Dic DIEM Lim SANG, CAN Lim SANG vA muc 50 NHAY CAM vol THUGC KHANG SINH 0 BENH NHAN NHIEM KHUAN HUYET DO TRUC KHUAN GRAM AM TAI BENH VIEN TRUNG UONG QUAN DOI 108 (1998 - 2003) Nguyén Trong Chinh* Triéu chung lam sang hay gap trong nhiém khudn huyét do true khudn Gram am gém s6t cao dao dng kém con rét run, gan to, ldch to, ban xudt huyét hoai tu, kém theo sé luong bach céu mau ngoai vi binh thuéng hodc gidm. Can nguyén vi khudén gram 4m thuéng gap la: E.coli, enterobacter va P, aeruginosa. Cac vi khuan nay khang voi nhiéu khang sinh théng thuéng, con khd nhay cam voi cephalosprin thé hé ba va ciprofloxacin, nhay cam t6t vdi amikacin va rat tot voi imipenem. 1. DAT VAN DE ‘Song trong thuc t&, NKH néi chung va NKH do 7 7 . truc khuan gram am [gram (-)] néi riéng van Nay nay, y hoc 48 dat duce nhiéu thanh ee tuu trong chan doan, di6u ti va chim s6c ete | 98V céng t2ng [en tén thé git [2,11], NKH do khde ngudi bénh, dac biét oO rat nhigu loai ene gram (), one tae ai 90 He khang sinh mél, hoat phé rong 6 kha. namg | Ahm trung co ho" hay “ahiém tring 6 diéu Giéu tri va dy phong nhi&m khuan huyét (NKH). kign" *TS., Khoa Truyén nhiém, Bénh vién Trung uong Quan 46i 108 35,Tap chi THONG TIN ¥ DUOC Bénh canh lam sang ca NKH rat da dang, chén doan xdc dinh dua vao phat hién vi khudn dudng tinh qua oa Sy mau, nhung khong phai bao gid cfing cho két qua ducng tinh, trén thuc té ti l@ cy mau 6 nhiing bénh nhan nghi ngd NKH chi dat tir 10,4-15% [3.9]. Day la kho khan cho chan doan xae dinh cla cac thay thudc lam sang. Mat khac can nguyén vi khudn rat da dang, tinh khang thuéc khang sinh thay déi thuéng xuyén, va sit dung khang sinh khéng hgp ly gay nén tinh trang gia tang tinh khang khang sinh cla cac loai vi khudn. Xuat phat tt thyc té trén, ching tdi tién hanh nghién ctu dé tai nhim - Tim hiéu dac diém lam sang va can lam sang cla NKH do true khuan gram am. - Banh gid tinh hinh nhay cam vdi thudc khang sinh ciia cac chting vi khuan phan lap dude. ll, BOL TUGNG VA PHUONG PHAP 1. Béi tupng nghién cuu: 93 bénh nhan dude chan doan xac dinh NKH gram (-) diéu tri ml. KET QUA S63 nam 2004 tai Bénh vién Trung yong Quan dai 108 (1998- 2003), déu duge cy mau phan lap vi khuan duang tinh, 2. Phuong phdp nghién cuu - Chi tiéu theo déi lam sang: bénh nhan duge xac dinh nguén nhiém; vi tri nhiém khudn tién phat va thir phat; tinh chat sét, con rét run; cc trigu chting tam than kinh; hé hap; tigu hoa va cdc dau hiéu ca séc nhiém khuan (diéu tra tién st, bénh stt, theo déi dién bién lam sang hang ngay). - Cac xét nghiém: bach cu, héng cau, tiéu cau, men gan (SGOT, SGPT), bilirulin, ure, creatinin... duc xét nghiém trudc khi vao vién, trong va sau khi két thie diéu tri ~ Cac ky thuat phan lap va dinh danh vi khudn duge tién hanh theo qui dinh cua TS chite Y t6 Thé gi6i va chung trinh ASTS... Ky thuat khang sinh dé theo phudng phéap Kirby - Baurer. 1. M6t s6 dac diém chung cua 93 BN nhiém khudn huyét gram (-) Béng 1: Tu6i, gidi va tién sitnoi mac bénh 2. Biéu hién lam sang 6 bénh nhén NKH do true khuan gram (-) 36 Phan logi theo tudi Not bj bénh Gidi__ 15 - 30 | 31-45 | 46-60 > 60 Ngoai bénh vién | Tai vién Nam | Nit STBN (A= 93)] 78 i 42 22 42 51 57 Ey TY 16 % 19,4 11,8 45,2 23.6 45,2 54.8 61.2 | 38,7 | Nhan xét: Lifa tudi NKH gram(-) hay gp nhat la trén 45 tudi (68,8%). Bang 2: Bénh ly va vi tri nhiém khudn (6 Bang 3: Mét sé triéu ching lam sang khi tién phat) 6 93 bénh nhdn NKH do true khuén | nhép vién 6 93 bénh nhdn NKH gram (-) gram (-) Biéu hién lam sang SO BN | TL% \Bénh ly va vj tri nhiém khuén | S6BN| TL% [Dao déng + Rét run 25 26,9 Khoaing v6 ctfa ng 3 [bien [Thanh con + Ret run 56__| 60.2 [Sdi than, viém tiét niéu, sinh duc | 26 sot [Lien tuc + con rét run far lhea |Sdi duéng mat, viém duéng mat | 24 thudng xuyén fe \Vét thyong nhiém trang “1 hier (225-38. [3 [86 Sau phdu thuat ey lag (38°1- 39°C 16 | 17.5 Tai bién mach ndo (thé may, m3 | 4 > 39°C __| 79 [849 kkhi quan...) 7 Da [Xung huyét 148 NK ving rang, ham, mat 4 43 Iniém |Ban dat san 27 __| 29,0 Bénh man tinh (ung thy, viém | 6 64 Imac _|Ban xuat huyét hoai ty 38 | 40,8 than man...) suy giam mién dich ia 16ng 26 | 27.9 {Bénh van tim (hep hd van BM, |) | 45 Itieu [Bung chuéng 32_| 34,4 van 2.) hea [Gan to 90 | 967 Cong 93_| 100 Lach to 71_| 763Tap chi THONG TIN Y DUOC S63 nam 2004 Bang 4: K6t qua xét nghiém khi vao vién 3. Can nguyén vi khudn va tinh nhay cdm ctia vi khudn voi khdng sinh pee Cie xa poten Bang 5: Can nguyén vi khudn gram (-) géy A : NKH IBach cdu (G/L) ean Triéu ching SOBN| TL% . . 35-36 Escherichia coli | 24 25,8 eng cau (TIL) 5-88 Enterobacter spp | 22 | 23,7 [scot (uty 5 a [Pseudomonas aeruginosa 20m F2toe| Wee 5 zo [Klebsiella spp 10 | 10.5 ISGPT (U/L) Get 380 IProteus spp 9 96_| Ure mau [Binh thudng _ \Acinetobacter 4 44 (mmovt Hang Citrobacter 2 | 22 Creatinin mau [Binh thuéng | : (mmo Tang Burkholderia pseudomallei 2 22 Brlirubin TF [Binh thudng | __Céng s3_| 100 | \(mmolt [Tang — ee Bang 6: Mutc dé nhay cam vdi thud khang sinh cila E.coli, enterobacter va P. aeruginosa ' Ty 16 % nhay cdm ] Khang sinh E.coli (test= 24) | Enferobacter (test= 22) | P.aeruginosa (fest= 20) _| _ Nhay [Trung gian | Khang |Nhay [Trung gian [Khang | Nhay [Trung gian | Khang Ampicillin 9.6 5,2 85,2 | 12.6 52 82,2 a 00 91,2 Cefotaxim 69,4 4,5 26,1 | 61,8 14,0 24.2 2,0 58,4 _Ceftriaxon | 72, [26.6 | 55. 40 | 40.0 40. 316 Ceftazidim | 83.4 96 [725] 12 | 263 80 | 33.2 Gentamycin | §3,2 43,5 | 55.0| 0.0 | 45.0 [32 {45.0 _| Amikacin 90,1 84 86.5 1.4 ae 0,0 19,3 Chloramphenicol | 22,0 [70.0 [180| 00 | @2.0 | an Es Cotrimoxazole | 19,2 80,2 | 200] 80 | 72,0 _ Ciprofloxacin 814 12,0 | 78,2 75 24,3 65,2 | 44 30.4 Imipenem 96,5 08 27 98,8 0,0 oo 94,5 0,0 5.5 IV. BAN LUAN Tiép theo nhiing déu higu thém kham lam 1. Dac diém lam sang & 93 bénh nhan NKH do tru khudn gram (-) - TY lé khéng 6 vi tri nhiém khudn (8,6%): 91,4% xac dinh duge vi tri nhiém khudn (6 tien | phat), theo thir ty la: sdi than va viém dung mat (27,9% va 258%), sau phau thuat | (12.9%), vét thuong nhiém tring (11,8%)... Két | qué nghién ctfu cla ching tdi cling giéng nhu nhan xét cilia cac tac gia trong nude va nuéc | ¢ ngoai [1, 4, 7]. Trong khi dé ctta vao (6 tién phat tty da niém mac) chiém ty 1 cao (70 - 85%) (1, 3, 5] - Trigu ching lam sang bénh nhén NKH do true khudn gram (-), chung téi thay dau hiéu s6t cao dao déng kém can rét run gap d ahiéu bénh shan (60,2%), sét thanh con rét run chiém ti 16 26.9%, cdn sét cao lién tuc + con rét run khéng thung xuyén chi gap 12,9%. 37 sang cling rat quan trong gitip thay thu lim sang c6 thém co sé dé nhan dinh xem xét cd phai la NKH khéng, d6 [a . ban dat sdn + ban xuat huyét hoai tir ho&e ban xuat huyét hoai tir (40,8%); va thuéng c6 gan to va lach to (96,7% va 76,3%). Mét s6 tac gia khac (Nguyén Dang Ngoa - 1985; Pham Vn Ca - 1995 va Pham My Ngoc - 1996) con thay nhiing bidu hién trigu chimg 6 duting tiéu héa gap ty 18 kha cao (85%), nhu chuéng bung (46,8% - 50,5%); ia tong (27,6%) va vang da (14,9%). Két qua nghién eéfu ctia ching tdi gap nhiimg biéu hien lam sang & dung tiéu hoa véi chuéng bung 34,4%, ia long 27,9%. 2. Cae xét nghiém cén lam sang - S6 lung bach cdu thudng gidm chiém ty 8 cao (87,1%) trong d6 bach cau giam trong khoang 3-5G/l chiém ty [8 kha cao (38,7%). Kam theo sé lugng héng cau giam ciing chiémTap chi THONG TIN ¥ DUOC S63 nam 2004 17.16 kha cao (61,3%), trong d6 ty 16 héng céu giam duéi 2,5T/ 1a 15,0%. - Bc biét, cac bénh nhan NKH gram (-) 66 tén thuong gan, vi biéu hién men gan tang (ca SGOT va SGPT) chiém ty 1é (89%), trong dé men gan tang gap 4 dén 5 lan binh thudng gp 55,9%. Két qua nghién ctu cia mot s6 tac gia khac c6 ti 1é tén thuong gan thép hon ching tdi (50-65%) [5, 6]. Biéu hién tén thuong than v6i ure, creatinin tang nhe chung tdi chi gp 40,9%, trong khi dé Pham My Ngoc (4] gap 57,5: 61,8%. Sy khac nhau nay con phy thudc vao nhiéu yéu té (bénh nhan dén mudn, bu nude dién gidi thiéu. 3. Can nguyén vi khudn va tinh nhay cam voi khang sinh = Can nguyén gay nhiém khuan huyét gram (-) chung tdi gap nhiéu nhat la E.coli (25,8%) enterobacter (23,7%) va P.aeruginosa (21,6%), tiép dén la Klebsiella (10,5%) va Proteus (9,8%). Bang imu y, ching tdi g&p 2,2% do Burkholderia pseudomallei (truc khudn Whitmore), day la nhitng truang hop rat hiém gap, bénh canh rat nang, cé tac gia con goi “nhiém khuan huyét md", vi khudn dén cac phu tang gay nén cac 6 apxe nhd 6 nhiéu co quan (hay goi la phdi, gan, lach) va cac 6 apxe trong cd va duéi da, vi khudn van con nhay cm t6t véi chloramphenicol va tetracyclin - Theo doi d6 nhay c&m véi khang sinh cla cdc ching phan lap duc tu bénh nh&n NKH gram (-), chting tdi chi phan tich khang sinh dé cilia E.coli, enterobacter va P.aeruginosa, cdn cc chiing khac phan lap duge cén it nén can tiép tuc theo doi Nhin chung, E.coli, enterobacter va P.aeruginosa déu khang vi cac khang sinh théng thuéng (ampicillin, chloramphenicol, co- trimoxazol) véi ty Ié rt cao (80-91,2%). Khang sinh nh6m cephalosporin thé hé Ill va ciprofloxacin con tudng déi nhay cam (tét hon c Ia ceftazidim ty 8 nhay 83,4-72,5%; véi P.aeruginosa thdp hon: 68,8%). Khang sinh con tét I& amikacin (nhay cam 80-90%) va rat tot la imipenem (ty 1é nhay cam 94,5-96,5%), tuy vay da xudt hién imipenem khang véi E.coli (2,7%), enterobacter (1.2%) va P.aereginosa (5.5%). Bdi vay khi ding khang sinh nay can chi dinh ding, tranh lam dung, dé han ché sv gia tng tinh trang khang v6i cdc khang sinh nay. V. KET LUAN 38 Qua két qua nghién ctu dac diém lam sang, can lm sang... 6 93 bénh nhan NKH gram (-), ching t6i c6 nhan xét nhu sau: - Nhiing trigu ching hay gap gitp huéng dén NKH gram (-): sét cao dao déng kem cé con rét run (60.4%); gan to, lach to; ngoai ra C6 ban xuat hién hoac ban dan san két hap véi ban xuat huyét hoai ti, kém theo ¢6 bach cau binh thuéng hoac gidm (87,1%), thiéu mau (61,3%) va c6 men transaminase tang (89%). - Can nguyén gay NKH gram (-) phan lap dude, thujng gap la E.coli (25,8%), enterobacter (23,7%), P.aeruginosa (21,6%), Klebsiella (10,5%) va Proteus (9,8%). E.coli, enterobacter, P.aeruginosa con nhay cam kha véi cephalosporin thé hé Ill va ciprofloxacin; con nhay cam tét véi amikacin va rt t6t vGi imipenem. SUMMARY Clinical and paractinical characteristics and the sensitivity to antibiotic in septicemia patients with Gram (-) bacteria We conducted a study on 93 patients suffering from septicemia who were treated in Central Military Hospital 108 from 1998 to 200. The results showed: - The main clinical symptoms of septicemia are fever with sweats (Rigor): 62.2%, liver and spleen palpable (90-71%), rash (40.8%), with white blood cell count normal (87.1%). - The main causes of septicemia gram negative are E.coli (25.8%), Enterobacter (23.7%), and Pseudomonas aeruginosa (21.5%). These pathogens still remains sensitive with cephalosporin Ill, ciprofloxacin (from 70-81%), amikacine (85-90%) and imipemem (92-96%). TAI LIEU THAM KHAO 4. Pham Van Ca: Can nguyén vi khudn va mét s6 yéu 16 lién quan trong NKH tai bénh vién Bach Mai 1989-1983. Luan an PTS khoa ‘hoc y duc, BH Y Ha Noi, 1995. 2. Gruneberf R.N., Felminglam D.: The Alexander project group diagnostic microbiology and infections diseases. SmithKine Beecham data on file, Sept 1996; 25: 169-181 3, Tran Van Hung: Tim higu can nguyén vi khudn gay NKH tai Bénh vién Trung uong Hué nam 1997- 1998, Luén van Thac s7 y dugc, Hoc vien Quan y, 1998. 4. Pham My Ngge: Gép phan nghién city ac diém lam sang va mdt s6 yéu t6 tién lyong 4 bénh nhan nhiém khudn do true khudn gram am, Ludn van Thac sf y duoc, Hoc vién Quan y, 1996.Tap chi THONG TIN Y DUOC 5. Nguyén Kim Nga: Mot s6 nhan xét v8 NKH 6 tr sd sinh da dude diéu tri tai Vien Nni 1992-1993. Luda van chuyén khoa iI, chuyén nganh Nhi, BH Y Ha N6i, 1994 6. Ng@ Thi Thi, Bang Thu Hing: Nhiém khudn huyét & tr em, c’n nguyen vi khudn va tinh hinh kang khang sinh. Mét sé céng trinh nghién ci vé 46 nhay So 3 nam 2004 3m ofa vi Khudn véi thuéc khang sinh (1997 - 11998). Vién y hoc lém sang cac bénh nhiét di, 1999; 119-119 Graw M. Hill L Sepsis and. septic shock Hamison’s Principles of internal Medicine, 1996, pp.511-515.9