{"id":26587,"date":"2023-04-23T21:38:51","date_gmt":"2023-04-23T14:38:51","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=26587"},"modified":"2023-04-23T21:38:51","modified_gmt":"2023-04-23T14:38:51","slug":"vancomycin-trong-thuc-hanh-lam-sang","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/23\/vancomycin-trong-thuc-hanh-lam-sang\/","title":{"rendered":"Vancomycin trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng"},"content":{"rendered":"

Vancomycin \u0111\u01b0\u1ee3c ph\u00e2n l\u1eadp l\u1ea7n \u0111\u1ea7u ti\u00ean n\u0103m 1953 t\u1eeb vi khu\u1ea9n Amycolatopsis<\/strong> orientalis (danh ph\u00e1p c\u0169 l\u00e0 Streptomyces orientalis v\u00e0 Nocardia orientalis) trong<\/strong> \u0111\u1ea5t thu\u1ed9c \u0111\u1ea3o Borneo \u1edf \u0110\u00f4ng Nam \u00c1<\/strong><\/p>\n

1. L\u1ecbch s\u1eed h\u00ecnh th\u00e0nh<\/h2>\n

Vancomycin \u0111\u01b0\u1ee3c ph\u00e2n l\u1eadp l\u1ea7n \u0111\u1ea7u ti\u00ean n\u0103m 1953 t\u1eeb vi khu\u1ea9n Amycolatopsis orientalis (danh ph\u00e1p c\u0169 l\u00e0 Streptomyces orientalis v\u00e0 Nocardia orientalis) trong \u0111\u1ea5t thu\u1ed9c \u0111\u1ea3o Borneo \u1edf \u0110\u00f4ng Nam \u00c1. Ch\u00ednh b\u1edfi kh\u1ea3 n\u0103ng kh\u1ed1ng ch\u1ebf t\u1ee5 c\u1ea7u qua nhi\u1ec1u l\u1ea7n c\u1ea5y chuy\u1ec3n m\u00e0 v\u1eabn kh\u00f4ng ph\u00e1t sinh \u0111\u1ec1 kh\u00e1ng n\u00ean thu\u1ed1c \u0111\u01b0\u1ee3c g\u1ecdi t\u00ean l\u00e0 vancomycin d\u1ef1a theo t\u1eeb \u201cvanquish\u201d (chinh ph\u1ee5c).
\nBan \u0111\u1ea7u d\u1ea1ng ch\u1ebf ph\u1ea9m thu\u1ed1c ch\u01b0a tinh khi\u1ebft c\u00f3 m\u00e0u n\u00e2u \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 \u201cb\u00f9n Mississippi\u201d s\u1eed d\u1ee5ng g\u00e2y \u0111\u1ed9c cho tai trong v\u00e0 th\u1eadn n\u00ean ch\u1ec9 \u0111\u01b0\u1ee3c d\u00f9ng \u0111\u1ebfn nh\u01b0 gi\u1ea3i ph\u00e1p cu\u1ed1i c\u00f9ng. Tuy nhi\u00ean d\u1ea1ng ch\u1ebf ph\u1ea9m vancomycin hydrochloride hi\u1ec7n nay c\u00f3 \u0111\u1ed9 tinh khi\u1ebft tr\u00ean 92% s\u1eed d\u1ee5ng an to\u00e0n h\u01a1n.
\nV\u1edbi th\u00e0nh ph\u1ea7n carbohydrate v\u00e0 peptid, vancomycin \u0111\u01b0\u1ee3c x\u1ebfp v\u00e0o nh\u00f3m kh\u00e1ng sinh glycopeptid. B\u00ean c\u1ea1nh t\u00e1c d\u1ee5ng v\u01b0\u1ee3t tr\u1ed9i kh\u1ed1ng ch\u1ebf t\u1ee5 c\u1ea7u kh\u00e1ng methicillin, vancomycin c\u00f2n \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u01b0\u1eddng u\u1ed1ng \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb vi\u00eam \u0111\u1ea1i tr\u00e0ng do Clostridium Difficile<\/p>\n

2.D\u01b0\u1ee3c l\u1ef1c h\u1ecdc v\u00e0 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc<\/h2>\n

Ngo\u1ea1i tr\u1eeb m\u1ed9t s\u1ed1 vi khu\u1ea9n Neisseria, nh\u00ecn chung vancomycin kh\u00f4ng c\u00f3 t\u00e1c d\u1ee5ng v\u1edbi vi khu\u1ea9n Gram \u00e2m m\u00e0 ch\u1ec9 ti\u00eau di\u1ec7t \u0111\u01b0\u1ee3c vi khu\u1ea9n Gram d\u01b0\u01a1ng. Ph\u1ed5 t\u00e1c d\u1ee5ng c\u1ee7a vancomycin ch\u1ee7 y\u1ebfu l\u00e0 c\u00e1c lo\u1ea1i t\u1ee5 c\u1ea7u, li\u00ean c\u1ea7u, Enterococcus faecalis v\u00e0 Clostridium sp. C\u01a1 ch\u1ebf t\u00e1c d\u1ee5ng c\u1ee7a vancomycin l\u00e0 g\u1eafn v\u00e0o D-alanyl-D-alanine c\u1ee7a peptid tham gia t\u1ed5ng h\u1ee3p v\u00e1ch vi khu\u1ea9n, qua \u0111\u00f3 \u1ee9c ch\u1ebf t\u1ed5ng h\u1ee3p v\u00e1ch vi khu\u1ea9n.
\nThu\u1ed1c h\u1ea5p thu k\u00e9m qua \u0111\u01b0\u1eddng u\u1ed1ng n\u00ean khi d\u00f9ng \u0111\u01b0\u1eddng u\u1ed1ng ch\u1ec9 nh\u1eb1m m\u1ee5c \u0111\u00edch ti\u00eau di\u1ec7t vi khu\u1ea9n trong l\u00f2ng \u1ed1ng ti\u00eau h\u00f3a. N\u1ed3ng \u0111\u1ed9 \u0111\u1ec9nh huy\u1ebft thanh \u0111\u1ea1t \u0111\u01b0\u1ee3c ngay sau khi truy\u1ec1n t\u0129nh m\u1ea1ch xong. Thu\u1ed1c ph\u00e2n b\u1ed1 r\u1ed9ng r\u00e3i trong c\u00e1c m\u00f4 v\u00e0 d\u1ecbch c\u01a1 th\u1ec3, ngo\u1ea1i tr\u1eeb d\u1ecbch n\u00e3o t\u1ee7y. Khi m\u00e0ng n\u00e3o vi\u00eam, t\u1ef7 s\u1ed1 khu\u1ebfch t\u00e1n t\u1eeb m\u00e1u v\u00e0o d\u1ecbch n\u00e3o t\u1ee7y t\u01b0\u01a1ng \u0111\u1ed1i t\u1ed1t, n\u1ed3ng \u0111\u1ed9 trong d\u1ecbch n\u00e3o t\u1ee7y khi \u0111\u00f3 th\u01b0\u1eddng cao h\u01a1n n\u1ed3ng \u0111\u1ed9 \u1ee9c ch\u1ebf t\u1ed1i thi\u1ec3u (MIC). Thu\u1ed1c g\u1eafn protein \u1edf m\u1ee9c \u0111\u1ed9 trung b\u00ecnh (55%).
\nTh\u1eddi gian b\u00e1n th\u1ea3i l\u00e0 4-6h, k\u00e9o d\u00e0i \u0111\u00e1ng k\u1ec3 khi suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn. \u1ede suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i, th\u1eddi gian n\u00e0y l\u00e0 7,5 ng\u00e0y. \u1ede tr\u1ebb s\u01a1 sinh, th\u1eddi gian b\u00e1n th\u1ea3i l\u00e0 6-10h c\u00f2n \u1edf tr\u1ebb nh\u1ecf th\u1eddi gian n\u00e0y l\u00e0 2-4h.
\nThu\u1ed1c th\u1ea3i tr\u1eeb ch\u1ee7 y\u1ebfu qua l\u1ecdc c\u1ea7u th\u1eadn, trong n\u01b0\u1edbc ti\u1ec3u c\u00f3 t\u1edbi 75% thu\u1ed1c \u1edf d\u1ea1ng ch\u01b0a bi\u1ebfn \u0111\u1ed5i trong 24h \u0111\u1ea7u. \u1ede ng\u01b0\u1eddi cao tu\u1ed5i, \u0111\u1ed9 thanh th\u1ea3i thu\u1ed1c gi\u1ea3m.<\/p>\n

\"Vancomycin\"<\/p>\n

C\u1ea5u tr\u00fac h\u00f3a h\u1ecdc Vancomycin<\/strong><\/p>\n

3. Ch\u1ec9 \u0111\u1ecbnh, ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh, li\u1ec1u d\u00f9ng, c\u00e1ch d\u00f9ng<\/h2>\n

C\u1ea7n ki\u1ec3m tra n\u1ed3ng \u0111\u1ed9 \u1ee9c ch\u1ebf t\u1ed1i thi\u1ec3u (MIC) c\u1ee7a vancomycin \u0111\u1ed1i v\u1edbi ch\u1ee7ng t\u1ee5 c\u1ea7u ph\u00e2n l\u1eadp \u0111\u01b0\u1ee3c. N\u1ebfu MIC \u2265 4 \u03bcg\/mL th\u00ec c\u1ea7n chuy\u1ec3n sang l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb kh\u00e1c. Xem x\u00e9t l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb thay th\u1ebf khi MIC > 1 \u03bcg\/mL. N\u1ebfu k\u1ebft qu\u1ea3 c\u1ea5y m\u00e1u sau 2- 3 ng\u00e0y \u0111i\u1ec1u tr\u1ecb v\u1eabn d\u01b0\u01a1ng t\u00ednh k\u00e8m theo b\u1eb1ng ch\u1ee9ng l\u00e2m s\u00e0ng c\u1ee7a nhi\u1ec5m tr\u00f9ng ti\u1ebfn tri\u1ec3n, cho d\u00f9 MIC l\u00e0 bao nhi\u00eau th\u00ec c\u0169ng v\u1eabn ph\u1ea3i coi nh\u01b0 th\u1ea5t b\u1ea1i \u0111i\u1ec1u tr\u1ecb vancomycin. Li\u1ec1u t\u1ea3i ban \u0111\u1ea7u \u0111\u01b0\u1ee3c t\u00ednh theo c\u00e2n n\u1eb7ng th\u1ef1c t\u1ebf c\u1ee7a b\u1ec7nh nh\u00e2n. Li\u1ec1u d\u00f9ng ti\u1ebfp theo c\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y trong huy\u1ebft thanh 10-15 \u03bcg\/mL (\u0111\u1ed1i v\u1edbi li\u00ean c\u1ea7u) ho\u1eb7c 15-20 \u03bcg\/mL (tr\u01b0\u1eddng h\u1ee3p t\u1ee5 c\u1ea7u). N\u1ebfu li\u1ec1u d\u00f9ng tr\u00ean 1g th\u00ec th\u1eddi gian truy\u1ec1n t\u0129nh m\u1ea1ch t\u1eeb 1,5-2h. VNTMNK do Enterococcus (ch\u1ee7ng kh\u00e1ng penicillin ho\u1eb7c b\u1ec7nh nh\u00e2n kh\u00f4ng th\u1ec3 d\u00f9ng \u0111\u01b0\u1ee3c beta-lactam): 15 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2 g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 12h k\u1ebft h\u1ee3p v\u1edbi gentamicin trong 6 tu\u1ea7n. C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y 15-20 \u03bcg\/mL. VNTMNK do t\u1ee5 c\u1ea7u v\u00e0ng kh\u00e1ng methicillin ho\u1eb7c nh\u1ea1y methicillin nh\u01b0ng kh\u00f4ng s\u1eed d\u1ee5ng \u0111\u01b0\u1ee3c beta-lactam: 15 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2 g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 12h, ho\u1eb7c 15-20 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2 g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 8-12h, \u0111i\u1ec1u tr\u1ecb trong 6 tu\u1ea7n. C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y 15-20 \u03bcg\/mL. Tr\u01b0\u1eddng h\u1ee3p van nh\u00e2n t\u1ea1o c\u1ea7n k\u1ebft h\u1ee3p v\u1edbi rifampicin v\u00e0 \u0111i\u1ec1u tr\u1ecb \u00edt nh\u1ea5t 6 tu\u1ea7n, b\u00ean c\u1ea1nh \u0111\u00f3 \u0111\u00f3 k\u1ebft h\u1ee3p v\u1edbi gentamicin trong 2 tu\u1ea7n \u0111\u1ea7u.
\nVNTMNK do li\u00ean c\u1ea7u nh\u00f3m viridans v\u00e0 S. bovis kh\u00f4ng dung n\u1ea1p v\u1edbi penicillin ho\u1eb7c ceftriaxon: 15 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2 g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 12h. Th\u1eddi gian \u0111i\u1ec1u tr\u1ecb l\u00e0 4 tu\u1ea7n \u0111\u1ed1i v\u1edbi van t\u1ef1 nhi\u00ean ho\u1eb7c 6 tu\u1ea7n \u0111\u1ed1i v\u1edbi van nh\u00e2n t\u1ea1o. C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y 15-20 \u03bcg\/mL.
\n\u0110i\u1ec1u tr\u1ecb theo kinh nghi\u1ec7m VNTMNK tr\u00ean van t\u1ef1 nhi\u00ean: 15-20 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 8-12h, k\u1ebft h\u1ee3p v\u1edbi ceftriaxon ho\u1eb7c gentamicin. C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y 15-20 \u03bcg\/mL.
\n\u0110i\u1ec1u tr\u1ecb theo kinh nghi\u1ec7m VNTMNK tr\u00ean van nh\u00e2n t\u1ea1o: 15-20 mg\/kg (li\u1ec1u t\u1ed1i \u0111a 2g) truy\u1ec1n t\u0129nh m\u1ea1ch c\u00e1ch 8-12h, k\u1ebft h\u1ee3p v\u1edbi gentamicin v\u00e0 rifampicin. C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y 15-20 \u03bcg\/mL.<\/p>\n

\u0110i\u1ec1u ch\u1ec9nh li\u1ec1u d\u00f9ng khi suy th\u1eadn:<\/p>\n

    \n
  • M\u1ee9c l\u1ecdc c\u1ea7u th\u1eadn > 90 mL\/ph\u00fat: kh\u00f4ng c\u1ea7n \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u<\/li>\n
  • M\u1ee9c l\u1ecdc c\u1ea7u th\u1eadn 50-90 mL\/ph\u00fat: gi\u00e3n kho\u1ea3ng c\u00e1ch li\u1ec1u m\u1ed7i 12h.<\/li>\n
  • M\u1ee9c l\u1ecdc c\u1ea7u th\u1eadn 15-49 mL\/ph\u00fat: gi\u00e3n kho\u1ea3ng c\u00e1ch li\u1ec1u m\u1ed7i 24h.<\/li>\n
  • M\u1ee9c l\u1ecdc c\u1ea7u th\u1eadn < 15 mL\/ph\u00fat: cho li\u1ec1u t\u1ea3i, sau \u0111\u00f3 theo d\u00f5i n\u1ed3ng \u0111\u1ed9 huy\u1ebft thanh \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u ti\u1ebfp theo. N\u1ebfu n\u1ed3ng \u0111\u1ed9 \u2264 20 \u03bcg\/mL th\u00ec d\u00f9ng li\u1ec1u k\u1ebf ti\u1ebfp, n\u1ebfu \u0111\u00e3 v\u01b0\u1ee3t 20 \u03bcg\/mL th\u00ec t\u1ea1m ng\u1eebng li\u1ec1u k\u1ebf ti\u1ebfp v\u00e0 ti\u1ebfp t\u1ee5c theo d\u00f5i n\u1ed3ng \u0111\u1ed9 huy\u1ebft thanh sau 12h.<\/li>\n<\/ul>\n

    4. T\u00e1c d\u1ee5ng ph\u1ee5 v\u00e0 x\u1eed tr\u00ed<\/h2>\n

    T\u1ed1t nh\u1ea5t n\u00ean tr\u00e1nh d\u00f9ng c\u00f9ng c\u00e1c thu\u1ed1c \u0111\u1ed9c v\u1edbi th\u1eadn. N\u1ebfu b\u1eaft bu\u1ed9c ph\u1ea3i s\u1eed d\u1ee5ng \u0111\u1ed3ng th\u1eddi c\u00e1c thu\u1ed1c \u0111\u1ed9c v\u1edbi th\u1eadn th\u00ec c\u1ea7n l\u01b0u \u00fd th\u01b0\u1eddng xuy\u00ean theo d\u00f5i ch\u1ee9c n\u0103ng th\u1eadn. Trong c\u00e1c k\u1ebft h\u1ee3p kh\u00e1ng sinh l\u01b0u \u00fd k\u1ebft h\u1ee3p v\u1edbi piperacillin\/tazobactam c\u00f3
    \nnguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p t\u00ednh cao h\u01a1n.
    \nH\u1ed9i ch\u1ee9ng \u0111\u1ecf ng\u01b0\u1eddi th\u01b0\u1eddng xu\u1ea5t hi\u1ec7n khi truy\u1ec1n vancomycin qu\u00e1 nhanh. N\u1ebfu li\u1ec1u d\u00f9ng tr\u00ean 1g th\u00ec th\u1eddi gian truy\u1ec1n t\u0129nh m\u1ea1ch t\u1eeb 1,5-2h.
    \nH\u1ed9i ch\u1ee9ng DRESS<\/strong> (drug reaction with eosinophilia and systemic signs\/symptoms) c\u00f3 bi\u1ec3u hi\u1ec7n t\u01b0\u01a1ng t\u1ef1 h\u1ed9i ch\u1ee9ng Stevens-Johnson nh\u01b0ng kh\u00f4ng t\u1ed5n th\u01b0\u01a1ng ni\u00eam m\u1ea1c. So v\u1edbi c\u00e1c kh\u00e1ng sinh kh\u00e1c c\u0169ng g\u00e2y t\u0103ng b\u1ea1ch c\u1ea7u \u00e1i toan, ri\u00eang vancomycin c\u00f3 nguy c\u01a1 cao g\u00e2y th\u00eam t\u1ed5n th\u01b0\u01a1ng da, th\u1eadn v\u00e0 gan. Nh\u1eefng ng\u01b0\u1eddi c\u00f3 HLA-A*32:01 t\u0103ng nguy c\u01a1 b\u1ecb h\u1ed9i ch\u1ee9ng DRESS sau d\u00f9ng vancomycin tr\u00ean 2 tu\u1ea7n.
    \nC\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5 hay g\u1eb7p kh\u00e1c bao g\u1ed3m s\u1ed1t, vi\u00eam da b\u1ecdng n\u01b0\u1edbc IgA, gi\u1ea3m b\u1ea1ch c\u1ea7u trung t\u00ednh, gi\u1ea3m ti\u1ec3u c\u1ea7u, gi\u1ea3m th\u00ednh l\u1ef1c. Nguy c\u01a1 gi\u1ea3m ti\u1ec3u c\u1ea7u v\u00e0 gi\u1ea3m th\u00ednh l\u1ef1c c\u00f3 l\u1ebd li\u00ean quan \u0111\u1ebfn n\u1ed3ng \u0111\u1ed9 \u0111\u00e1y cao k\u00e9o d\u00e0i.<\/p>\n","protected":false},"excerpt":{"rendered":"

    Vancomycin \u0111\u01b0\u1ee3c ph\u00e2n l\u1eadp l\u1ea7n \u0111\u1ea7u ti\u00ean n\u0103m 1953 t\u1eeb vi khu\u1ea9n Amycolatopsis orientalis (danh ph\u00e1p c\u0169 l\u00e0 Streptomyces orientalis v\u00e0 Nocardia orientalis) trong \u0111\u1ea5t thu\u1ed9c \u0111\u1ea3o Borneo \u1edf \u0110\u00f4ng Nam \u00c1 1. L\u1ecbch s\u1eed h\u00ecnh th\u00e0nh Vancomycin \u0111\u01b0\u1ee3c ph\u00e2n l\u1eadp l\u1ea7n \u0111\u1ea7u ti\u00ean n\u0103m 1953 t\u1eeb vi khu\u1ea9n Amycolatopsis orientalis (danh ph\u00e1p c\u0169 l\u00e0 […]<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[12,33],"tags":[],"yoast_head":"\nVancomycin trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng<\/title>\n<meta name=\"description\" content=\"Vancomycin trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng l\u00e0 kh\u00e1ng sinh th\u01b0\u1eddng \u0111\u01b0\u1ee3c d\u00f9ng. 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