Tác nhân gây nhiễm trùng tiểu và tình hình đề kháng kháng sinh tại bệnh viện chợ rẫy 2013

Y Hpc TP. Hb Chi M m h * Tap 18 * Phu ban ciia So 4 * 2014

Nghien cmi Y hpc

TAC NHAN GAY NHIEM TRUNG TIEU vA TINH HINH DE KHANG
KHANG SINH TAI BENH VIEN CHO RAY 2013
Tidn Thi Thanh Nga*
TOMTAT
Ddt van lU: Nham ddnh gid thuc trang ve nhiem triing tim b nhung benh nMn nam vien tqi cdc klioa 1dm
sdng ve khia canh zn khuah hgc va su di khdng Ididng sinh vdi cdc khdng sinh dang diing trong dieu tri Hen nay
tqi Binh znen Chg RSy.
Phucmgphdp: Qua Mi cuu kei qud cay ducmgtinhcm 708 man nieac tieu trong ndm 2013.

Kii qud: Cdc vi Idiuan diian ti li cao Id E. coli, Enterococcusfijecalis,Pseudomonas aeniginosa, Klebsiella
sp, vd Adnetobacter baumanii, Enterococcus faedum.
Kei ludn: Mdc do de khdng khdng sinh ciia cdc tdc nhan gay iiMem triingtieungdy cdng gia tdng vdi cdc
khdng sinh dang sie dung.Viec su dung kMng sinh trmg dieu trinhOm triing tiai ^n than trgng vd theo hudng
dan dieu tri de tranh tinh trqng lam tdng muc do dekhdng Ididng sinh im duy tri tuoi thg cua cdc kMngsinh hien
CO trong khi chd dgi cdc kMng sinh mdi tMy the
Tir khoa: nhiem triingtiai,de kMng khdng sinh
ABSTRACT
THE PATHOGENS URINARY TRACl' INFECTION AND ANTIMICROBIAL RESISTANCE AT
CHORAY HOSPITAL IN 2013
Tran Thi Thanh Nga * Y Hoc TP. Ho Chi Minh * Vol. 18 - Supplement of No 4- 2014:119 -122
Objective: To evaluate the situation of UTI of dinical zoards in microbiological asped as zveU as tM
resistance to available antimicrobials which current used at Choray hospital.
Methods: Through retrospectivefromculture positive results of urine samples 708 in 2013.

Results: TM high percentage of bacteria is E. coli, Enterococcus faecalis. Pseudomonas aeruginosa,
Kldfsiella sp, vd Adnetobacter baumanii, Enterococcus faedum.
Coficluticms:TM resistance to available antimicrobials of these uropatMgais increased day by day.TM

antimicrobials in tM treatmmt of UTI sMuld be used pnidmtly andfallowedtlie treatment guideline to avoid tM
increasing tM level of antimicrobial resistance and preserve tM Ufa of available antimicrobials whie waiting fa
tM repladng of tM new ones.
Key words: Urinan/ trad infrction (UTI), Antimicrobial resistance.
DAT VAN DE
nguoc bang quang nieu quan, dat sonde tieu luu
hoac CO tien hanh nhirng thu thuat 6 duong tieu,
^Jhiem trimg Heu (NTT) la mot benh ly
^^ ^ _ ^..^ ^ ^ ^ ^ ^ Lupus do he thong,
thuong gap 6 benh vien cung nhu trong cong
^ ^ j ^ . ^ ^ ^ _ ^ ^ ^ corticosteroid, soi nieu,
dong, NTT duoc dinh ngMa la nude tieu co vi
t j ^ i,^ jh"an kinh co ton thuong bang quan^n.
khuah (bacteriuha) vo. su hien dien cua cac tneu
^ ^ j ^. ^^ ^ ^ ^^^ ^^^ ^ ^ _j„ ^^
Chung lam sang. Co nhieu yeu to nguy co lien
^^ ^ g ^^ ^^ ^^ ^^^^^ ^.. ^ ^ ^ ^ ^
quan den NTT: nghen Be duong heu, trao
•Khoa Vi Sinh BV Chd Kay
Tdc gia Uen Inc. BS. CKI. Tran Thi Thanh Nga

Chuyen De Than Nieu

DT 0908185491

Email:

119

Y Hpc TP. Ho Chi Minh * Tap 18 * P h u ban ciia So 4 * 2014

Nghien ciiii Y hpc

vien nhiem trung tieu gap tren benh nhan npi va
ngoai khoa, ke ca benh nhan noi tni va ngoai tni,
nhung benh nhan nam vien dai ngay, dac biet la
nhung b^nh nhan dupe dat sonde tieu lim rat de
bi nhiem trung. Chiing toi trong nghien cihi nay
voi muc dich danh gia thuc trang ve nhiem
trimg tieu 6 nhiing benh nhan nam vien tai cac
khoa lam sang ve khia canh vi khuah hpc va sir
de khang khang sinh voi cac khang sinh dang
dimg trong dieu tri hien nay de nham xay dung
mot phac do dieu tri thich hgp cho nhiem trung
tieu t^ benh vien Cho Riy.
PHl/ONG PHAP NGHIEN CUtJ
Muc tieu nghien ciiu: khao sat ti 1^ cac
mau cay nuoc heu duong tinh ciia cac khoa
lam sang t?i B^nh vi?n Chp Ray voi chan doan
nhiem trung tieu va ti le ciia cac loai vi khuah
la tac nhan gay benh, dong thoi danh gia miic
do de khang khang sinh ciia cac vi khuan nay
theo tung nam. Phuong phap hoi ciiu
(retrospechve study): thu thap so lieu ciia cac
mau nuoc tieu oia cac khoa lam sang giii den
khoa vi sinh co ket qua cay duong tinh va
dupe lam khang sinh do ket hpp vol cac dii
li^u CO dupe tir lam sang. Thoi gian thuc hien
01/2013 - 12/2013 tai khoa Vi Sinh b?nh vien

Chp Ray. So lieu thu thap dupe trinh bay duoi
dang cac bang bieu va ti le phan tram.
KETQUA

STT
5
6

%

n = 708

ViKhudn
Aanetobacter

baumannii

35

4,95

fcteaum

29

4,10 1

Enterococcus

Cac vi khuan khac < 4%: Klebsiella

pneumoniae, Proteus vulgaris, Pseudomonas sp
Providencia, S. saprophyticus, S. epidermidis, S.
coagulase negative, S. aureus, Stenotrophomonas
maltophilia, nam Candida sp. ...
Bdng 2: Di Ididng Ididng sinh ciia E. coli z>d Klebsiella
sp
Ecoll


l^el>slella sp

%R

Amikacin

7,1

Amikacin

27,9

Ampicillin

97.3

Ampicillin

100,0

Cefepime

33,4

Cefepime

48,9

Ce^>odo>dme

79,1

Cefpodoxime

71,1

Ceftazidime

54,0

Ceftazidime

84,4

Ceftnaxone

74,9

Ceftnaxone

68,9

Ciprofloxacin

79,8

Ertapenem

Cipnafloxacin

73,3

8.0

Ertapenem

37,8

Gentamicin

57,1

Gentamicin

60,0

Imipenem

6,7

Imipenem

31,1

Levofloxacin

31,6

Meropenem

37,8

Meropenem

7,2

Netilmicin

35,6

Netlmian

11,2

Nitrofurantoin

28,9

4,0

Ticarcillin

71,1

61,4

Trimethoprim /
sulfametiioxazole

72,7

Nitrofurantoin
Ticarcillin
Trimethopnm /
sulfamethoxazole

73,6

E. coli de khang cao vol Quinolone va cac
cephalosporin the he 3,4. Vi khuan nay con nhgy
cam tot voi nhom Carbapenem, nitiohirantoine,
Piperacilline/Tazobaetam,
amikadne,
netilmycine. Klebsiella sp. de khang cao voi tat ca
Ket qua khao sat ve cac tac nhan gay nhiem
cac loai khang sinh dang dimg, chi con nhay cam
trung tieu va miic do de khang vol cac khang
voi nhom Carbapenem 6 miic dp 30 %.
sinh dang dimg nhu sau:
Bdng 1: Cdc tdc nlidn gay binh chii yeii trong nhiem Bdng 3; De Ididng Ididng sinh cua Enterococcus

faecalis vd Enterococais faedum
triing tieu 2013
Trong thoi gian nam 2013 co tat ca 3.540 mlu
nuoc tieu dupe giii den khoa vi sinh, ket qua cay
duong tinh 708 mau vdi ti le tning binh 20%.

STT
1
2

Vi K h u i n
Esdienc^ia
Enterococcus

coli
faecalis

Enterococcus
faecalis

%R

Enterococcus
faecium

%R

375

52,96

Azifliromyan

91,8

Azittiromyan

100,0

n = 708

%

49

6,93

Doxycycline

22,4

Doxycydine

51,7

3

Pseucfomonas aenjginosa

47

6,65

Fosfomycin

8,2

Fosfomycin

65,5

4

Klebsiella sp

45

6,36

Gentamicin

46,9

Gentamicin

86,2

Chuyen De Than Nieu

•Kfi"

wmmn'

Y Hoc TP. Ho Chi Minh * Tap 18 * Phu ban ciia So 4 * 2014
Enterococcus
faecalis
Levofbxaan

%R

Ent^ococcus
faecium

%R

63,3

[.evofloxacin

100,0

Nitrofurantoin

8,9

Nitrofurantoin

30,8

Vancomycin

4,1

Vancomycin

24,1

Nghien cihi Y hpc

chiem ti le thap khoang 4% - 1% cho moi loai
vi khuain.

Tinh hinh de khang khang sinh cua cac vi
khuSm Gram am, dac biet la cae vi khuah Gram
am tiei men beta lactamase pho rpng (ESBL) nhu
Enterococcusfaecalisva Enterococcusfaedumde £ coli hoac Klebsiella hoac cac vi khuan khong len
khang cao voi tat ca cac loai khang sinh dang
men khang voi cac khang sinh dang dimg hien
dimg, chi con nhay cam duy nhat voi
nay lam kho du tru khang sinh de dieu tri ngay
Vancomycin, Nitrohirantoin, Fosfomycin.
cang giam trong nhiem trimg noi ehung va
Bdng 4: ESc khdng khang sinh cita Pseudomonas
nhiem trimg nieu noi rieng. Theo ket qua mot so
aeruginosa vd Adnetobader baumanii
nghien aiu trong nuoQ va ket qua theo doi giam
sat \i khuan tiong nhieu nam qua aia khoa vi
Adnetobacter
%R

Pseudomonas
%R
baumanii
aeruginosa
sinh benh vien Chp Ray, ti le cac vi khuain Gram
Amikacin
Amikaan
60,0
62,9
am tiet ESBL kha cao tCr 40-60%, ti le nay cung
Cefepime
Cefepime
88,6
70,2
phii hpp voi nghien aiu SMART tai vimg chau
Ceftazidime
Ceftazidime
68,1
85,7
A Thai Binh Duong.
Ciprofkixaan

72,3

Ciprofloxacin

Colistin

0,0

Colistn

2,9

Fosfomycin

81,0

Doxycydine

30,3

Gentamicin

69,6

Gentamicin

80,0

Imipenem

53,2

Imipenem

65,7

Meropenem

69.6

Meropenem

65,7

Netilmicin

61,7

Netilmicin

60,0

Ticarcillin

85,1

Ticarcillin

80,0

Tnmethoprim /
sulfamethoxazole

76.5

82,9

Psaidomonas aeruginosa va Adnetobacter

baumanii de khang cao voi tat ca cac loai khang
sinh dang dimg chi con nhay cam voi Colistin.
BAN LUAN
Ket qua ciia nghien ciiu hoi ciiu t^i Benh
vien Chp Riy cho thay ti le cay duong tinh aia
nuoc tieu khoang 20% trong so benh nhan
nhap vien voi chan doan la nhiem trimg tieu.
Ket qua aia nghien ciiu nam 2013 voi ket qua
cay nuoc tieu duong tinh cho thay cac tac
nhan gay benh thuang gap nhat la: Escherichia
coli, Enterococcus faecalis, Pseudomonas
aeruginosa, Klebsiella sp, vd Adnetobacter
baumanii, Enterococcus faecium theo thii tij.
Klebsiella pneumoniae, Proteus vulgaris,
Pseudomonas sp Providencia, S. saprophyticus, S.
epidennidis, S. coagulase negative, S. aureus,
Stmotrophomonas maltophilia, nam Candida sp..

Chuyen De Than Nieu

Ve tac nhan gay benh trong nhiem trimg tieu
chii yeu la vi khuan Gram anf'\ trong n ^ e n
aiu oia chiing toi £. coli diing hang dau chiem ti
1§ > 50%, ti le nay ciing phii hgp voi bao cao aia
Hsueh PR tai Hoi nghi ve nhiem trimg tieu co
bi&i chiing ciia Vimg Chau A Thai Binh Duong
to chiic tai thai Lan nam 2011'-'> trong do ghi
nhan £. coli chiem ti le cao 6 cac nuoe Viet nam,
Trung Quoc va An Dp, mot dac diein quan trpng
doi voi E. coli trong nhiem trimg tieu ia co su de

khang cao voi Fluoroquinolone. Trong nghien
aiu cua chiing toi ti le de khang vdi
Gprofloxadn 79.8%
Voi cac vi khuah khac thupc nhom
Enterobacteriaceae nhu Klebsiella ciing de khang
cao vol cae thuoc khang sinh hien eo, ehi co
colistine va cae khang sinh thupc nhom
Carbapenem con nhay cam cao voi cac vi khuan
thupc nhom nay.
Bao cao tai Hoi nghi nhiem trimg nieu vimg
Chau A Thai binh Duong cung cho tfiay voi cac
vi khuah khong len men nhu Pseudomonas
aeruginosa va Adnetobader baumanii khong co
thuoc nao ttiuoc nhom Carbapenem nhu
hnipenem, Meropenem co hieu luc tren 80% va
tren 31% voi Adnetobader baumanii.'^^ Trong
nghien ciiu aia chiing toi cho thay vdi


Nghien cixu Y hpc

Y Hpc TP. Ho Chi Minh * Tap 18 * Phu ban ciia So 4 "* 2014

Pseudomonas aeruginosa nhom Carbapenem chi
con hieu luc tir SCo den <70. De giai thich hien
tupng giam khang tuong doi ciia Pseudomonas
aeruginosa, can phai xac dinh gen cac chimg nay
bang. Voi Adnetobader baumanii chi con hieu luc
khang sinh < 50%. Nhu vay da khang thuoc
(multidrug resistance) trong nhiem triing tieu

dang la mpt van de giong nhu cae nhiem trimg
khac eho khu vuc chau A'^*"-'.

Adnetobacter baumanu khang vdi tat ca khang
sinh hien cd, chi con nhay cam duy nhat vdi
Colistin. Nhiem trimg tieu vdi nhdm vi khuah
Gram duong nhu Enterococais sp. Staphylococcus
aureus hoac coagulase negative Staphylococais
cung khong cd nhieu lua chpn trong dieu tri, chii
yeu chi con Vancomycine, Teicoplanin va
Rifampicine, nen viec sir dung cac thuoc nay
ciing can than trpng de tranh lam gia tang nhdm
MRSA b-6 thanh nhdm VRSA.

Tl 1? nhiem trimg tieu do nhom cau khuan
Trudc tinh hinh khang khang sinh ngay cang
Gram duong co ti le thap va thuong lien quan
gia tang, van de dat ra cho cac bac si lam sang la
den van de thu fhu|t, thuong gap la do
Enterococcus sp. (Enterococcusfaecalis;Enterococcuslam the nao keo dai tuoi thp oia cac khang sinh
con dang hieu luc. Vi vay vi|c dieu tri nhiem
faedum). Tuy nhien hi#n nay nhiem trimg voi
trimg tieu Hen tai can chii y theo diing cac
nhom VI khuah Gram ducmg nay cung tro nen
hudng dan dieu trj de tranh lam gia tang miic dp
quan trpng truoc het la vi vi khuan chi nhay chii
khang
thuoc. Can can nhac dieu tri khang sinh
yeu voi Vancomydne va co kha nang chuyen di
cho nhimg trudng hpp nude tieu cd vi khuah

vat heu di truyen khang Vancom}'cine tii'
nhung khong cd bieu hien lam sang va cac
Enterococcus eho Staphylococcus lam cho nguy
trudng hpp lien quan den ngoai khoa de cd the
CO xuat hi§n nhom VRSA cang ngay cang cao, vi
dgt dupe ket qua dieu tri toi uu.
vay ehi dinh thuoe khang sinh cho nhom nay can
than trong va chi nen dimg trong fhoi gian ngan.
KET LUAN

TAI LIEU THAM KHAO
1

Burke A (2010) Cunha Urosepsis in critical care InfeciioAis
diseases in Critical care p.286-294

Ti 1^ cay duong tinh aia tong so mau nuoe
2
Burite ]P, Yeo TW (20O4) Nosoconual urinaiy trad infections
In: Mayhall CG, ed. Hospital Efndemiology and Infection
tieu giri den khoa vi sinh nam 2013 khoang 20%
Control 3rd ed FTuladelphia, P A Lij^pincott Williams &
tuong duong voi ket qua 5 nam tir 2007-2011'^.
Wtlkins,:267-286
Cae tae nhan gay benh dupe xac dinh Id E. Coli, 3
Qarkson MR, Brenner BM (2005), Urinaiy tract infection,
pyelonephritis, and reflux nephropathy. The Kidney 7^
Enterococcus sp., Klebsiella sp, Psmdomonas
edition Elsevier. P253-272
aeruginosa, vd Adnetobader baumanii;tiiiitu oia 4. Concensus review of the e^ndeiuology aiui afiprcpriate

cac VI khuah nay co the thay doi theo timg nam
atiliiracrobial dierapy of comphcated urinary tract infections
inAsia-Paafic region (2011), Journal of Infection; 63(2) p, 114nhung diing dau trong nhiem trimg tieu van la
123
E coli chiem khoang > 50%, cac vi khuan khae it
5
Curao D (2008) TreatnYOit of recument urosepsis with
tigecydine: a pharmacological perspective I Q m Microbiol;
gap hon chiem ti 1? thap hem khoang 1%. Cac vi
46'1892-1893
khuan dudng rupt hp Enterobaderiacea (E. coli,
6
Koomanaehai P, Tiengrun S, Kiratisin P, Thamlilaticul V
Klebsiella, Proteus mirabilis...) tie't men Beta
(200?) Efficacy and safety of colistin {colistimeftiate sodium)
for therapy of infections caused by multidrug-resifitant
Lactamase pho rpng (ESBL) va cac vi khuah
Pseudonuinas aeruginosa and Adnetobacter baumannu in
khong len men nhu Psmdomonas sp.;
Siriraj Hospital, Ban^(d(, Thailand Int J Infect Ete, 11402-406
Adnetobacter baumanh hien tai la nhung vi khuah 7 Tian Quang Binh, Tran TW Thanh Nga. (2013) Nhian trimg
tieii: Vi sinh hoc va tinh hinh de khang khang a n h t^u b ^
da khang, de khang cao voi cac khang sinh dang
vien Cho ray tii 2007 - 20II; Tap chi Y HpcTP. Ho Oii Minh,
dimg, nhat la cac khang sinh hp Quinolone, hp
t $ p ] 7 p h y ban, so 2-2013
Beta lactams, hp Carbapenem cung cd khuynh
Ngdy nhan bdi bdo:
13/5/2014
hudng bl tang de khang trong nhirng nam gan

day. Dac biet vdi Pseudomonas aeruginosa, Ngdy phdn bien nhan xet bdi bdo: 01/6/2014
Ngdy bdi bdo dugc dang:
10/7/2014
Chuyen De Than Ni^u