Tài liệu_XỬ TRÍ VIÊM PHỔI CỘNG ĐỒNGTRONG KỶ NGUYÊN KHÁNG THUỐC

Ho Chi Minh city 9-2013

XỬ TRÍ VIÊM PHỔI CỘNG ĐỒNG
TRONG

KỶ

NGUYÊN
Nguyễn Văn Thành. MD; PhD

KHÁNG

THUỐC


MÔ HÌNH TỬ VONG

TOÀN CẦU (WHO 2004)

Mô hình tử vong toàn cầu 2004 (WHO)

Per cent

P•-r ceal

~

Deaths

Dtsea.., or.,,..,

(mjllon,I

World

lsdlaemic hean disease

2

Cerebro•-ascu lard isease

3

t.ewer re.spira tory inf ecnons

4

1

122

5.7

2

9J

CDPD

5

Diarrhoeal diseases

6

HIV/AIDS

7

7.2

4.2

7.1

3.0

5.1

2.2

3J

2.0

Tube rt.ulosls

8

Tra(hea., bro nc:hus., lung c:ance,s

9

Road t,afflcao::fdents
10

1.3

3

35

Prematurity and low b1rth weight

2

3

CDPD

9.4

Diarrhoeal diseases

1.8
1S

6.9

HIV/AIDS

5

Cerebreva scubr disease

1S

6

COPD

0.9

7

Tubertulosls

1.3

2.3

8

t~~onar.al lnfecdons'

9

Malari.

1.2

11.2

2S

25

0.9

5.6
3.6

3.5

09
09

3.4

3.3

P~ma tu rit)' 1u,d IO'N birth Y1o-elght

10

2.0

5.7

l.2

0.8

Hl9'J+lnct1m• countMs
I

Cerebro ..-ascu lar d tsease

lsdlaemic hean disease

lschaemic heart disease

29

4

ltMddlr..lnaJm• countri•s

·1

LaNer respirator)' infections

1.5

2.2

deMhs

(rN•lon!I

Low-in

dNths

1

De,1ths

Dtsease or l•Ju'Y

lol•I

«
IOhl

3.4

1.8

3.5

2

13.9

3

7.4

4

4

lcrNer respiratory inf ecuons

09

5

Trachea., bronchus., lung cancers

0.7

6

Road traffic accidents

0.7

lschae.mic heart disease

1.3

16.3

0.8

9.3

03

3.8

14.2

Cerebro..ra scullr disease
Tracnea, bronchus., lung cancers

OS

5.9

lcrNer respirator;• infections

3.8
5

COPD

6

AJzheimerandother dementias

7

Colon and recmm cancers

2.9

3.5

03

3.4

03

2.8
03

3.3


Nhiễm

khuẩn

hô

nhiều nhất đi khám
180

165

160

140
1
120

80

60

Source: Verispan PDDA 2004

Số lần khám chủ yếu (đơn vị triệu lượt)

100

1
9

65

hấp

là

lý

do


75% các kê toa

kháng

sinh trên toàn thế giới là
dành cho Nhiễm khuẩn hô hấp
Anonymous (1998). Acute respiratory infections: the forgotten pandemic. Communique from the International Conference on

Acute Respiratory Infections, Canberra, Australia 7-10 Jult 1997. International Journal of Tuberculosis and Lung Disease 2,
2-4.


V ệt Nam 2009
Siingapore

Nguồn: WHO - Asia

2009


TABLE 1. Incidence

of specific

pathogens

in

pneumonia by site of care

community-acquired

AMBULATORY

NORMAL

INTENSIVE

WARD

CARE UNIT

Pathogen
No yield

45.9-50o/o

Streptococcuspneumoni
Streptococcuspneumoniae

32.9%-48.7%

34-38°/o

27-48%

Haemophi/us influenzae
3-13°/o
Mycoplasma
Mycoplasmapneumoniae

8-23%

6-7°/o

Bochud PY, Moser F, Erard P, et al. Community-

9-21°/o

acquired pneumonia: a prospective outpatient study. Medicine (Baltimore) 2001;80(2):75-87

Lim WS, Macfarlane JT, Boswell TC, et al. Study management guidelines. Thorax of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for
2001;56(4):296The aetiology, management and outcome of seve
Committee and The Public Health Laboratory Service. Respir Med 1992;86(1):7-13

301
re community-acquired pneumonia on the intensive care unit. The British Thoracic Society Research

14-28%

7-12%
3-22%

Chlamydophilapneumoni
ae

45-48%

4°/o

2-7%


Câu hỏi 1.

Tình hình
kháng
thuốc

Tình

hình

Thấp (<10%)
Ý
Đức

S pneumoniae
Trung bình (10-30%)
Irland
Bồ Đào Nha

Anh

Hungary

Thụy Sỹ

Canada

Benelux
Scandinavia

Ác-hen-ti-na

kháng

PNC
Cao (>30%)
Pháp
Tây Ban Nha
Cộng hòa Slovac
Bungari
Rumani

Brazin

Thổ Nhĩ Kỳ

Bắc Phi

Isreal

Mỹ

Pê- ru

Arập Saudi

Mê-hi-cô

Kenia

Bắc Phi

Nigeria

Thái Lan

Philippines

Nhật bản

Singapore

Hàn Quốc

Australia

Đài Loan

New Zealand

Hồng Kông

Việt Nam
F. Paradisi et al. 2001 CMI. 7 (S 4). 34-42.


Kháng

của Pneumococi với
ANSORP

penicillin
∼ 2001)

(1996

80
: :J

0,

E
N

"

•
•
•

70
60

J\J

u
~
2

50

(J)

c

40

~

v i

-

c

Clinical

isolates (1996-1997)

Carriage isolates (1998-1999)

Clinical isolates

(2000-2001)

30


;;;
(J)

20

a,

c
:

c..

~0
u

c

I ~

10
0 ~
~

~..

't ....
0

..,,

,,'=?,

a,

Song JH & A160RP. Antirmcrob Agents Chemother. 48;2101,2004

-·

,>.

't

~

~
~

~

t
~'9

1

~

~

%,
~

~

-:,..,,

~

~
~<>

I
~-

di~

~

~

o,..
0

v. d' ,.
~
< ~,;;,

..,,

~

..,,

~~ a;,
'::>-:,<

<;)

I_
~

1,.

~

~-

4%

'?

0
d'

o
~


S.PNEUMONIAE

KHÁNG

THUỐC

S.PNEUMONIAE

(SOAR VIET NAM 2011)
95.3
100

94

96.2

86.8
90

82.6

.
80 9

80
72.8

70
60
50
40
30
2

0

1

0
0

0 ~

(SOAR Viet Nam 2011)

.


ANSORP News: A multicenter study on antibiotic resistance of 204 S. pneumoniae in Vietnam


B-lactam resistance in pneumococci: Asia
MIC90

(mg/L)

Country
Penicillin
Vietnam

4

8

Amoxicillin
8

Cefuroxime

Ceftriaxone

2

Korea

4

4

8

1

Hong Kong

4

2

8

1

Taiwan

4

2

8

1

2

2

8

1

Thailand

Data from the multinational surveillance study clearly documented distinctive increases in

Singapore

2
1
4
the prevalence rates and the
levels of antimicrobial
resistance

China

2
4

among S. pneumoniae isolates
in many2Asian countries,
which are 1among the highest in

Malaysia
Philippines

the world published to date.
2
0.25
0.03

1

2

4

1

0.03

0.25

0.25

< 0.03

0.12

< 0.25

India

* ANSORP data (2000-2002)

Song JH & ANSORP.

Antimicrob Agents Chemother. 48;2101,2004


Invasive

pneumococci: resistance to

fluoroquinolones
(2000–2001)

(%) Resistance

ANSORP

®
~

")
*685 isolates

\

®

®
~~~

t~
i '

'

~

,. ~>

,·:?
~

>

'

'

.

~% ~,

~

Song JH & ANSORP. Antimicrob Agents Chemother June 2004, p. 2101–2107

~

®

®

~~

~~~

~~

'@

~


Evolution of FQ Resistance among
Pneumococci

•

•

Levofloxacin resistance
- 1995:

< 0.5%

- 1998:

5.5%

- 2000:

13.3%

LR% in pen R

Sử dụng FQ ở HK

in Hong Kong

(MIC >4

strains

µg/ml)

- 27.3%

Ho, et al, JAC 48:659, 2001


Summary

Resistance

: clinical

impact

Resistance

Major

of pneumococcal

Clinical

Clinical

resistance

antibiotic class

Rate / MICs
relevance

areas

failures

Penicillins

Cephalosporins

Macrolides

in RTI therapy
/

Asia

variable

Asia

/

Asia

Very few

Few

Increasing

Reports
Fluoroquinolones

/

Asia

Few

(HK)

(levofloxacin)

Not significant

Not significant

Relatively
significant

Undetermined


H. influenzae tạo beta-lactamase

% chủng beta-lactamase [+]

Quốc gia
(Số chủng)

H. influenzae

Korea (51)

64.7

100

Hong Kong (41)

17.1

100

Japan (281)

8.5

96.7

France (193)

31.1

97.3

USA (276)

25.7

94.1

M. catarrhalis


Resistance

70%

Intermediate
4%

60%

Ac

Amoxicillin-

60%

clavulanate
50%

Cu

40%

7%

Cefuroxime Cefaclor

Cr

Ampicillin

Am

Azithromycin

49%

48%

Az Bt
30%

Sulphamethoxazoletrimethoprim
BLM

20%

β-

lactamase production
0%

10%

0%

1%

8%

0%

0%

8%

0%

Ac

Cu

H.

influenzae
multicenter

(P.H.Van et al, 2005)

Cr

Am

with

antibiotic

study in HCMC,

Az

Bt

resistance:
Vietnam

BLM(+)

H.

Influenzae

kháng

thuốc

H.INFLUENZAE
(SOAR VIET NAM 2011)
100
90

83

•R •I

88.4

80
70

68.8

60

50

43.8

40

30
20
10
0

(SOAR Viet Nam 2011)

•S


M.pneumoniae

< 16 tuổi

16-19 tuổi

kháng

macrolide

> 20 tuổi với CAP

Miyashita N et al. Int J Antimicrob Agents 2010, 36(4): 384–385.


Fifty-three Mycoplasma pneumoniae strains were

isolated from pediatric patients in Shanghai
Distribution of MICs of 10 antimicrobial agents for 53 M. pnewnoniae strains

No. of strains with MIC (µgiml) of:
Antimicrobial
~0.007

0.015

0.03

0.06

0.12

0.25

0.5

2

4

8

16

32

64

128

>128

5

Erythromycin
Clarithromyci

4

4

6

3

n
Azithromycin
Josamycin

4

3

7

1

Tetracycline

1

Doxycycline

2

2
7

2

6

1

Ciprofloxacin

5

Levofloxacin

8
Yang

7
2
1

1

5

8

1
1
6

14

3

Liu et

2

3
0

1
11
1

2
6

1

10

2

1
7
27

6

7

Minocycline

Moxifloxacin

4

9
2
4

3

6

6

2

4

24

al., Antimicrobial agents and chemotherapy

May 2009

7

4
20


Time course of Mycoplasma pneumoniae (DNA copy number) in
the nasopharynx of nine patients with macrolide-sensitive M.
pneumoniae

pneumonia

before and after antimicrobial therapy
Y Kawai et al. Respirology (2012) 17, 354–362

.

copies
The

·1000000

microbiological

and

clinical

efficacies

of macrolides for treating patients with MR M. pneumoniae pneumonia were
low. These results show that macrolides are clearly less effective in patients
with MR M. pneumoniae pneumonia.

100000

MCL T3

10000
MNC T3

1000
100

10
1
Before antimicrobial

48 h after

End of

treatment

antimicrobial

antimicrobi


Comparison of children with community-acquired pneumonia and
macrolide-resistant and

macrolide-sensitive M.

pneumoniae infection

Result

Outcomes during macrolide

Macrolid~resistant

treatment
1W;

pneumoniae (n =

~)

MacroIidesensitive
M pneumoni,ie =
(n

Pvalue

J~)

Total no. of feorile days, median (range)

7 (~lJ)

No. of febrile days duru1g macrolide admu1istrationi median (range)

4 (1.. IQ)

15 (l..J)

O.OJ

No. of days with cough during macrolide administration, meaian (range)

, (1.. 14)

2(1..it)

0.04

No. of patients with a feorile period 4~ l1 after macrolide aaministration

7 (~15)

1 (JJ)

<0.000

7 (~15)

IO (16J)

10 (1-J1)

4 (1-20)

W (l,--

14

46)

(10..21)

(%)
No. (%) of patients with a cl1ange of prescription after macrolide
aaministration
Median duration of hospitafaatio111 days (range)
Fabio
Cardinale
et al. (Italy).
Journal of Clinical
Microbiology
Median
duration

of antibiotic
therapy,
aays 2013. 51 (2): p. 723–724

4 (1.. IQ)

036

1
0.002
O.OJ
0.02


Community-Associated

MRSA

•

Four pediatric deaths 1997-1999 in Minnesota

•

North Dakota (MMWR 1999;48:707)
–

Predominantly skin and soft tissue

Clinical manifestations

• 59% of purulent SSTI in 11 ED, 78% of S.

•

–

Necrotizing fasciitis

–

Necrotizing pneumonia

aureus

Different from HA-MRSA
–

SCCmec type IV

–

Panton-Valentine Leukocidin exotoxin associated with tissue necrosis and leukocyte destruction (or
other toxin?)

JAMA 2003;290:2976-2984

and

Community-acquired methicillin-

S.

resistant

aureus

Pneumonia

80

20
18

70

16
60
14

-

c:

50

12

v,

n

Q)
v,

ca

40

10

ct

(.)

8

Q)

er

·2::::,

~

30

:::,

6
20
4
10

2

0

0
2000

2001

2002

2003

2004

2005

Rajesh Thomas et al. Respirology (2011) 16, 926–931

2006

2007

2008

en

0:::

:E


Câu hỏi 2.
Mục tiêu của Kháng sinh trị liệu?