da 6 mdi can can thiép néi soi ho’ mé mo. KS va uu éng dan Iwu tay theo tién trién cia bénh. KS diéu trj hiéu va ky khi nén sir dung ngén han (3-7 ngay). Dan lu duge rit khi dich trong din hoge djch edn it, (dui 10-20 mL/ ngay) va kim sing ci thién! « Ap xe gan: ngay nay hiém gp. 80% ap xe gan do vi tring, 20% cdn lai do ky sinh tring (a mip) va vi ndm. Trong sd 4p xe gan do vi tring 50% khéng tim thay ngudn géc. vi tring thudng gap la E. coli, K. pneumoniae va cdc true tring khéc. Ap xe gan do vi tring thudng Ia dang da 6 nhé hon Icm. Diéu tri KS tir 4-6 thuan, néu 6 mi to thi nén dan Iu." + Ap xe lich vo cing hiém gap: diéu tri KS va ct lich!) + Viéma tuy, thit phat, nhiém tring tuy hogi tit hoc dp xe tuy: chiém 10-15% céc trudng hop viém tuy xudt huyét nang. KS diéu trj theo kinh nghiém vai tuan sau khi bi viém tuy, sé lim giim tinh trang ning va ha ty 1g tir vong, Nhiéu nghién etiu tién citu cho thay Carbapenems va Fluoroquinolones bao vé nhu mé tuy tt nhét. Bén canh dé nén at ng nudi an qua khdi géc Treitz cia héng tring dé gidm sy nhigm tring cia nhu mé tuy. Nudi An qua duéng truyén hé tra néu can. 6" Lam sing ggi ¥: sau viém tuy cdp, xudt hién HC dap tg viém toan than (s6t, bach cdu ting cao va tOn thuong chitc nang tang) trén BN dign bién tét ban dau... dé rdi roi vao HC nhiém tring 2-3 tudn sau d6. Chan dodn, theo doi bing CT scan va cing chge hiit qua huéng din cia CT scan, lay dich nhugm gram va cdy vi tring la digu then chét. Néu c6 “bong khi” trong t5 chtic tuy, phai can thigp phdu thudt. Muc dich cia phiu ‘huge IB mé vao hau cung mac néi: lay di ce 6 nhiém tring, cat b6 cdc t8 chite hoai i" 5. Nhiém tring c4e co quan ldng ngye ©Nhiém tring xuong tec sau mé tee Bén mite 46 nhiém tring xuong irc, sau mé ite: D6 1: ndng, mii tir md dudi da (noi vét mé xuong tc) An xubng. D6 2: sdu, ch mé ite: phai mé Iai, cét loc sAt tring-lim sach vi tring. DG 3: edt tty vidm xuong tte. DO 4: mii lan dén trung 1 au. 1. Néu nhigm tring nhe (Nhiém tring xuong ite d6 1). Nén chon cefuroxime (thé hé 11): ligu khdi du 1,5 g= 2 Io IV, sau d6 18 0,75 g/ mdi 4 gid, trong lic mo, Sau mé: 0,75 g/méi 6 gid (zinacef dang chich, sé xuéng thang chuyén thinh dang udng 1a zinnat). Ma doi khi cé thé ding cefazoline vi gid ré va thoi gian ban hity dai.!"!227) 2. Néu nhiém tring n&ng (49 2,3,4), thudng la do tu cau vang, chia lim 2 logi loai nhay methicilline (cefuroxime) va logi khang. Nén ding cephalosoporins thé hé II (cefuroxime) + vancomycine (liéu khéi du 18 15 mg/kg, tiém mach, sau khi ngung twin hon ngoai co thé: 10mg/ kg. Trong thdi ky hu phdu: 500mg/ méi 6 gid). Gan day, khuynh hung sir dung céc cephalo thé he IIT nhu: ~Cefotaxime (Claforan Io 1g x 3/ ngay Roussel). ~Ceftriaxone (Rocephine 1g lo x1-2g/ ngay Roche); Megion (Biochemie, Ao) -Ceftazidime (Fortum 1g x 3/ ngiy, Glaxosmithkline); Kefadim (Lilly)Nhiém tring ngogi khoa - Khéng sinh trong phéiu thug - GS. TS. Nguyén Cong Minh. 15 Vidm ngi tim mac sau thay van Nén tun thit cdc bude saul 1. Phai ding KS diét tring, dya trén KS dd. 2. it nhét phai ding phdi hgp 2 logi KS c6ng luc. 3. Thai gian sir dung KS phai tir 6-8 tuan, 6. Nhiém tring da va phan mém am hai logi (¢6 can thigp ngoai hay Khong): chin han *Nhiém tring da néng nhu »40, viém quang (erysipelas) va vim mo thoat ma, dn Iuu mi - Thuéng la nhiém da khudn, do 46 KS cho ca vi triing gram am, gram duong, cd hiéu _nhur: vancomycin + earbapenem; hoe penicillins G liéu cao (16.000- nihigm céc logi Clostridium. Cée vi tring edy duge thudng 1a Pseudomonas aeruginosa, Clostridium perfringens ho§e Streptococcus pyogenes. 03 ~ Chit ¥, vai logi KS ho quinolones nhu ciprofloxacin hap thu t6t qua durémg uéng, ké cd trong cde trugng hop nhigm tring ning, chi ding dutng tiem mach khi dung teu hoa NGUYEN TAC SU DUNG KHANG SINH DIEU TRI + KS diéu tr thuong duge sir dung theo kinh nghigm eda ting thay thude.[619) Cp nhgt cém nang diéu trj (guide line), Sit dung KS pho rng tap trung vao nhém vi tring nghi ngo gay bénh. Khi dat higu qua rdi, sau dé phai xudng thang thu hep dan phd khang sinh. Str dung KS theo dudng toan than (truée chich sau uudng). = V6i nhiém tring nhg (BN ngogi tré) chi cin KS uéng. Voi nhiém tring ning, anh hug ton than, nén ding KS tiém mach. BN ni iém tring nang phai danh gi is ngly. Sau 3 ngiy str dung KS diéu tri ma LS khéng cai thign (BN vn s6t, bach cau van con cao), phai thay déi KS hoc di tim cdc nguyén nhan khéc.!""9) Neguyén t tie digu tri nl iém tring do phiu thuat + Dieu trj két hop v6i cde KS cng lye, hau dat higu qua my man. + Lun nhé ring: KS khéng gitt vai trd de nhét trong kiém soat nhiém trang", - Khang sinh chi hé trg bao vé tai ché ... cho dén khi todn than dui sire chéng a6. Sau 3-5 ngay sé cé hing rao bao vé (phan tng viém) déi véi vi trang. Néu nhiém tring lan rong hoe nhiém tring su, thoi gian digu trj doi hoi phai lau hon ~ Voi nhigm tring ngoai Khoa, KS khéng thé thay thé cho phdw thudt ma chi gitt vai trd hd tro. Nghia 1a néu cé mu, phai rach thoat va lay hét md, vat la, mé hoai tu. Néu 6 mi 4 hinh thanh vé boc (ap xe), KS sé kém higu qua. Dit cho six dung KS todn than, mie 46 ngim cia KS vao trong 6 gp xe s& rt kém. Bai vi KS chi the dung t6 trong lhe vi tring dang sinh san, phan bao. + Ludn phai héi ring st x dung KS eh hop chua (loai KS nao, liéu lugng can thiét). Do 46.06 5 vin dé dat ra:'® ~ Phu thugt 06 gi quyét hét 6 nhigm tring chua ? = Néu gidi quyét tét ri thi cht ¥ cée bién chémng 6 thé xay ra? - Van dé nhiém tring & chd khdc lan dén ching ? - Ligu Iuong va thoi gian sir dung KS cé di chua ? ~ Cin két hop cng lure cdc logi KS nao 20°)Nhiém tring ngoqi khoa - Khang sinh trong phau thugt - GS. TS. Nguyén Cong Minh. 16 ‘Lya chon KS didu tri * Khuyén cdo ciia higp hi nhiém tring do phdu thugt trong sir dung KS didu tri: - Dimg nén ding Metronidazole hoc Clidamycin don thuan dé diéu tri nhiém tring hon hyp, vi cdc loai nay khéng da kha nang chéng vi tring hiéu khi dung ruét. Ciing Khong nén ding m6t loai KS don 18.613) ~ Véi BN ning chi nén tiém mgch hoe dudng truyén tinh mach (PIV) béi vi sy hdp thu qua dudng tiéu héa bi gidi han r6 rét néu BN dang séc.!°"3), ~ Ngudi Ién dinh liéu trén can nfng. Tré em dinh liéu trén dién tich dal"), * Vig chon Iya KS dé diéu tri trén m6t BN nhiém tring ty thuée vao:!) - Vi tri va nguén géc 6 nhiém tring: logi vi tring gay bénh (dua vao ngudn géc léy nhiém va KS 46). ~ Phai logi trir duge déc tinh cia KS trén timg BN nhu *Tré em; *Ngudi cao tudi; “Nau 6 bénh co dja nhw suy thén, suy gan, tiéu dudng va “Ngudi bi suy gidm mign dich. Tinh trang dj tmg vi KS vita duge sir dung trude dé! . ~ Phai ph6i hgp KS céng lye (kh6ng déi khdng) ting cudng téc dung digt tring dé: *Mo rng phé khang tring va *Ngan ngita sy phat sinh céc ching khang thudc. + Néu nhiém tring bénh vign nghT do *Vi tring gam duong: tét nhdt 1a chon Vancomycin. *Néu nhiém Pseudomonas ning: két hop B-lactam véi Aminoglycoside, (chit ¥ dé phong t6n thuong than cp). Ba s6 nhiém Pseudomonas, tién rong xu.) tr] thudng duge tién hanh trude khi cé két qua cdy, do d6 phai doin gc logi vi tring nao anh hudng nhat gay nhiém tring, chang han nhu vi tring hi, ky khi va cd nhiém tring bénh vién, Nhu vay, néu chua chdc chin, KS diéu tri ban du muén higu qua la phai khéng ché duge ca 3 loai vi triing trén, trong Ite che doi KS dé! * Nhiém tring ng ghép (protese) thudng 1a do cdu tring gram (), khée v tring trén ton thuong dap nét mé mém, thudng 14 nhiém tring hén hgp.!"4) ‘dc nhiém 'S digu tri phai duge ngung va khong nén kéo dai thém qué 48-72 gid. Danh gid higu qua cia m6t KS diéu tri la: BN phai ngung sét sau 48 gid va lim sing cai thign r6 rét (tri gidc tot, tiéu binh thudng tré lai). C6 mét digu phai chi y 1a dit di ngung khang sinh, néu bach cdu van con cao, coi ching nhiém tring © co hdi bing phat tré Iai, nhét 1a trong cdc trudng hop cé sit dung két hop corticoid hoe thudc tre ché min dich. Vi vay, khi bach cau tré lai binh thudng thi xem nhu chéc chin da khéng ché duge nhiém tring.©"3) Tay mye dich sit dyng, thoi gian sir dung KS theo kinh nghigm thutmg tir 3-5 ngay hod ngiin hon.!'3) © KS diéu trj cdc trudng hop nhiém don khudn nhu:!3) - Nhigm tring tiéu: 7-10 ngay. ~ Viém phi (cy mau 4m tinh) va du khudn huyét (cdy méu dong tinh): 14-21 ngay. ~ KS diéu tr] viém xuong, viém ndi tam mac hogc nhiém tring éng ghép: phai két hop nhiéu KS v6i thoi gian kéo dai tir 6 dén 12 tuin. Tinh Lam sao nong d6 KS trong mau phai cao hon néng dé ite ché t6i thiéu (MIC). ~ Vi nhigm tring ning hogc nhiém tring t4i phat, nén ding hai hoc nhidu logi KS két hgp, die bigt vai vi tring da khéng: qua dung tiém mach 1-2 tuan. Néu lam sing cai thign, sau dé xudng thang chuyén thanh KS dang uéng.!"")Nhiém tring ngogi khoa - Khéng sink trong phd thugt - GS. TS. Nguyén Cong Minh. 17 # Viém phic mac la tinh trang nhiém da khudn, thoi gian diéu tri cing thay déi:!") - Véi vét thuong thing dudng tiéu héa, nhumg chu lan toa: ding KS 12-24 gid la du. = Viém rugt thira vo hoge viém rudt thita hoai thu: 3-5 ngay. ~ Vigm phtic mac phan hoc trén céc BN gidm mién dich: 7-14 ngay. Chi y, Iie ndo cling kiém soat nguén nhiém tring sau mé nhu: dp xe tn Iuu hode bye ede migng néi, Vin aé dj tng khang sinh « Phai hdi ky tién cin ela bgnh nhan véi cdc logi KS dic biét dé dj ting truéc Khi sir dung. Bai vi biéu hign qua man va phan vé nhur mai day. Chi ¥ co thit phé quan (nguy hi tir vong) hoac cdc r4i loan tigu hoa"! Dj ting Peni chiém nhiéu nhat, 0,7-10%.!"3) Dé phéng phan ding chéo véi cdc nhém beta-lactam (penicillin va cdc dain xudt nhu cae cephalosporins, cdc beta lactam khde nhur carbapenem, monobactam...) trén cic BN c6 tig cin dj émg v6i penicillin: *Nhiéu nhat 14 véi carbapenems; *{t hon, véi céc loai cephalosporins (tir 5-79) va *Cye ky it hay khng hé gip trén cc logi monobactams.! (it sit dung tai VN). Dé phang tran tai bién séc phan v¢ tir KS dy phong, nhidu phuong céch duge dé xudt: -Phuong céich pha loing ngiy nay it ding. -V6i logi KS dic bigt d8 gay di tng, cée téc gia d& nghj sir dung véi tang lig truée thoi diém chi dinh tiém mach dy phong dé héa gi vé khi sir dung KS dy phong. in ngay ding, trdnh duge s6e phan Sy t6n kém trong lam dyng khang sinh : Sut lam dung KS trén cdc bgnh nhan ngi va ngogi tra ngdn mot long In ngan séch y té quéc gia, chua ké dc tinh, séc phan vé, gia ting khéng thudc va hign tugng méi tri day cia cdc logi nhiém tring gay viém rugt do Clostridium difficile. Tai M9, uéc tinh tén khodng 20 ty dé la chi cho vige sir dung KS moi nam. Vi lé dé KS dy phong chi nén sir dung diing trude mé, KS digu tr] theo kinh nghiém phai ngung sau khi cdy tring (-) va lam sang ci thign. KS dy phong chi ding lic dgt dan lu ngye, chan han, nhung khéng nén kéo dai trong sudt thoi gian hu éng (ké ca dan Iuu mat, dan Inu 6 bung va dan leu 6 ap xe).! img nén pha KS trong dung dich tuéi ria - Din Iuu dich. Phai Iuén logi bo ¥ nghi la sit dung KS nhur la m6t khi gidi bd dp Iai cho m6t cude mé khdng hoan chinh.“ PHAN KET LUAN Tir khi cé khang sinh, viée sir dung KS nhur la mt phan khng thé tach réi trong digu tr} ngoai khoa két hop. Kién thire sir dung KS phat trién dan theo tién b6 clia nginh hoc va nganh chong nhiém tring (antisepsis). ‘Van dé nhiém tring do phau thuat xudt hign nhu mot quy ludt chir khéng phai 1 mot ngogi Ig. Nha sire dé khang t6t ciia con ngudi va cdc ky thuat v6 tring higu qua, cde cuge mé cé thé Linh t6t ty nhién ma khong can dén khang sinh. Nguéi Thay thuée phai nam chic nguyén téc va phdi din do truéc khi chi dinh sir dung m6t loai KS (cd dyr phong ln didu trj) hau han ché tinh trang khdng thude cua cdc dng vi tring, mét té nan nguy hiém xuét hién trong vai thép nién gan day") Trén thyc té, néu khéng ké dén KS dy phong thi trén nhiéu tinh hudng, viée chon KS didu trj thug dua trén cdc co sé khGng chinh xc, ngudi ta chi dya vao dyrdosn, suy lugn, 1 Ivan chit quan tty theo trinh 49 va kinh nghiém cia tig Thay thuéc.Nhiém tring ngogi khoa - Khang sinh trong phd thugt - GS. TS. Nguyén Cong Minh. 18 Boi vi lam sao danh gid chinh xéc duge vi tring chit yéu nao gay bénh; Lai phai quyét dinh chon KS trong nhiing tinh hudng c4p rap. Hon nia, tinh khang thuéc ella vi triing ciing thay 46i theo timg dja phuong va theo thai gian. Trong nhiéu céng trinh khao sit gin day cho thy: ¢6 gan 50% céc tinh hudng sir dung KS diéu tr] déu khdng thich dang (khéng higu qui). Do vay vige sir dung KS lu6n 1a dé tai mudn thud, mang tinh bite thiét va thoi sy.4) CAC THE HE CEPHALOSPOREINS VA KHANG SINH HIEN NAY Khdng sinh thude dong B-Lactam (bao gdm: Penicillins va Cephalosporins) va eée loai khang sinh méi hign nay. C6 hon 20 khang sinh durge xép vao bén “thé hé” chinh cita Cephalosporins."8) ~ ThE he thi nhét va thir hai thug duge st dng trong KS dy phong, ee nhiém tring khdng c6 bién chimg hoge diing trong céc truéng hop 'xuéng thang" KS diéu tr). ~ Thé h@ thet ba higu qué véi true tring gram am (mét vai thir dc higu kiém sodt duge Pseudomonas), nhung lai khong higu qua trén cdc cau tring gram am va yém khi,”4) ~ Cie Cephalosporins khong chéng duge cdu khuan rudt (Enterococci).!®! ~ Cefepime (Cephalosporins thé hé IV) higu qua trén cc Pseudomonas va céc cdu tring gram dm, nhung khdng tée dung trén céc ty edu ving khéng Methicilline (MRSA). 1. Nafeillin: Tén bigt duge: Nallpen, Unipen. Piperacillin: Tén bigt duge: Pipracil. jin/ Két hop khdng beta lactamase — sulbactam. Tén bigt duge: Unasyn. Ticarcillin-clavulanate. Tén bigt durge: i Piperacillin-tazobactam. Tén biét dugc: Zosyn.!"3) 3. Cephalosporins thé hé I ~ Cephalosporins thé hé thir nhét (cefadroxil, cefazolin (cephazolin), cephalexin, cephalothin, cephapirin, and cephradine) 6 téc dung higu qua trén vi khuan gram duong, nhét la trén tu cdu khdng khéng Methiciline (MRSA) va chudi cau. ~ Giéng nhu penicillin G va cae cephalosporins khée, Cephalothin va cefazolin ngan sy téng hgp cita thanh té bao vi tring. Cephalothin va cefazolin thai nhanh qua than.?71 ~ Sit dung Cephalosporins thé h@ thit nhat bing dung tiém mach vn con git vai tro quan trong trong KS dy phong. Cac Cephalosporins thé hé 1 * Duong tiém: Cephazolin, Cephalexin, Cefalothin (Cephalothin), Cephapirin, Cefatexin (CEPODEX, MEDOLEXIN, SEPRXIN, SPORIDEX, KEFORAL) Cefatothin (INTRALOTINE, KEFFLIN) Cephapirin Cephradine Cefatoridin (CEPHORINE) + Dung uéng: Cefalexin, Cephradine, Cefadroxil""?5) Cefadroxil (ORACEPHAL)Nhiém tring ngogi khoa - Khang sinh trong phdu thugt - GS. TS. Nguyén Cong Mink. 19 4. Cephalosporins thé hé II - Trong didu ti: cephalosporins thé hg th II khng manh hon eée KS khéc, bOi vi ching ‘chi tac dng higu qua trén trye tring gram am.7*122!) Cephalosporins thé hé thir II c6 khuynh huéng lam v6 higu hogt déng cia cde vi khudn ky khi. Loai nay higu qua trén Streptococei hiéu khi va ky khi nhung mit téc dung véi Staphylococci nhay v6i Methicillin.""! Cefoxitin higu qua trong cdc nhiém-tring 6 bung, bao gbm viém phic mgc va cae loai ap xe trong 6 by ~ Trong du phéng ‘Trong thap nién 70, vige sir dung KS dy phng cephalosporins thé hé thir Il, trong céc phdu thudt tim va lng nguc duge wa chugng nhat: cefamandole tt hon cefazolin. Cefuroxime li KS dur phong rét quan trong trong cdc phau thuat tim va long ngye. Né téc dung higu qua trén Staphyllo aureus, tuong ty nhu cefamandole. Cephalosporins thé hé thir II cing thuéng duge sit dyng dy phéng trong chdn thuong nhung hitu higu trong mot thai gian ngin,!""!?+! Cac Cephalosporins thé hé II Cephalosporins thé hé thir IT bao_gém cefaclor, cefamandole, cefmetazole, cefori cefotetan, cefoxitin va cefuroxime,”*) Cefuroxime ngin sy tng hop thanh té bao vi tring , giéng nhu cac cephalosporins khéc. Cé hai dang: Cefuroxime sodium dung tiém, Cefuroxime axetil during uéng.!") © Tac dung trén Haemophilus) + Dudng tiém: Cefamandol, Cefuroxim, Cefonicid, Ceforanide. + Dudng udng: Cefaclor, Cefuroxim axetil, ceftibuten, Cefdinir, Cefprozil, Cefpodoxime. Cefaclor (CECLOR, KEFLOR, MEDOCLOR, NOCKWOO CEFACLOR. ALFATIL). # Téc dng trén Bacteroides (vi tring ky khi duvng ru6t) + Dutng tigm: Cefoxitin, Cefotetan, Cefmetazole + Duong udng:) Cefamandol (KEFANDOL) Cofuroxim (LYNACEF, SEROXIN, SUPERO, ZINACEF, ZINNAT, CUROXIME) Cefoxitin (MEFOXIM). Cefotetan (APACEF). 5. Cephalosporins thé hé III Higu qu ten tye tring gram dm nhung khong tée dung trén vi tring gram duong (ngosi tit ceftriaxone).!"! - Cepbatesnarns thé hé thir ba wu thé véi trye khudn gram dm (mét vai loai dic bigt chéng duge ca véi Pseudomonas nhur ceftazidime), nhung hau hét bat lye véi cau khudn_ gram durong va khong khéng ché duge cde vi khudn yém khi. - Day IA loai KS du phéng tt nhat trong cdc cugc mé tim va Idng ngye hign nay. Véi tinh khang tring rong, nhigu logi cé thai gian bin hiy dai: chi cdn ding lai sau mdi 12 hoge 24 gid. No la KS dy phong higu qua v6i nhiém tring gram 4m trong cdc phdu thuat mé re. Tée dung hitu higu véi tu cdu vang (Staphyllo aureus). Mac dit kha dat nhung liéu ding it hon, gid ca sé chan héa, Day Ia loai KS ding hich 1é vi eéc phau thudt ling ngye - tim mach, nhét la tinh trang nhiém tring bénh vign gan day!?2., = Nh@ tinh khing triing rng ma ngay nay ngudi ta dura vao danh séch KS digu 221)Nhiém tring ngogi khoa - Khing sink trong phd thugt - GS. TS. Nguyén Cong Minh. 20 Céic Cephalosporins thé hé III Cephalosporins thé Ill bao gém: cefoperazone, cefotaxime, ceftazidime va ceftriaxone.!'} * Duong ‘eftriaxone, Cefotaxime, Cetizoxime, Ceftazidime, Cefepime. Ceftriaxone higu qua trén vi tring gram Am va vi tring gram duong. Ceftriaxone la mgt KS duy nhit e6 thoi gian én huy trong miu liu (ain § gi), do a6 chi ding mt hode hai ligu trong ngay, dic bigt dé dang vao dich nao tuy. * Dudng udng: khéng ‘Khang phé réng va khang Pseudomonas + Dudng tiém: Ceftazidime, Cefepime. + Dudng udng: khdng cé."! Cefoperazon (CEFOBIS, DARDUM, MEDOCEF) Cefotaxim (CLAFORA, FORTAX, INTRATAXIME, KAFLOXIM, PETCEF). Ceftriaxone (AXON, LICEFT, OFRAMAX, PACEPHIN, POWERCEF, ROCEPHINE) Ceftazidim (CEFTIDIN, FORTUM, KEFADIM). Cefixim (OROKEN). Nay durge xem li Cephalosporein thé hé thir IV. Cefpodoxim (ORELOX). Latamoxef (MOXALACTAM). 6. Cephalosporins thé hé IV Cephalosporins thé hé thir tur dang thin hanh tai My, chéng higu qua v6i Pseudomonas (vugt xa ceftazidime) va hau hét cdu khudn gram duong (né tong duong véi_nhém Cephalosporins thé hé thir nhat), nhung sé khong higu qua véi nhém ty cdu vang khéng Methicillin (MRSA =Methicillin Resistance Staphyllo aureus). Su khac biét vé phé khdng tring, dc biét trong nhém Cephalosporins thé hé III, str dung phai doi héi su hiéu biét sdu sic vé loai KS nay.""") ~ Phd khang tring gram am cia Cefepime manh hon ca Cephalosporins thé hé thit ba. - Tuong ty Carbapenems, Cefepime thye chat khang manh véi nhém “ thy phn béi B- lactamases” va higu qua véi nhém “sin sinh men beta lactamase phé réng” (ESBL: Expanded Spetrum Beta-Lactamase).”*) Cephalosporins thé hé IV Cefepime Ceftaroline la mot thé phat trién tir Cephalosporein thé hé IV: la Cepalosporeins duy nhat kiém soat durge MRSA .(liéu 600mg tiém mach mdi 12 gid). 7. Carbapemems + Dudng tiém cé 4 thudc: Imipenem-cilastatin, Meropenem, Doripenem, Ertapenem dang thinh hanh 6 Mg."3) Amipenem-cilestatin Rét higu qua ten chub clu tniéu va ky ‘khi, ty chu nay voi Methicillin va héu hét trén cdc true trang gram am! + Dudng udng: khéng cé. 8. Monobactams + Dudng tiém: Azfreonam duy nhat higu qua trén cdc tryc tring gram am. Tuong ty nhu ci Cephalosporeins thé hé II, Aztreonam khng kiém sost duge vi tring gram duong hod ky khi.! + Duong udng: khéng c6.'710, Te 12 13, 14, 15. Nhiém tring ngoai khoa - Khang sinh trong phéu thu - 'GS. TS. Nguyén Cong Minh, 21 TAI LIEU THAM KHAO ABRAHMAN A K and HASLINA A F. (2012): " Cefuroxime ". Kucers’ the use of antibiotics. 6" edition, Editor-in-chief : M Lindsay Grayson. Taylor & Francis Group. USA: 286-294. ACOSTA JA. WILSON WC. COIMBRA R. (2007): “Miscellaneous Trauma and Critical Care Considerations”. Trauma Critical Care, Ed by W C Wilxon, C M Grande, D B Hoyt. Informa Healthcare. NY: 1233-1240. 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