C\u00e1c kh\u00e1ng sinh polymyxins l\u00e0 colistin (polymyxin E) v\u00e0 polymyxin B ra \u0111\u1eddi v\u00e0o nh\u1eefng n\u0103m 1950 nh\u01b0ng m\u00e3i \u0111\u1ebfn g\u1ea7n \u0111\u00e2y m\u1edbi \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng kh\u00e1 ph\u1ed5 bi\u1ebfn tr\u00ean l\u00e2m s\u00e0ng, v\u00e0 hi\u1ec7n l\u00e0 c\u1ee9u c\u00e1nh v\u1edbi c\u00e1c b\u1ec7nh nhi\u1ec5m tr\u00f9ng vi khu\u1ea9n gram \u00e2m \u0111a kh\u00e1ng thu\u1ed1c.<\/p>\n
B\u1ed9 khuy\u1ebfn c\u00e1o n\u1ea7y \u0111\u01b0\u1ee3c n\u00eau ra th\u00e1ng 1\/2019 v\u1edbi s\u1ef1 \u0111\u1ed3ng thu\u1eadn c\u1ee7a c\u00e1c H\u1ed9i sau:
\n– H\u1ed9i D\u01b0\u1ee3c l\u00e2m s\u00e0ng Hoa K\u1ef3 (ACCP, American College of Clinical Pharmacy),
\n– Hi\u1ec7p h\u1ed9i Vi sinh l\u00e2m s\u00e0ng v\u00e0 B\u1ec7nh truy\u1ec1n nhi\u1ec5m ch\u00e2u \u00c2u (ESCMID, European Society of Clinical Microbiology and Infectious Diseases),
\n– Hi\u1ec7p h\u1ed9i b\u1ec7nh truy\u1ec1n nhi\u1ec5m Hoa K\u1ef3 (IDSA, Infectious Diseases Society of America )
\n– H\u00f4i D\u01b0\u1ee3c l\u00fd ch\u1ed1ng nhi\u1ec5m khu\u1ea9n (ISAP, International Society for Anti\u2010infective Pharmacology),
\n– H\u1ed9i h\u1ed3i s\u1ee9c c\u1ea5p c\u1ee9u (SCCM, Society of Critical Care Medicine)
\n– H\u1ed9i d\u01b0\u1ee3c s\u0129 c\u00e1c b\u1ec7nh truy\u1ec1n nhi\u1ec5m (SIDP, Society of Infectious Diseases Pharmacists)<\/p>\n
C\u00e2u h\u1ecfi 1 : L\u00e0m th\u1ebf n\u00e0o \u0111\u1ec3 l\u00e0m test nh\u1ea1y c\u1ea3m v\u00e0 \u0111i\u1ec3m d\u1eebng breakpoint n\u1ed3ng \u0111\u1ed9 \u1ee9c ch\u1ebf t\u1ed1i thi\u1ec3u v\u1edbi c\u00e1c Polymyxin ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 1: \u1ee6y ban ch\u00e2u \u00c2u v\u1ec1 th\u1eed nghi\u1ec7m \u0111\u1ed9 nh\u1ea1y c\u1ea3m v\u1edbi kh\u00e1ng sinh (EUCAST) v\u00e0 nh\u00f3m nghi\u00ean c\u1ee9u v\u1ec1 \u0111i\u1ec3m d\u1eebng polymyxin c\u1ee7a Vi\u1ec7n ti\u00eau chu\u1ea9n l\u00e2m s\u00e0ng v\u00e0 ph\u00f2ng th\u00ed nghi\u1ec7m (CLSI) khuy\u1ebfn ngh\u1ecb s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p test ti\u00eau chu\u1ea9n ISO \u2010 74 20776 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n v\u1edbi n\u01b0\u1edbc canh Mueller Hinton c\u00f3 \u0111i\u1ec1u ch\u1ec9nh cation, v\u1edbi mu\u1ed1i sunfat c\u1ee7a colistin trong khay polystyrene kh\u00f4ng c\u00f3 ch\u1ea5t ph\u1ee5 gia nh\u01b0 polysorbate \u2010 80, ph\u1ea3i s\u1eed d\u1ee5ng mu\u1ed1i sunfat c\u1ee7a polymyxin (kh\u00f4ng s\u1eed d\u1ee5ng d\u1eabn xu\u1ea5t methanesulfonate c\u1ee7a colistin – v\u00ec thu\u1ed1c kh\u00f4ng ho\u1ea1t \u0111\u1ed9ng, ph\u00e2n h\u1ee7y ch\u1eadm trong dung d\u1ecbch) Hi\u1ec7n t\u1ea1i th\u00ec canh Agar, khu\u1ebfch t\u00e1n \u0111\u0129a v\u00e0 khu\u1ebfch t\u00e1n gradient kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb l\u00e0m b\u1edfi CLSI \u2010 EUCAST v\u00ec c\u00e1c ph\u01b0\u01a1ng ph\u00e1p n\u00e0y mang l\u1ea1i t\u1ef7 l\u1ec7 l\u1ed7i cao kh\u00f4ng ch\u1ea5p nh\u1eadn \u0111\u01b0\u1ee3c.
\nCh\u00fang t\u00f4i khuy\u00ean r\u1eb1ng c\u00e1c \u0111i\u1ec3m d\u1eebng c\u1ee7a Nh\u00f3m l\u00e0m vi\u1ec7c chung CLSI \/ EUCAST n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng cho colistin nh\u01b0 sau:
\n\u0110\u1ec3m d\u1eebng MIC cho Colistin v\u1edbi Acinetobacter sp, P. aeruginosa, Enterobacteriace l\u00e0 <= 2 mg\/L. \u0110\u1ed1i v\u1edbi c\u00e1c ch\u1ee7ng vi khu\u1ea9n Enterobacter aerogenes, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, v\u00e0 Raoultella ornithinolytica, CLSI x\u00e1c \u0111\u1ecbnh kh\u00f4ng \u0111\u1ee7 d\u1eef li\u1ec7u l\u00e2m s\u00e0ng v\u00e0 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc \/ d\u01b0\u1ee3c l\u1ef1c h\u1ecdc (PK \/ PD) \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111i\u1ec3m d\u1eebng PK\/PD v\u00e0 n\u00eau ra gi\u00e1 tr\u1ecb ng\u01b0\u1ee1ng 2 mg \/ L d\u1ef1a tr\u00ean c\u00e1c ngu\u1ed3n d\u1eef li\u1ec7u MIC.<\/p>\n
C\u00e2u h\u1ecfi 2: C\u00f3 m\u1ee5c ti\u00eau tr\u1ecb li\u1ec7u PK\/ PD \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t \u0111\u1ec3 t\u1ed1i \u0111a h\u00f3a hi\u1ec7u qu\u1ea3 c\u1ee7a Colistin v\u00e0 Polymyxin B kh\u00f4ng?<\/p>\n
– Khuy\u1ebfn c\u00e1o 2 : \u0111\u1ed1i v\u1edbi colistin, di\u1ec7n t\u00edch d\u01b0\u1edbi \u0111\u01b0\u1eddng cong n\u1ed3ng \u0111\u1ed9 thu\u1ed1c trong huy\u1ebft t\u01b0\u01a1ng trong 24 gi\u1edd \u1edf tr\u1ea1ng th\u00e1i \u1ed5n \u0111\u1ecbnh (AUC ss , 24 gi\u1edd ) l\u00e0 ~ 50 mg.gi\u1edd \/ L \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c n\u1ed3ng \u0111\u1ed9 tr\u1ea1ng th\u00e1i h\u1eb1ng \u0111iinh trung b\u00ecnh m\u1ee5c ti\u00eau (C ss, avg ) ~ 2 mg \/ L. M\u1eb7c d\u00f9 m\u1ee5c ti\u00eau n\u00e0y l\u00e0 t\u1ed1i \u01b0u v\u1edbi nhi\u1ec5m tr\u00f9ng h\u00f4 h\u1ea5p d\u01b0\u1edbi, l\u01b0u \u00fd \u0111\u00e2y l\u00e0 n\u1ed3ng \u0111\u1ed9 kh\u00e1 cao v\u00e0 n\u1ed3ng \u0111\u1ed9 cao h\u01a1n m\u1ee9c n\u00e0y l\u00e0m t\u0103ng t\u1ef7 l\u1ec7 m\u1eafc v\u00e0 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng c\u1ee7a t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p t\u00ednh AKI, Acute Kidney Injury.
\nM\u1ed9t th\u00f4ng s\u1ed1 PK\/PD kh\u00e1c l\u00e0 fAUC:MIC c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c xem x\u00e9t…<\/p>\n
C\u00e2u h\u1ecfi 3: c\u00f3 n\u00ean \u01b0u ti\u00ean s\u1eed d\u1ee5ng m\u1ed9t lo\u1ea1i Polymyxin h\u01a1n lo\u1ea1i kia kh\u00f4ng ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 6: ch\u00fang t\u00f4i khuy\u00ean d\u00f9ng polymyxin B l\u00e0 t\u00e1c nh\u00e2n \u01b0u ti\u00ean s\u1eed d\u1ee5ng to\u00e0n th\u00e2n trong \u0111i\u1ec1u tr\u1ecb nhi\u1ec5m tr\u00f9ng h\u1ec7 th\u1ed1ng. L\u00fd do cho khuy\u1ebfn ngh\u1ecb n\u00e0y l\u00e0 polymyxin B c\u00f3 c\u00e1c \u0111\u1eb7c t\u00ednh d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc PK v\u01b0\u1ee3t tr\u1ed9i c\u0169ng nh\u01b0 gi\u1ea3m kh\u1ea3 n\u0103ng \u0111\u1ed9c th\u1eadn (Polymixin B not yet available in VN, nd)<\/p>\n
– Khuy\u1ebfn c\u00e1o 7: Ch\u00fang t\u00f4i khuy\u00ean d\u00f9ng colistin l\u00e0 polymyxin \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1eddng ti\u1ec3u d\u01b0\u1edbi do ti\u1ec1n thu\u1ed1c prodrug Colistin MethaneSulfonate (CMS) \u0111\u01b0\u1ee3c thanh th\u1ea3i th\u1eadn chuy\u1ec3n th\u00e0nh colistin ho\u1ea1t t\u00ednh \u1edf \u0111\u01b0\u1eddng ti\u1ebft ni\u1ec7u.<\/p>\n
C\u00e2u h\u1ecfi 4: \u0110\u1ed1i v\u1edbi CMS, m\u1ed1i quan h\u1ec7 gi\u1eefa c\u00e1c \u0111\u01a1n v\u1ecb li\u1ec1u l\u01b0\u1ee3ng kh\u00e1c nhau trong c\u00e1c c\u00f4ng th\u1ee9c l\u00e0 g\u00ec?<\/p>\n
– Khuy\u1ebfn c\u00e1o 8: Ch\u00fang t\u00f4i khuy\u1ebfn c\u00e1o c\u00e1c h\u01b0\u1edbng d\u1eabn s\u1eed d\u1ee5ng n\u00ean vi\u1ebft theo li\u1ec1u CMS trong s\u1ed1 \u0111\u01a1n v\u1ecb qu\u1ed1c t\u1ebf (IU) ho\u1eb7c miligram colistin base (CBA), t\u01b0\u01a1ng \u1ee9ng v\u1edbi quy \u01b0\u1edbc ghi nh\u00e3n \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u1edf m\u1ed7i qu\u1ed1c gia. H\u1ec7 s\u1ed1 chuy\u1ec3n \u0111\u1ed5i l\u00e0 1 tri\u1ec7u IU CMS t\u01b0\u01a1ng \u0111\u01b0\u01a1ng v\u1edbi ~ 33 mg CBA.<\/p>\n
C\u00e2u h\u1ecfi 5 C\u00f3 c\u1ea7n ph\u1ea3i th\u1ef1c hi\u1ec7n li\u1ec1u t\u1ea3i t\u0129nh m\u1ea1ch khi b\u1eaft \u0111\u1ea7u tr\u1ecb li\u1ec7u b\u1eb1ng CMS kh\u00f4ng?<\/p>\n
– Khuy\u1ebfn c\u00e1o 9: Ch\u00fang t\u00f4i khuy\u00ean n\u00ean b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb IV v\u1edbi li\u1ec1u t\u1ea3i CMS 300 mg CBA (~ 9 tri\u1ec7u IU) \u0111\u01b0\u1ee3c truy\u1ec1n trong 0,5 gi\u1edd – 1 gi\u1edd v\u00e0 ch\u1ec9 \u0111\u1ecbnh li\u1ec1u duy tr\u00ec ti\u1ebfp theo trong 12 gi\u1edd – 24 gi\u1edd sau \u0111\u00f3.<\/p>\n
C\u00e2u h\u1ecfi 6 : Li\u1ec1u duy tr\u00ec h\u00e0ng ng\u00e0y c\u1ee7a CMS \u1edf b\u1ec7nh nh\u00e2n c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn b\u00ecnh th\u01b0\u1eddng?<\/p>\n
– Khuy\u1ebfn c\u00e1o 10: \u0111\u1ed1i v\u1edbi m\u1ed9t b\u1ec7nh nh\u00e2n c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn b\u00ecnh th\u01b0\u1eddng, n\u00ean d\u00f9ng li\u1ec1u duy tr\u00ec h\u00e0ng ng\u00e0y 300mg – 360mg CBA (~ 9-10 tri\u1ec7u UI CMS), chia l\u00e0m hai v\u00e0 truy\u1ec1n trong 0,5 gi\u1edd-1 gi\u1edd, kho\u1ea3ng th\u1eddi gian chia li\u1ec1u l\u00e0 12 gi\u1edd.<\/p>\n
Theo d\u00f5i ch\u1ee9c n\u0103ng th\u1eadn v\u00e0 \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u h\u00e0ng ng\u00e0y ph\u00f9 h\u1ee3p d\u1ef1a theo \u0111\u1ed9 thanh th\u1ea3i Creatinin, \u0111\u00edch Css,avg of 2 mg\/L
\n– ClCr = 0 => 130 mg CBA, # 3,95 MUI CMS
\n– ClCr 5 – < 10 => 145 mg CBA # 4,40 MUI CMS
\n– ClCr 10 – <20 => 160 mg # 4,85 …
\n– ClCr 20 – < 30 => 175 mg # 5,30…
\n– ClCr 30 – <40 => 195 mg # 5,90…
\n– ClCr 40 – <50 => 220 mg # 6,65…
\n– ClCr 50 – <60 => 245 mg # 7,40…
\n– ClCr 60 – <70 => 275 mg # 8,35…
\n– ClCr 70 – < 80 => 300 mg # 9,00…
\n– ClCr 80 – < 90 => 340 mg CBA # 10,3 MUI CMS
\n– ClCr > 90 => 360mg CBA # 10,9 MUI CMS<\/p>\n
C\u00e2u h\u1ecfi 7: C\u00f3 c\u1ea7n \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u h\u00e0ng ng\u00e0y c\u1ee7a CMS n\u1ebfu b\u1ec7nh nh\u00e2n b\u1ecb suy th\u1eadn?<\/p>\n
– Khuy\u1ebfn c\u00e1o 11 : Ch\u00fang t\u00f4i khuy\u00ean n\u00ean \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u CMS \u1edf b\u1ec7nh nh\u00e2n suy th\u1eadn nh\u01b0 tr\u00ean.<\/p>\n
C\u00e2u h\u1edfi 8: Li\u1ec1u d\u00f9ng CMS ti\u00eam t\u0129nh m\u1ea1ch trong tr\u01b0\u1eddng h\u1ee3p l\u1ecdc m\u00e1u ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 12 : Ch\u00fang t\u00f4i khuy\u00ean \u0111\u1ec3 nh\u1eafm m\u1ee5c ti\u00eau colistin plasma Css, avg 2 mg \/ L \u1edf b\u1ec7nh nh\u00e2n ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o gi\u00e1n \u0111o\u1ea1n (IHD, intermittent hemodialysis), ph\u00e1c \u0111\u1ed3 li\u1ec1u \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u01b0 sau : V\u00e0o ng\u00e0y nondialysis, cho m\u1ed9t li\u1ec1u CMS 130 mg CBA \/ ng\u00e0y (~ 3,95 tri\u1ec7u IU \/ ng\u00e0y). V\u00e0o ng\u00e0y l\u1ecdc m\u00e1u, cho li\u1ec1u b\u1ed5 sung CMS 40 mg CBA (~ 1,2 tri\u1ec7u IU) ho\u1eb7c 50 mg CBA (~ 1,6 tri\u1ec7u IU) cho m\u1ed7i phi\u00ean IHD 3 ho\u1eb7c 4 gi\u1edd. Li\u1ec1u h\u1eb1ng ng\u00e0yc\u00f2n l\u1ea1i n\u00ean cho sau khi phi\u00ean l\u1ecdc m\u00e1u k\u1ebft th\u00fac.<\/p>\n
– Khuy\u1ebfn c\u00e1o 13 : Ch\u00fang t\u00f4i khuy\u00ean n\u00ean nh\u1eafm m\u1ee5c ti\u00eau colistin Css huy\u1ebft t\u01b0\u01a1ng , trung b\u00ecnh 2 mg \/ L \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh ch\u1ea1y th\u1eadn “l\u1ecdc m\u00e1u k\u00e9o d\u00e0i t\u1ed1c \u0111\u1ed9 ch\u1eadm h\u00e0ng ng\u00e0y” (SLEDD, Sustained low-efficiency daily diafiltration, v\u1edbi th\u1eddi gian l\u1ecdc k\u00e9o d\u00e0i h\u01a1n, l\u01b0u l\u01b0\u1ee3ng m\u00e1u ch\u1ea1y th\u1ea5p h\u01a1n so v\u1edbi ch\u1ea1y gi\u00e1n \u0111o\u1ea1n, ph\u01b0\u01a1ng ph\u00e1p n\u1ea7y \u0111\u01b0\u1ee3c xem nh\u01b0 ” \u1edf gi\u1eefa” l\u1ecdc m\u00e1u li\u00ean t\u1ee5c v\u00e0 ch\u1ea1y th\u1eadn ng\u1eaft qu\u00e3ng), v\u00e0 th\u01b0\u1eddng l\u00e0 10% li\u1ec1u CMS \u0111\u01b0\u1ee3c th\u00eam v\u00e0o li\u1ec1u c\u01a1 b\u1ea3n h\u00e0ng ng\u00e0y trong m\u1ed7i gi\u1edd ch\u1ea1y SLEDD.<\/p>\n
-Khuy\u1ebfn c\u00e1o 14: Ch\u00fang t\u00f4i khuy\u00ean \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh \u0111i\u1ec1u tr\u1ecb thay th\u1ebf th\u1eadn li\u00ean t\u1ee5c (CRRT,Continuous renal replacement therapy), \u0111\u1ec3 \u0111\u1ea1t m\u1ee9c colistin huy\u1ebft t\u01b0\u01a1ng Css, avg 2 mg \/ L, n\u00ean d\u00f9ng CBA 440 mg \/ ng\u00e0y (~ 13,3 tri\u1ec7u IU \/ ng\u00e0y). \u0110i\u1ec1u n\u00e0y t\u01b0\u01a1ng \u0111\u01b0\u01a1ng v\u1edbi 220 mg CBA m\u1ed7i 12 gi\u1edd (~ 6,65 tri\u1ec7u IU m\u1ed7i 12 gi\u1edd).<\/p>\n
– C\u00e1c khuy\u1ebfn c\u00e1o 15-18 li\u00ean quan Polymyxin B n\u00ean kh\u00f4ng n\u00eau (nd)<\/p>\n
C\u00e2u h\u1ecfi 13: v\u1ec1 vai tr\u00f2 c\u1ee7a TDM (therapeutic drug monitoring) ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 19: ch\u00fang t\u00f4i khuy\u1ebfn ngh\u1ecb n\u00ean c\u00f3 TDM v\u00e0 gi\u00e1m s\u00e1t \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u th\u00edch h\u1ee3p khi d\u00f9ng nh\u00f3m thu\u1ed1c n\u00e0y (We recommend that TDM and adaptive feedback control (AFC) be used wherever possible for both colistin and polymyxin B.<\/p>\n
C\u00e2u h\u1ecfi 14 : Nh\u1eefng chi\u1ebfn l\u01b0\u1ee3c n\u00e0o c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 gi\u1ea3m t\u1ef7 l\u1ec7 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p t\u00ednh \u1edf b\u1ec7nh nh\u00e2n \u0111ang \u0111i\u1ec1u tr\u1ecb b\u1eb1ng Colistin ho\u1eb7c Polymyxin B?<\/p>\n
– Khuy\u1ebfn c\u00e1o 20: Ch\u00fang t\u00f4i khuy\u1ebfn ngh\u1ecb, b\u1ea5t c\u1ee9 khi n\u00e0o c\u00f3 th\u1ec3, n\u00ean tr\u00e1nh c\u00e1c t\u00e1c nh\u00e2n g\u00e2y \u0111\u1ed9c th\u1eadn \u0111\u1ed3ng th\u1eddi \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n d\u00f9ng colistin ho\u1eb7c polymyxin B ( m\u1ee9c khuy\u1ebfn c\u00e1o m\u1ea1nh, b\u1eb1ng ch\u1ee9ng trung b\u00ecnh)<\/p>\n
– Khuy\u1ebfn c\u00e1o 21 : Ch\u00fang t\u00f4i khuy\u00ean n\u00ean tr\u00e1nh d\u00f9ng li\u1ec1u l\u1edbn h\u01a1n li\u1ec1u \u0111\u01b0\u1ee3c k\u00ea trong h\u01b0\u1edbng d\u1eabn n\u00e0y cho colistin ho\u1eb7c polymyxin B trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng c\u00f3 TDM, m\u1ee9c khuy\u1ebfn c\u00e1o cao nh\u1ea5t.<\/p>\n
– Khuy\u1ebfn c\u00e1o 22: \u1ede c\u00e1c qu\u1ed1c gia c\u00f3 s\u1eb5n c\u1ea3 hai ho\u1ea1t ch\u1ea5t, ch\u00fang t\u00f4i khuy\u00ean n\u00ean s\u1eed d\u1ee5ng \u01b0u ti\u00ean polymyxin B \u0111\u1ec3 h\u1ea1n ch\u1ebf t\u1ef7 l\u1ec7 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p AKI li\u00ean quan \u0111\u1ebfn polymyxin (m\u1ee9c khuy\u1ebfn c\u00e1o y\u1ebfu, ch\u1ee9ng c\u1ee9 th\u1ea5p)<\/p>\n
– Khuy\u1ebfn c\u00e1o 23 : Cho \u0111\u1ebfn khi c\u00f3 th\u00eam d\u1eef li\u1ec7u, ch\u00fang t\u00f4i kh\u00f4ng khuy\u1ebfn ngh\u1ecb s\u1eed d\u1ee5ng ch\u1ea5t ch\u1ed1ng oxy h\u00f3a th\u01b0\u1eddng xuy\u00ean v\u00ed d\u1ee5 Vit C, acid ascorbic cho m\u1ee5c \u0111\u00edch gi\u1ea3m \u0111\u1ed9c t\u00ednh li\u00ean quan \u0111\u1ebfn polymyxin ( khuy\u1ebfn c\u00e1o y\u1ebfu, b\u1eb1ng ch\u1ee9ng r\u1ea5t th\u1ea5p ).<\/p>\n
– Khuy\u1ebfn c\u00e1o 24: Ch\u00fang t\u00f4i khuy\u00ean n\u1ebfu m\u1ed9t b\u1ec7nh nh\u00e2n c\u00f3 x\u1ea3y ra AKI khi d\u00f9ng colistin, n\u00ean gi\u1ea3m li\u1ec1u h\u00e0ng ng\u00e0y xu\u1ed1ng v\u00e0 \u0111i\u1ec1u ch\u1ec9nh th\u00edch h\u1ee3p theo ClCr cho m\u1ee9c colistin C ss, avg l\u00e0 2 mg \/ L.<\/p>\n
– Khuy\u1ebfn c\u00e1o 25 : Ch\u00fang t\u00f4i khuy\u00ean kh\u00f4ng n\u00ean gi\u1ea3m li\u1ec1u, ngo\u00e0i c\u00e1c khuy\u1ebfn c\u00e1o v\u1ec1 li\u1ec1u cho suy th\u1eadn \u0111\u1ed1i v\u1edbi colistin, \u0111\u1eb7c bi\u1ec7t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb AKI khi colistin ho\u1eb7c polymyxin B \u0111ang \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng cho nhi\u1ec5m tr\u00f9ng \u0111e d\u1ecda t\u00ednh m\u1ea1ng, nhi\u1ec5m tr\u00f9ng t\u1ea1ng ho\u1eb7c khi vi khu\u1ea9n l\u00e2y nhi\u1ec5m c\u00f3 MIC cao h\u01a1n 1 mg \/ L (khuy\u1ebfn c\u00e1o m\u1ea1nh, b\u1eb1ng ch\u1ee9ng th\u1ea5p) .
\nN\u1ebfu MIC c\u1ee7a m\u1ea7m b\u1ec7nh l\u00e2y nhi\u1ec5m v\u00e0\/ ho\u1eb7c b\u1ea3n ch\u1ea5t c\u1ee7a nhi\u1ec5m tr\u00f9ng cho th\u1ea5y n\u1ed3ng \u0111\u1ed9 m\u1ee5c ti\u00eau trong huy\u1ebft t\u01b0\u01a1ng th\u1ea5p h\u01a1n c\u00f3 th\u1ec3 l\u00e0 \u0111\u1ee7, n\u00ean c\u00e2n nh\u1eafc gi\u1ea3m li\u1ec1u \u0111\u1ec3 nh\u1eafm m\u1ee5c ti\u00eau C ss , avg colistin \u0111\u00f3 (khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t) .<\/p>\n
– Khuy\u1ebfn c\u00e1o 26: Ch\u00fang t\u00f4i khuy\u00ean n\u00ean ng\u1eebng \u0111i\u1ec1u tr\u1ecb nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb AKI n\u1ebfu ch\u1ea9n \u0111o\u00e1n nhi\u1ec5m tr\u00f9ng l\u00e0 kh\u00f4ng ch\u1eafc ch\u1eafn hay khi c\u00f3 s\u1eb5n m\u1ed9t lo\u1ea1i thu\u1ed1c kh\u00e1c ph\u00f9 h\u1ee3p \u00edt g\u00e2y \u0111\u1ed9c cho th\u1eadn h\u01a1n (khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t) .<\/p>\n
C\u00e2u h\u1ecfi 16 : N\u00ean s\u1eed d\u1ee5ng \u0111\u01a1n tr\u1ecb li\u1ec7u hay ph\u1ed1i h\u1ee3p cho Polymyxin B ho\u1eb7c Colistin \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n b\u1ecb nhi\u1ec5m tr\u00f9ng CRE (carbapenem\u2010resistant gram- enterobacteriaceae ) ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 27: Ch\u00fang t\u00f4i khuy\u00ean v\u1edbi c\u00e1c tr\u01b0\u1eddng h\u1ee3p nhi\u1ec5m tr\u00f9ng x\u00e2m l\u1ea5n do CRE, polymyxin B ho\u1eb7c colistin n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng k\u1ebft h\u1ee3p v\u1edbi m\u1ed9t ho\u1eb7c nhi\u1ec1u kh\u00e1ng sinh b\u1ed5 sung m\u00e0 m\u1ea7m b\u1ec7nh c\u00f3 nh\u1ea1y c\u1ea3m (khuy\u1ebfn c\u00e1o m\u1ea1nh, b\u1eb1ng ch\u1ee9ng th\u1ea5p).<\/p>\n
– Khuy\u1ebfn c\u00e1o 28 :N\u1ebfu kh\u00f4ng c\u00f3 thu\u1ed1c th\u1ee9 hai m\u00e0 CRE hi\u1ec3n th\u1ecb MIC nh\u1ea1y c\u1ea3m, ch\u00fang t\u00f4i khuy\u00ean n\u00ean s\u1eed d\u1ee5ng polymyxin B ho\u1eb7c colistin k\u1ebft h\u1ee3p v\u1edbi t\u00e1c nh\u00e2n kh\u00f4ng nh\u1ea1y c\u1ea3m th\u1ee9 hai v\u00e0 \/ ho\u1eb7c th\u1ee9 ba (v\u00ed d\u1ee5: carbapenem). N\u00ean \u01b0u ti\u00ean cho m\u1ed9t t\u00e1c nh\u00e2n kh\u00f4ng nh\u1ea1y c\u1ea3m c\u00f3 MIC th\u1ea5p nh\u1ea5t so v\u1edbi \u0111i\u1ec3m d\u1eebng nh\u1ea1y c\u1ea3m t\u01b0\u01a1ng \u1ee9ng (khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t, \u1edf \u0111\u00e2y nh\u1ea5n m\u1ea1nh tr\u1ecb li\u1ec7u ph\u1ed1i h\u1ee3p v\u00ec s\u1ee3 polymycine b\u1ecb kh\u00e1ng khi d\u00f9ng \u0111\u01a1n tr\u1ecb li\u1ec7u, k\u1ebft h\u1ee3p th\u01b0\u1eddng g\u1eb7p l\u00e0 v\u1edbi carbapenem, nd )<\/p>\n
C\u00e2u h\u1ecfi 17. N\u00ean s\u1eed d\u1ee5ng li\u1ec7u ph\u00e1p \u0111\u01a1n tr\u1ecb li\u1ec7u hay ph\u1ed1i h\u1ee3p cho Polymyxin B ho\u1eb7c Colistin \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n m\u1eafc CRAB, (carbapenem\u2010resistant A. baumannii)<\/p>\n
Khuy\u1ebfn c\u00e1o 29: Ch\u00fang t\u00f4i khuy\u00ean r\u1eb1ng \u0111\u1ed1i v\u1edbi c\u00e1c tr\u01b0\u1eddng h\u1ee3p nhi\u1ec5m tr\u00f9ng x\u00e2m l\u1ea5n do CRAB, n\u00ean s\u1eed d\u1ee5ng polymyxin B ho\u1eb7c colistin k\u1ebft h\u1ee3p v\u1edbi m\u1ed9t ho\u1eb7c nhi\u1ec1u t\u00e1c nh\u00e2n b\u1ed5 sung m\u00e0 m\u1ea7m b\u1ec7nh hi\u1ec3n th\u1ecb MIC nh\u1ea1y c\u1ea3m ( khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t )<\/p>\n
Khuy\u1ebfn c\u00e1o 30 : N\u1ebfu kh\u00f4ng c\u00f3 t\u00e1c nh\u00e2n ho\u1ea1t \u0111\u1ed9ng th\u1ee9 hai m\u00e0 CRAB l\u00e2y nhi\u1ec5m hi\u1ec3n th\u1ecb MIC nh\u1ea1y c\u1ea3m, ch\u00fang t\u00f4i khuy\u00ean n\u00ean s\u1eed d\u1ee5ng polymyxin B ho\u1eb7c colistin m\u1ed9t m\u00ecnh nh\u01b0 \u0111\u01a1n tr\u1ecb li\u1ec7u ( \u1edf \u0111\u00e2y nh\u1ea5n m\u1ea1nh vai tr\u00f2 duy nh\u1ea5t c\u1ee7a Polymyxin v\u1edbi CRAB, nd )<\/p>\n
C\u00e2u h\u1ecfi 18 : N\u00ean s\u1eed d\u1ee5ng li\u1ec7u ph\u00e1p \u0111\u01a1n tr\u1ecb li\u1ec7u hay ph\u1ed1i h\u1ee3p cho Polymyxin B ho\u1eb7c Colistin \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n m\u1eafc CRPA carbapenem\u2010resistant P. aeruginosa?<\/p>\n
– Khuy\u1ebfn c\u00e1o 31: Ch\u00fang t\u00f4i khuy\u00ean v\u1edbi c\u00e1c tr\u01b0\u1eddng h\u1ee3p nhi\u1ec5m tr\u00f9ng x\u00e2m l\u1ea5n do CRPA, polymyxin B ho\u1eb7c colistin n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng k\u1ebft h\u1ee3p v\u1edbi m\u1ed9t ho\u1eb7c nhi\u1ec1u t\u00e1c nh\u00e2n b\u1ed5 sung m\u00e0 m\u1ea7m b\u1ec7nh hi\u1ec3n th\u1ecb MIC nh\u1ea1y c\u1ea3m ( Khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t ).<\/p>\n
– Khuy\u1ebfn c\u00e1o 32: N\u1ebfu kh\u00f4ng c\u00f3 t\u00e1c nh\u00e2n ho\u1ea1t \u0111\u1ed9ng th\u1ee9 hai m\u00e0 CRPA nhi\u1ec5m hi\u1ec3n th\u1ecb MIC nh\u1ea1y c\u1ea3m, ch\u00fang t\u00f4i khuy\u00ean n\u00ean s\u1eed d\u1ee5ng polymyxin B v\u00e0 colistin k\u1ebft h\u1ee3p v\u1edbi t\u00e1c nh\u00e2n kh\u00f4ng nhi\u1ec5m khu\u1ea9n th\u1ee9 hai v\u00e0\/ ho\u1eb7c th\u1ee9 ba (v\u00ed d\u1ee5: carbapenem). N\u00ean \u01b0u ti\u00ean cho m\u1ed9t t\u00e1c nh\u00e2n kh\u00f4ng nh\u1ea1y c\u1ea3m v\u1edbi MIC th\u1ea5p nh\u1ea5t so v\u1edbi \u0111i\u1ec3m d\u1eebng nh\u1ea1y c\u1ea3m t\u01b0\u01a1ng \u1ee9ng ( khuy\u1ebfn c\u00e1o th\u1ef1c h\u00e0nh t\u1ed1t nh\u1ea5t )<\/p>\n
C\u00e2u h\u1ecfi 19: Polymyxin kh\u00ed dung n\u00ean \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh cho b\u1ec7nh nh\u00e2n m\u1eafc HAP \/ VAP, (vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n, vi\u00eam ph\u1ed5i th\u1edf m\u00e1y ) v\u00e0 n\u1ebfu v\u1eady, t\u00e1c nh\u00e2n n\u00e0o \u0111\u01b0\u1ee3c \u01b0a th\u00edch?<\/p>\n
– Khuy\u1ebfn c\u00e1o 33: Ch\u00fang t\u00f4i khuy\u00ean nh\u1eefng b\u1ec7nh nh\u00e2n c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng polymyxin IV v\u00ec nhi\u1ec5m vi khu\u1eabn XDR gram \u00e2m trong HAP hay VAP n\u00ean \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3 b\u1eb1ng li\u1ec7u ph\u00e1p kh\u00ed dung polymyxin ( khuy\u1ebfn c\u00e1o y\u1ebfu, b\u1eb1ng ch\u1ee9ng th\u1ea5p ).<\/p>\n
– Khuy\u1ebfn c\u00e1o 34: Ch\u00fang t\u00f4i khuy\u00ean \u0111\u1ed1i v\u1edbi li\u1ec7u ph\u00e1p kh\u00ed dung polymyxin, colistin ho\u1eb7c polymyxin B \u0111\u1ec1u ph\u00f9 h\u1ee3p<\/p>\n
C\u00e2u h\u1ecfi 20 : C\u00f3 xem x\u00e9t vi\u1ec7c ti\u00eam Polymyxin ti\u00eam trong n\u00e3o th\u1ea5t, Intraventricular (IVT) or ti\u00eam t\u1ee7y s\u1ed1ng, intrathecal (ITH) trong vi\u00eam m\u00e0ng n\u00e3o hay vi\u00eam n\u00e3o th\u1ea5t v\u1edbi c\u00e1c t\u00e1c nh\u00e2n gram \u00e2m \u0111a kh\u00e1ng ?<\/p>\n
– Khuy\u1ebfn c\u00e1o 35: S\u1eed d\u1ee5ng polymyxin ti\u00eam n\u00e3o th\u1ea5t (IVT) ho\u1eb7c ti\u00eam t\u1ee7y s\u1ed1ng (ITH) v\u1edbi li\u1ec1u 125.000 IU CMS (~ 4,1 mg CBA) ho\u1eb7c polymyxin B 5 mg (50.000 IU) m\u1ed7i ng\u00e0y khi b\u1ecb vi\u00eam m\u00e0ng n\u00e3o do vi khu\u1ea9n \u0111a kh\u00e1ng hay to\u00e0n kh\u00e1ng MDR v\u00e0 \u200b\u200bXDR gram \u00e2m.<\/p>\n
– Khuy\u1ebfn c\u00e1o 36: Do kinh nghi\u1ec7m h\u1ea1n ch\u1ebf v\u1edbi polymyxin B, CMS l\u00e0 polymyxin \u0111\u01b0\u1ee3c \u01b0a th\u00edch \u0111\u1ec3 ti\u00eam t\u1ee7y s\u1ed1ng ho\u1eb7c ti\u00eam trong n\u00e3o th\u1ea5t .<\/p>\n