B Y T TRNG I HC DC H NI LY LEAB KHO ST TNH HNH S DNG KHNG SINH TI BNH VIN VIT NAM THY IN UNG B KHA LUN TT NGHIP DC S H NI - 2014 B Y T TRNG I HC DC H NI LY LEAB KHO ST TNH HNH S DNG KHNG SINH TI BNH VIN VIT NAM THY IN UNG B KHA LUN TT NGHIP DC S (2009 2014) Ngi hng dn: 1.TS. Nguyn Thnh Hi 2.TS. Nguyn Quang Lng Ni thc hin: 1.B mn Dc Lm Sng2.BnhvinVitNamThyin Ung B H NI - 2014 LI CM N Trc tin, em xin by t lng bit n chn thnh v su sc ti: 1. TS. Nguyn Thnh Hi BM Dc Lm Sng, trng H Dc H Ni. 2.TS. Nguyn Quang Lng Bnh vin Vit Nam Thy in Ung B. l nhng ngi thy trc tip hng dn, ch bo tn tnh v gip em trong sut qu trnh lm kha lun ny. EmxinbytlngbitnsuscnThS.ngThXunPhng;DS. Trn Th nh v cc thy c gio B mn Dc lm sng, trng i hc Dc H Ni gip sa cha v hon thin kha lun, v truyn t cho em nhng kin thc b ch trong thi gian hc tp ti Vit Nam. Em xin gi li cm n chn thnh ti: Ban gim hiu, Phng o to trng i hc Dc H Ni v cc cn b Phng k hoch tng hp bnh vin Vit Nam Thy in Ung B nhit tnh gip v to mi iu kin cho em trong qu trnh thc hin ti. Em xin gi li cm n chn thnh nht ti chnh ph Vit Nam cung cp hcbngvtomiiukinrtthunlichoisngcaemtrongsutqu trnh hc tp 6 nm y. Cui cng, em xin gi li cm n su sc ti gia nh v bn b lun bn cnh, ng vin gip em trong sut qu trnh hc tp v thc hin kha lun ny. H Ni, ngy 13 thng 5 nm 2014. Sinh vin LYLEAB MC LC DANH MC CC CH VIT TT DANH MC CC BNG DANH MC CC HNH, S T VN ............................................................................................................ 1 CHNG 1. TNG QUAN ...................................................................................... 3 1.1. I CNG V KHNG SINH ................................................................... 3 1.1.1. Lch s ra i v nh ngha ca khng sinh ................................................ 3 1.1.2. Phn loi khng sinh ................................................................................... 3 1.1.3. S khng khng sinh ca vi khun .......................................................... 6 1.1.4. Chng trnh qun l khng sinh ................................................................. 8 1.1.5. Nguyn tc s dng khng sinh ................................................................... 9 1.1.6. Mt s iu cn lu khi dng khng sinh................................................ 12 1.2.GIITHIUCHUNGVBNHVINVITNAMTHYIN UNG B. .............................................................................................. 14 1.2.1. S t chc bnh vin Vit Nam Thy in Ung B ......................... 14 1.2.2. Quy m bnh vin ..................................................................................... 14 1.2.3. Hng dn iu tr ti bnh vin ............................................................... 15 CHNG 2. I TNG V PHNG PHP NGHIN CU ...................... 16 2.1. I TNG NGHIN CU ....................................................................... 16 2.1.1. Tiu chun la chn .................................................................................. 16 2.1.2. Tiu chun loi tr .................................................................................... 16 2.2. PHNG PHP NGHIN CU ................................................................. 16 2.2.1. Thit k nghin cu ................................................................................... 16 2.2.2. Phng php chn mu ............................................................................. 16 2.2.3. Phng php thu thp thng tin ................................................................. 17 2.3. NI DUNG NGHIN CU .......................................................................... 17 2.3.1.Kho stcimcamunghincutibnhvinVitNamThy in Ung B ...................................................................................................... 17 2.3.2. Khost thc trng s dng khng sinhtibnhvinVit Nam Thy in Ung B ...................................................................................................... 17 2.4. PHNG PHP X L S LIU ............................................................. 18 CHNG 3. KT QU NGHIN CU ............................................................... 19 3.1. MT S C IM CA MU NGHIN CU ...................................... 19 3.1.1. c im v tui v gii tnh..................................................................... 19 3.1.2. c im v chc nng thn ...................................................................... 20 3.1.3. Phn loi ICD chn on khi ra vin ......................................................... 20 3.1.4. c im s bnh mc km ca mu nghin cu ....................................... 22 3.1.5. c im cc bnh nhim khun ca mu nghin cu ............................... 22 3.1.6. c im cc vi khun phn lp c trong mu nghin cu .................... 23 3.2.KHOSTTHCTRNGSDNGKHNGSINHTIBNH VIN NAM THY IN UNG B ............................................................... 24 3.2.1. T l v s lng cc khng sinh v nhm khng sinh c s dng ........ 24 3.2.2. Mt s ch tiu v thc trng s dng khng sinh ti bnh vin Vit Nam Thy in Ung B .......................................................................................... 25 3.2.3. c im s dng khng sinh theo mc ch s dng ................................ 27 3.2.4. c im phc khng sinh trong iu tr ............................................... 29 3.2.5. c im thay i phc khng sinh ...................................................... 32 3.2.6.Ccbincbtlighinhnctrnbnhnhniutrbngkhng sinh ..................................................................................................................... 33 3.2.7. Thi gian dng khng sinh v thi gian nm vin ...................................... 34 3.2.8. Kt qu iu tr lc ra vin ........................................................................ 34 CHNG 4. BN LUN ....................................................................................... 36 4.1. C IM CHUNG CA MU NGHIN CU ....................................... 36 4.1.1. c im v tui v gii tnh..................................................................... 36 4.1.2. c im v chc nng thn ...................................................................... 36 4.1.3. c im vi khun phn lp c trong mu nghin cu .......................... 36 4.2.THCTRNGSDNGKHNGSINHTIBNHVINVIT NAM THY IN UNG B .......................................................................... 37 4.2.1. Khng sinh v nhm khng sinh c s dng nhiu trong bnh vin ....... 37 4.2.2. ng dng khng sinh ............................................................................ 37 4.2.3. Khng sinh d phng ................................................................................ 38 4.2.4. Phc khng sinh n c v phi hp ................................................... 38 4.2.5. Kt qu iu tr lc ra vin ........................................................................ 39 4.3. HN CH CA NGHIN CU .................................................................. 39 KT LUN V XUT ..................................................................................... 41 TI LIU THAM KHO PH LC DANH MC CC CH VIT TT BA BV C1G C2G : : : : Bnh n Bnh vin Cephalosporin th h 1 Cephalosporin th h 2 C3G DH :: Cephalosporin th h 3 Dc ng hc ICD:Phn loi bnh tt quc t (International Classification of Diseases) KS:Khng sinhNK SD STT : : :Nhim khun lch chun S th t TB:Trung bnh VK VSV : : Vi khun Vi sinh vt DANH MC CC BNG Bng 1.1. Phn loi KS da vo tnh nhy cm ca VK ............................................... 5 Bng 1.2. Kh nng thm u tin ca mt s KS vo cc c quan v t chc ............ 10 Bng 3.1. Phn b bnh nhn theo tui v gii tnh .............................................. 19 Bng 3.2. Chc nng thn ca bnh nhn theo h s thanh thi creatinin ................. 20 Bng 3.3. c im chn on chnh ca bnh nhn khi ra vin ............................... 20 Bng 3.4. c im s bnh mc km ca mu nghin cu ....................................... 22 Bng 3.5. c im chn on nhim khun ca mu nghin cu ............................. 22 Bng 3.6. Danh mc cc vi khun phn lp c trong mu nghin cu ................... 23 Bng 3.7. T l v s lng cc KS v nhm KS c s dng .................................. 24 Bng 3.8. S lng KS ng ung v ng tim trong mt BA .............................. 26 Bng 3.9. T l ng dng khng sinh ..................................................................... 26 Bng 3.10. Phn loi BN theo mc ch s dng KS .................................................. 27 Bng 3.11. c im bnh nhn s dng khng sinh trong iu tr ........................... 28 Bng 3.12. c im BN s dng KS d phng NK trong phu thut ........................ 28 Bng 3.13. Phn b cc phc khng sinh n c v phi hp ............................. 29 Bng 3.14. Phn b cc phc khng sinh n c ................................................ 30 Bng 3.15. Phn b cc phc khng sinh phi hp ............................................... 31 Bng 3.16. T l bnh nhn c thay i phc khng sinh ...................................... 32 Bng 3.17. L do thay i phc khng sinh ........................................................... 33 Bng 3.18. Thi gian dng khng sinh v thi gian nm vin trung bnh ................... 34 Bng 3.19. Kt qu iu tr lc ra vin ...................................................................... 34 DANH MC CC HNH, S Hnh 1.1. S t chc bnh vin Vit Nam Thy in Ung B .......................... ..14 Hnh 3.1. Biu phn b cc nhm khng sinh c s dng trong iu tr .......... ..25 Hnh 3.2. Biu phn b BN s dng KS d phng NK trong phu thut ............... .29 Hnh 3.3. Biu cc bin c bt li ghi nhn trn bnh nhn s dng khng sinh .. .33 1 T VN Khng sinh l mt trong nhng loi thuc c dng ph bin trong lm sng vi vai tr hu ch trong iu tr cc bnh l nhim khun. Cho n nay, khng sinh l mt loi thuc c s dng nhiu nht v cng l thuc b lm dng nhiu nht trn lm sng. Hu qu khng th trnh khi ca vic lm dng ny chnh l s lan trn cc vi khun khng thuc.Khosttnhhnhsdngkhngsinhticccschmscsckhelmt trong cc gii php gp phn a ra cc xut gip cho vic s dng khng sinh an ton hn, hp l hn, nng cao hiu qu v rt ngn thi gian iu tr.Bnh vin Vit Nam Thy in Ung B do chnh ph v nhn dn Vng quc Thy in gip xy dng ti thnh ph Ung B, tnh Qung Ninh v a vo hot ngtnm1981.Lmtbnhvinakhoathuctuyntrungnghng1,trc thuc B y t, hin nay bnh vin c 34 khoa phng v 850 ging bnh, p ng nhu cu khm, cha bnh v chm sc sc khe cho nhn dn tnh Qung Ninh v cc khu vc ln cn. Cc cng tc tp hun s dng thuc an ton, hp l, c bit l s dng cc khng sinh theo ng cc hng dn s dng thuc ca Bnh vin hoc ca B y tluncBangimc,hingthucviutrcaBnhvinquantmv hng ng tch cc. Tuy nhin, trn thc t hu ht cc nghin cu v kho st tnh hnh s dng khng sinhctinhnhphnlnmtsbnhvinnhbnhvinBchMai,bnh vin Vit c, bnh vin Hu Ngh Trong khi , nghin cu kho st tnh hnh s dngkhngsinhtibnhvinVitNamThyinUngBvnchacthc hintrongnhngnmgny.Chnhvvy,chngtitinhnhthchinti: KhosttnhhnhsdngkhngsinhtibnhvinVitNamThyin Ung B vi hai mc tiu sau: 2 1.KhostcimcamunghincutibnhvinVitNamThyin Ung B. 2.KhostthctrngsdngkhngsinhtibnhvinVitNamThyin Ung B. Trncs,aracnhngxutnhmgpphnnngcaotnhan ton, hiu qu trong vic s dng khng sinh ti Bnh vin Vit Nam Thy in Ung B. 3 CHNG 1. TNG QUAN 1.1. I CNG V KHNG SINH 1.1.1.Lch s ra i v nh ngha ca khng sinh 1.1.1.1.Vi nt v lch s ra i ca khng sinh Nm 1877, Pasteur v Joubert pht hin mt s loi nm mc ckh nng sn sinh ra cc cht dit c vi khun. Tuy nhin, cc cht ny li c hi vi con ngi nnkhngcsdngtronglmsng.Mcdvy,phthinnygimmt hng nghin cu mi da trn nm mc to ra cc cht c hot tnh khng khun [13]. Nm1929,AlexanderFlemingphthinrakhnngkhngkhuncanm Penicilliumnotatum,muchonghincuvsdngkhngsinh.Nm1938, Florey v Chain thc nghim penicilin trong iu tri. Nm 1942, Waksman pht hin ra streptomycin v c gii Nobel [5]. Nm1962,GeorgeLeshervcngscngbacidnalidixic,dnchtutin cchngminhcgitrsdngtronglmsngnhmtthuckhngsinh.Nm 1964,acidnalidixiccphduyttiAnhchoiutrnhimkhuntitniunh cha c bin chng [13]. 1.1.1.2.nh ngha Khng sinh l cht ly t vi sinh vt (nm hoc vi nm) c tc dng chng vi khun v c chit xut t nhin, tng hp hoc bn tng hp ha hc [3], [4], [7]. 1.1.2. Phn loi khng sinh 1.1.2.1.Theo cu trc ha hc Chia khng sinh thnh cc nhm chnh nh sau: -Nhm lactam: + Penicilin: benzylpenicilin, oxacilin, ampicilin 4 + Cephalosporin: cephalexin, cefaclor, cefotaxim + Cc beta-lactam khc: carbapenem, monobactam, cht c ch lactamase.- Nhm aminoglycosid (aminosid): streptomycin, gentamincin, tobramycin -Nhm macrolid: erythromycin, clarithromycin, spiramycin -Nhm lincosamid: lincomycin, clindamycin. -Nhm phenicol: cloramphenicol, thiamphenicol. -Nhm tetracyclin: tetracyclin, doxycyclin -Nhm peptid: + Glucopeptid: vancomycin. + Polypeptid: polymycin, bacitracin. -Nhm quinolon: acid nalidixic, ciprofloxacin, ofloxacin -Nhm co-trimoxazol: co trimoxazol [4]. 1.1.2.2.Da vo tnh nhy cm ca vi khun vi khng sinh Tnhnhycmcakhngsinhcxcnhdavonngcchtithiu (MIC) v nng dit khun ti thiu (MBC): -Nngcchtithiu(MICMinimalInhibitoryConcentration)camt khng sinh l nng thp nht m khng sinh c kh nng c ch s pht trin ca vi khun sau khong 24 gi nui cy. -Nngditkhuntithiu(MBCMinimalBactericidalConcentration)l nng thp nht lm gim 99,9% lng vi khun. Davotnhnhycmcavikhunvikhngsinh,ngitachiakhngsinh thnh2nhmchnh:Khngsinhkmkhunvkhngsinhditkhun[3],[4],[33] (Bng 1.1.). 5 Bng 1.1. Phn loi KS da vo tnh nhy cm ca VK [33] Khng sinh km khunKhng sinh dit khun Nhm macrolid Nhm sulfamid Nhm tetracyclin Nhm lincosamid Nhm phenicol Ethambutol Nitrofuran Nhm beta lactam Nhm quinolon Nhm aminoglycosid Nhm nitroimidazol Nhm peptid Pyrazinamid Isoniazid 1.1.2.3.Theo c ch tc dng ca khng sinh Da vo c ch tc dng, khng sinh c chia thnh cc nhm: -Thuccchtnghpvchtbovikhun:lactam,vancomycin, bacitracin, fosfomycin. -Thuccchhocthayitnghpproteincavikhun:cloramphenicol, tetracyclin, macrolid, lincosamid v aminoglycosid. -Thuc c ch tng hp acid nhn: quinolon, rifampicin. -Thuc c ch chuyn ha: co trimoxazol. -Thuclmthayitnhthmcamngtbo:polymycin,amphotericin[3], [4], [9], [35]. 1.1.2.4.Theo mc ch iu tr -Cc khng sinh khng khng lao. -Cc khng sinh khng lao. -Cc khng sinh khng nm. 6 -Cc khng sinh chng khi u [19]. 1.1.3.S khng khng sinh ca vi khun Khng khngsinh l hin tngvi sinh vt mt i tnhnhy cmbanu ca n trong mt thi gian hay vnh vin vi tc dng ca khng sinh [6]. 1.1.3.1. khng khng sinh C hai dng khng: khng gi (khng khng do di truyn)C 3 nguyn nhn chnh gy khng thuc gi: -Khi h thng min dch ca bnh nhn b suy gim, c th khng kh nng loi tr c nhng vi khun b khng sinh c ch. -Khi vi khun chui su vo t bo, to v bc, khng sinh sn v pht trin. Do , khng chu tc ng ca khng sinh (tuy nhin, khi phn chia s li chu tc ng ca khng sinh). -Khi c vt cn, tun hon tr, khng sinh khng thm ti vim th vi khun cng gy ra khng. Sau khi loi b vt cn th khng sinh tr li pht huy tc dng. khng tht khng tht c th chia ra hai nhm: - Khng thuc t nhin: l c trng ca tng loi VSV nht nh i vi mt s khng sinh nht nh no . -Khngthucthuc(khngthucminhn):lkhngthucdobinidi truyn, trong vi khun t ch khng c tr thnh c gen khng. Ngha l, ADN cavikhunckhnngtbingenhocnhngenkhngtvikhunkhc truyn cho [3], [8]. 7 1.1.3.2.Tnh hnh khng khng sinh trn th gii v Vit Nam Hin nay, tnh trng vi khun khng khng sinh l mt vn mang tnh ton cu, thm ch xut hin nhng chng vi khun a khng thuc. mt s khu vc trn th gii, 25% cc trng hp vim phi mc phi ti cng ng do Streptococcus pneumoniae khng vi penicilin. Vi s pht trin khng sinh gn y, vancomycin c coi l khng sinh c hiu qu nht iu tr vi khun akhngStaphylococcusaureusnhnghinnaycbocovtrnghp Staphylococcusaureuskhnghontonvivancomycin[24].TiAsiatheokt qu nghin cu ca Song JH v cng s (2000 2001), Streptococcus pneumoniae khngerythromycinrt cao tiiLoan(86,00%),Hn Quc(80,60%), HngKng (76,80%) v tiTrung Quc (73,90%) [31]. Mtnghin cutiAustralia(Tapsallv cngs,1992),ciprofloxacincghinhnvsthtbitrongiutrnhim khun do lu cu [28].Ti Vit Nam, mt nghin cu TP H Ch Minh cho thy trong 10 nm, t l cc chngPneumococcuskhngpenicilinphnlptmuvdchnotytngt8% (19931995)ln56%(giaion19992002)[16],[30].Nm20002001,Vit Nam c t l khng penicilin (71,40%) cao nht trong 11 nc khu vc Chu [16], [22],[30].Trongkhongnm20002002,tlHaemophillusinfluenzaekhng ampicilin c ghi nhn l khong 57% [29]. 1.1.3.3.Cc bin php hn ch s gia tng tnh khng khng sinh ca vi khun -Ch dng khng sinh iu tr khi chc chn nhim khun. Cn nhc k khi iu tr d phng hoc phi hp khng sinh. -Chnkhngsinhtheoktqukhngsinh,cbitutinkhngsinhc hot ph hp, c hiu. -Chn khng sinh khuch tn tt nht vo v tr nhim khun: ch nhng thng s DH ca khng sinh c dng. 8 -Phi hp khng sinh hp l, c bit nhng bnh phi iu tr ko di. -Gim st lin tc tnh hnh khng ca vi khun v thng bo kp thi cho bc s iu tr. -Tng cng bin php kh khun v v khun. Khi c nhim khun bnh vin v mm bnh khng khng sinh th phi dng ngay vic s dng khng sinh m mm bnhkhngcngnhcckhngsinhcngnhmccngtcdngvphitrin khai cc bin php v sinh cn thit tiu dit mm bnh v trnh ly lan [7], [9]. 1.1.4.Chng trnh qun l khng sinh Qun l khng sinh (Antimicrobial stewardship) l mt qu trnh h thng ca vic s dng khng sinh mt cch hp l t c hiu qu trong iu tr cho bnh nhn, trnh c tnh,trnh slan trn cavi khun khngthuc,v nhngtcdngkhng mong mun khc [27]. TheoDaleN.Gerding,mtchngtrnhqunlkhngsinhttlslachn thuc, liu, khong thi gian iu tr ti u nhm em li hiu qulm sng v ngn nga trit nhim khun, hn ch ti a c tnh trn bnh nhn v s khng thuc v sau [27]. Theo tng kt ca Dellit v cng s, mt chng trnh qun l khng sinh hiu qu cthemlilichvkinhtcngnhvicchmscsckhechobnhnhn. Chng trnhqunlkhngsinhttcth lmgim2236%tlsdngkhng sinh v tit kim chi ph cho cc bnhvin 200,000 900,000 lami nm ti cc bnhvinchuynkhoalncngnhccbnhvinakhoa(NewYork,M)[25], [27]. Chng trnh c hai chin lc chnh:- nhgi tnhhnh s dngkhngsinh:vicnhgisdngkhngsinhcn cthc hin quanhng tng tc trc tip v phnhit ngikn.Phn hi 9 ny c th thu thp t cc bc s chuyn khoa hoc cc dc s lm sng c o to v bnh l nhim khun. -Xy dng danh mc thuc khuyn co: chin lc ny ch yu nhm gii hn vic s dng khng sinh v kim sot tng th xu hng dng khng sinh trong bnh vin, t gip tit kim chi ph s dng thuc [25]. 1.1.5.Nguyn tc s dng khng sinh 1.1.5.1.Nhng nguyn tc s dng khng sinh trong iu tr C 4 nguyn tc s dng khng sinh trong iu tr: Ch s dng khng sinh khi c nhim khun-Cckhngsinhthngdngchctcdngvivikhun,rttkhngsinhc tc dng vi virus, nm gy bnh Mi nhm khng sinh li ch c tc dng vi mt s loi vi khun nht nh. V vy, ch s dng khng sinh khi c nhim khun. -Ccbccnphilmtrckhiquytnhsdngmtloikhngsinhbao gm:thmkhmlmsng,ccxtnghimlmsngthngquy,tmvikhungy bnh [1], [2], [4]. Phi bit la chn khng sinh hp lLa chn khng sinh hp l ph thuc vo 3 yu t: La chn khng sinh phi ph hp vi vi khun gy bnh -Tu theo v tr nhim khun, thy thuc c th d on kh nng nhim loi vi khun no v cn c vo ph khng sinh m la chn cho thch hp. - nh gi nhy cm ca VK vi KS: tt nht l da vo khng sinh . La chn khng sinh theo v tr nhim khun Khngsinhphithmcvonhimkhun,nhvyngithythucphi nmvngccctnhdcnghccathucmicthchnckhngsinh thch hp (Bng 1.2.). 10 Bng 1.2. Kh nng thm u tin ca mt s KS vo cc c quan v t chc [1] C quan, t chcKhng sinh Tuyn tin litCo trimoxazol, fluoroquinolon, C3G, erythromycin Xng khpLincomycin,lindamycin,fluoroquinolon,C1G,C2G, C3G... Dch no tyPenicilin G, chloramphenicol, co trimoxazol, C3G... MtAmpicilin, cefoperazon, ceftriaxon... La chn khng sinh theo c a bnh nhn - Nhng khcbitvsinhltrnh,ngicaotui,phncthai... uc nh hng n DH ca khng sinh. -Nhng thay i bnh l nh suy gim min dch, bnh gan, thn nng u lm gim r rt chuyn ho v bi xut thuc gy tng mt cch bt thng nng khng sinh c th dn ti ng c v tng tc dng ph. -Cctrngthibnhlkhcnhbnhnhnbbnhnhcc,thiumen G6PD... u c th lm nng thm cc tai bin v tc dng ph ca thuc [1], [2]. Phi bit nguyn tc phi hp khng sinh Mc ch ca phi hp khng sinh l: -Tng tc dng ln cc chng khng mnh: s dng cho iu tr nhim khun mc phi bnh vin hoc nhng trng hp bnh chuyn thnh mn tnh do iu tr nhiu ln khng khi. -Gim khnngkhng thuc hoc trnhto nhngvikhunkhng:thng p dng khi iu tr cc nhim khun ko di. - Ni rng ph tc dng ca khng sinh [1], [4]. Phi s dng khng sinh ng thi gian quy nhNguyn tc chung l: -S dng khng sinh n khi ht vi khun trong c th: + 2-3 ngy ngi bnh thng v + 5-7 ngy bnh nhn suy gim min dch. 11 - Thct,tkhiciukincyvikhunsaukhiiutr,docoilhtvi khun khi bnh nhn gim st, trng thi c th ci thin: n ng tt hn, tnh to... Vinhimkhunnh,tdiutrthngkodikhong7n10ngy,nhng vinhimkhunnng,nhimkhunnhng tchcmkhngsinhkhthmnhp (mng tim, mng no, xng...) th t iu tr ko di hn; ring vi bnh lao, phc ngn ngy cng phi ko di ti 8 thng [1], [2], [4]. 1.1.5.2.Nhng nguyn tc s dng khng sinh d phng nhim khun trong phu thut Khngsinhdphngphuthutlkhngsinhcdngdphngnhim khun trong phu thut [33]. C3nguyntccnnmvngkhisdngkhngsinhdphngnhimkhun trong phu thut: Thi im a thuc phi ng t c iu ny, thi im a thuc ty thuc ng dng. -Tim tnh mch: tt nht l a thuc sau khi m, c bit trong phu thut tim mch; tuy nhin cng c th a trc thi im m khong 1/2 gi n 1 gi nu l loi khng sinh phi truyn tnh mch qung ngn (metronidazol, aminosid). -Timbp:dthchin,tngiantonnhngcnhcimlnng thuc trong mu sau khi tim bp thng ch bng 1/3 n 1/2 so vi tim tnhmch v thi im thuc c tc dng chm hn. Nu a bng ng ny nn tim trc khi phu thut t 1/2 gi n 1 gi. -ngtrctrng:cthsdngttrctrngmetronidazolchoccphu thutvngchuvvngbng(itrng,trctrng,tcung).Nuttrctrng, thi im t thuc phi trc lc m 2 gi. 12 -ngung:chnndngkhngsinhngungtrongcctrnghpm phinstkhunrutchunbchophuthutngtiuha.Khngsinhng ung vo ngy hm trc. Ch nn coi liu php khng sinh ny l h tr v vn nn dngkhng sinh timngaytrckhimbomnngkhngsinhtrongmu cao nht lc rch dao. Chn khng sinh phi ng -V ph tc dng ca khng sinh: mi phu thut c mt hnh nh vi khun khc nhau. Nn chn loi ph rng, c tc dng c ln hu ht tc nhn gy bnh hay gp nht trong loi phu thut . -Vditcdngcakhngsinh:nnchnloicthigianbnthi(t1/2) khng qu ngn c th gim c s ln a thuc. Tiu chun ny rt quan trng vi cc loi phu thut ko di. -V kh nng khuych tn vo t chc cn phu thut: khng sinh phi thm tt votchccnphuthut.ctnhnyrtquantrngkhitinhnhphuthutti cc t chc m khng sinh kh thm nh tuyn tin lit, xng, mt di ca t iu tr phi ng Vnguyntc,chsdngkhngsinhnkhihtnguycthmnhpcavi khun gy bnh. V liu u tin c dng lc khi m nn sau khi m xong ch cn dng tip 1 2 liu na l . Khng nn dng khng sinh ko disau m v s lm bnh nhn mt mi, km n, do lu phc hi v cn gy tn km v ti chnh [1]. 1.1.6.Mt s iu cn lu khi dng khng sinh 1.1.6.1.ng dng khng sinh - ngung:ngin,thunli,ddng.Tuyvy,hiuqucathucph thuc vo mc hp thu qua ng tiu ha. 13 - Tim bp: do thuc phi a vo su trong c bp nn cn thn trng vi ngi ang dng thuc chng ng, ngi c bnh mu hoc c ri lon cm mu. - ng tnh mch: thng c ch nh trong cc nhim khun nng. Ty tng trng hp m tim tnh mch trc tip hoc truyn nh git tnh mch chm (nh vi metronidazol, vacomycin, amphotericin B). - iutrtich:chdngkhngsinhathngvomngbng,mngphi, ng sng khi tht cn, v cng c nhng bin chng nht nh [7]. 1.1.6.2.Tc dng khng mong mun ca khng sinh Phn ng d ng -Sc phn v: l mt trong nhng phn ng d ng nguy him nht c th xy ra khi s dng khng sinh, c bit l cc khng sinh penicilin. -Hi chng Stevens Johnson v Lyell: cng l nhng hi chng d ng rt nguy him c t l t vong cao. - Ccphnngdngkhc:niban,myay,vimmchhoit,vimda khp, gim bch cu [1], [3], [4], [34], [35]. Bi nhimBi nhim l hin tng nhim khun trong hoc sau khi dng khng sinh, c bitlcckhngsinhphrnghockhiphihpnhiuloikhngsinhmcc khng sinh ny thi nhiu qua phn. Cc khng sinh ny tiu dit h vi sinh vt c ch nn to iu kin thun li cho cc chng vi khun gy bnh pht trin [3], [4]. Cc tc dng khng mong mun khc -Ri lon tiu ha (erythromycin). -c vi thn, thch gic (cc aminoglycosid, cephalosporin). -c vi h to mu (cloramphenicol). -nh hng ti s pht trin ca rng, xng (tetracyclin) [3], [4]. 14 1.2. GII THIU CHUNG V BNH VIN VIT NAM THY IN UNG B 1.2.1. S t chc bnh vin Vit Nam Thy in Ung B Hnh 1.1. S t chc bnh vin Vit Nam Thy in Ung B 1.2.2. Quy m bnh vin Bnh vin Vit Nam Thy in Ung B l bnh vin a khoa khu vc hng 1trcthuc BYt,cchcnngnhimvkhmchabnhvchmscsc kho cho nhn dn vng ng Bc Vit Nam.Bnhvinc7phngchcnng,8khoacnlmsng,19khoalmsng,2 trung tm trc thuc, vi bin ch 619 nhn vin v 850 ging bnh. Hng nm, bnh vin tip nhn: khm bnh cho 140 000 lt ngi, iu tr ni tr 33 000 bnh nhn, phu thut 9 500 ca (trong 800 ca p dng k thut cng ngh cao), cp cu 14 000 ca bnh nng, him ngho, s dng 1000 ltmu trong iu tr. B Y t Hi ng t vn -Hi ng KC -HT & T Ban Gim c on th Cc phngchc nng (7 phng) Cc khoacn lm sng(8 khoa) Cc khoalm sng (19 khoa) Cc TT trc thuc(2 TT) 15 1.2.3. Hng dn iu tr ti bnh vin Bnh vin Vit Nam Thy in Ung b l mt trong s rt t cc bnh vin c xy dng ring hng dn iu tr ca bnh vin nhmmc ch nng cao vn s dng thuc an ton, hiu qu v hp l trong cng tc chm sc sc khe cho ngibnh.Minm,hingthucviutrutchchpcibincc hngdniutrcaBnhvintheohngcpnhtlintcccthngtint thngt/hngdniutrcaBythoctcchngdniutrcacc nc tin tin trn th gii.Trong hng dn iu tr ca bnh vin, khng sinh l nhm thuc ng vai tr v cng quan trng trong hu ht cc bnh l c yu t nhim khun. V vy, nhm p ng cp nht thng tin v thc trng s dng thuc ti bnh vin trong nm va qua, chng ti hy vng ti ny s gip ch mt phn nh cho hi ng thuc v iu tr ca Bnh vin trong vic nng cao s dng thuc khng sinh an ton, hp l v hiu qu hn. 16 CHNG 2. I TNG V PHNG PHP NGHIN CU 2.1. I TNG NGHIN CU i tng nghin cu l bnh n ca cc bnh nhn iu tr ni tr ti bnh vin VitNamThyinUngBtngy01/01/201331/12/2013thamncc tiu chun la chn v tiu chun loi tr sau: 2.1.1. Tiu chun la chn -C thi gian nmvin trong2 ngy tr ln ti bnhvin Vit Nam Thy in Ung B trong thi gian nghin cu. - c kniutrbngtnhtmtloikhngsinhtrongthigiannm vin. 2.1.2. Tiu chun loi tr - Cctrnghpbnhnhncthigianiutrngoitrhocxutvin trong cng mt ngy. -c k n iu tr bng khng sinh dng ti ch (tra mt, dng ngoi da). -Cc bnh nhn suy gim min dch: + Bnh nhn HIV dng tnh. + Bnh nhn vim gan virus dng tnh. 2.2. PHNG PHP NGHIN CU 2.2.1. Thit k nghin cuNghin cu c tin hnh theo phng php hi cu m t. Thu thp d liu thng qua ghi chp thng tin vo phiu thu thp thng tin bnh nhn (PH LC 1). 2.2.2. Phng php chn mu Ton b bnh n c lin quan n s dng khng sinh tha mn tiu chun la chn v tiu chun loi tr, c thi gian nhp vin tiBV Vit Nam Thy in Ung B t ngy 01/01/2013 31/12/2013 c a vo nghin cu. 17 Theo s liu cung cp t b phn thng tin lu tr ca Phng k hoch tng hp BV Vit Nam Thy in Ung B, t ngy 01/01/2013 31/12/2013, bnh vin c24824bnhnclinquannsdngkhngsinh.Trndanhsch24824 bnh n, nhm nghin cu tin hnh sp xp ngu nhin da vo phn mm Excel ly mu ngu nhin v ly 220 bnh n u tin tin hnh nghin cu trc trng s dng khng sinh ti Bnh vin Vit Nam Thy in Ung b. Trong qu trnh thu thp thng tin, nhm nghin cu loi b 4 bnh n khng tha mn tiu chun la chn v tiu chun loi tr. V vy, s lng thu thp c thng tin v s dng khng sinh l 216 bnh n. 2.2.3. Phng php thu thp thng tin Ccbnhnthamntiuchunlachnvtiuchunloitrcin thng tin vo mt mu phiu thu thp thng tin bnh nhn (PH LC 1). 2.3. NI DUNG NGHIN CU 2.3.1. Kho st c im camu nghin cu ti bnh vin Vit Nam Thy in Ung B Cc tiu ch m t c im nhn khu hc ca bnh nhn: -c im v tui v gii tnh -c im v chc nng thn -Phn loi ICD chn on khi ra vin -c im s bnh mc km ca mu nghin cu -c im cc bnh nhim khun ca mu nghin cu c im cc vi khun phn lp c trong mu nghin cu 2.3.2. Kho st thc trng s dng khng sinh ti bnh vin Vit Nam Thy in Ung B Cc tiu ch m t c im s dng khng sinh bao gm: -T l v s lng cc khng sinh/nhm khng sinh c s dng: + S lng khng sinh trong mi nhm 18 + Cc nhm khng sinh-Mt s ch tiu v thc trng s dng khng sinh ti bnh vin Vit Nam Thy in Ung B: + S lngkhng sinhvskhng sinhtrung bnh/bnhnhn theong dng + ng dng khng sinh -c im s dng khng sinh theo mc ch s dng: + Phn loi bnh nhn theo mc ch s dng khng sinh+ c im bnh nhn s dng khng sinh trong iu tr +cimbnhnhnsdngkhngsinhdphngnhimkhuntrong phu thut -c im phc khng sinh trong iu tr: + Phn b cc phc khng sinh n c v phi hp + Phn b cc phc khng sinh n c + Phn b cc phc khng sinh phi hp -c im thay i phc khng sinh: + T l bnh nhn c thay i phc khng sinh + L do thay i phc khng sinh -Cc bin c bt li ghi nhn c trn bnh nhn iu tr bng khng sinh -Thi gian dng khng sinh v thi gian nm vin -Kt qu iu tr lc ra vin 2.4. PHNG PHP X L S LIU S liu thu thp trong nghin cu c nhp v x l bng phn mm thng k STATA 11.Cc gitr so snhc skhcbitnhau cnghathngknuP < 0,05. 19 CHNG 3. KT QU NGHIN CU 3.1. MT S C IM CA MU NGHIN CU Chng ti lm nghin cu kho st 216 bnh n trong nm 2013, thu c kt qu nh sau: 3.1.1.c im v tui v gii tnh Quakhost216 bnhnca bnh nhn,chothyt lbnh nhntheo cc la tui v gii tnh c thng k trong bng nh sau:Bng 3.1. Phn b bnh nhn theo tui v gii tnh Nhn xt: V mt gii tnh ca bnh nhn iu tr ni tr ti bnh vin, qua khostchothytrongmunghincugmccbnhnhnchyulngii (57,87%) chim t l cao hn nam gii (42,13%) vi s khc bit c ngha thng k vi P < 0,05. Bnh nhn n ch chim t l cao hn nhm bnh nhn nam tui 18 60 thi (44,91%; 20,83%). Cn cc nhm tui khc (< 1; 1 18 v > 60 tui) th nhm bnh nhn nam u chim t l cao hn nhm bnh nhn n. Bnh nhn tui 18 60 chim t l cao nht c nam v n gii (chim 65,74%). Nhm tui NamNTng S BN T l (%) S BN T l (%) S BN T l (%) < 194,1741,85136,02 1 18 188,33146,483214,81 18 60 4520,839744,9114265,74 60198,80104,632913,43 Tng T l (%) 9142,1312557,87216100,00 P < 0,05 20 3.1.2.c im v chc nng thn nh gi chc nng thn ca bnh nhn gip thy thuc la chn thuc cng nh liu dng ca thuc mt cch hp l hn. Chc nng thn ca bnh nhn c nh gi bng h s thanh thi creatinin (Clcr). Trong tng s 216 bnh n c 159 bnh n (chim 73,61%) c ghi y thng tin tnh h s thanh thi creatinin, cn 57 bnh n (chim 26,39%) thiu thng tin cn nng hoc ch s creatinin ca bnhnhn.Do,saukhitnhthanhthicreatinintheocngthctrnhby trong PH LC 2 vi 159 bnh n v chng ti thu c kt qu nh sau: Bng 3.2. Chc nng thn ca bnh nhn theo h s thanh thi creatinin Mc suy thnClcr (ml/pht)S BNT l (%) 0Clcr > 6011974,84 I40 < Clcr 602113,21 II20 < Clcr 40159,43 IIIa10 < Clcr 2030,63 IIIb5 < Clcr 1000,00 IVClcr 511,89 Tng159100,00 Nhnxt:Theoktqunghincuchothy,phnlnbnhnhncchc nngthnbnhthng(74,84%),cnbnhnhnbsuygimchcnngthnch chim t l 25,16%. 3.1.3.Phn loi ICD chn on khi ra vin Chngtitinhnhphnloibnhnhnchnonravintheophnloi bnh tt quc t ICD 10, kt qu nghin cu c trnh by bng 3.3. nh sau: Bng 3.3. c im chn on chnh ca bnh nhn khi ra vin STTM ICDNhm bnh lS BNT l (%) 1A, BBnh nhim khun v k sinh vt73,24 2CKhi u41,85 21 3D Bnh mu, c quan to mu v ri lon min dch 41,85 4E Bnhnitit,dinhdngvchuyn ha 20,93 5GBnh h thn kinh10,64 6HBnh mt v phn ph62,78 7IBnh h tun hon83,70 8JBnh h h hp4018,52 9KBnh h tiu ha3013,89 10LBnh da v m mm20,93 11MBnh c xng khp v m lin kt20,93 12NBnh h tit niu sinh dc177,87 13OThai nghn, sinh v hu sn7032,41 14P Mt s bnh l xut pht trong thi k chu sinh 10,46 15S Ngcvhuqucamts nguyn nhn bn ngoi 156,94 16TChn thng, vt thng v bng41,85 17V Ccnguynnhnngoisinhcabnh v t vong 10,46 18Z Ccyutinhhngntnhtrng sc khe v tip xc dch v y t 20,93 Tng216100,00 Nhn xt: Kt qu cho thy s bnh nhn vo bnh vin v nhng vn lin quan n thai nghn, sinh v hu sn chim t l cao nht (32,41%). Trong khi ,ccbnhllinquannbnhhthnkinh(chim0,46%),mtsbnhl xutphttrongthikchusinh(chim0,46%),ccnguynnhnngoisinhca bnh v t vong (0,46%) chim t l thp nht. 22 3.1.4.c im s bnh mc km ca mu nghin cu Trong 216 bnh nhn nghin cu c 51 bnh nhn c ghi cc bnh mc km nh bnh tng huyt p, gin ph qun, lao phi, vim d dy, i tho ng typ II,rungnh,thiumu,hKalimu,vimphi,ngoitmthu,dngkhngr nguyn nhn, tiu chy cp, suy thn cp. Kt qu c trnh by qua Bng 3.4.: Bng 3.4. c im s bnh mc km ca mu nghin cu STTS bnh mc kmS bnh nhnT l (%) 1Khng c14567,31 2Mt bnh4118,98 3Hai bnh94,17 4Ba bnh10,46 5Khng r209,26 Tng216100,00 Nhnxt:Theoktqunghincuchothyphnlnbnhnhnkhngc bnhmckm(67,31%)vsbnhmckmnhiunhtlbabnhchimtl thp nht (0,46%).3.1.5.c im cc bnh nhim khun ca mu nghin cu Nghincukhost216bnhnhn,c78bnhnhncghirbnhim khun. Kt qu cc bnh nhim khun ca mu nghin cu km theo cc bnh mc km c th hin trong bng 3.5.: Bng 3.5. c im chn on nhim khun ca mu nghin cu STT Dng nhim khun Ch nh chnhCh nh mc km S BNT l (%)S BNT l (%) 1Chn thng33,8516,67 2NK ng h hp3342,31533,33 3NK thn - tit niu 56,4100,00 4NK ng tiu ha1215,38746,67 5NK khc2532,05213,33 Tng78100,0015100,00 23 Nhn xt: Kt qu cho thy bnh nhn b nhim khun ng h hp l ph bin nht (chim 42,31%), cn bnh nhn b nhim khun ng tiu ha c bnh mc km cao nht (chim 46,67%). 3.1.6.c im cc vi khun phn lp c trong mu nghin cu Xt nghimvi khun lmt bngchng cnlm sng khngnhchay khng c s nhim khun trn bnh nhn. Kt qu vi khun phn lp c s gip cc bc s la chn khng sinh iu tr hp l hn. Qua nghin cu kho st 216 bnhnhn,chngtithuc25bnhnhncphnlpcvikhun.Ktqu cc vi khun phn lp c trnh by trong bng di y: Bng 3.6. Danh mc cc vi khun phn lp c trong mu nghin cu Loi VKVi khunS BNT l (%)Tng (%) VK Gr (+) Staphylococcus aureus312,00 48,00Streptococcus pneumoniae936,00 VK Gr (-) Escherichia coli28,00 52,00 Enterobacter sp312,00 Enterobacter geroviae14,00 Klebsiella sp14,00 Helicobacter pylori28,00 Mycobacterium tuberculosis14,00 Kluyvera cryocrescens14,00 Haemophillus influenzae28,00 Tng25100,00

Nhnxt:Theoktqukhostcachngti,trong25bnhnhnphn lp vi khun th nhm vi khun Gram (-) chim t l cao hn nhm vi khun Gram (+)(52,00%;48,00%,tngng).Ktquphnlpvikhunchothy Streptococcus pneumoniae chim t l cao nht (36,00%), sau l Staphylococcus aureus (12,00%) v Enterobacter sp (12,00%). 24 3.2. KHO ST THC TRNG S DNG KHNG SINH TI BNH VIN VIT NAM THY IN UNG B.3.2.1. T l v s lng cc khng sinh/nhm khng sinh c s dng Trong qu trnh iu tr ti cc khoa trong bnh vin, cc bnh nhn c s dng nhiu loi khng sinh. Kt qu thu c th hin qua bng 3.7:Bng 3.7. T l v s lng cc KS/nhm KS c s dng STTNhm khng sinh S lt T l (%) Tng T l (%) 1Beta lactamAmoxicilin4611,91 229 59,32 Ampicilin 51,30 Cefaclor 112,84 Cefotaxim 13936,01 Ceftazidim 143,63 Ceftriaxon 30,78 Cefixim 71,81 Cefoperazon 41,04 2AminoglycosidAmikacin 30,78 70 18,13Gentamicin 6316,32 Netilmicin41,04 3MacrolidAzithromycin 20,52 10 2,60 Clarithromycin 30,78 Erythromycin 41,04 Streptomycin 10,26 4Quinolon Ciprofloxacin 297,51297,51 5Co trimoxazol Co trimoxazol 10,2610,26 6Phenicol Cloramphenicol10,2610,26 7Nitroimidazol Metronidazol 4511,65 46 11,92Tinidazol 10,26 Tng386100,00386100,00 25 Nhnxt:Cefotaximlmtloikhngsinhcsdngnhiunht (chim36,01%)ticckhoaiutrtrongbnhvin,tiptheolgentamicin (chim 16,32%), amoxicilin (chim 11,91%) v metronidazol (chim 11,65%). Theo nghin cu kho st ca chng ti, trong 216 bnh nhn nghin cu c 7 nhm khng sinh c s dng trong iu tr.

59,32%18,13%11,92%7,51%2,60%0,26%0,26%010203040506070Beta lactam AminoglycosidNitroimidazolQuinolon Macrolid PhenicolCo - trimoxazol Hnh 3.1. Biu phn b cc nhm KS c s dng trong iu tr Nhn xt: Theo kt qu nghin cu cho thy nhm beta lactam (ch yu l cephalosporinthhIII)csdngnhiunht(chim59,32%),tiptheol nhm aminoglycosid (chim 18,13%). Cn nhm khng sinh c s dng t nht ticckhoaiutrtrongbnhvinbaogm:phenicol(chim0,26%)vco trimoxazol (chim 0,26%). 3.2.2.MtschtiuvthctrngsdngkhngsinhtibnhvinVit Nam Thy in Ung B 3.2.2.1.S lng khng sinh vskhng sinh trungbnhtrnbnh nhn theo ng dng. Ktqukho st skhngsinhngungvngtimtrnbnhnhn c th hin trong bng 3.8. di y: 26 Bng 3.8. S lng khng sinh ng ung v ng tim/bnh nhn STT S KS tim / BN S BN T l (%) S KS ung / BN S BN T l (%) 107534,72014366,20 215826,8516530,09 327434,26283,70 4373,24 5420,93 Tng216100,00216100,00 S KS trung bnh / BN (TB SD)1,67 0,74 Nhnxt:Theoktquchothybnhnhnkhngcdngkhngsinh ngungchimtlcao66,20%,saubnhnhncdngmtkhngsinh ngungchimtl30,09%.Cnbnhnhnkhngcdngkhngsinh ng tim chim t l 34,72% tng ng bnh nhn c s dng hai khng sinh ng tim (chim 34,26%). S khng sinh trung bnh s dng cho mt bnh nhn l 2 khng sinh. 3.2.2.2.ng dng khng sinh Khosttrong216bnhnhn,chngtithucktqulinquann ng dng khng sinh nh sau: Bng 3.9. T l ng dng khng sinh STTng dng khng sinhS khng sinhT l (%) 1Tim15657,78 2Ung8531,48 3Tim v ung269,63 4Khc31,11 Tng270100,00 27 Nhn xt: Khng sinh ng tim c s dng nhiu nht ti cc khoa iu trtrongbnhvinVitNamThyinUngb,chimtl57,78%;sau khngsinhngung(chim31,48%)vkhngsinhdngcngtimv ng ung chim t l 9,63%. 3.2.3. c im s dng khng sinh theo mc ch s dng 3.2.3.1.Phn loi bnh nhn theo mc ch s dng khng sinh Qua nghin cu kho st 216 bnh nhn, chng ti phn loi cc bnh nhn theo mc ch s dng khng sinh nh sau: Bng 3.10. Phn loi BN theo mc ch s dng KS STTMc ch s dngS BNT l (%) 1S dng KS iu tr8941,20 2Sdng KS d phng10850,00 3S dng KS c iu tr v d phng198,80 Tng216100,00 Nhnxt:Theoktqukhostchothybnhnhncsdngkhng sinh d phng chim t l cao nht (50,00%), cn bnh nhn s dng khng sinh c iu tr v d phng chim t l thp nht (8,80%). 3.2.3.2.c im bnh nhn s dng khng sinh trong iu tr Quakhost216bnhnhn,chngtathuc142bnhnhncsdng khng sinh trong iu tr vi 5 mc ch nh sau: 28 Bng 3.11. c im bnh nhn s dng khng sinh trong iu tr STTc im BN s dng khng sinhS BNT l (%) 1Chnonnhimkhunrrng,cyucu xt nghim vi sinh 5538,46 2Chnonnhimkhunrrngnhngkhng yu cu xt nghim vi sinh 4027,97 3Khng c chn onnhim khun r rng, c yu cu xt nghim vi sinh 32,09 4Phn lp c vi khun gy bnh2517,48 5Lmkhngsinhkhicktqunuicyvi khun dng tnh 2013,99 Tng143100,00 Nhnxt:TheoktqunghincuchothyBNcchnonnghim khun r rng, c yu cu xt nghim vi sinh chim t l cao nht (38,46%), cn BNkhngcchnonnhimkhunrrng,cyucuxtnghimvisinh chim t l thp nht (2,09%). 3.2.3.3.c im bnh nhn s dng khng sinh d phng nhim khun trong phu thut Trong216bnhnhnnghincu,chngtithuc97bnhnhncs dng khng sinh d phng nhim khun trong phu thut. c im s dng khng sinh theo thi im phu thut c trnh by trong bng 3.12.: Bng 3.8. c im BN s dng KS d phng nhim khun/phu thut STTc im bnh nhn s dng KSS BNT l (%) 1S dng KS trc phu thut00,00 2S dng KS sau phu thut5859,79 3S dng KS trc v sau phu thut cng mt KS3030,93 4S dng KS trc v sau phu thut vi hai KS99,28 Tng 97100,00 29

59,79 % 30,93 %9,28 %BN ch s dng KS sau phu thutBN s dng KS trc v sau phu thut cng mt loi KSBN s dng KS trc v sau phu thut vi hai loi KS

Hnh 3.2. Biu phn b BN s dng KS d phng NK trong phu thut Nhnxt:Theoktqutrongbng3.12vhnh3.2chothyBNchs dng KS sau phu thut chim t l cao nht (59,79%), sau l BN s dng KS trc v sau phu thut cng mt loi KS chim t l 30,93%. Cn BN ch s dng KS trc phu thut khng c. 3.2.4.c im phc khng sinh trong iu tr 3.2.4.1.Phn b cc phc khng sinh n c v phi hp Diylbngbiuthtlsdngkhngsinhncvphihpti cc khoa iu tr trong bnh vin Vit Nam Thy in Ung B. Bng 3.9. Phn b cc phc khng sinh n c v phi hp STTBnh nhn s dng khng sinhS bnh nhnT l ( %) 1n c11754,17 2Phi hp7032,41 3C n c v phi hp2913,43 Tng216100,00 Nhnxt:Theoktqutrnchothybnhnhnsdngkhngsinhn cc dng nhiunht(chim54,17%), cnbnh nhns dngckhng sinh n c v phi hp t c dng (chim 13,43%). 30 3.2.4.2.Phn b cc phc khng sinh n c Nghin cukho st trong216bnh nhn,chngtithucs phc c s dng khng sinh n c c th hin trong bng 3.14.: Bng 3.14. Phn b cc phc khng sinh n c STTTn khng sinh S lngphc T l (%) S ngy dng S ngy dng TB 1Amoxicilin 3822,891 72,95 2Ampicilin 53,013 96 3Azithromycin 21,206 108 4Cefaclor 116,631 115,91 5Cefixim 74,221 53 6Cefotaxim 5734,331 185,93 7Ceftazidim 74,221 94,28 8Ceftriaxon 31,815 86,67 9Ciprofloxacin 2112,651 105,67 10Cloramphenicol 10,6055 11Co trimoxazol 10,6055 12Erythromycin 31,813 85 13Gentamicin 53,011 72,80 14Metronidazol 42,411 53,25 15Streptomycin 10,6044 Tng166100,00 Nhnxt:Phckhngsinhnccsdngnhiunhtl cefotaxim chim t l 34,33%, tip theo l khng sinh amoxicillin (chim 22,89%). 3.2.4.3.Phn b cc phc khng sinh phi hp C3mcchchnhcavicphihpkhngsinhl:tngtcdngln cc chng khng mnh, gim kh nng khng thuc hoc trnh to nhng vi khun khng v ni rng ph tc dng ca khng sinh. 31 Quanghincukhostcachngti,cckiuphihpkhngsinhtrong iutrrtphongphvdiylsphckhngsinhphihptrong216 bnh nhn nghin cu ti bnh vin: Bng 3.15. Phn b cc phc khng sinh phi hp Tn khng sinh S phc T l (%) S ngy dng S ngy dng TB Amikacin + Cefotaxim10,9116 Amikacin + Tinidazol10,9166 Ceftazidim + Amikacin10,911212 Ceftazidim + Netilmicin10,9133 Cefotaxim + Amoxicillin10,9111 Ciprofloxacin + Amoxicillin10,9122 Ciprofloxacin + Ceftazidim10,9122 Ciprofloxacin + Netilmicin10,9133 Clarithromycin + Amoxicillin32,735 107.33 Gentamicin + Ampicillin10,9188 Gentamicin + Cefoperazon32,737 108 Gentamicin + Cefotaxim5045,451 95.96 Gentamicin + Ceftazidim32,735 76 Metronidazol + Amoxicillin21,813 75 Metronidazol + Cefoperazon10,9133 Metronidazol + Cefotaxim3027,272 167.13 Metronidazol + Ceftazidim 10,9133 Metronidazol + Ciprofloxacin43,631 105 Metronidazol + Erythromycin10,9133 Metronidazol + Gentamicin10,9155 Ciprofloxacin+Netilmicin+Ceftazidim10,9111 Metronidazol+Ceftazidim+Netilmicin10,9111 Tng110100,0 32 Nhnxt:Ktquchothyphckhngsinhphihpcsdng nhiunhtlcpgentamicin+cefotaxim(chim45,45%),tiptheolcp metronidazol + cefotaxim (chim 27,27%). 3.2.5.c im thay i phc khng sinh 3.2.5.1.T l bnh nhn c thay i phc khng sinh S thay i phc khng sinh trong iu tr c xc nh l thm, bt hoc thay i t nht mt khng sinh trong phc s dng khng sinh.Qua kho st 216 bnh nhn, chng ti thu c kt qu nh sau: Bng 3.16. T l bnh nhn c thay i phc khng sinh STTS lt thay i phc khng sinhS bnh nhnT l (%) 1016877,78 213717,13 32104,64 4310,46 Tng 216100,00 Nhn xt: Theo kt qu trong bng 3.16, ta thy phn ln bnh nhn khng thay i phc khng sinh (chim 77,78%). Bnh nhn c thay i phc khng sinh nhiu nht l 3 ln v chim t l rt thp (0,46%).3.2.5.2.L do thay i phc khng sinh Chngtikhostccldothayikhngsinhtrongiutr,cktqu c th hin trong bng 3.17.: 33 Bng 3.17. L do thay i phc khng sinh STTL doS BNT l (%) 1Theo din tin lm sng610,00 2Theo kt qu vi sinh/ khng sinh 58,33 3Lin quan n phu thut1321,67 4Thay i liu/dng bo ch58,33 5Do tc dng ph46,67 6Khng r2745,00 Tng60100,00 Nhnxt:Phn lnldothayiphckhngsinhlkhngr(chim 45,00%), tip theo v l do lin quan n phu thut (chim 21,67%). 3.2.6.Cc bin c bt li ghi nhn c trn BN iu tr bng khng sinh Kho st qua cc bnh n trong nghin cu cho thy trong 216 bnh n ch c 11 bnh n c thng tin ghi r v cc bin c bt li xut hin trong qu trnh iu tr bng khng sinh nh d ng v ri lon tiu ha. Kt qu thu c th hin trong hnh 3.3.:

Hnh 3.3. Biu cc bin c bt li ghi nhn trn bnh nhn s dng khng sinh 34 Nhn xt: Theo kt qu nghin cu cho thy hu ht cc bin c bt li ca thuc trong qu trnh iu tr bng khng sinh u t ghi nhn c trong cc bnh n hi cu, ch chim t l 5,09%. Cc bin c bt li ny u khng nguy him v c x l kp thi. 3.2.7.Thi gian dng khng sinh v thi gian nm vin Mttrongnhngnguyntcsdngkhngsinhliutrthigian quy nh.iunygipgim hin tngkhng thuc cavi khun.Ktqukho st thi gian s dng khng sinh v thi gian nm vin trung bnh c biu hin qua bng 3.18.:Bng 3.18. Thi gian dng KS v thi gian nm vin trung bnh STTThi gian dng KS v thi gian nm vin(TB SD) ngy 1Thi gian dng khng sinh6,98 4,01 2Thi gian nm vin7,97 6,05 Nhn xt: Thi gian dng KS trung bnh trn mi BN l 7 ngy v thi gian nm vin trung bnh ca mi BN c s dng khng sinh l 8 ngy. 3.2.8. Kt qu iu tr lc ra vin Hiu qu iu tr c nh gi theo quyt nh ca bc s v u c ghi li trong h s bnh n. Kho st ch tiu ny, chng ti thu c kt qu nh sau: Bng 3.19. Kt qu iu tr lc ra vin STTKt qu iu trS BNT l (%) 1Khi15370,83 2, gim5927,31 3Khng thay i10,46 4Nng hn10,46 5Chuyn vin20,93 Tng216100,00 35 Nhn xt: T l bnh nhn iu tr khi chim t l cao (70,83%), tip theo ltlbnhnhniutr,gimchimtl27,31%.Chaitrnghpbnh nhnchuynvin(0,93%),chcmttrnghpbnhnhnkhngthayi (chim 0,46%) v mt trng hp na bnh nhn b bnh nng hn (chim 0,46%). 36 CHNG 4. BN LUN 4.1. C IM CHUNG CA MU NGHIN CU 4.1.1.c im v tui v gii tnh Trong mu nghin cu ca chng ti, nhm bnh nhn n chim t l cao hn nhmbnhnhnnamtui1860(44,91%;20,83%).Cnccnhmtui cnlithbnhnhnnamuchimtlcaohnbnhnhnn,nhngskhc bit khng c ngha thng k. Bnh nhn tui 18 60 chim t l cao nht c nam v n gii (65,74%).Ccbnhnhnchyulngii(57,87%)chimtlcaohnnamgii (42,13%) vi s khc nhau c ngha thng k vi p < 0.05.4.1.2.c im v chc nng thn Chc nng thn tnh theo thanh thi creatinin (cng thc Cockroft & Gault) l mt trong nhng ch s quan trng nht cn gim st khi s dng cc khng sinh c c tnh cao trn thn nh nhm aminoglycosid, cephalosporin. Hn na, ch s ny cng cn tnh liu dng hoc gin khong cch a thuc khi bnh nhn c suy gim chc nng thn [17], [26].Phn ln bnh nhn trong mu nghin cu ca chng ti c chc nng thn bnh thng (chim 74,84%). Cn bnh nhn b suy gim chc nng thn ch chim t l 25,16%. y lnhmitngcnphicnnhckhisdngliudngivi vic s dng khng snh trn bnh nhn c chc nng thn suy gim, c bit cc khng sinh nhm cephalosporin v aminoglycosid. 4.1.3.c im vi khun phn lp c trong mu nghin cu: Xtnghimvikhunlmtbngchngcnlmsngkhngnhchay khng c s nhim khun trn bnh nhn. Kt qu vi khun phn lp c s gip cc bc s la chn khng sinh iu tr hp l hn. Theoktqunghincukhostcachngti,Streptococcuspneumoniae chimtlcaonht(36,00%).SaulStaphylococcusaureus(12,00%), 37 Enterobactersp(12,00%),Haemophillusinfluenza(8,00%)vEscherichiacoli (8,00%). y l nhng vi khun gy nhim khun ng h hp v ng tiu ha ph bin nn phn lp bnh nhn trong nghin cu thng b nhim khun ng hhp(42,31%)vngtiuha(15,38%).Cntheoktqunghincuca TrnHngvcngs(2012)tibnhvinakhoathnhphCnTh,cho thyStreptococcuspneumoniaevHaemophillusinfluenzeuchimtlcao trong cc vi khun phn lp c (38,00% v 37,00%) [19]. 4.2.THCTRNGSDNGKHNGSINHTIBNHVINVIT NAM THY IN UNG B 4.2.1.Khng sinh v nhm khng sinh c s dng nhiu trong bnh vin Trong qutrnhiutrtibnhvin,ccbnhnhncsdngnhiuloi khng sinh. Nhm beta lactam (ch yu l nhm cephalosporin 46,11%v nhm penicilin13,21%)csdngnhiunht(59,32%),saulnhm aminoglycosid (18,13%). Cefotaxim,mtloikhngsinhcephalosporinthh3dngngtimtnh mch chm, c ph khng khun kh rng v ch yu trn vi khun gram (-) c sdngnhiunht(36,01%)ticckhoaiutrtrongbnhvin,saul gentamicin (16,32%), amoxicilin (11,90%) v metronidazol (11,65%). Kt qu ny tngngviktqunghincucaTrnThThinm2010chothy cefotaximcng lkhng sinhcsdngnhiunht(35,67%)[20]vtheokt qunghincucaNguynThHinLngtibnhvinVitc,giaion 2009 2011 cho thy cefotaxim cng c s dng nhiu nht ti bnh vin vi t l 34,84 % [15]. 4.2.2.ng dng khng sinh Khilachnkhngsinhphhpvibnhthviclmcncnnhctip theochnhllachnngdngchokhngsinhkhngsinhcs dng mt cch hp l v hiu qu [14], [10]. 38 Theo kt qu nghin cu kho st ca chng ti, khng sinh ng tim chim tlcao(57,78%);khngsinhngungchimtl31,48%;khngsinhdng cng timvngungchimtl9,63%vkhngsinhdngtheong khcchim tl 1,11%. Theo ktqu nghincucaLTh Hngtikhoani bnh vin a khoa Tuyn Quang cho thy dng thuc tim chim t l 60,57% v thuc ungchim tl 39,43% [12]. Cntheoktqu caTrnThHng Nhung nghincutrnbnhnhnsuythntikhoanhi,bnhvinBchMaichothy khng sinh ng tim chim t l 69,60% v ng ung 30,40% [21]. y c th lsuyhngiutrkhngsinhngtim,truynkhiiutrnitrtibnh vin. 4.2.3.Khng sinh d phng Theo nghin cu ca Miles v Bruke, dng khng sinh d phng ng s gim c 50% nguy c nhim khun sau phu thut [11], [23]. Quanghincukhostcachngtitrong216bnhn,ktquchothy khngsinhcsdngvimcchdphngchimtlcaonht(50,00%), trong khi khng sinh c s dng vi mc ch c iu tr v d phng chim t l 8,80%. Theo kt qu cho thy s bnh nhn chn on ra vin do thai nghn, sinh v husnchimtlcaonht(32,41%)vtrongnhmbnhnhnnythngl bnh nhn m ly thai. Do , phc khng sinh c s dng vi mc ch d phng nhim khun sau m ly thai chim mt t l ln trong mu nghin cu.Vmc chsdngkhngsinhdphngphuthut,ktquchothyphn lpbnhnhntrongmunghincucdngkhngsinhdphngsauphu thut (chim 59,79%). 4.2.4.Phc khng sinh n c v phi hp Mc ch phi hp khng sinh ni rng ph tc dng, tng hiu qu iu tr v lm gim t l khng thuc [1]. Ngy nay, do s xut hin khng sinh ph rng 39 nntrongiutrkhngkhuynkchphihpvcthgpnhngtngtcbt lidokhngnmvngctnhdcnghccngnhcchtcdngca khng sinh. Kho st 216 bnh n, kt qu cho thy bnh n c phc khng sinh n c c dng vi t l 54,17%, phc khng sinh phi hp 32,41% v bnh n c c phc khng sinh n c v phi hp 13,43%. Cn theo kt qu nghin cu ca LThHngtikhoaNi,bnhvinakhoaTuynQuangchothyphc khngsinhncchimtl51,22%vphckhngsinhphihp48,78% [12]. C166trnghpsdngphckhngsinhnc.Trongcefotaxim c s dng nhiu nht (chim 34,33%), sau l amoxicillin (chim 22,89%). C 110 trng hp s dng phc khng sinh phi hp. Trong , hu ht l phc phi hp 2 khngsinhvinhau, ch c 2 bnhncphc phihp3 khngsinh.Phckhngsinhphihpcsdngnhiunhtlcp gentamicin + cefotaxim (chim 45,45%), tip theo l cp metronidazol + cefotaxim (chim 27,27%). 4.2.5.Kt qu iu tr lc ra vin T l bnh nhn iu tr khi chim t l cao 70,83%, sau l t l bnh nhn iu tr , gim chim t l 27,31%. iu ny c th chng t rng qu trnh iu tr ti cc khoa trong bnh vin ni chung v vic s dng khng sinh ni ring l tng i hp l ti bnh vin Vit nam-Thy in Ung b trong nm 2013. 4.3. HN CH CA NGHIN CU Nghin cu ca chng ti c mt s hn ch nh sau: -Nghincucthchintheophngphphicumt.Dovy,cc kt qu thu c ph thuc hon ton vo cc thng tin c ghi trong bnh n. Do tnh cht ca nghin cu hi cu, mt s thng tin c th khng ghi nhn c y 40 vkpthinhcnnngbnhnhn,nngcreatinin,theodivxlcc bin c bt li ca bnh nhn -Vnghincutinhnhkhosttrnttcccloikhngsinhcs dng ti cc khoa iu tr trong bnh vin nn c mt s ch tiu lin quan n vic s dng khng sinh m chng ti khng th kho st ht. Cc ch tiu bao gm: liudngvnhpathuckhngsinh,tngtcthuckhngsinh,tnhhnhvi khunkhngkhngsinh,ldochnhphckhngsinhutintrongiu tr 41 KT LUN V XUT 1. KT LUN QuanghincuhicuKhosttnhhnhsdngkhngsinhtibnh vin Vit Nam Thy in Ung B trong nm 2013, chng ti rt ra mt s kt lun nh sau: 1.1. c im chung ca mu nghin cu-Nhm bnh nhn tui 18 60 chim t l cao nht c nam v n gii (65,74%).Trong,bnhnhnn(57,87%)chimtlcaohnbnhnhnnam (42,13%). -Phnlnccbnhnhntrongmunghincucchcnngthnbnh thng (chim 74,84%). -T l bnh nhn b nhim khun ng h hp chim t l cao nht ti bnh vin (42,31%), sau nhim khun ng tiu ha (chim 15,38%). -NhmvikhunGram(-)chimtlcaohnnhmvikhunGram(+) (52,00%; 48,00%, tng ng). -Trongccvikhunphnlpctrongmunghincu,Streptococcus pneumoniaechimtlcaonht(36,00%).SaulStaphylococcusaureus (chim 12,00%), Enterobacter sp (chim 12,00%), Haemophillus influenza (chim 8,00%) v Escherichia coli (chim 8,00%).1.2.ThctrngsdngkhngsinhtibnhvinVitNamThyin Ung B -Nhmbetalactam(chyulcephalosporinthhIII)csdng nhiunhtchimtl59,32%,tiptheolnhmaminoglycosidchimtl 18,13%. -Cefotaxim l thuc c s dng nhiu nht chim t l 36,01%. Sau l gentamicinchimtl16,32%,amoxicilinchimtl11,91%vmetronidazol chim t l 11,65%. 42 -Khng sinh ng tim c s dng nhiu nht, chim 62,59%. -Khng sinh c dng vi mc ch d phng chim t l 54,40%. -Phckhngsinhnccsdngphbintibnhvin,chim 60,88%. -Phn ln bnh nhn khng thay i phc khng sinh khi s dng, chim t l 77,78%. -S khng sinh s dng trung bnh trn bnh nhn l 2 khng sinh.-Thi gian dng khng sinh trung bnh cho mi bnh nhn l 7 ngy v thi gian nm vin trung bnh/bnh nhn l 8 ngy. -T l bnh nhn iu tr khi chim 70,83%; sau l bnh nhn iu tr , gim chim t l 27,31%. 2. XUT Qua qu trnh thc hin ti nghin cu ny, chng ti c mt vi xut nh sau:-Cnxc nh cn nngcabnhnhn ycth nhgichnh xc chc nng thn ca bnh nhn v hng ti hiu chnh liu khng sinh hp l hn khi cnthit, nht l vicckhng sinh c c tnhcaotrnthnnhkhngsinh nhm aminoglycosid v cephalosporin. -Tip tc c cc nghin cusu hnv tondinhnvvicnhgitnh hp l trong vic s dng khng sinh to tin cho vic xy dng mt hng dn s dng khng sinh ph hp vi tnh hnh bnh vin hin ti. TI LIU THAM KHO I.TING VIT 1.B mn Dc Lm Sng Trng i hc Dc H Ni (2011), Dc lm sng i cng, NXB Y hc, tr. 174 191.2.B mn Dc Lm Sng Trng i hc Dc H Ni (2007), Ha dc Dc l III (DcLmSng),Sch otoDc strunghc, NXB Y hc, tr. 102 109.3.Bmn Dc lc Trng i hc Dc H Ni (2004), Dc l, tp 2, NXB Y hc, tr. 111 153.4.Bmn Dc lc Trng i hc Dc H Ni (2007), Dc l, tp 2, NXB Y hc, tr. 130 141. 5.Bmn Ha dc Trng i hc Dc HNi(2007), Ha dc,tp 2, NXB Y hc, tr. 102 103. 6.BmnVisinhvSinhhcTrngihcDcHNi(2008),Vi sinh vt hc, NXB gio dc, tr. 94 97. 7.BYT,Bantvnsdngkhngsinh(2007),Hngdnsdng khng sinh, NXB Y hc, tr. 7 50. 8.B Y T (2006), Dc lm sng, NXB Y hc, tr. 174 191. 9.BYT(2005),Tiliutphunsdngthuchpltrongiutr,Chng trnh hp tc Y t Vit Nam Thy in, tr. 55 60. 10. ThHu(2010),Khosttnhhnhsdngkhngsinhtikhoatai mi hng tr em bnh vin tai mi hng Trung ng, Kha lun tt nghip Dc s, Trng i hc Dc H Ni.11. 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Vuillemin,P.VuilleminetAssociationfranaise,Actionantibiotique, Notes et mmoires, Vol. 11, 1890, p. 525 543. PH LC PH LC 1: PHIU TM TT BNH N NI TR M lu tr h s bnh nhn: ...M bnh nhn: ... I.THNG TIN BNH NHN 1H tn: Tui: .... Cn nng:............(kg) Gii tnh: Nam N 2Ngy vo vin: / .. /20 Ngy ra vin:../ .. /20.. S ngy nm vin: ................... 3Khoa:................................................................................... 4Chn on ra vin (M ICD nu c):........................................................... 5Bnh mc km: 6Ktquiutr:KhiKhngthayi Chuyn vin gim Nng hn II. THNG TIN S DNG KHNG SINH di i dng khng sinh: T / .. /20. n/ .. /20 V ............ ngy STT Tn khng sinh Ngybt u Ngykt thc Liu dng ng dng (U/TM/Khc) Phc u 1 NANANANANA 2 NANANANANA 3 NANANANANA 4 NANANANANA 5 NANANANANA NANANANANA III.THNG TIN V PHC KHNG SINH U TIN 1.Nu phc c khng sinh u tin c dng cho ngoi khoa Bnh nhn c tri qua phuthut hay th thut can thip? Th thut Phu thut C haiTh thutTn:......................Ngy: / .. /20. NA Phu thut V tr phu thut:.............Ngy: ./.. /20. NA Khng sinh c s dng vo thi im? TrcSau Trc v sau cng mt loi khng sinh Trc v sau vi hai loi khng sinh khc nhau NA 2.Nu phc c khng sinh u tin c dng cho ni khoa a.Thng tin chn on C chn on nhim khun cho vic dng khng sinh u tin c ghi r trong bnh n khng? C Tn chn on nhim khun: NA Khng V tr nhim khun (m ICD): NA b.Thng tin v xt nghim vi sinh C chn on nhim khun cho vic dng khng sinh u tin c ghi r trong bnh n khng? C Ngy yu cu../ ..... /20. NA Kt qu cy vi khun Dng tnh m tnh NA Khng Bnh nhn c c ch nh khng sinh C Khng NA VI.XT NGHIM VI KHUN V KHNG SINH Ngy gi mu: ..Ngy tr: ... Bnhphm: Dch vt m Mu Dch no ty m, dch ht ra ph qun Dch mt Nc tiu Dch bng Dch dn lu Khc: . Yu cu xt nghimKt qu Trc tip Nui cy KS Chng vi khun lm khng sinh : Khng sinhSIRKhng sinhSIR AMAmpicilinGMGentamicin AMCAmo/a. clavulanicIPMImipenem ANAmikacinLVXLevofloxacin ATMAztreonamMEMMeropenem CChloramphenicolMNOMinocyclin CAZCeftazidimMTRMetronidazol CFCefalothinNETNetilmicin CFPCefoperazonNORNofloxacin CIPCiprofloxacinOXLOxacilin/ph cu CMClindamycinPPenicilin CROCeftriaxonSAMAmpi/sulbactam CSColistinSCFCefoperazon/sulbactam CTXCefotaximSXTCo-trimoxazol CXMCefuroximTCCTicarcilin/a. clav EErythromycinTETetracyclin ETPErtapenemTMTobramycin FEPCefepimTZPPiperacilin/tazobactam FOXCefoxitinVAVancomycin IV.BIN C C HI LIN QUAN N THUC C GHI NHN TRONG BNH N STTCc bin c c hiThi gian xut hinX trKt qu 1 2 3 4 5 PH LC 2: CCH TNH H S THANH THI CREATININ Chc nng thn ca bnh nhn c nh gi bng h s thanh thi creatinin (Clcr), h s ny c tnh ton thng qua nng creatinin trong huyt thanh theo cng thc Cockroft & Gault: Clcr nam =Clcr n= 0,85 x Clcr nam oCreatinin (mol/l) = Creatinin (mg/dl) x 88,4 oTrong : Clcr: H s thanh thi Creatinin (ml/pht) Creatinin: Nng creatinin trong mu (mg/dl), (mol/l)T: Tui (nm) P: Khi lng c th (kg) PH LC 3: DANH SCH BNH NHN NGHIN CU TI BNH VIN VIT NAM THY IN UNG B STT H v tn Gii tnh Tui (nm) M bnh nhnNamN 1Nguyen Xuan C607321415 2Nguyen Van H3807294936 3Phung Van H5507288213 4Tran Thi B6007273472 5Vu Vinh H112560330 6Do Hong C2912558263 7Vu Van T4511524032 8Bui Duc K411508502 9Nguyen Duc G211505635 10Tran Van T1110485754 11Bui Thi T4610469389 12Hoang Thi L2613644926 13Tran Thi T2213645955 14Tran Thi L2013646075 15Trinh Thi Thanh T412572664 16Bui Van T6412575090 17Nguyen Bao T0.312595896 18Pham Quoc A0.112598612 19Bui Thu H2513601093 20Vu Van L9513605297 21Dinh Thanh T5613606287 22Dinh Van S3513606339 23Nguyen Thi D6608365365 24Tong Thi H2313601249 25Le Hong H508356993 26Vu Khac M7608353834 27Dinh Van H4708338563 28Nguyen Thi X2609425854 28Nguyen Thi Thuy D2009414690 30Nguyen Thi L8209397452 31Nguyen Thi D2708383015 32Bui Thi A5600161800 33Nguyen Duc M1007326955 34Vu Thi T3113647496 35Pham Nguyen Anh H211505635 36Tran Trung A0.713618725 37Nguyen Thi Tuyet M3106254611 38Nguyen Van T2709406357 39Nguyen Van T5500140546 40Dinh Thi D2909403276 41Trinh Thi Thuy N2813648801 42Pham Thi X2513648646 43Nguyen Thi Y2608362638 44Bui Van N2412582282 45Pham Quoc A112598612 46Le Hong H508356993 47Dinh Thi S3513604273 48Vu Thi Minh N3013601951 49Vu Van L9513605297 50Nguyen Trung H113641289 51Luc Nam A0.513644056 52Cao Thi O3613621958 53Le Thi T3213636237 54Pham Nguyen Anh H311505635 55Le Chi D7113618895 56Tran Van S4613618936 57Bui Van L2113620227 58Nguyen Ngoc H2513624026 59Nguyen Thi Thu T2913623967 60Nguyen Thi L5213623868 61Pham Thi Hong N2413637595 62Nguyen Thi K2513636253 63Dao Thi X2313636387 64Tran Trung A0.613618725 65Vu Van T5213634439 66Nguyen Xuan T2413633585 67Pham Thu H1713630971 68Le Thi T2513631024 69Dang Thi Q2313627664 70Dang Van T1313626672 71Do Thi Ngoc L3013625734 72Bui Thi H2613624884 73Phi Thi Thu T2413632478 74Nguyen Mai P0.713607144 75Nguyen Thi T5213648803 76Nguyen Thi Y3413602412 77Tran Van D7807262707 78Trinh Van H3006253733 79Trinh Thi C5406252188 80Dinh The P1706206516 81Hoang Thi P5806174077 82Nguyen Thi M3105178856 83Hoang Thu H805173030 84Dao Thi D6305169293 85Phan Bao N0.513620042 86Bui Van D4113617100 87Vu Thi Hong N0.113616946 88Bui Thi G4613615894 89Le Thi N3113615226 90Nguyen Van B4913613649 91Nguyen Anh V3613612587 92Do Thi My H2313611800 93Do Huu K4613611266 94Tran Duc M3013610496 94Hoang Thi Y2413610234 96Nguyen Ngoc T3213608169 97Nguyen Van T4613607080 98Nguyen Thi N2213633004 99Trieu Ha L113632804 100Dang Thi V1913638258 101Tran Kim N213639004 102Dinh Thi T1713638342 103Pham Thi D3213638275 104Nguyen Thi N3300151355 105Le Thi M2300152024 106Dinh Thi L7500171294 107Vu Van T2700059006 108Nguyen Thi Hong X2408325022 109Vu Thi V5900046917 110Vu Thuy N3007314044 111Vu Van K3907304334 112Hoang Van O2907304836 113Pham Thi Viet H3207301914 114Bui Thi L5706200285 115Dang Thi H3106228620 116Le Van S3906221046 117Nguyen Manh O113540758 118Nguyen Van K7506242335 119Tran Ngoc T7506246379 120Luc Thi H3606213787 121Hoang Van N6807310342 122La Duc N3408330659 123Nguyen Van T6505171948 124Nguyen Cong H5307258299 125Nguyen Van U7300146097 126Le Van N7700136419 127Vu Van N5513643868 128Vu Quoc T3000100724 129Vu Duc Chinh5700020491 130Dinh Thi D2909403276 131Nguyen Van T5500140546 132Nguyen Thi N2707299209 133Nguyen Tien D5807291127 134Pham Van D4207288307 135Vu Thi T2807278244 136Nguyen Quang L3607264102 137Nguyen Thi N4007261775 138Nguyen Van U7300146097 139Nguyen Cong H5307258299 140Nguyen Van N4806249513 141Nguyen Ngoc T1006234414 142Truong Van T3306206637 143Nguyen Minh N1006203207 144Nguyen The H7307256143 145Tran Danh D0.413604100 146Do Thi T2613604208 147Nguyen Thi T1313605179 148Bui Thanh G113605930 149Nguyen Quang C8413606260 150Le Thi Y2513606545 151Nguyen Minh H3313606695 152Cao Thi Q3913608047 153Nguyen Thi H2213608767 154Truong Thi L2413641707 155Trinh Anh T113619185 156Nguyen Thi T2213616569 157Pham Thi Q2213616548 158Luu Thanh T2713616408 159Nguyen Thi Thu H2013616167 160Nguyen Thi N8913615445 161Le Vu Hai L0.813614279 162Nguyen Thi M5113613524 163Vu Manh V0.513612601 164Nguyen Thi Hai Y2613611676 165Hoang Thi N2813611498 166Dam Tri D3713610986 167Tran Thi Thanh N2313642584 168Nguyen Thi T2613643008 169Le Thi N2613643167 170Dang Thi K3213644087 171Dinh Thi T2313639248 172Nguyen Thi N7113641286 173Le Thi T2313647113 174Le Thi N2411508180 175Vu Thi H3012578323 176Nguyen Thi Hong P912596837 177Nguyen Thi L4412600232 178Nguyen Thi Q2413621112 179Vu Thanh N1613622875 180Ra Tien D3413623752 181Phung Duc L1513627106 182To Thi Thuy D2013624042 183Hoang Van T3013623820 184Bui Thi T6006229358 185Pham Tran T2307280505 186Nguyen Phuong L2513626935 187Cao Thi N2812589561 188Dam Thi D2713625831 189Nguyen Thi T3013621076 190Hoang Van V4613620891 191Phi Thi N2708358433 192Pham Van L7408351406 193Nguyen Thi C2710458150 194Vu Thi N7809387748 195Ngo Quynh A609405266 196Tran Hong T6600057118 197Dinh Dieu L212561576 198Nguyen Thi T3713647486 199Nguyen Thi T3806205971 200Nguyen Viet T0.113607073 201Nguyen Hoang A2213634021 202Tran Tuyet M2605177258 203Phung Thi N2207291203 204Nguyen Duy H5507319292 205Nguyen Quang H2606248848 206Hoang Van L5307323943 207Duong Thi L5307270853 208Ngo Thi N7313638174 209Tran Thi H2713634022 210Vu Kim N813634952 211Tran Thi V3313637121 212Nguyen Thi T2913630089 213Nguyen Thi H2613631998 214Vu Thi Thu H2013632851 215Pham Cong T0.113623106 216Pham Van L7408351406