{"id":4093,"date":"2019-03-09T09:26:50","date_gmt":"2019-03-09T02:26:50","guid":{"rendered":"https:\/\/www.vnras.com\/drug\/?p=4093"},"modified":"2019-03-09T09:26:50","modified_gmt":"2019-03-09T02:26:50","slug":"lua-chon-khang-sinh","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/lua-chon-khang-sinh\/","title":{"rendered":"L\u1ef1a ch\u1ecdn kh\u00e1ng sinh"},"content":{"rendered":"<h2>Ca l\u00e2m s\u00e0ng<\/h2>\n<p>B\u1ec7nh nh\u00e2n n\u1eef, 70 tu\u1ed5i, 3 tu\u1ea7n tr\u01b0\u1edbc \u0111\u00f3 \u0111\u00e3 v\u00e0o vi\u1ec7n do \u0111\u1ee3t c\u1ea5p b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u1ea1n t\u00ednh, nay nh\u1eadp vi\u1ec7n tr\u1edf l\u1ea1i t\u1eeb tr\u1ea1i d\u01b0\u1ee1ng l\u00e3o ngh\u0129 nhi\u1ec1u do vi\u00eam ph\u1ed5i. Ban \u0111\u1ea7u b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng piperacillin\u2013tazobactam v\u00e0 vancomycin. Ba ng\u00e0y sau b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c chuy\u1ec3n \u0111\u1ebfn \u0111\u01a1n v\u1ecb h\u1ed3i s\u1ee9c t\u00edch c\u1ef1c do t\u00ecnh tr\u1ea1ng h\u00f4 h\u1ea5p x\u1ea5u \u0111i v\u00e0 suy th\u1eadn c\u1ea5p.<\/p>\n<p>Ngay tr\u01b0\u1edbc khi \u0111\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n, th\u00e2n nhi\u1ec7t \u0111o \u0111\u01b0\u1ee3c l\u00e0 38,1 \u0111\u1ed9 C, nh\u1ecbp tim l\u00e0 110 l\u1ea7n\/ph\u00fat, b\u00e3o ho\u00e0 oxy l\u00e0 89% qua th\u1edf oxy m\u1eb7t n\u1ea1 100%. Nghe ph\u1ed5i ran nhi\u1ec1u hai b\u00ean.<\/p>\n<p>X\u00e9t nghi\u1ec7m c\u00f3 k\u1ebft qu\u1ea3 nh\u01b0 sau (gi\u00e1 tr\u1ecb tham chi\u1ebfu trong ngo\u1eb7c vu\u00f4ng):<br \/>\nNa (mEq\/L) 130 [136-145]; ur\u00ea (mmol\/L) 11,42 [3.57-7.14]; creatinine (\u00b5mol\/L) khi suy th\u1eadn l\u00e0 144, c\u01a1 s\u1edf l\u00e0 72 [53-97]; ALT (IU\/L) 57 [0-35]; AST (IU\/L) 63 [0-35]; b\u1ea1ch c\u1ea7u (G\/L) 13.5 [4.5-11]. N\u1ed3ng \u0111\u1ed9 \u0111\u00e1y c\u1ee7a vancomycin l\u00e0 15 mg\/L.<\/p>\n<p>X-quang ng\u1ef1c th\u1ea5y c\u00e1c \u0111\u00e1m th\u00e2m nhi\u1ec5m lan to\u1ea3 \u1edf thu\u1ef3 tr\u00ean ph\u1ed5i tr\u00e1i v\u00e0 thu\u1ef3 d\u01b0\u1edbi ph\u1ed5i 2 b\u00ean.<\/p>\n<h2>\u0110i\u1ec1u tr\u1ecb n\u00e0o sau \u0111\u00e2y l\u00e0 th\u00edch h\u1ee3p nh\u1ea5t trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y?<\/h2>\n<p>A. Th\u00eam azithromycin; thay piperacillin\u2013tazobactam b\u1eb1ng meropenem; ti\u1ebfp t\u1ee5c d\u00f9ng vancomycin<br \/>\nB. Thay vancomycin b\u1eb1ng daptomycin; ti\u1ebfp t\u1ee5c d\u00f9ng piperacillin\u2013tazobactam<br \/>\nC. Ng\u1eebng piperacillin\u2013tazobactam; th\u00eam levofloxacin; ti\u1ebfp t\u1ee5c d\u00f9ng vancomycin<br \/>\nD. Ng\u1eebng piperacillin\u2013tazobactam; th\u00eam ceftriaxone; ti\u1ebfp t\u1ee5c d\u00f9ng vancomycin<br \/>\nE. Ng\u1eebng piperacillin\u2013tazobactam v\u00e0 vancomycin; b\u1eaft \u0111\u1ea7u d\u00f9ng ceftriaxone v\u00e0 azithromycin<\/p>\n<h2>\u0110\u00e1p \u00e1n: A.<\/h2>\n<p>\u0110i\u1ec3m m\u1ea5u ch\u1ed1t: \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh ph\u00f9 h\u1ee3p v\u1edbi m\u1ed9t b\u1ec7nh nh\u00e2n COPD vi\u00eam ph\u1ed5i \u0111a \u1ed5, suy h\u00f4 h\u1ea5p v\u00e0 suy th\u1eadn c\u1ea5p bao g\u1ed3m meropenem, vancomycin k\u00e8m v\u1edbi ho\u1eb7c m\u1ed9t macrolide, ho\u1eb7c m\u1ed9t fluoroquinolone.<\/p>\n<h3>Gi\u1ea3i th\u00edch chi ti\u1ebft:<\/h3>\n<p>B\u1ec7nh nh\u00e2n n\u00e0y m\u1edbi v\u00e0o vi\u1ec7n do \u0111\u1ee3t c\u1ea5p COPD v\u00e0 hi\u1ec7n v\u00e0o vi\u1ec7n tr\u1edf l\u1ea1i t\u1eeb tr\u1ea1i d\u01b0\u1ee1ng l\u00e3o do vi\u00eam ph\u1ed5i \u0111a \u1ed5. B\u1ec7nh nh\u00e2n \u0111\u00e3 xu\u1ea5t hi\u1ec7n suy th\u1eadn c\u1ea5p trong khi d\u00f9ng vancomycin v\u00e0 piperacillin\u2013tazobactam. C\u00e1c b\u1eb1ng ch\u1ee9ng m\u1edbi nh\u1ea5t g\u1ee3i \u00fd r\u1eb1ng vancomycin ph\u1ed1i h\u1ee3p piperacillin\u2013tazobactam c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 \u0111\u1ed9c t\u00ednh tr\u00ean th\u1eadn so v\u1edbi c\u00e1c ph\u1ed1i h\u1ee3p kh\u00e1ng sinh kh\u00e1c, nh\u01b0 v\u1eady vi\u1ec7c thay piperacillin\u2013tazobactam b\u1eb1ng meropenem cho b\u1ec7nh nh\u00e2n n\u00e0y l\u00e0 h\u1ee3p l\u00ed.<\/p>\n<p>Ph\u00e1c \u0111\u1ed3 kh\u00e1ng sinh ban \u0111\u1ea7u bao g\u1ed3m piperacillin\u2013tazobactam v\u00e0 vancomycin c\u0169ng kh\u00f4ng bao v\u00e2y \u0111\u01b0\u1ee3c c\u00e1c ch\u1ee7ng kh\u00f4ng \u0111i\u1ec3n h\u00ecnh nh\u01b0 Legionella pneumophila. Vi\u1ec7c b\u1ec7nh nh\u00e2n c\u00f3 bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng c\u1ee7a vi\u00eam ph\u1ed5i n\u1eb7ng kh\u00f4ng c\u1ea3i thi\u1ec7n trong v\u00f2ng 72 gi\u1edd sau ph\u1ed1i h\u1ee3p piperacillin\u2013tazobactam v\u00e0 vancomycin c\u00e0ng khi\u1ebfn ngh\u0129 nhi\u1ec1u \u0111\u1ebfn vi\u00eam ph\u1ed5i do Legionella. Th\u00eam n\u1eefa, t\u00ecnh tr\u1ea1ng COPD c\u1ee7a b\u1ec7nh nh\u00e2n c\u00e0ng l\u00e0m t\u0103ng nguy c\u01a1 m\u1eafc vi\u00eam ph\u1ed5i do Legionella.<\/p>\n<p>B\u1ec7nh l\u00ed do Legionella \u0111\u00f4i khi \u0111i k\u00e8m v\u1edbi t\u00ecnh tr\u1ea1ng h\u1ea1 natri m\u00e1u, t\u0103ng transaminase, c\u00e1c tri\u1ec7u ch\u1ee9ng \u1edf \u0111\u01b0\u1eddng ti\u00eau ho\u00e1 v\u00e0 nh\u1ecbp tim nh\u1ecbp tim ch\u1eadm t\u01b0\u01a1ng \u0111\u1ed1i, m\u1eb7c d\u00f9 c\u00e1c tri\u1ec7u ch\u1ee9ng n\u00e0y kh\u00f4ng \u0111\u1eb7c hi\u1ec7u. \u0110i\u1ec1u tr\u1ecb vi\u00eam ph\u1ed5i do Legionella b\u1eb1ng m\u1ed9t kh\u00e1ng sinh macrolide ho\u1eb7c fluoroquinolone. Vi\u1ec7c b\u1eaft \u0111\u1ea7u s\u1eed d\u1ee5ng m\u1ed9t trong c\u00e1c kh\u00e1ng sinh n\u00f3i tr\u00ean v\u00e0 duy tr\u00ec kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng l\u00e0 ph\u00f9 h\u1ee3p trong khi ch\u01b0a c\u00f3 ch\u1ea9n \u0111o\u00e1n ch\u1eafc ch\u1eafn. Vi\u1ec7c l\u1ef1a ch\u1ecdn kh\u00e1ng sinh macrolide hay fluoroquinolone tu\u1ef3 thu\u1ed9c v\u00e0o t\u1eebng b\u1ec7nh nh\u00e2n c\u1ee5 th\u1ec3; trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y, b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 cao b\u1ecb b\u1ec7nh l\u00ed g\u00e2n x\u01b0\u01a1ng do fluoroquinolone do tu\u1ed5i cao, do \u0111\u00f3 l\u1ef1a ch\u1ecdn macrolide l\u00e0 th\u00edch h\u1ee3p h\u01a1n.<\/p>\n<p>Kh\u00f4ng n\u00ean thay th\u1ebf vancomycine b\u1eb1ng daptomycine, do daptomycine c\u00f3 hi\u1ec7u qu\u1ea3 h\u1ea1n ch\u1ebf trong vi\u00eam ph\u1ed5i.<\/p>\n<h2>&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;&#8212;-<br \/>\nT\u00e0i li\u1ec7u tham kh\u1ea3o<\/h2>\n<p>1. Cunha BA. Legionnaires&#8217; disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am 2010 Feb 23; 24:73.<\/p>\n<p>2. Kalil AC et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016 Sep 1; 63:e61.<\/p>\n<p>3. Luther MK et al. Vancomycin plus piperacillin-tazobactam and acute kidney injury in adults: a systematic review and meta-analysis. Crit Care Med 2018 Jan; 46:12.<\/p>\n<p>Ngu\u1ed3n: NEJM.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Ca l\u00e2m s\u00e0ng B\u1ec7nh nh\u00e2n n\u1eef, 70 tu\u1ed5i, 3 tu\u1ea7n tr\u01b0\u1edbc \u0111\u00f3 \u0111\u00e3 v\u00e0o vi\u1ec7n do \u0111\u1ee3t c\u1ea5p b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u1ea1n t\u00ednh, nay nh\u1eadp vi\u1ec7n tr\u1edf l\u1ea1i t\u1eeb tr\u1ea1i d\u01b0\u1ee1ng l\u00e3o ngh\u0129 nhi\u1ec1u do vi\u00eam ph\u1ed5i. Ban \u0111\u1ea7u b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng piperacillin\u2013tazobactam v\u00e0 vancomycin. Ba ng\u00e0y sau b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c [&#8230;]\n","protected":false},"author":1,"featured_media":3371,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-4093","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-y-te-suc-khoe"],"acf":[],"_links":{"self":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/4093","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/comments?post=4093"}],"version-history":[{"count":0,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/4093\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media\/3371"}],"wp:attachment":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media?parent=4093"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/categories?post=4093"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/tags?post=4093"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}