1. VIEMPHOI-THACHTHUC-28-8

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<p> KHNG KHNG SINH TRONG VIM PHI CNG NG V VIM PHI BNH VIN TI VIT NAM V CC NC CHU PGS.TS. Trn Vn Ngc</p> <p>S PHN T THUC KHNG SINH MI NG K C FDA HOA K PH DUYT MI 5 NMTng s thuc khng sinh mi</p> <p>IDSA CID 2011</p> <p>TC NG CA S KHNG KHNG SINH LN T L T VONG, THI GIAN NM ViNNhim trng v vi khun gy bnh Tng nguy c t vong 1.9 3.4 2.1 1.8 - 5.4 5.0 Thi gian nm vin c th (ngy) 2.2 2.6 6.2 5.7 6.5 9.0 5 13 Tng 1.6</p> <p>Vi khun huyt MRSA Nhim trng phu thut MRSA Nhim trng VRE Nhim trng P. aeruginosa khng thuc Nhim trng enterobacter khng thuc</p> <p>Nhim trng acinetobacter khng 2.4 6.2 thuc Maragakis LL et al. Expert Rev Anti Infect Ther 2008; 6:751763. Nhim trng E. coli hay Klebsiella 3.6</p> <p>DCH T HC :</p> <p>T vong khng gim t khi Penicilline c s dng n nay. </p> <p>T l t vong i vi bnh nhn ngai tr &lt; 1% Bnh nhn ni tr khong 10%-14% Bnh nhn nhp ICU t 30%-40%.</p> <p>Vit Nam: VPC nguyn nhn thng gp nht trong cc bnh nhim trng. S dng KS khng hp l VK khng thuc ngy cng tng .</p> <p>VIM PHI NHIM KHUN HANG U GY T VONG CAC NC ANG PHAT TRINTRIU NGI</p> <p>WHO 2006</p> <p>Source: Mathers, C.D., A.D.Lopez, and C.J.L.Murray 2006.The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001. In Global Burden of Disease and Risk Factor, ed.A.D.Lopez, C.D.Mathers, M.Ezzati, D.T.Jamison, and C.J.L.Murray, table 3.6 new York: Oxford University Press</p> <p>Tnh hnh S.pneumoniae khng PNCThp (30%)Php Ty Ban Nha Cng ha Slovac Bungari Rumani Th Nh K</p> <p>Bc PhiP- ru New Zealand</p> <p>IsrealArp Saudi Kenia Nigeria</p> <p>MM-hi-c Bc Phi Thi Lan</p> <p>PhilippinesSingapore Australia</p> <p>Nht bnHn Quc i Loan Hng Kng</p> <p>Clinical Microbiology and Infection, Volume 7, Sup 4, 2001</p> <p>Vit Nam</p> <p>Pneumococci khng Macrolide ANSORP (20002001)100Erythromycin-resistant (MIC 1 mg/L) isolates as % of all S. pneumoniae</p> <p>92</p> <p>90 80</p> <p>86</p> <p>81</p> <p>77</p> <p>74</p> <p>7060 50 40 30</p> <p>2010 0</p> <p>685 invasive isolates from 11 countries</p> <p>Song et al. Antimicrob Agents Chemother 2004; 48:21012107</p> <p>Pneumococci khng Fluoroquinolone chu 1212Ciprofloxacin-resistant (MIC 4 mg/L) isolates as % of all S. pneumoniae</p> <p>685 invasive isolates from 11 Asian countries</p> <p>10 8 6 4</p> <p>20</p> <p>Song et al. Antimicrob Agents Chemother 2004; 48:21012107</p> <p>PD Fluoroquinolone140</p> <p>(72-120)120 Ngn chn s khng ~AUC/MIC100</p> <p>Free AUC/MIC</p> <p>100 80 60 40</p> <p>100</p> <p>(41-69) (24-40)35</p> <p>(13-21)20</p> <p>Hiu qu ~AUC/MIC35</p> <p>0Levofloxacin Levofloxacin Gemifloxacin Moxifloxacin 500 mg 750 mg 320 mg 400 mgMoran G. J Emerg Med. 2006;30:377-387.</p> <p>KT HP KHNG PNC V KHNG CC KHNG SINH KHCCefotaxime Erythromycin TMP/SMX Tetracycline Levofloxacin Pen S 0 3.2% 6.6% 1.3% 0.1% Pen I 2.8% 35.1% 49.4% 19.1% 0.3% Pen R 42.4% 61.3% 92.3% 25.5% 0.7%</p> <p>R &gt; 3 thuc : 14%(Whitney, et al. NEJM 343:1917, 2000)</p> <p>TiN TRIN KHNG QUINOLONES CA PH CU TI HONG KONG</p> <p>khng Levofloxacin (MIC &gt;4 g/ml)1995 1998 2000 &lt; 0.5% 5.5% 13.3%</p> <p> khng ca cc chng khng PNC : 27.3% Tt c chng khng FQ u khng PNC, cefotax, eryth</p> <p>(Ho, et al, JAC 48:659, 2001)</p> <p>H. influenzae tit -lactamaseNghin cu a trung tm trn 248 chng ti VN70% 60% 7% 50% 40% 30% 20% 10% 0% 0% Ac 1% 0% Cu 0% 8% Am Az Bt BLM(+)Ac Cu Cr Am Az Bt BLM Amoxicillin-Clavulanic acid Cefuroxime 48% Cefaclor Ampicillin Azithromycin Sultamethoxazol-Trimethoprim Beta-lactamase</p> <p>R</p> <p>I 4% 60% 49%</p> <p>8% 0% Cr</p> <p>Y Hc TP. H Ch Minh. 11(suppl.3): 47-55:2007</p> <p>T l khng ampicillin cc quc gia Tt TBDng do H. influenzae tit men betalactamaseQuc giaKorea Hong Kong Australia Singapore Malaysia Japan Vietnam</p> <p>% khng ampicillin65% (Protekt 2000) 18 25% (Seto 2003) 20% (Turnidge 2003) 20% (Alexander Project 1999) 25% (Rohani 2000) 8.5% (Protekt 2000); BLNAR common 49% (P.H.Van, 2006)</p> <p>MRSA TRONG CNG NG TI CHU % MRSA / NHIM TRNG DO S. aureus%</p> <p>5040.5</p> <p>40 30</p> <p>38.8 30.1 28.2 20.5</p> <p>20 10 0Taiw an Sri Lanka Philippines VietNam Korea</p> <p>13.8 8.4 8.4 6.9 2.2India Hong Kong Hong Kong China Thailand</p> <p>ANSORP Surveillance in Asia-2005-6</p> <p>TINH HINH KHNG KHNG SINH CA CC VK GY VPBV</p> <p>CC VI KHUN KHNG KS CHU YU TRONG BNH ViN</p> <p>VK Gram dng:MRSA VRE</p> <p>VK Gram m:</p> <p>PA v Acinetobacter </p> <p>Khng Quinolone Khng Cephalosporin v penicillin Khng Carbapenem Chromosomal beta-lactamases ESBLs Khng Quinolone Khng Carbapenem</p> <p>Enterobacteriaceae </p> <p>VI KHUN NGUY HiM, KHNG C THUC TR1</p> <p>Nhm chuyn gia nh gi tnh kh dng ca khng sinh (Antimicrobial Availability Task Force) ca Hi Bnh Nhim Trng Hoa K (IDSA)1 nh danh cc vi khun gy bnh c bit kh gii quyt </p> <p>A. baumannii v P. aeruginosa Enterobacteriaceae sinh ESBL MRSA Enterococcus khng vancomycin</p> <p>Cc u t nghin cu pht trin ESBL gim dn 2 khng sinh: Extended spectrum beta lactamaseMRSA: Methicillin resistant Staphylococcus aureus</p> <p>1. Infectious Diseases Society of America. Bad Bugs, No Drugs: As Antibiotic Discovery Stagnates, A Public Health Crisis Brews. http://www.idsociety.org/pa/IDSA_Paper4_final_web.pdf. July, 2004. Accessed March 17, 2007. 2. Talbot GH, et al. Clin Infect Dis. 2006;42:657-68.</p> <p>TC NHN GY VIM PHI BNH VIN14% 6% 4% 42%</p> <p>10% 24%</p> <p>Acinetobacter baumannii Klebsiella pneumoniae Staphylococcus aureus</p> <p>Pseudomonas aeruginosa Escherichia coli Khc2</p> <p>Nguyn Th Hng Thy, KY cc cng trnh NCKH BV Bch Mai, 2008, tp</p> <p>T L VPTM -2010Tc nhn gy bnh A. baumannii P. aeruginosa Klebsiella sp E. coli S. aureus TngNguyn hu Ngoan 2010</p> <p>S lng 47 9 8 4 9 77</p> <p>% 61 11,7 10,4 5,2 11,7 100</p> <p>A. BAUMANNII KHNG KS (%)Khang sinh H.Lnh-2000 K.Tuyen-2001 T.Anh-2002 N.Thao-2003 NTBE.TVN2004</p> <p>Cefepim</p> <p>66.7%</p> <p>66.6%</p> <p>91%</p> <p>83%</p> <p>Ceftriaxone LevofloxacinCiprofloxacin Amikacin Piper /Tazo Ceftazidim</p> <p>78.9%</p> <p>27.5%</p> <p>82%</p> <p>100% 82%</p> <p>82.6% 73.3%71.6% 69.6% 47.7% 38.3%</p> <p>68.2% 66.7% 54.5% 76.2%</p> <p>34.8% 13.6% 11.76% 26.6%</p> <p>7.1% 38.5% 19% 82%</p> <p>7.6% 76% 55% 100%</p> <p>Ticar/clavuColistin Imipenem 6.7% 8%</p> <p>33.3%8.7% 4.4%</p> <p> SMART </p> <p>Study</p> <p>40 trung tm / 17 nc - 2002 76 trung tm / 32 nc - 2005 , 93 trung tm -2007</p> <p>MYSTIC study Lagamayo et al. AJIC May 2008</p> <p>Adapted from Chow JW, et al. Surg Infect (Larchmt). 2005;6(4):439448; Gallagher G, et al. Poster presented at: 17th European Congress of Clinical Microbiology and Infectious Diseases; 31 March3 April 2007; Munich, Germany. Poster #663.</p> <p>Acinetobacter spp.Khng sinh Amp/sulbacta m Amikacin Ceftazidime Ciprofloxacin Imipenem Pip/tazo %khng KS 2002 72% %khng KS 2007 71%</p> <p>74%77% 79% 8% 55%</p> <p>73%81% 81% 53% 74%</p> <p>Pseudomonas aeruginosaKhng sinh Amikacin Ceftazidime Ciprofloxacin % khng 2002 23% 25% 36% % khng 2007 17% 35% 31%</p> <p>Imipenem Pip-tazo</p> <p>19% 18%</p> <p>30% 20%</p> <p>VI KHUN SINH -LACTAMASES-lactamases</p> <p>Serine enzymes Class A enzymes Class C enzymes Class D enzymes</p> <p>Metallo-enzymes Class B enzymes</p> <p>(Plasmid)</p> <p>(Chromosomal)</p> <p>(Equivalent to Class C but plasmid)</p> <p>(Chromosomal)</p> <p>ESBLTEM,CTX-M,SHV</p> <p>Amp CCMY,FOX,MOX,DHA</p> <p>OXAOXA-48,-181..</p> <p>MbLNDM,IMP,VIM</p> <p>Pen-Cephs-Inh-R KPC</p> <p>Cephs-Inh-R</p> <p>Pens, esp Oxa Inhib-R</p> <p>Carbapenems Inh-R</p> <p>Bush. Rev Inf Dis 1987;10:681; Bush et al. Antimicrob Agents Chemother 1995;39:12111233 Bush. Curr Opin Investig Drugs 2002;3:12841290</p> <p>VK sinh ESBL ti Chu -TBD</p> <p>Adapted from Hawser SP., et al. Emergence of high levels of ESBL-producing gram-negative bacilli in the Asia-Pacific region: data from the SMART program 2007. Antimicrobial Agents and Chemotherapy 2009, 53(8): 3280-3284</p> <p>T l vi khun sinh ESBL gia tng ti Vit NamBNH VINASTS program - MOH (2004) Ch Ry Hospital (2005) Vit c Hospital (2005) Bnh nh Hospital (2005) Vit Tip Hospital (2005) Bch Mai Hospital (2005) Bch mai Hospital (2006) Klebsiella spp. 23.7 (n = 485) 61.7 (87/141) 39.3 (55/140) 19.6 (29/148) 25.7 (09/35) 20.1 (37/184) 28.7 (99/347) E. coli 7.7 (n = 548) 51.6 (145/281) 34.2 (66/193) 36.2 (51/141) 36.1 (22/61) 18.5 (28/151) 21.5 (77/359)</p> <p>Bch mai Hospital (2007)Bch mai Hospital (2008)</p> <p>32.5 (105/323)33.7 (85/253)</p> <p>41.2 (136/330)42.2 (97/231)</p> <p>* Chng trnh ASTS 2002-2006 t 10 n v thnh vin Bc ,Trung, Nam; * D liu 6 thng u nm 2006</p> <p>Hn 60% chng vi khun E.coli, Klebsiella sinh ESBL225 200 175 150 125 88 (36.2%) 100 75 50 16 (45.7%) 25 0 EnterobacterAnh L.T.K.3, Hai V.T.C4</p> <p>ESBL [+] ESBL [-] 155 (63.8%)</p> <p>202 (66.4%)</p> <p>102 (33.6%)</p> <p>19 (54.3%)</p> <p>E. coli</p> <p>Klebsiella</p> <p>Nghien cu a trung tam khao sat tnh hnh e khang cac khang sinh cua cac trc khuan Gram [-] de moc gay nhiem khuan benh vien phan lap t 1/2007 en 5/2008 Van P.H.1,2,*, Bnh P.T.1,2, Y Hc TP. H Ch Minh; Tp 13; Ph bn S 2; Trang 138-148; 2009</p> <p>NDM-1</p> <p>Yu t di truyn 180-kb d dng c chuyn sang cho cc Enterobacteriaceae khc v cha : metallo--lactamase mi d dng thy phn penicillins, cephalosporins, v carbapenems Cc genes bt hot erythromycin, ciprofloxacin, rifampicin, v chloramphenicol. Bm khng sinh ra ngoi c kh nng gy khng thm vi khng sinh</p> <p>VK Gram m a khng</p> <p>Klebsiella Pneumoniae Carbapenemase (KPC)</p> <p>KPC : nhm A -lactamase</p> <p>Khng tt c -lactams k c extendedspectrum cephalosporins and carbapenems</p> <p>Ch yu t EnterobacteriaceaeThng nht l Klebsiella pneumoniae K. oxytoca, Citrobacter freundii, Enterobacter spp., Escherichia coli, Salmonella spp., Serratia spp., t nht 1 bo co t Pseudomonas aeruginosa</p> <p>iU TR THT BI CAO KHI MIC CA MRSA I VI VANCOMYCIN CAO</p> <p>Sakoulas, et. al., 2004 JCM 42:2398; Moise-Broder et al. 2004 CID 38: 1700-5; Hidayat et al. 2006 Arch Intern Med 166:2138-2144; Moise wt al. 2007 AAC 51:2582-6</p> <p>PHN B MIC ca MRSA ti Vit Nam (NGHIN CU TI CH RY V BCH MAI)100 MRSA: 46 % 2 mg/L, 93% 1.5 mg/L</p> <p>50 40</p> <p>Frequency</p> <p>30 20 10 00.5 0.75 1 1.5 2 2.5</p> <p>MIC (mg/L)MICs measured by Etest. 43 isolates from Bach Mai Hospital in Hanoi, 57 isolates from Ch Ry Hospital in Ho Chi Minh City J. Clinical Medicine, Bach Mai hospital, No.35, Dec, 2008</p> <p>Cc yu t gp phn lm gia tng khng khng sinh</p> <p>BN ni tr nng c ch min dch k thut mi /thit b mi Bng n VK khng thuc Kim sot nhim khun khng hiu qu Tng s dng KS d phng , KS kinh nghim S dng KS nhiu</p> <p>Patterson JE; Chest 2001</p> <p>Yu t nguy c khng khng sinh : Nhim trng BV dng KS trc (VAP:OR 12.5) Dng KS ph rng (VAP:OR 4.1) Nm vin di ngy Th my ko di (VAP:OR4.1) S dng thit b xm ln Nm vin ti : ICU, khoa ghp tng , lc mu . Vim phi / NTH lin quan chm sc sc khe Nhp vin trc y Dng cephalosporin, fluoroquinolone trc y C tr lu di ti nhng trung tm chm sc ( nursing home) Lc mu Kollef MH;CID 2000</p> <p>KT LUN </p> <p>Khng thuc ngy cng trm trng trn hu ht cc vi khun Ngun khng sinh ngy cng cn kit , kh tr , Tng t vong Tng thi gian nm vin Tng chi ph iu tr CN C MT CHIN LC MI CN S DNG KS HP L V KHN</p> <p>12 bc phng nga khng thuc12 B gy mc xch NT Ngn ly truyn 11 Phn lp VK 10 Ngng tr khi khi bnh 9 Bit khi no ni khng vi vanco 8 iu tr NT, khng tr c tr VK S dng KS khn ngoan 7 iu tr NT , khng tr vy nhim 6 S dng d kin vi sinh ti ch 5 Thc hin kim sat KS 4 Tham kho s nh gi ca chuyn gia Chn an &amp; iu tr hiu 3 iu tr hng n VK qu 2 Rt catheter 1 Tim phng Phng nga nhim trng</p> <p>Xin chan thanh cam n !</p>