nguyen tac su dung khang sinh 2013-doan trang

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NGUYN TC S DNG KHNG SINH

i tng: Dc 4, h chnh quy

Thi lng: 4 tit

TS. ng Nguyn oan TrangThS. on Vn Khnh

Ni dung

A. Tnh hnh khng khng sinhB. Nguyn tc s dng hp l KS trong iu tr

1) Ch nh KS ph hp vi tc nhn gy bnh2) La chn KS iu tr thch hp

a) KS iu tr theo kinh nghim lc ub) KS iu tr sau khi c kt qu vi sinh

3) ng s dng KS hp l4) Liu lng v khong cch dng phi v hiu qu5) Thi gian iu tr vi KS thch hp6) Phi hp vi cc phng php iu tr h tr

C. Nguyn tc s dng hp l KS trong d phng phu thutD. Chin lc ci thin tnh hnh s dng khng sinh

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Mc tiu hc tp

1) Gii thch c l do phi tun th cc nguyn tc s dng KS

2) Trnh by c nguyn tc xc minh s nhim khun

3) Trnh by c cc yu t nh hng n vic la chnKS/phi hp KS v ng s dng KS trong iu tr theo kinhnghim lc u v iu tr sau khi c kt qu vi sinh hc

4) Trnh by c nguyn l dc ng-dc lc hc ca KStrong vic la chn liu v khong cch dng ca KS

5) Trnh by c cc yu t nh hng ln thi gian iu tr KS

6) Trnh by c nguyn tc la chn loi KS, ng s dng vthi gian s dng KS d phng trong phu thut

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A. Tnh hnh khng khng sinh

Nm 1969: Bnh nhim trng b ch ng - bc s WilliamStewart, M

Bo co thin tai-dch bnh th gii nm 2000 ca WHO: Bnhnhim trng l k git ngi ln nht (13 triu ngi cht trongnm 1999)


S ti xut hin (hi sinh) ca mt s bnh nhim trng: lao, st rt, st xut huyt, t...

Cc vn mi ny sinh trong bnh nhim trng: Nhim trng lin quan n chm sc y t

Cc k thut xm ln, suy gim min dch, qu ti bnh nhn, thiu nhn lc y t...

Vi khun a khng thuc: MRSA: Methicillin-resistant Staphylococcus aureus VRE: Vancomycin-resistant Enterococci ESBLs: Extended-spectrum Beta-lactamases MDR-TB: Multi-drugs resistant Tuberculosis

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L s khng li khng sinh, VK khng c kh nng chu ng 1

nng KS cao hn so vi VK bnh thng m khng b tiu dit


VK khng P. aeruginosa A. baumanniiMeropenem 18% 46.2Imipenem 25% 47.1

MRSA T l nhy cm (%)BV Ch Ry 91BV Bch Mai 100

T l MRSA cn nhy cm vi vancomycin:

T l khng vi cc carbapenem:

S liu nm 2008. Ngun GARP. SITUATION ANALYSIS-Antibiotic Use and Resistance in Vietnam. 2010

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K. pneumoniae E. coli

BV Ch Ry nm 2005 61.7% 51.6%

BV Bch Mai nm 2005 20.1% 18.5%

BV Bch Mai nm 2006 28.7% 21.5%

BV Bch Mai nm 2007 32.5% 41.2%

BV Bch Mai nm 2008 33.6% 42.2%

T l tit ESBLs ca cc trc khun gram (-) ng rut:

S liu nm 2008. Ngun GARP. SITUATION ANALYSIS-Antibiotic Use and Resistance in Vietnam. 2010

C ch khng

khng t nhin: Do h gen t nhin ca vi khun quy nh

VD: E.coli khng vancomycin do phn t vancomycin rt ln khng thm c vo TB vi khun

khng thu nhn: t bin gen sinh ra gen khng v truyn gen ny cho

cc th h vi khun tip sau ( khng theo chiu dc)

Thu nhn gen khng t cc vi khun khc qua cc plasmid, transposon ( khng theo chiu ngang)

Ryback. Pharmacotherapy 2004; 24:203S-215S

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VK khng mi

VK nhy cm

VK khng

Di chuyn gen khng

C ch khng

Cch thc khng ca vi khun

To enzym bt hot/ ph hy khng sinh

Bin i im tc ng ca khng sinh

Gim tnh thm ca khng sinh vo trong vi khun

Thay i con ng chuyn ha

To ra bm ngc (P-gp)

Levy SB. Scientific American. 1998: 46-53

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Yu t gp phn gy khng

Yu t thuc v vi khun: Kh nng nhn i rt nhanh Xc sut t bin gen trong qu trnh sao m

Yu t thuc v ngi s dng: V sinh bnh vin (qu ti BN, iu kin VS, st trng) S dng KS khng hp l:

Khng ng KS, dng KS khi khng cn thit Khng nng KS (liu, khong cch, dc ng hc ca KS) Khng thi gian Dng KS thng xuyn (bnh vin, cng ng, gia sc) Lm dng khng sinh ph rng

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S pht trin khng sinh

Gerard D. Wright. Nature Reviews. Microbiology 5, 175-186 (2007)

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S pht trin khng sinh mi

Ch 7 hot cht trong tng s 225 thuc mi trong giai on 1998-2002 (3%) l cc KS

12 KS mi c a vo s dng t 1998

Boucher, et al. CID 2009; 48:1-12

S pht trin khng sinh mi

Khng sinh Nm ph duyt Nhm KS miRifapentine 1998 KhngQuinupristin/dalfopristin 1999 KhngMoxifloxacin 1999 KhngGatifloxacin 1999 KhngLinezolid 2000 OxazolidinoneCefditoren pivoxil 2001 KhngErtapenem 2001 KhngGemifloxacin 2003 KhngDaptomycin 2003 LipopeptideTelithromycin 2004 KhngTigecycline 2005 KhngDoripenem 2007 Khng

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S pht trin khng sinh miTn hot cht Nhm ng dng Ch nh Liu

Ceftobiprole Cephalosporin IVcSSSI

Phase III: CAP, HAP Phase II: NT mu

500mg BID

Ceftaroline Cephalosporin IV cSSSI, CAPFDA duyt nm 2010

600mg Q12h

Iclaprim Diamino-pyrimidine IVcSSSI

Phase III: HAP, HCAP, VAP 0.8- 1.6 mg/kg BID

Telavancin Glycopeptide IV cSSSI Phase III: HAP 10mg/kg hng ngy

Oritavancin Glycopeptide IVcSSSI

Phase II: NT mu t catheter

400-800mg hng ngy

1200mg x1

Cethromycin 2nd generation ketolide POCAP

Phase II: vim xoang 300mg daily

Ramoplanin Glycolipo-depsipeptide PO CDAD 200 hoc 400mg BID

Hot tnh trn MRSA!!

cSSSI: complicated skin and skin structure infection

CDAD: Clostridium difficile-Associated Diseases

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Tin trnh iu tr mt bnh nhim trng

Bc 1Xc minh yu cu iu tr KS v c gng xc nh tc nhn gy bnh

Bc 2

Bc 3

Bc 4

Bc 5



Bc 2 La chn phc KS iu tr theo kinh nghim lc u

Bc 3 Theo di iu tr KS ban u: hiu qu v c tnh

Bc 4

Bc 5

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Bc 2 La chn phc KS iu tr theo kinh nghim lc u

Bc 3 Theo di iu tr KS ban u: hiu qu v c tnh

Bc 4iu chnh KS iu tr theo tc nhn gy bnh c xc nh

Bc 5 Theo di iu tr: hiu qu v c tnh

B, Nguyn tc s dng hp l KS trong iu tr

1) Ch nh KS ph hp vi tc nhn gy bnh

2) La chn KS/ phi hp KS iu tr phi thch hpa) KS iu tr theo kinh nghim lc u

b) KS iu tr sau khi c kt qu vi sinh

3) ng s dng KS phi hp l

4) Liu lng v khong cch dng phi v hiu qu

5) Thi gian iu tr vi KS phi hiu qu

6) Phi hp vi cc phng php iu tr h tr

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1. Ch nh dng KS phi ph hp vi tc nhn gy bnh

Ch dng KS khi c nhim khun: Cn xc minh s nhim khun chng minh yu cu v

l do s dng KS

Dng KS d phng nhim khun: cn ph hp

S dng sai/ khng hp l/ lm dng KS: Lm tng nhanh s khng ca VK Tng nguy c c tnh Tng chi ph iu tr

Xc minh s nhim khun

a, Triu chng v du hiu: Ton thn: st Vt thng: sng, , chy m

Cc du hiu khc c th hu ch Cc ch du vim nhim: VS (ESR), CRP, procalcitonin S lng bch cu (WBC), BC trung tnh, band C BC hoc VK hin din trong mu, dch no ty,

nc tiu* Cc xt nghim khc: ng huyt, phn tch nc tiu

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Xc minh s nhim khun

b, XN tm vi khun gy bnh Cy vi khun (v th nhy cm vi KS)

Nhim trng nng hoc nhim trng vi khun khng

Nhum Gram, soi knh hin vi Phn ng huyt thanh hc, PCR

Lu : mu lm sng (mu, BAL, m, dch r vt thng,

nc tiu) cn ly trc khi khi u KS iu tr

Th nghim nhy cm ca VK vi KS (th nghim KS )

Gi tr MIC: S: Nhy cm

I: Nhy cm va phi

R: khng

MIC l nng thp nht ca KS ngn s tng sinh ca VK quan st

c sau khi trong mi trng nui cy c hiu trong 24 gi.

Gi tr ny c hiu cho c khng sinh v vi khun

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2. La chn phc KS iu tr phi thch hp:

Cho hiu qu ti u nht: iu tr hoc ngn nga c nhim trng vi thi gian

dng KS ngn nht

t tc dng ph nht Gim thiu ti a s xut hin v lan truyn VK

khng Chi ph hp l nht


2. La chn KS/ phi hp KS iu tr phi thch hp:

a, La chn KS/ phi hp KS iu tr theo kinh nghim lc u

b, La chn KS/ phi hp KS iu tr sau khi c kt qu cy vi khun v KS

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Thi im chn

on/nghi ng nhim

trng

Thi im c kt qu cy VK v

KS

KS theo kinh nghim lc u KS sau khi c kt qu vi sinh hc

nh nhanh !

nh mnh !

nh lin tc !

Cc yu t cn cn nhc/ xem xt khi la chn KS iu tr

Bnh nhn

Nhng VK gy bnh thng gpti ni iu tr

VK c kh nng gy bnh caonht bnh nhn

Mc khng ti ni iu tr

Cu trc ha hc, c ch tc ng Dc ng/ Dc lc ca KS c tnh ca KS S khng ca VK vi KS Chi ph

V tr nhim trng Mc nhim trng Tui Tnh trng BN (c thai, ) Chc nng gan-thn, h min dch Bnh km theo, kh nng tun th

Khng sinh

Vi khun

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a. La chn KS/phi hp KS iu tr theo kinh nghim lc u

Hiu qu lm sng l quan trng nht: KS la chn cn ph hp vi tc nhn VK nghi ng/ bit

v ph hp vi kt qu KS /mc khng ca VK tini iu tr

La chn KS/phi hp KS da trn: V tr nhim trng

D on nhng VK c kh nng gy bnh (Phn tham kho-t hc)

Cn c th gip chn liu v ng s dng KS (VD: nhim trng nitm mc, mng no, xng khp cn dng KS ng tim, liu caov thi gian di)

Tnh trng bnh v c a bnh nhn

Nhim trng phi-VPC

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Vim tai gia

Vim mng no

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Nhim trng da-m mm

Nhim trng bng

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Nhim trng ng tiu di/ vim bng quang

Nhim trng ng tiu trn/ vim thn-b thn

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Vim vng chu

Tnh trng, c a bnh nhn

Tin s d ng thuc: D ng penicillin: cn nhc khi chn KS nhm beta-

lactam Type I (shock phn v, co tht PQ): chng ch nh cc

penicillin, cephalosporin, carbapenem Non-type I (ban da): c th dng cephalosporin (d ng

cho 5-10%)

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Tnh trng/ c a bnh nhn

Suy gim chc nng gan-thn: Thn l c quan o thi phn ln cc KS:

Aminoglycosid, vancomycin, beta-lactam

Gan l c quan chuyn ha chnh o thi mt s KS: Clindamycin, macrolid, metronidazol, chloramphenicol v rifampin

Tch t cc KS, tng nguy c c tnh nu khng chnh liu: c thn: aminoglycosid, vancomycin, colistin, sulfamid, tetracyclin th

h 1, mt s cephalosporin

c gan: thuc khng lao, nitrofurantoin, chloramphenicol, Thng phi chnh liu KS thi qua thn khi Clcr < 30 mL/pht


Ph n c thai: Nguy c d tt thai nhi do KS:

Penicillin, cephalosporin v erythromycin: an ton

Ticarcillin, metronidazol: qui thai ng vt

Tetracyclin: vng rng, h men rng, nh hng pht trin xng

Quinolon, rifampin, trimethoprim: sinh qui thai cha bit r

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Tui tc: VK gy bnh thay i theo tui: VD: vim mng no do VK:

Tr s sinh: Listeria spp. V Streptococcus spp. nhm B Ngi trng thnh: S. pneumoniae v Neisseria meningitidis Ngi gi: Streptococcus pneumoniae and Listeria spp.

Chc nng gan - thn thay i theo tui: Chc nng thn gim tr sinh non, tr s sinh, ngi gi

Mt s KS khng nn dng cho tr nh: quinolon, tetracyclin


Cc bnh l/ bt thng km theo: Cc bnh gy gim min dch: khi u, BN ghp c quan, HIV:

D a n nhim trng

Thng phi chn KS mnh, loi dit khun v dng thi gian di hn

Bt thng trn di truyn hay chuyn ha: BN bnh mch mu ngoi bin: gim hp thu KS ng IM BN thiu G6PD: b tn mu khi dng sulfonamid, nitrofurantoin,

dapson, thuc tr st rt v cloramphenicol

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nh hng ca cc thuc dng ng thi/ trc : KS la chn cn khc nhm KS iu tr trc

S hp thu ca KS quinolon b gim bi cc thuc cha

cation a ha tr (antacid; thuc b cha Ca, Fe)

Phi hp KS iu tr mt cch hp l

Ch phi hp KS khi cn thit: mc ch phi hp: Hip ng tc dng trn VK khng cao

Phc KS iu tr theo kinh nghim BN bnh nng khicha xc nh c VK gy bnh v kt qu KS

Ni rng ph khng khun trong nhng nhim trng gy ra bi nhiu VK

VD: cepha 3 hoc fluoroquininolon + metronidazol trong iu tr nhim trng bng*

Ngn nga s xut hin ca chng VK khng thuc (iu trlao, phong)

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Mt s phi hp KS cho tc dng hip ng

c ch cc bc khc nhau/ qu trnh chuyn ha: Sulfamethoxazol + trimethoprim Sulfadoxim + pyrimethamin

c ch s bt hot KS gy bi enzym: Cht c ch beta lactamase + KS beta-lactam

Clavulanat + amoxicillin Sulbactam + ampicillin Tazobactam + pipericillin

Tng cng s thu nhn KS vo TB VK: Cc beta-lactam + aminoglycosid *

Ampicillin v gentamicin Ceftazidim v amikacin

Vancomycin + aminoglycosid

Bt li khi phi hp khng sinh

i khng tc dng: Penicillin + clortetracyclin < penicillin trong iu tr vim mng no do ph

cu (Lepper v Dowling, 1951)

Ampicillin + cloramphenicol + streptomycin < ampicillin trong iu tr vimmng no (Mathies v cs, 1967)

Trn chung penicillin ph rng v aminoglycosid bt hotaminoglycosid* (McLaughlin v cs, 1971; Riff LJ v cs, 1972)

Tng chi ph iu tr Tng tc dng bt li (phn ng d ng v c tnh ca KS)*

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b. La chn KS khi c kt qu vi khun v KS

La chn theo kt qu vi khun gy bnh phn lpc v KS Chnh xc nht Vic cy VK v lm KS: cn thi gian v tn chi ph,

thng ch p dng trong nhim trng nng, lm sng

khng r rng hoc khng p ng vi iu tr

Lu : tnh trng, c a BN, kh nng tun th,tnh cht dc ng-dc lc ca KS, gi thnh

3. ng s dng khng sinh cn ph hp

Ty vo mc nng ca nhim trng: Nhim trng nh, iu tr ngoi tr: ng ung

Nhim trng nh-trung bnh, iu tr trong BV: ng tim IM, IV hoc c th dng KS ung nhng phi c SKD cao

Sinh kh dng cao vi Linezolid, fluoroquinolon, SMZ/TMP; metronidazol (gn 100%)

Nhim trng nng, e da tnh mng: ng tim IV

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4. Liu lng KS v khong cch dng phi thch hp, hiu qu

Huyt tng

Ni tc ng

Nng khng sinh

Hiu qu iu tr

Ch liu

Dc ng hc ca KSCmaxTmax, T1/2AUC

Dc lc hc ca KSMIC

0 6 18 2412

Nn

g

MIC

AUC > MIC

AUC / MIC

T > MIC

Thi gian CKS > MIC

Cmax

Cmax / MIC

Thi gian (h)


Thng s PK/ PD ca KS:

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55

c im khng khun ca KS

Kiu dit khun: Dit khun ph thuc nng : Dit khun ph thuc thi gian (khng ph thuc

nng )

Hot tnh khng khun ch tng trong mt khong nng nh (1xMIC ti 4xMIC)

Khong thi gian m nng KS trn MIC tng quanvi hiu qu dit khun

56

c im khng khun ca KS

Hiu ng hu KS (PAE = post-antibiotic effect): Hiu lc c ch VK tng trng vn xy ra khi

khng tip tc dng KS Thng xy ra vi VK gram dng, t trn VK gram

m Ch c vi mt s nhm KS: aminoglycosid,

fluoroquinolon, beta-lactam, Thng PAE in vivo > in vitro

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Kiu tc ng ca KS

Kiu 1 Kiu 2 Kiu 3

c im khng khun

Dit khun ph thuc nng

PAE di

Dit khun ph thuc thi gian

PAE ti thiu

Dit khun ph thuc thi gian

PAE di

Khng sinh

Aminoglycosid Ketolid Fluoroquinolon Metronidazol

Cc -lactam Erythromycin Clindamycin Linezolid

Azithromycin Tetracyclin Streptogramin Vancomycin

Mc tiu Ti u ha nng Ti u ha thi gian tip xc vi KS

Ti u ha lng thuc

Thng s PK/ PD quyt nh hiu qu

Cmax , AUC Thi gian CKS trn MIC AUC


fCmax/ MIC = 8-10

Kiu 2 Kiu 3Kiu 1

f Time > MIC> 70% DI (Gr m)> 40-50% DI (Gr. +)

fAUC0-24h/ MICFluoroquinolon:fAUC24h/MIC > 125 (Gr m)fAUC24h/MIC > 40 (Gr +)Vancomycin:fAUC24h/MIC > 125 (>400 vi VK khng)

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Khng sinh aminoglycosid

Khong cch dng: Theo truyn thng: tng liu chia 3 ln/ ngy Tng liu dng 1 ln/ ngy

Nng nh cao hn Dit khun tt hn, hiu qu hn PAE di hn

Nng y thp hn t c tnh hn (gim tnh thm ca KS vo thn/ thi gian?) PAE pht huy tc dng khi nng thp hn ngng tr liu


Dng 1 ln/ ngy so vi phc truyn thng

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p dng ch tng liu dng 1 ln/ ngy: Di 65 tui Chc nng thn bnh thng Thi gian iu tr < 1 tun Khng phi nhim khun do Enterococci hoc

Pseudomonas spp

5. Thi gian iu tr vi KS phi hiu qu

Khng c quy nh c th Ty thuc tng BN da vo p ng LS v kt qu X-quang, c th cn

hng dn ca chuyn gia nhim trng

iu tr ngn ngy: NTT khng phc tp/ n: 3 ngy

Vim phi ngoi cng ng: 5 ngy

Vim phi lin quan my th: 8 ngy (tr BN nhim Pseudomonas

hoc suy gim MD)

iu tr di ngy: Vim ni tm mc, vim ty xng v apxe bng (4-6 tun)

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5. Thi gian iu tr vi KS phi hiu qu

Nguyn tc chung: sau khi ht VK dng thm KS: 2-3 ngy BN bnh thng

5-7 ngy BN suy gim min dch

Tiu ch lm sng nh gi ht VK: Th trng BN ci thin (au gim, gim ho, ht m )

S lng BC v thn nhit tr v bnh thng

Ci thin trn X-quang (c th mun hn ci thin LS)

6. Theo di p ng iu tr vi KS

Thng s trn LS : Ci thin triu chng v du hiu (gim st, tim nhanh hoc ln ln),

Ci thin gi tr cn LS (s lng BC gim) v X-quang (kch thc vng apxe gim)

Kt qu vi sinh hc: Theo di nng KS/ mu:

Aminoglycosid

Vancomycin

Xt nghim khc (chc nng thn, gan) Kh nng dung np vi KS ca BN

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6. Theo di p ng iu tr vi KS

Vi BN khng cho p ng vi iu tr KS trong 2-3 ngy, cn nh gi li nhm xc nh:

Chn on ng?

t c nng tr liu KS/ mu?

BN c suy gim MD?

BN c nhim trng bi nhim (apxe, vt l/ c th)?

Pht trin VK khng?

7. Phng php iu tr h tr

Dn lu phu thut hoc ct b m b nhim*

iu chnh p ng vim ca k ch vi nhim trng: Corticosteroid ton thn: c li trong iu tr vim mng no, vim

phi do Pneumocystis BN AIDS

Tm thi ngng hoc gim liu iu tr vi cc thuc c ch MD

Yu t kch thch dng BC ht (BN gim BC ko di b nhim nm si xm ln)

Globulin min dch, IV: trung ha c t/ VK trong iu tr vim mc hoi th do Streptococci nhm A

Probiotic (cc chng Lactobacillus v Saccharomyces): iu tr tiu chy do C. difficile

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C. Nguyn tc s dng KS d phng trong phu thut

Khng sinh d phng: l KS s dng trc, trong v sau mt qui trnh chn on, iu tr hoc phu thut ngn s nhim trng

Phu thut c im

SchVt m khng nhim khun, khng vim cp, khng thng vi ng hhp, tiu ha, ming hu, ng sinh dc, ng tiu, ng mt.Khng c gin on trong quy trnh m v khun.

Sch-nhimM thng c kim sot ng h hp, tiu ha, ming hu, ng sinhdc, ng tiu, ng mt vi lng r rt nh/sai st k thut nh

NhimC tnh trng vim cp, khng m hin din vt m. C lng r nhiut ng tiu ha/Gin on lu trong k thut m

D Tnh trng nhim khun hin r (apxe, m hoc m hoi th hin din)

Tc nhn gy nhim thng gp

Phu thut Vi khun thng gy nhim

Lng ngc-tim Staphylococcus aureus, staphylococci coagulase (-)

Tiu ha Trc khun gram m ng rut, vi khun k kh, enterococci

Phn ph (m o, bng, ct t cung qua bng)

Trc khun gram m ng rut, streptococci nhm B, enterococci, vi khun k kh

Chnh hnh S. aureus, staphylococci coagulase (-)

Mch muS. aureus, staphylococci coagulase (-), Trc khun gram m ng rut

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KS la chn phi: An ton Tng i r tin Hot tnh dit khun vi ph khng khun in vitro

bao ph c loi vi khun c kh nng gy nhim trong khi phu thut

Khng chn lc ra chng khng thuc

Cc cephalosporin Ph khng khun

Cepha th h 1:ng ung: Cefadroxil, Cephalexin, ng tim: Cefazolin

VK Gram dng: Strep. pyogenes, Strep. viridans, Staph. aureus, S. pneumoniae

VK Gram m: E. coli, Klebsiella pneumoniae, Proteus mirabilis

Cepha th h 2:ng ung: Cefaclor, cefprozil, Cefuroxime axetilng tim: Cefotetan, Cefoxitin, Cefuroxime

VK Gram dng: tng t cepha I tr Cefotetan, Cefoxitin

VK Gram m: E. coli, Klebsiella pneumoniae, Proteus mirabilis, Haemophilus influenzae

Neisseria spp. (tr Cefotetan, Cefoxitin)

VK k kh: Cefotetan, Cefoxitin

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Cc cephalosporin Ph khng khunCepha th h 3:ng ung: Cefdinir, Cefditoren, Cefpodoxime proxetil, Ceftibuten, Cefiximeng tim: Cefotaxime,Ceftazidime, Ceftizoxime, Ceftriaxone

VK Gram dng: Strep. pyogenes, Strep. viridans, Staph. aureus (mc trung bnh), S. pneumoniae

VK Gram m: E. coli, Klebsiella pneumoniae, Proteus spp., Haemophilus influenzae

Neisseria spp. , Borrelia burgdorferi, vi Enterobacteriaceae

Cepha th h 4:ng tim: Cefepime, cefpirom

VK Gram dng: Strep. pyogenes, Strep. viridans, Staph. aureus (mc trung bnh), S. pneumoniae

VK Gram m: E. coli, Klebsiella pneumoniae, Proteus spp., Haemophilus influenzae

Neisseria spp. , nhiu Enterobacteriaceae, Pseudomonas aeruginosa

Cepha th h 5:ng tim: ceftaroline

VK Gram dng: nhiu loi k c MRSA VK Gram m: nh cepha 3

La chn KS d phng

Phu thut Vi khun thng gy nhim Cc KS khuyn co

Lng ngc-tim Staphylococcus aureus, staphylococci coagulase (-)Cefazolin, cefuroxime , vancomycin*

Tiu ha Trc khun gram m ng rut, vi khun k kh, enterococci

Cefoxitin, cefotetan, ampicillin/sulbactam, cefazolin + metronidazol

Phn ph (m o, bng, ct t cung qua bng)

Trc khun gram m ng rut, streptococci nhm B, enterococci, vi khun k kh

Cefoxitin, cefotetan, cefazolin, ampicillin/sulbactam

Chnh hnh S. aureus, staphylococci coagulase (-) Cefazolin, cefuroxime, vancomycin*

Mch muS. aureus, staphylococci coagulase (-), Trc khun gram m ng rut

Cefazolin, vancomycin*

*: Ch dng khi nghi ng MRSA hoc t cu coagulase (-), khng khuyn co dng thng quy

4/19/2014

37


ng s dng: u tin ng tim IV v cho nng ti u ti v tr phu

thut trong sut qu trnh phu thut

Thi im dng KS d phng:

Lc rch da

Kt thc PT

Qu trQu sm ng thi im


Thi im dng KS d phng: Trong vng 1 gi trc khi rch da (ti u l trc rch da

30 pht), trong vng 2 gi nu dng vancomycin

C th phi cn nhng liu b sung trong khi phu thut nhm duy tr nng c hiu qu/ mu

Thi gian dng KS d phng: Khng qu 24 gi sau khi kt thc phu thut (khng qu

48 gi vi phu thut tim-lng ngc)

KS d phng sau khi ng vt m: cho thy khng c li

4/19/2014

38

D. Chin lc ci thin s dng KS trong BV

Nng cao hiu qu o to Xy dng cc phc v hng dn iu tr Ci thin cc xt nghim chn on Gii hn s dng KS C chin lc quay vng khng sinh s dng

Ti liu tham kho

1. Infectious Disease Society of America. Bad Bugs and No Drugs 2004.2. Steven C. Ebert. Application of Pharmacokinetics and Pharmacodynamics

to Antibiotic Selection. P&T community. Vol. 29 No. 4 (2004).3. Surbhi Leekha et al. General Principles of Antimicrobial Therapy. Mayo

Clin Proc. 2011;86(2):156-167.4. Treatment Guideline. The Medical Letter. Vol. 5 (Issue 57). 2007.5. G. S. Guven and O. Uzun. Principles of good use of antibiotics in hospitals.

Journal of Hospital Infection (2003) 53: 9196.6. Alan R. Salkind and Kavitha C. Rao. Antibiotic Prophylaxis to Prevent

Surgical Site Infections. American Family Physician, Volume 83, Number 5, March 1, 2011.

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