khang sinh 2010-son

7/24/2019 Khang Sinh 2010-Son

1/13

3 28 2012

1

NGUYN TC DNG THUCKHNG SINH V KHNG KHUN Phn tch c 4 nguyn tc s dng khng

sinh trong iu tr, nu v d minh ha

Phn tch c 3 nguyn tc s dng khngsinh d phng NK sau phu thut, cho v dminh ha

MC TIU

SDNG KHNG SINH TRN LM SNG

Cc khng sinh s dng trn lm sng theo 3

cch:

iu tr theo kinh nghim

iu tr khi xc nh c vi khun

Khng sinh d phng

SDNG KHNG HP L KHNG SINH

Nhim trng khng iu tr bng khng sinh

VSV n boNm

Virus

S DNG KHNG HP L KHNG SINH (TIP)

iu tr st khng r

nguyn nhn

Thng tin v vi khun hc

khng y

S DNG KHNG HP L KHNG SINH(TIP)

S dng khng sinh vi liu khng ng

Ch s dng khng sinh nh bin php duy

nht iu tr NK


2/13

3 28 2012

2

HU QU ?

Cc chng khng khng sinh tng nhanh chng

VK thng VK chtVK khng

NGUY C KHNG THUC

T bin i thch nghi

Truyn trctip cho nhau

Truyn cho nhauqua trung gian

Nhng nguyn tc s dng

khng sinh trong iu tr

NHNG NGUYN TC S DNG KHNGSINH TRONG IU TR

1. Ch s dng khng sinh khi c nhim

khun2. Phi bit la chn khng sinh hp l

3. Phi bit nguyn tc phi hp khng

sinh

4. Phi s dng khng sinh ng thi gian

quy nh

1. CH S DNG KS KHI C NHIM KHUN

- Thm khm lm sng:

- o nhit

- Phng vn bnh nhn, khm bnh

- Cc xt nghim lm sng thng quy

Lm sao bit nhim vi khun ?


3/13

3 28 2012

3

1. CH SDNG KS KHI C NHIM KHUN

Tm vi khun gy bnh

- Bin php chnh xc nht, kt hp c vi lmkhng sinh la chn KS ti u

1. CH SDNG KS KHI C NHIM KHUN

Tm vi khun gy bnh

- C nhiu hn ch v kh khn

-i khi khng cn thit

LM G TUN TH NGUYN TC 1 ?

NHNG NGUYN TC SDNG KHNGSINH TRONG IU TR


khun

2. Phi bit la chn khng sinh hp l

3. Phi bit nguyn tc phi hp khng sinh


quy nh

2. LA CHN KHNG SINH HP L

KhKhng sinhng sinh

Vi KhuVi Khunn BBnh nhnnh nhn


- La chn KS ph hp vi VK gy bnh

- La chn KS theo v tr NK

- La chn KS theo ca BN

LA CHN KHNG SINH PH HPVK GY BNH

Mt vi khun/ngi bnh thngMt vi khun/ngi bnh thng


4/13

3 28 2012

4

HVI KHUN CH

La chn khng sinh ph hp VK gy bnhLa chn khng sinh ph hp VK gy bnh

MI QUAN HVK CH VK GY BNH

La chn khng sinh ph hp VK gy bnh

CC NK DOVK THNG TR

NK niu/ SD

NK tiu ha

Vim phi

vim ni tm mc

NK huyt

NK rng, li, hngAp-xe


VK GY BNH

S. aureus

Str. pyogenes

Str. pneumoniae

E. coli

K. pneumoniae

Enterobacter


P. aeruginosa

CC NK DO PSEUDOMONAS

NK hTKT

NK ti ch

NK huyt

Vim mngtrong tim

NK titniu

NK h h hp- mn BN xnang- cp BN #

NK da vxng vtthng

BNG 1: NH HNG MM BNH THEOV TR NHIM KHUN- T THEO KINH NGHIM

V tr NK Vi khun gy bnh

Vim hng Lin cu nhm A

Vim amydal Lin cu, t cu, VK k khVim tai gia cp cchy m TE

H.influenza(+++), ph cu (++), tcu vng, Enterobacteries

NK rng ming Lin cu, Actinomyces,VK k kh

Vim phi MPC Ph cu (50%), H.influenzae,S.aureus, K.pnemonie, Mycoplasma,

Vim bng quang E. coli (80%), P. mirabilis, Klebsiella.

Trng c, chc l,.. T cu(++), Str.pyogenes


5/13

3 28 2012

5

La chn khng sinh bao trm phn lnchng vi khun gy bnh

Tnh khng khng sinh ti a phng/csiu tr

Sau khi inh hng vi khun gy bnhBNG 2: T KHI BITVK GY BNH

KHNG SINH

VK Bnh l 1st 2nd 3rd

S. aureus Ap xe, NKmu, vim

NTM, VP, ...

Oxacilin,Nafcilin

1Cepha. G1

Vancomycin

Clindamycin

1Macrolid

1FQ(GP) +Rifam

Str. pyogenes Vim huhng, taigia,

Penicillin,Amoxicilin

1Cepha. G1

Vancomycin

Clindamycin

1Macrolid

Str.pneumoniae

nt Penicillin,Amoxicilin

1Cepha. G1

Vancomycin

Clindamycin

1Macrolid

Co-trimox

E. coli Vim titniu

Cipro / levo

1 Cepha G1

1 AG, 1 peni+ 1 peni-ase I

Nitrofurantoin,Co-trimox




- La chn KS theo ca BN

LA CHN KHNG SINH THEOV TR NHIM KHUN

2 c tnh quan trng :- C hot lc cao vi vi khun gy bnh.

- Thm tt vo t chc nhim bnh.

BNG 3: KH NNG THMU TIN CA MT SKHNG SINH VO C QUAN, T CHC

C quan, t chc Khng sinh

Mt Ampicillin, tetracyclin, rifampicin,cefoperazon, ceftriaxon, nafcillin,erythromycin...

Tuyn tin lit Erythromycin, cloramphenicol,co-trimoxazol, fluoroquinolon, C3G...

Xng khp Lincomycin, clindamycin, rifampicin,fluoroquinolon, C1G, C2G, C3G...

BNG 4: KH NNG THM CAKSVODCH NO TY

* t nng iu tr :

Co-trimoxazol, cloramphenicol, rifampicin, metronidazol

* t nng iu tr ch khi MN b vim:

Penicilin G, ampicilin sulbactam, ticarcilin acid clavulanic,

cefotaxim, ceftriaxon, ceftazidim, imipenem, meropenem,

vancomycin, aztreonam, ofloxacin, ciprofloxacin.

* Khng t nng iu tr

Aminoglycozid, cefoperazon, clindamycin, C1G, C2G


6/13

3 28 2012

6


Mt s TH c bit: u tin ng dng ti ch, t nng cao

- NK da v m mm: thuc st khun/ KS ti ch

sau khi lm sch.- NK tai- mi- hng: KS phun ti ch (aerosol),

thuc st khun sc ming, vin ngm, KS nhtai, mi...

- NK mt: dng KS nh, tra mt, bi vo m mt,tim di kt mc....

KS dng ngoi

TOBRAMYCIN

Nh mt, tra mt

NEOMYCIN

Nh mt, mi, tai.


Cn s dng ng dng bo ch cho tngng dng

Thuc nh tai c c tnh cao, trc khi sdng phi thm khm k.




- La chn KS theo ca BN:- Tr em - Ngi cao tui

- Ph n c thai, CCB - Ca d ng

- Suy gim chc nng gan, thn

C a mn cm, d ng

KS l nhm thuc c nguy c gy dng cao !!!

D penicilin

D cho

D ampicilin

Khai thc k tin s

Lm test da trc khitim KS

LA CHN KHNG SINH CHO TR EM

CC cc khng sinh c c tnh trn s phttrin v c thuc khc an ton hn.

Phi hiu chnh li liu theo la tui.

Nhm KS cn lu v liu dng l aminosid,glycopeptid, polypeptid (colistin)


7/13

3 28 2012

7

BNG 5: S DNG KHNG SINH CHOTR EM CC LA TUI

KS Tr non S sinh 1thng -> 3 tui > 3 tui

Aminosid + + + +

-lactam + + + +

Macrolid + + + +

Phenicol 0 - - +

Co-trimoxazol

0 0 + +

Cyclin 0 0 0 >8

Quinolon 0 0 0 >18

2. PHI BIT LA CHN KHNG SINHHP L


- La chn KS theo v tr NK- La chn KS theo ca BN:

- Tr em - Ngi cao tui



LA CHN KHNG SINH CHO PNCT

Trong NK nng e da n tnh mng thlun u tin cho ngi m.

Trnh tuyt i cc KS c c tnh cao vc th thay th: cloramphenicol, tetracyclin,co-trimoxazol...

SDNG KHNG SINH CHO PNCT

Khng sinh 3 thngu

3 thnggia

3 thng cui

Macrolid + + +

Penicillin G, A + + +

Cephalosporin + + +

Co-trimoxazol 0 0 0

Cyclin 0 0 0

Phenicol 0 0 0

Aminosid 0 0 0

Quinolon 0 0 0

CC NGUYN TC S DNG KHNG SINH




- La chn KS theo ca BN:- Tr em - Ngi cao tui



LA CHN KHNG SINH CHO BN SUY THN

Bnh nhn suy thn: Gia tng nng KS thi

tr ch yu qua thn dng c hot tnh

tng c tnh ca KS

- Lu cc thuc c c tnh trn thn

- Hiu chnh liu theo chc nng thn


8/13

3 28 2012

8

MC C VI THN CA KHNG SINH

Khng sinh Mc c vi thn

Aminosid ++

Beta-lactamin 0

Cyclin th h I/II +/0

Phenicol 0

Sulfamid +

Vancomycin ++

5-nitro imidazol 0

Cephaloridin* ++

LA CHN KHNG SINH CHO BN SUY GAN

Bnh nhn suy gan: gim chuyn ha KS

ti gan --->Gia tng nng KS chuyn

ha gan

-- tng c tnh ca KS

- Lu cc thuc c c tnh trn gan

NHNG KHNG SINH B CHUYN HA GAN> 70%

Acid fusidic Clindamycin Rifampicin

Amphotericin Pefloxacin Griseofulvin

Acid nalidixic Clortetracyclin Ketoconazol

Metronidazol Cloramphenicol

NHNG KHNG SINH T BCHUYN HA GAN

Cc aminosid

Cc tetracyclin

Cc penicillin

Thiamphenicol

Vancomycin

Cc cephalosporin, tr:

Cephalothin, cefotaxim

Mt s quinolon :

. Ofloxacin

. Norfloxacin



khun2. Phi bit la chn khng sinh hp l


sinh


quy nh

3. PHI HP KHNG SINH HP L

- Tng t/d trn cc chng khng mnh (NK

bnh vin hoc NK mn tnh)

VD: Pen A+

cht c ch Beta lactamase

- Gim khng thuc: trong iu tr lao, H.

pylori


9/13

3 28 2012

9

3. PHI HP KHNG SINH HP L(TIP)

- Ni rng ph tc dng :

- Trn vi khun k kh

- Trn cc NK do cVK Gram (+)/(-)

- T kinh nghim / NK nng cha xc nh c

nguyn nhn: khng dng ko di

- Lu yphi hp cn tranh (SGK)



khun



sinh


quy nh

4. S DNG KHNG SINH NG THIGIAN QUYNH

- Liu dng, nhp a thuc: Lu v KS ph

thuc thi gian, KS ph thuc nng

- di ca t s dng KS:

- Ht VK + 2-3 ngy

- Vi NK nh : 7-10 ngy

- Vi NK nng, v tr kh thm: di ngy

Nhng nguyn tc sdng

khng sinh trong dphng

phu thut

DCH T

CDC M : 2.6% s ca phu thut b

nhim trng vt m, lm thi gian nmvin ca BN tng ln t 7-10 ngy, v chi

ph tng khong $3,000/ ca nhim trng

hu phu.

NHIM TRNG VT M

Da

M di da

M mm su(c)

C quan/ xa

NK vt

m nng

NK vt msu

NK c quan/xa


10/13

3 28 2012

10

MC CH CAKSDP

- Gim tng lng khng sinh s dng

- Gim chi ph iu tr bnh nhn

CC YU T NH HNG NCH NH KS/ PT

Phn loi phu thut

Nguy cNT hu phu : Ch s theo di nhim

trng BV (NNISS):

Loi PT

nguy cca PT

Thi gian m

PHN LOI PHU THUTTHEO NGUY C NHIM KHUN

Loi 1: Phu thut sch (Clean Surgery)

(nguy cNK: 1-5%; KSDP: 15%; KSDP< 15)L PT chn thng mi khng nhim bn,

PT cc cquan nhim khun

Pt ng mt, tit niu, sinh dc khi cnhim khun

Bng, mt da din rng

Li v trng nng

PHN LOI PHU THUTTHEO NGUY C NHIM KHUN

Loi 4: Phu thut bn (Dirty/or Infected

Surgery) (Nguy cNK >30%; KSDP : gim)

L cc phu thut chn thng trn 4h, vt

thng hoi t ...

Phu thut tng v, thng hoc hoi th, NT

c m, nhim phn hay vt l

Sang chn m mm h


11/13

3 28 2012

11

CC YU T NH HNG N CH NHKS/ PT

Phn loi phu thut

Nguy cNT hu phu : Ch s theo di nhimtrng BV (NNISS):

Loi PT

nguy cca PT

Thi gian m

NGUY C CA PHU THUT

ASA1: BN khng c bnh mc km

ASA2: BN c ri lon 1 chc nng ln mc TB

ASA3: BN c ri lon 1 chc nng ln

mc nng

ASA4: BN c tin lng sng xu

ASA5: BN hp hi


Phn loi phu thut


trng BV (NNISS):

Loi PT

nguy cca PT

Thi gian m

CH S THEO DI NHIM TRNG BV(NNISS)

Bng phn loi PT : loi 3,4: 1

nguy cPT (ASA): 3,4,5: 1

Thi gian m TB: tg m >TB : 1


Phn loi phu thut


trng BV (NNISS):

Loi PT

nguy cca PT

Thi gian m TB

NGUY C NT HU PHU

Ch s NNISS () Nguy c NT (%)

0 1,5

1 2,6

2 6,8

3 13,0


12/13

3 28 2012

12

CH NH KS / PHU THUT

Loi PT KSDP

1 -Khng cn-b: PT tim, khp gi

- NNISS = Nguy c NT>5%2 KSDP

3+4 KSDP +KS tr liu

BN nguyc

Nm vin > 48h, dng KS trcPT, b m li sm, suy gim MD,...

CC NGUYN TC SDKS /D PHNG PT

1. Thi im a thuc phi ng

2. Chn khng sinh phi ng

3. di ca t iu tr phi ng

1. THI IM A THUC PHI NG Nguyn tc : nng KS cao nht lc rch dao

Dng khng sinh ng Dng khng sinh qumun

MI LIN QUAN C TNH PK-THI GIAN DNG KS

Nng

KS IV

Thi gian

M

Mu

M

Tim tnh mch: Sau khi m / tim TM -1h khi truyn TM qung ngn

Tim bp: trc phu thut -1h

BNG 11. SDAO NG NNG CEFAZOLIN

HUYT THANH THEO NG A THUC.

C

(mcg/ml)

5

min.

15

min.

30

min.

1 h 2 h 4 h

IM(1g)

- - 60,1 63,8 54,3 29,3

IV(1g)

188,4 135,8 106,8 73,7 45,6 16,5


13/13

3 28 2012

1. THI IM A THUC PHI NG

ng trc trng: trc m 2h

ng ung:- PT tiu ha: ung 1 ngy trc m

- PT tit niu: FQ

2. CHN KS PHI NG

2.1. Ph ca KS: rng

2.2. T khng qu ngn: gim s ln a thuc

2.3. Thm tt vo t chc cn PT

BNG 12. MT S TH DV LA CHNKHNG SINH DPHNG NK/ PT

Loi PT Vi khun Khng sinh

Tai - Mi -Hng

S.aureus,

S.epidermidis

K kh ming

C1G / C2G

Tim mch S.aureus,S.epidermidis

E.coli v VK G (-) #

C1G / C2G/Vancomycin

Ti mt

S.aureus

E.coli v VK G (-) #K kh (nu tc mt)

C1G hoc C2G

MT S TH DV LA CHN KHNG SINHDPHNG NK/ PT (TIP)

Loi phu thut Vi khun Khng sinh

i trng -Trc trng

E.coli & VK G (-) #

K kh, c bit lB.fragilis

C1G / C2G (1g)

+ Metronidazol

Sn - ph khoa K kh, c bit lB.fragilis

C1G / C2G (1g)

+ Metronidazol

3. DI CAT IU TR PHI NG

Nng

KS IV

Thi gian

M

Mu

M

3. DI CAT IU TR PHI NG

Khng ko di qu 24h sau m

Trong a s TH: 1-2 liu

S ln dng thuc ph thuc: Loi phu thut

di cuc m

T ca khng sinh

khang sinh 2010-son

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