B Y TTRNG I HC Dc H NI^)07//^e'Jcih KHOST TNH HNH SDNG KHNG SINH
IU TR VIM MNG NO M TI KHOA NHI BNH VIN BCH MAI( KHO LUN TT NGHIP
DUC s KHO 2001-2006)Ngi hng dn:THS. Phan QunhLanTS. BS. Nguyn Tin
Dng Ni thc hin: Khoa Nhibnh vinBchMaiB mn Dc LmSng trng ihcDcThi
gian thc hin:08/2005- 03/2006.V .^ ')''. 1H Ni, 5 - 2006\ ., /u L i
LI em RTi xin by t lng chn thnh bit n ti:THS PHAN QUNH LAN TS.BS
NGUYN TlN DNGNhngngithy tntnhhng dnvdnhchotis gip qu hu trong sut
thi gian hc tp, nghin cu v hon thnh kho lun.ng thiti cng xin chn
thnh cm n:Cc thy ctrong B mn DcLmSng,ccthycgiotrongtrngihcDc toiu
kin ti c th hon thnh kho lun ny.Ti xin by t lng bit nti nhng ngi
thntrong gia nh,nhng ngiluntoiukincngnhngvin,khchltitrongsutqu
trnhhctp. Ti xin chn thnhcm n nhng ngi bn gip ti rt nhiu trong thi
gian hon thnh kho lun.H Ni ngy17 thng 5 nm 2006 Sinh vin V Th c
HnhCH GII CH VIT TTC3GCephalosporin th h 3.DNTDch no tu.G(-)Vi khun
gram m.G(+)Vi khun gram dng.KSKhngsinh.KSKhng sinh .TMCTruyn tnh
mch chm.11MTim tnh mch.VMNMVim mng no mH.influenzaeHaemophilus
influenzaeL.monocytogenesListeria
monocytogenes.N.meningitidisNeisseria meningitidis.s.
pneumoniaeStreptococcus pneumoniae.020202MC LCT VN
............................................................................................PHN1:TNG
QUAN...........................................................................1.1nh
ngha........................................................................................1.2
Phn
loi...........................................................................................1.3
Dch
t...............................................................................................1.4
Cc loi vi khun thng gy vim mng no m tr em....................
031.5C ch bnh sinh vim mng no
m......................................................031.6 Triu
chng bnh vim mng no m tr em.......................................
051.7 Chn on xc nh vim mng no
m................................................. 061.8Cc bin chng
v di chng ca vim mng no m.............................. 071.9 Nguyn
tc iu tr vim mng no
m...................................................071.10 Khngsinh
trong iu tr vim mng no m tr
em.........................091.10.1Nguyn tcs dng khngsinh trong iu
tr VMNM.................. 091.10.2 Phc khngsinh iu tr vim mng no
m.............................. 121.10.3 Mt s khng sinh thngs dng
trong iu tr VMNM..............14PHN 2:I TNG V PHNG PHP NGHINc u
.............. 172.1. i tng nghin
cu...........................................................................2.2.
Phng php nghin
cu......................................................................PHN
3:KT QU NGHIN eu V BN LUN.............................193.1.Mt s c
im ca nhm bnh nhn nghin cu................................ 193.1.1.
Tui v gii ca nhm bnh nhn nghin
cu..................................193.1.2. Tinh hnh mc bnh theo
thi gian...................................................
193.1.3. Tmh trng dng khng sinh trc khi nhp
vin............................. 203.1.4. Kt qu phn lp vi khun t
dch no tu.......................................223.1.5Cc bnh mc km
vim mng no m........................................... 223.2. Tmh
hnh s dng khng sinh trong iu tn vim mngno m........ 233.2.1Cc loi
khng sinh c s
dng...................................................3.2.2 La chn
khng sinh cho cc bnh nhn cha c chn on vimmng no m lc nhp
vin.......................................................32.3La
chn khng sinh nhng bnh nhn c chn on vimmng no m lc nhp
vin..........................................................3.2.4Liu
dng cc khng sinh cs
dng.........................................3.3. Tc dng khng mong
mun ca thuc............................................... 343.4.
di t iu tr
khngsinh..............................................................3.5.Hiu
qu iu
tr...................................................................................PHN
4:KT LUN V
XUT.....................................................Ti liu tham
khoPh lcT VN Vim mng no m l mt bnh nhim khun cp tnh nguy him vi t l
t vong c th ln ti100% nhng trng hp khng c iu tr v 30% nhng bnh nhn
c cha tr[12].iungquan tm l bnh licc dichng htsc nng n nh:ic,lit,
haygim thnh lc nngn...T l di chngtng i cao, ln ti30% trs sinh
v15-20% tre ln[20].Trn th gii,vics dng vaccin phngvim mng no m do
mts tc nhn lm gim ng k t l mc bnh (v d nh gim ti 55%s ca b
vimmngnorndoH.influ6nz6itsncchuAu[25]).Ricng Mtlmcbnh hinnayl
2-3trn100.000dn,thp hnt lmcbnh
cchy10nml4-6trn100.000dn[12].Dogithnhcnkhcao, vaccin phng vim mng
no m vn cha c s dng rng ri Vit Nam. Vit
Namchacthngkchnhxc,nhngnhiunghincucho thyvimmng nom l bnh haygp th
3trongccbnhnhim khuan trem[1].Bnh thngc pht hin mun;tl khng thucca
vi khun gybnhcao.Thmvo,s raica nhiuloikhngsinhmivvic
lmdngkhngsinhnnvimmngnomlvncncquantm nghin cu,c bit l vics dng
khngsinh hp l v hiu qu[2].ChngtitinhnhtiKhosttnhhnhsdngkhngsinh
iutrvimmngnomtikhoaNhibnhvinBchMaivimc ch:>
Khosttnhhnhsdngkhngsinhtrongiutrbnhvim mng no m ti khoa Nh bnhvin
Bch Mai.>Qua xut kin gp phnmbos dng thuchp l v anton hn.PHN
1:TNG QUAN1.1. NH NGHA [1]VMNM l tnh trng bnh lgy nn do VK (i khi l
do k sinh trng) c kh nngsinh m xm nhp vo mng no vi bnh cnh lm sng
ch yu lhichngnhimkhuncpvhichngmngno.VMNMcchn
ondavoktquchcddchnotu:tmcVK;ksinhtrngqua
soivnuicy;tmckhngnguynVKchiuhocccbiniv sinh ho, t bo c xu hng vim
m.1.2. PHN LOI[1]1.2.1. Phn loi theo la tuiC nhiu cch phn nhm VMNM
theo tui.Mt trong cc cch l chiathnhVMNM trdi1 thng,t1
thngn3thngtuivtrn3 thng tui.Cch phn chia ny thun li cho vic iu tr v
mi la tui u c nhng tc nhn gy bnh v c im iu tn khac nhau.1.2.2. Phn
loi theo c ch xm nhp ca vi khun vo mng no + VMNM tin pht:Thng gp tr
di 5tui.+ VMNM ti pht nhiu t;Thng xy ra tr c cc c im nh :>D dng
mng no, chn thng rn v nn s, xng .>C vim mn tnh ng tai mi hng
(xoang, taigia,xng chm,...) khng c iu tr.>Suygim min dch.1.2.3.
Phn loi theo cn nguyn gy bnh c thVim mng no m do
H.infuenzae,N.meningitidis, E.coli,...1.3.DCH TVMNMl mt bnhnhim
khun thn kinhgp tnginhiu c tr em v ngiln[1].Vit Nam cha c thng k y
v tnsut mc bnh
nhngcctcgiuthyVMNMlbnhhaygptrem,trongtptrungchyutuiTcnhngybnht nhim
khun trongc th,cbitl ccvtr k cn mng no nh tai gia,xng chm, cc xoang
xm nhp vo>CcVKcsntrongc th,gpiukinthunli(chnthng,tai
binmchmuno,mngno,dtt)xmnhpvomngnogyVMNM.Khi VKxm nhp
cvomngno,chngsgiiphngra mt lot
ccchtnhlipopolysaccharid,nict(vikhunG(-))hayacidtechnoic
(vikhunG(+)).Nhngchtnylmtngqutrnhsnsinhracccytokine
nhinterleukinI,VI;prostaglandinE2;yuthoitkhiu(TNF)vcc
monocytluhnhtdotrongmu.Nhngcytokinenyngvaitrquan trng trong vic thc
y gn leukocyte vo tbo mng trong mao mch no
vcngtoiukinthunlichovicdichuyncaleukocytevotrong mng no.Trongqu
trnh gn vo mng trong no,leukocyte gii phngsn phm c tph hu t bo, lm
tng hot ng thm bo, m rng ch khp
nivthmchlmtngtnhthmcahngromuno.Mngnovim
chophpsxmnhpcaalbuminvdodnnphno.Phnokt hp vis tc nghn ca dch no tu
lm tng p lc nis v thay i dng chytun hon no.Qu trnh ny thngi km vi
vicmt kh nngiu
hotngnotimvgytnthngthnkinh,tnthngnokhnghiphc.1.6.TRIUCHNG BNH VIM
MNG NO M TR EM1.6.1.Triu chng lm
sngTuvotnglatui,triuchnglmsngcaVMNMcnhngc
imkhcnhau.TrcmghpinhnhVMNMcnhngtriuchnglm
sngsau:[1],[4],[8],[20]a.St:L biuhinca hichngnhimkhuncp
tnh.TrbVMNMthng stcao,ckhintrn40c.Tuynhintrssinh,ikhitriuchng ngc
li, tr c th b h thn nhit.b. Hi chng mng no:-
trnhtriuchnglmsnggm:Thp phpphng,nnnhiu,a chy, cng gy, co git.-tr
ln, triu chng lm sng thng c tam chng mng no:>Nhc u lin tc, c 2
bn nht l vng thi dng chm.>Nn:thng nn t nhin, nn vt d dng, khng
ph thuc ba n.>To bn i khi c th gp a lng, au bng.c.Cc triuchng
khc:Thng thay i tu thuc vo tng bnh
nhn.-Triuchngthcth:Kemig(+),Brudzinski(+), triuchngtngcmgic au, t
th nm hnh csng, chngs nh sng.-Triuchngthn kinh:Rilon trigicnh tnh
trngl m,km theo cn ht hong vt v. Th nng cng c th gp cc mc hn m khc
nhau.1.6.2 Triu chng cn lm sng [1],[8],[20]Xt nghim DNT l xt nghim
quan trng nht, c tnh quyt nh cho chn on VMNM. Trng hp in hnh, DNT
thng c nhng bin i sau:a. p lc dchno ty
tngBnhthngkhitrnmyn,tcchycaDNTkhichct10-20 git/pht (tng ng50-100 mm
nc), tr ln t100-200 mm nc.b. Mu sc dch no
tyThngvncrviccmckhcnhau(nhncda non,nc vo go hay c nh m).DNT c th
trong trong mt s trng hp nh:chc tusngsm trong 24h u ca bnh hoc
trong giai on bnh iu tr d dang.c.Soi, cy tm thy v khun trong dch no
tyy l mt ch tiu xc nh chc chn VMNM.d.Cc thay i sinh ho.-Protein
tng:thng >1.2gA tr di1 thng, >0.45gA tr
trn1thng.-Glucose:Thng gim nhiu,c khi ch cn vt.Lng glucose nh
hn1.1mmolA tr di1 thng, v nh hn 2.2 mmolA tr trn1thng.-Clo:Bnh thng
hay gim nh (bnh thng l122 mmol/1)-C th thy LDH, acid lactic, CRP
tng (>20mg/l), phn ng Pandy (+).e.T bo:C th tng ti hng nghn,ch
yu l bch cu a nhn trung tnh. C th thy bch cu a nhn thoi ho.Bnh
thngs lng t bo trong DNT:+tr non < 50 t bo/mm^+ trs sinh < 30
t bo/mm^+ tr lfn hn, ch yu l lymphocytes < 5t bo/mm^1.7.CHN ON
XC NH VIM MNG NO M[1],[4],[20]-VMNM c chn on chc chn khi c t nht mt
trong cc c im sau;+ Dch no tu c nh nc da non, nc vo go, hoc dch
m.+Soi hoc cy DNT tm c VK gy
bnh.+TimcthnhphnkhngnguyncaVKtrongdchnotu(qua
phnngELISA,indimindchiluhayngngktchiu,CRP).- Nhng trng hp dch no
tutrong:Chn on xcnh thng kh khn nhtltrongtrnghpVMNMciutrKS
trc.Vicchnon phidavoccbiuhinlmsng;ccbinihosinhvt botrong
DNT(cbitlCRP>20mg/l,LDHvacidlactictng);yutdcht; ng vo VK v i khi
phi cn nhc c din bin v kt qu iu tr
th.1.8.CCBINCHNGVDICHNGCAVIMMNGNOM[1]1.8.1. Bin chng-Shock nhim
khun-Hn m, ri lon chc nng h hp v tun hon thng do ph no-Tinh trng
lit khu tr-Trn dch mng cng,apxe no-Ngoi ra c th gp tc mch mu no,
vim dnh no tht..1.8.2. Di chng-ic hoc gim thnh lc nng n:L di chng
tng i ph bin (chim10-15%s bnh nhi mc VMNM) nhng nc ta cn chac ch
.-No nc;Vng u to nhanh, cc khp s gin-Chmpht trin vnng,chmpht trintr
tu haychai,nu nngthng tr c tr tu n n km theo tnh trng tng trng lc
c.-ng kinh.19NGUYNTClUTRVIMMNGNOMU [1],[4],[8],[9],[19]1.9.1.Chng
nhim khunDngKSngaykhicchnonVMNM.Tuvocimcabnh
nhncthchnccKSthucnhmsau:penicillin,cephalosprin,
phenicol,...Sau3-5ngy iu tr nu khng nn i thuc hocs dng kt
hpKS[l],[4].1.9.2. iu tr h tra.Chm sc,
nungPhitheoditnhtrngdinhdng,cnbngnc-ingii,theodi cht ch chc
nngsng.Khi cn,phi p dng cc bin php cho n qua ng thng, th oxy, ht m
di, truyn dch.b. iu tr ri lon cc chc nngiu tri st cao-Chm lnh v
thuc h nhit (paracetamol).-Chng co git:Diazepam (Valium,Seduxen)
0,2mg/kg/ln, TMC. Chns ph no-Lp li cn bng nc - in
gii.-Thuc:Manitol, dung dch 20%,g/kg, TTM hoc
FurocemidImg/kg-Dexamethason,Img/kg, TTM hoclOmg/mVngy,chia 4
ln-ChcDNT.Chns sc hoc tnh trans truy mach-Liu php truyn
dch-Prednisolon 5mg/kg, TTM-DCA (desoxycoteron acetat) 2-5mg,
TB-Heparin:khicbiu hinngmuniqun100nv/kgAn,TTM, cch nhau 4-6h.Pht
hinv iu tri cc di chns1.10. KHNG SINHlU TR VIM MNG NO M TR
EM.1.10.1.Nguyntcs dngkhngsinhiutrvimmngnom tr ema.La chn khng sinh
c kh nng thm tt qua mng no
[1],[21]NhngcimcaKSnhhngtitnhthmcathucquamng no gm:Kch thc phnt v
kh nns Hn kt vi protein huyt
tnsChdngtdothucmickhnngthmttquamngno.Khi thuc dng lin kt vi
protein, kch thc ca phc hp thuc-protein ln
nnkhnngthmquamngnokm.Dovy,utinlachnKS ckch thc phn t nh, kh nng lin
kt vi protein huyt tng thp.Bng1.2. c im ca mt s khng sinh thng dng
trong iu trvim mng no m[21]Khng sinhThi gianbn thi(h)Th
tchphnb(i/kg)T l linkt protein huyt tng (%)Ampicillin 0.75 0.30
20Ceftazidim 1.90 0.25 17Cefotaxim 1.00 0.35 40Ceftriaxon 6.0 8.0
80-95Chloramphenicol 3.0 0.90 50Tnh tantrone lDdv ion ho ca thucDo
cu to ca mng no ch yu l lipid nn nhng thuc tan trong lipid
(chloramphenicol,metronidazol)sthmquamngnomtcchddng
ngaytrongiukinbnhthng.Nhngthuctantrongnc(aminosid,
vancomycin)srttvhunhkhngthmquamngno.Cnlinhng thucbnphnccnh
penicillin,cephalosporinthmtquamngnobnh thng,nhnglithmqua tt hn
khimngnobvimvcthtc
nngditkhuncnthit.Nguynnhncasthayinylkhimngnobvim,pHcahuyttngthayi,thngltngtnhacid,dnti
tnglngthucdngkhngphnlynntngtnhthmcathucqua mngno.Thmvod,s
thayicamtsc ch vnchuyntchcc cng to iu kin thun li cho thuc thm qua
mng no.b. La chn khng sinh t nng dit khun trong dchno tu [1],[21]
ThucthmttquamngnostoranngKScaotrongDNT.
NngKStrongDNTttnhtlgp10lnnngditkhuntithiu
(MIC)[1].imnyrtquantrng,vtrongmtstrnghpVKkhng
khngthucnhngtrongqutrnhbnhcthxuthinnhngvchngn
trongmngno,lmthuckhthmquamngno.Dntilmgimtc dngca thuc.Trong trcmg
hp nyphi u tins dng thucc thmvoDNTcao[21].'TilA c fliomT s nng KS
trong DNT/MICKhng sinh11 Ic lVk3inal nhp vo DNTVi khun nhy cm
vi(3-lactamVi khun khng vip-lactamPenicillin/ Ampicillin5-15%1-10
20%^>10nang nghin cuCefotaxim/ Ceftriaxon5-15%>101-10Cefipim/
Meropenem5-15%>101-10Vancomycin20%>10>10c.Dngkhngsinhngaykhcchnonxcnhvimmngnom[1U4]KhicchnonVMNM
nndngKS theo kinhnghimngay.ng
dngthucnndngtimtnhmchtnngcaotrongmu.Saukhi c kt qu soi v nui cy
DNT, c th thay i phc ban u cho ph
hp.10d.Khngsinhditkhunphinhycmvicnnguyngybnh
[IM3MI9]-NuktqusoihocnuicyVK(+),cthlmKS.Davokt qu KS la chn thuc hp
l.-Trong trng hp kt qu soi hoc nui cy(-), vic la chn thuc ch yuda
vo kinhnghim.Lcnyphixemxtnccyu t vc
imlmsng,yutdcht(tui,vngal),ctnhkhng thuc ca VK tng vng.Bng1.4. Tnh
nhy cm ca mt s vi khungy vim mng nom(%)[3]Vi khun Amikacin
Ampicillin Cefotaxim Ceftazidim
CeftriaxonChloramphenicolGentamicinE.coli89,5 9,0 60,2 66,3 51,2
37,4 45.7Klebsiella spp84,2 53,1 23,4 66,1 67,2 51,9 65,9Proteus
spp92,4 32,1 89,3 93,7 92,3 34,2 69,9Enterobacterspp73,2 2,0 35,9
50,8 43,2 36,5 42,7p. aeruginosa54,114,0 43,2 8,526,6H.
influenzae12,825,0 40,0 12,7 60,6s.pneumoniae 63,4s. aureus53,3
79,654,0 42,3e.La chn khng sinh t dcvi tr em [1].Tr em c cc c im dc
ng hc v thuc(l ccqu trnh hp thu,phn b,chuyn ho,thitr)ckhcbitso vi
ngiln.cbit tr emangtrongqutrnhphttrin.Dovy,khilachnthuccncnnhc gia
li ch v nguy c.TrongthcttcKSnopngycciukintrn.Trong nhng KS c s dng
cc nc ang pht rin, chlorampenicol c coi
l11thucltngdotc3chtiu(khnngthmvoDNTcao,tl
khngthuccnt5-6%,githnhthp),nhngmtsnccmdngdo c vi tuxng[1].Trong khi
,Cephalosporin th h3l la chn hng u ccnc pht trin nhnggi thnh li qu
cao.V vy, tu trng hp c th c cch la chn KS ph hp
nht[1],[8],[19].1.10.2.Phc khng sinh iu tr vim mng no m tr em.a.
Phc khng sinh ban u (phc khng sinh khi cha c kt quxt
nghim)KhoaNhibnhvinBchMaisdngphckhngsinh(2004)da theo khuyn co ca
WHO c chnh sa cho ph hp vi c im bnhVMNM tr em ti Vit Nam nh
sau:Bng1.5. Phc khng sinh ban u[4]La tuiTc nhn thng gpPhc khng sinh
ban u2thng tuiH.influenzae,N.meningitidis, s. pneumoniae
Staphylococcus...ChloramphenicolHoc1 thucthucnhmC3G(ceftnaxon,
cefotaxim)b. Phc khng sinh sau kh c kt qu xt nghimvi khun [4],
[7],[8].-Nu ktqu xt nghimVKca DNT m tnh,viciu tr tip theoscnc vo p
ng ca bnh nhn vi phc KS .-Trongtrng hp tm c VK gybnh,tt nht l cnc
voKS la chnKSiutrtip.NukhnglmKS,theotcgiLNamTr,cthnh hng iu tr tip
nh sau; [8]>Vi khun gy bnh l cu khun G(-)-.Thng l
N.meninigitidis.DngpenicillinG.LulVMNMdoN.meningitidiscthgy thnh
dch, trong trng hp ny d phng bng rifampicin.12>Vikhungybnh l
vikhunG(+);Thngl s. pneumoniae.Dng penicillin G. Nu VK khng
penicillin G,dng chloramphenicol.>Vi khun gy bnh l t cu vng:C th
dng rifampicin,oxacillin.>Vi khun gy bnh l H.influenzae:Phi hp
ampicillin vi cefotaximhoc chloramphenicol.>Vi khun gy bnh l trc
khun m xanh:Dng ceftazidim hocticarcillin.Khng sinhCchdngPenicillin
G250.000UI/kg/ngyX3-41n/ngy, TB hoc1 IMAmpicillin100-200 mg/kg/ngy
X4 ln/ngy, TTMAmoxillin+acid clavulaniclOOmg/kg/ngy x3ln/ngy,
TTMCefotaxim*'^100-200 mg/kg/ngyX4 ln/ngy, TTMCeftriaxon50-100
mg/kg/ngyX1-2 ln/ngy, TTMCeftazidim100-150 mg/kg/ngy X3ln/ngy,
TTMChloramphenicol100 mg/kg/ngy X21n/ngy, TTMRifampicin10-20mg/kg,
TTMTicarcillin200-300 mg/kg/ngyx4-6/ngy, TTMAmikacin15-20 mg/kg/ngy
X3 ln/ngy, TB, TTMGentamicin4-6 mg/kg/ngy, TB,
TTMCiprofloxacin30-25mg/kg/ngy X3ln/ngy, TTMOfloxacin30-25mg/kg/ngy
X3ln/ngy, TTMPefloxacin30-25mg/kg/ngy X3ln/ngyGhi ch:Vitr 15tui,cth
dng chotr nh khi VK a khng thuc [8]c.Thi gian iu tr khng sinh
[8].13Tu theo din bin lmsng v cn lmsng ca tng bnh nhn.Bnh
nhnkhibnhkhiccduhiulmsngxtchshosinhcaDNTv
bnhthng.ThngthngviVMNMdoN.meningitidis,thigianiu tr c th t 7-10
ngy.VMNM do cc loi VK khc thi gian iu tr ti thiu l 2-3tun.1.10.3.
Mt s khng sinh thng s dng trong iu tr vim mng no ma. c im mt s'khng
sinh dng trong iu tr vim mng no m. Bng1.7:c im ca cc khng sinh thng
c s dng trong iu tr vim mng nom[6],[7],[10],[19]Phn loi KSPh tc
dngc im DHC ch tc dngPenicillinPenicillin GG(+):Staphylococcus,
Streptococcus, H. influenzae G{-)N.meningitidis, N.
gonorrhoeaeHpthutheongTB,thm c qua mng no khi vim.
Tcdngtheothigian,khng cPeTT, ; 2 =30-60pht ngi bnh thng.Thi tr ch
yu qua nc tiuThuc to phc vi enzym transpeptidase, carboxypeptid-
ase l cc enzym xc tc cho qua trnh to vch ca vi khun. Kt qu l vi
khun khng to c vch v b tiu ditAmpicillinG(+): Tc dng km penicillin
G(-): E.coi, Klebsiella, PseudomonasHpthutheongung,TB,
TTM.Thmquamngnokhi b vim, nng KS trong DNT t10-35%nngthuc
tronghuytthanh.Tcdng phuthucthigian,khngc PAE.T,f=1,68h.Thitr ch yu
qua thn.C3GCeftazidimG(+): Tc dng km penicillin G(-):Pseudomonas,
E. coli, Klebsiella, H. influenzae, N.
meningitidisHpthutheongTTM,TB. Thmvomngnokhivim, nng trong DNT t
nng iutr.T| / 2 =2,2h.Bnvi beta lactamase. Thi tr ch yu
quanctiu,mtphnnh qua mtGn vi cc protein lin kt vi penicillin, c ch
tng hp vch t bo do vy c ch s nhn ln ca t bo CefotaximTng t nh
ceftazidim, nhng trn Pseudomonas th km hofnDngmuihpthuquang
l'B.Hpthunhanhsaukhi tim. Nng thuc trong DNT cng t nng iu tr.T1/2=
1 h. Thi tr ch yu qua thn14Phn loi Khng sinh Ph tc dngc imdcnghcC
ch tc dngC3GCeftriaxonTng t nh ceftazidim, trn chngPseudomonas cng
km ceftazidimHpthuquangTTM,TB. Bnvngvinhiulactamase.
ThmttvoDNT.Gnnhiu viprotein(85-90%).Ti/ 2=6-8 h. Thi tr qua c thn v
gan.PhenicolCloramphe-nicolPh rng, c tc dng ln nhiu vi khuan G(-) v
G(+). Khng tc dng ln PseudomonasHpthuquangung,tim. Thm tt voDNT, t
nng gnbngnnghuyttng khi mngno vim.T|/2=4h, ko dihntrssinhvtr non.
Thi tr qua thncch tng hp Protein do gn vo tiu th 50sca
ribosomQuinolonCiprofloxacinTc dung mnh ln VK G(-):E.'
coli,Haemophilus, p.aeruginosa,...
G(+):Staphylococcus,Streptococcus.VK ni boHp thu qua ngung, TTM. C
Tj/ 2ko di(ciproxacin l 3- 5h,ofloxacinl5-7h).Ckh nngthmvoDNT,tnng
iutr.CPAEkodi. Thitrcliyuquanctiu (75%), phn v qua mtThuc gn vi
ADN-gyrase, do khng c kh nng m vng xon thc hin vic sao chp m di
truyn, VK b tiu ditOfloxacinPefloxacinAminosid'*AmikacinVi khun a
kh G(-). Tc dng hip ng vi cc penicillin dit
Pseudomonas.Hpthuquangtim.t thmquadnt.T/ 2 =4-5htr nh,kodihnrtnhiu
bnhnhnsuythn.Thitr dng khng bin i qua thnNgn chn qu trnh tng hp
protein do gn vi tiu th 30S ca riboxomeGentamicinVi khun a kh G(-)
v cc t cu khunHpthuquangTB,TTM. T[ / 2 =2-3h,cth ko di hn tr s
sinh. t thm vo dnt. Thi tr chyuquathn.Mt phn nh c th gy tch ly
thnGhich:Nhngkhngsinhkhngcmttrong phc khngsinhiutrvimmngno mli
khoaNhi bnh vin Bch Mai,nhiig vn c trong cc phc do AHFS
[19]b.Tcdngkhngmongmunvlu khis dngcckhngsinhiu tr vim mng no
m15Bng1.8. Tc dng khng mong mun v lu khi s dng khng sinh ..nrkmiinf
trppmr71.ri01.rX91Khng sinha i e u i n VICIIIIiiaiig ^M. ^ |_- J7 I
. ---------
______________________________________________________Tc dung khng
mong munLu Thng gp ADR >1/100t gp1/100 > ADR>1/1000Him gp
ADR c bcs chn on xc nh l VMNM.>Thi gian iu tr KS ti vin t nht l
03ngy.>C nh gi v hiu qu iu tr lc ra vin.2.1.2.Tiu chun loi
tr>Thi gian iu tr KS t hn ba ngy>Cha nh gi c hiu qu iu tr ca
KS do gia nhxin bnh nhn v hoc chuyn vin.2.2.PHNG PHP NGHIN cu+
Nghin cu hi cu trn h s bnh n lu tr ti phng k hoch tng hp bnh vin.+
Tin cu khng can thip ti khoa Nhi bnh vin Bch Mai.+ Mi bnh n c ghi
chp c th vo mt phiu thu thp thng tin(Phlc).Nidung nghin cu:a.Kho st
v yu t lin quan n c im bnhnhn>Tui v gii ca nhm bnh nhn.>Tinh
hnh mc bnh theo thi gian>Tinh trng dng khngsinh trc khi nhp
vin>Cc bnh mc km VMNM.b.Kho st v khng sinh s dng trong iutr vim
mg no m.17>Cc loi KS c s dng.>La chn KS cho cc bnh nhn cha c
chn on VMNM lc nhp
vin(PhcKSlachnbanu;KSsaukhicktquxtnghim,...)>La chn KS nhng bnh
nhn c chn on VMNM.>Liu dng ca cc KS cs dng.>Tc dng khng mong
mun gp phi.> di t iu tr khngsinh.>Hiu qu iu tr.+ Tiu chun nh
gi;a.Liu dng khng sinh:-Vi nhng khngsinh c trong phc iu tr ca khoa
Nhi bnh vin Bch Mai, liu dng c nh gi theo liu c khuyn co.-Vi nhng
khngsinh khng c trong phc iu tr ti khoa Nhi, liu dng c nh gi theo
liu ghi trong Dc th.b.Tc dng khng mong mun ca khng sinh:-c thu thp
theo cc TD KMM c ghi trong bnh n.c.Hiu qu iu tr:-Da trn nh gi ca
bcs lc ra vin (khi, , khng , n nh, cht)+ X l s liu trn phn mm Excel
2003,SPSS10.018PHN 3.KT QU NGHINcu VBN LUN51bnh nhn c chn on VMNM v
iu tr ni tr ti khoa Nhi bnh vin Bch Mai trong 7 nm
(01/1999-12/2005) c a vo nghin cu.3.1. MT S C IMCA NHM BNH NHN
NGHINcu.3.1.1.Tui v gii ca nhm bnh nhn nghin cu.Theo nhiu nghin cu
c th kh nng mc bnh VMNM c lin quan ti tui v gii. Mi lin h ny trn
nhng bnh nhn trong nghin cu ca chng ti c th hin bng3.1.Bng 3.1. T l
tr vim mng no m tnh theo tui v gii tnh.STT La tuiTnhchungT l%Nam
NSlngT l%SlngT l%1Di3tui19 37,3 15 29,4 4 7,82Lfn hn 3tui32 62,7 26
51,0 6 11,8Tng s 51 100,0 41 80,4 10 19,6Nhn xt:S tr nmc bnh chgn
bng1/4s trnam.iu ny ph hp vi ccsch ghi[1],[12].62,7%trmcbnhln
hn3tui.Tuy nhintheo mts tiliu,bnhchyugp tr
