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Gio trnh Bnh nhim
93
VIM PHI CNG NG (VPC)
BS. Nguyn vn K
Mc tiu hc tp
1. Lit k c cc tc nhn gy bnh, c im dch t, sinh bnh hc ca
VPC
2. M t c cc biu hin lm sng v hi chng thng gp ca VPC
3. Nu c phng php chn on xc nh v nguyn nhn ca VPC
4. Trnh by c cc bin php iu tr v phng bnh VPC
I. I CNG
Vim phi l bnh nhim trng nhu m phi, do nhiu loi vi khun,
mycoplasma,
chlamydiae, rickettsiae, virus, vi nm v k sinh trng gy nn. Mi
loi c dch t
hc, sinh bnh hc, biu hin v din tin lm sng khc nhau. y l nhim
trng
nng so vi nhim trng ph qun, chn on lm sng i khi kh v xc nh
tc
nhn gy bnh phi tinh vi.
Vim phi cng ng (CommunityAcquired Pneumonia/CAP hoc
Pneumonies
Communautaires) l nhng bnh vim phi mc phi cng ng, ngc li vi
vim phi bnh vin mc bnh vin.
Khi vim phi xy ra cc vin chm sc lu di (nh t thin, ) th nhiu bc
s
xem nh l VPC; tri li, nhiu ngi khc xem nh vim phi bnh vin.
II. DCH T HC
Vim phi xy ra nhiu nht vo nhng thng ma lnh, thng gp nht la
tui nh v gi, v nam mc bnh nhiu hn n.
Cc yu t nguy c mc VPC gm nghin ru, hen, suy gim min dch, v
tui
trn 70. Mt tr, ng kinh, suy tim huyt, bnh mch mu no, ht thuc,
nghin
ru, v bnh phi tc nghn mn tnh (COPD) l nhng yu t nguy c vim
phi
do ph cu, trong ht thuc l nguy c mnh nht mc bnh ph cu xm ln.
Yu t nguy c mc bnh do legionella l nam gii, ang ht thuc, tiu
ng,
bnh mu c tnh, ung th, bnh thn giai on cui, v nhim HIV.
Ngi nghin ru nng (v d, ung >100g ethanol /ngy trong sut 2 nm
trc)
mc vim phi do vi khun gramm cao hn, triu chng lm sng xu hn,
v
cn iu tr khng sinh tim mch lu hn ngi khng ung. Bnh nhn vim
phi do ph cu nghin ru kinh nin st ko di hn, chm khi hn, v d
b
trn m mng phi (empyema) hn ngi khng ung. Hn na, ung ru qu
l mt yu t nguy c pht trin hi chng nguy kch h hp cp (ARDS).
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Gio trnh Bnh nhim
94
III. TC NHN GY BNH
Trn 100 mm bnh gy VPC ghi nhn gm vi khun, vi nm, virus, v k
sinh trng. May mn thay, hu ht cc trng hp vim phi do mt t mm
bnh
thng thng, gm S. pneumoniae, H. influenzae, S. aureus, M.
pneumoniae, C.
pneumoniae, Moraxella catarrhalis, Legionella spp., trc khun
gram m hiu kh,
Influenza viruses, Adenovirus, v Respiratory syncytial virus
(RSV).
1. Tc nhn gy vim phi cng ng:
Trong k nguyn trc khng sinh, vim phi hu nh ng ngha vi nhim
S.
pneumoniae. Ph cu cn chim 3060% ca tt c VPC c th xc nh
nguyn nhn. c bit n c th gy VPC nng cn nhp vin v gy vim
phi ngi gi trn 60 tui.
Nguyn nhn vi khun thng th hai l H. influenzae, chim khong 10%,
c
bit bnh nhn COPD d mc. Moraxella catarrhalis thng t hn H.
influenzae
nhiu. Cng nh H. influenzae, bnh nhn bnh tim phi d b vim phi do
M.
catarrhalis. Staphylococci v trc khun gram-m thng t hn nhiu,
nhng gy
bnh nng hn. Trong cng ng, vim phi do staphylococci thng xy ra
sau
cm, vim phi do trc khun gramm thng nht xy ra bnh nhn mi nhp
vin v iu tr khng sinh, ngi ht thuc v c bnh phi mn tnh, v
bnh nhn suy gim min dch. Tip xc vi nc phun nhim l yu t nguy
c
nhim Pseudomonas aeruginosa, v nghin ru c kh nng mc vim phi
do
Klebseilla. Vim phi do Meningococcus him thy. Nhiu loi vi khun
khc
gm L. pneumophila c th gy VPC. Vi bnh nhn c th mc bnh do ht
hn
hp nhiu vi khun thng tr trong ming.
Khong mt na trng hp VPC khng th xc nh c tc nhn gy bnh.
Cc tc nhn khng phi do vi khun (cn gi l khng in hnh) cn l
nguyn
nhn ca nhiu trng hp, nht l bnh nhn tr. C. pneumoniae cng nhn
bit
nh l nguyn nhn VPC ngi ln mc COPD. Cc virus h hp gm
Respiratory syncytial virus (RSV), Adenovirus, v Influenza hoc
Parainfluenza,
cng c th gy VPC tt c mi la tui.
2. Tc nhn gy vim phi bnh nhn suy gim min dch:
Bnh nhn suy gim min dch, c bit AIDS, d nhim mt chui rng mm
bnh phi. Thm vo nhiu mm bnh gy VPC v VPBV, h cn nhy cm vi
nhiu mm bnh c hi khng chc gy vim phi ngi c min dch bnh
thng.
Nguyn nhn thng gp:
- Pneumocystis (PCP): cn chim hn ca.
- S. pneumoniae: 100300 ln hn bnh nhn khng nhim HIV.
- H. influenzae v S. aureus: cng l nhng tc nhn gy bnh thng
gp.
- Mycobacteria: tuberculosis v non-tuberculous.
- Cryotococcus neoformans v CMV.
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Gio trnh Bnh nhim
95
Tc nhn gy vim phi khng in hnh thp. Khong 1/3 ca khng bit c
nguyn nhn.
Bng 1. Tc nhn gy VPC theo th t tn sut gn ng
BNH NHN NGOI TR BNH NHN NM VIN VIM PHI NNG/SSB
Streptococcus pneumoniae S. pneumoniae S. pneumoniae
Mycoplasma pneumoniae H. influenzae Legionella spp.
Chlamydia pneumoniae M. pneumoniae H. influenzae
Haemophilus influenzae C. pneumoniae M. pneumoniae
Virus h hp Nhim trng hn tp Trc khun gramm ng
rut
Linh tinh, gm Legionella spp.,
P. carinii, v vi nm
Trc khun gramm ng
rut
Pseudomonas aeruginosa
Vi khun k kh (vim phi
ht)
Mycoplasma pneumoniae
Virus h hp Virus h hp
Legionella spp. Linh tinh, gm C.
pneumoniae,
M. tuberculosis, S. aureus,
P. carinii, v vi nm
Linh tinh, gm M.
tuberculosis, S. aureus,
Moraxella catarrhalis,
P. carinii, v vi nm
Adapted from American Thoracic Society: Guidelines for
management of adults with community-
acquired pneumonia: Diagnosis, assessment of severity, initial
antimicrobial therapy, and
prevention. Am J Respir Crit Care Med 2001;163:17301754.
IV. SINH BNH HC
1. Cc c ch bo v k ch
Bnh thng, phi khng cha vi trng. ngi khe mnh, mt chui c ch bo
v phc tp duy tr tnh cht v trng i u vi s xm lng vi sinh nng n
ng h hp trn, ht phi hng ngn vi khun hng ngy, v ht cht tit ca
ng h hp trn gn nh din ra trong sut gic ng hng m. Khim khuyt
cc c ch bo v k ch l nguyn nhn ca hu ht cc trng hp vim phi.
Suy gim min dch l yu t thun li xy ra nhim trng, c th thy trong
cc
trng hp:
Ct lch hoc lch mt chc nng,
Gim bch cu ht, bch cu ht khng c, hoc chc nng v hiu,
Nhim HIV,
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Gio trnh Bnh nhim
96
Gammaglobulinmu ton thn hoc khu tr gim hoc khng c (thiu IgA
xut tit),
Tr sanh thiu thng v tui gi, nghin ru, tiu ng, suy dinh dng,
thng l nguyn nhn xy ra bnh phi do bin i cc hng ro min dch.
2. Ly truyn mm bnh vo phi
2.1. ng khng kh
Quan trng nht, vi s xm nhp vo cy khph qun ca cc mm bnh ngoi
sinh (Streptococcus pneumoniae, Haemophilus influenzae,
Mycoplasma
pneumoniae, Legionella pneumophila, ) hoc ni sinh (vi khun hoi
sinh
ming, ng t h hptiu ha v vng ph cn).
Mm bnh t ng h hptiu ha trn. Yu t thun li gm: ri lon nut,
lit,
hn m, bnh tai mi hng hoc ming, nht l u bu. Cng c th do tai
nn
(ngt nc).
Ht phi nhng git kh dung l nguyn nhn ly truyn virus h hp, nh cm,
ly
lan nhiu v thng xy ra khi c dch. Tng t, Mycoplasma spp. ly truyn
t
ngi sang ngi gy vim phi khng in hnh nguyn pht, Chlamydiae ly
truyn t loi chim (Chlamydia psittaci) hoc ngi (C.
pneumoniae).
Mycobacterium tuberculosis ly lan t ngi sang ngi bi cc git phun.
Mm
bnh gy nhim vi nm ton thn c l ht phi t cc ngun ca thin nhin.
Trong cc vi khun gy vim phi, Legionella pneumophila l loi c l ly
lan do
ht cc cht phun xut pht t nc ngt nhim. Pneumococci lan trn t
ngi
sang ngi bi cc git kh dung, nhng vim phi do ph cu ly khng nhiu
v
gy ra trong nhiu ca ht mm bnh mi hu, c ch nhim trng quan trng
th
hai. Ht phi mm bnh mi hu xy ra hu nh tt c mi ngi sut khi ng
v c l chu trch nhim trong hu ht cc vim phi do vi khun, gm
Staphylococci, trc khun gramm: chc chn l nguyn nhn ca vim phi
hoi
t, do ht cc vi khun thng tr hn hp ming.
2.2. ng mu
Ly lan theo ng mu, t thng nht, l nguyn nhn ca cc ca vim phi
do
t cu (Staphylococci) l t bnh nhn b vim ni tm mc van ba l hoc
vim
tc tnh mch nhim trng. C ch ny cng chu trch nhim cho nhiu vim
phi
do trc khun gramm bnh nhn nhim trng huyt, phi ng vai tr ci
lc
vi khun.
3. Thay i dn lu kh-ph qun
L kt qu ca s ph hy cu trc thng b hoc ca mt chng ngi vt dn
n thi tr mm bnh v hiu:
Vim ph qun mn, gin ph qun, bnh x nang (mucoviscidose), nghin
thuc l, ht bi hoc c cht.
Hp ng th do u bu hoc nguyn nhn khc.
Bnh ph qun cp do virus, v d cm.
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Gio trnh Bnh nhim
97
4. p ng m
Mc d p ng vim l cn bn kim sot nhim trng, n c th gy tn hi
m, h hng tc dng ca nhung mao, v ngn cn thc bo.
p ng vim vi Streptococcus pneumoniae hoc Haemophilus
influenzae
thng to nn ng c thy, nhng hoi t m him khi c. Ngc li,
Staphylococci v nhiu trc khun gramm thng gy hoi t, c th dn n
to l hng v ngay c pxe thc s, c im l quanh ph qun, nhng ng
c thy c th xy ra. Virus thng gy vim m k hn l tit dch trong
khong
khng. Nhim trng thng hai bn v gy tn thng ph nang lan ta v ph
m k. p ng m tng t c th gy bi Mycoplasma, Chlamydia, v
Legionella spp., bi nhim trng huyt gramm (sc phi), v bi cc
nguyn
nhn khc ca hi chng nguy kch h hp cp. Mycobacteria v vi nm to
p
ng ht chm mt cch in hnh.
i vi nh bnh hc, vim phi l mt nhim trng ph nang, ng h hp xa,
v m k phi, biu hin bi trng lng phi tng, thay th tnh xp bnh
thng
ca phi bng s ng c, v ph nang y bch cu, hng cu v fibrin.
V. LM SNG
Vim phi c th biu hin t nh n ti cp v gy t vong, vi bnh trm
trng
xy ra ngay c nhng ngi mnh khe trc y. Bnh c th khi pht t
ngt v nguy kch hoc t t. St km n lnh hoc lnh run, ho khan hoc
khc
m nh m hay c mu g st, au nhi ngc, v kh th l cc biu hin in
hnh ca vim phi. i khi nhc u, bun nn, i, tiu chy, au c, au
khp,
hoc mt mi. L ln c th l biu hin quan trng ngi gi.
Triu chng thc th gm th nhanh, g c, rung thanh tng, rale n, v
ting c
mng phi. Du hiu nng hu ch duy nht l nhp th > 30 ln /pht
ngi
khng c bnh phi trc.
Vi nguyn nhn v mm bnh kt hp vi t l t vong cao. T vong cao
nht
(>50%) l vim phi gy ra bi P. aeruginosa, k n l Klebsiella
spp., E. coli, S.
aureus.
Hu ht nhng bnh nhn nhp vin v vim phi l ngi gi v c nhiu bnh i
km (tiu ng, suy tim huyt, hen ph qun, hoc bnh tim thiu mu,
).
Nhiu bin chng xy ra sut thi gian nm vin, thng nht l suy h hp,
suy
tim huyt, sc, ri lon nhp tim, nhi mu c tim, xut huyt tiu ha, v
suy
thn. T l t vong bnh vin khong 8%, nguyn nhn cht tc th thng
nht
l suy h hp, suy tim v nhim trng, mt na do vim phi, mt na do cc
bnh
i km.
Cc hi chng vim phi cng ng thng gp:
1. VPC cp
Bnh nhn thng tui gia 50 v cui 60, hu ht c mt hoc nhiu bnh mn
tnh trc, gm COPD, bnh tim mch, thn kinh, tiu ng, hoc nghin
ru.
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Gio trnh Bnh nhim
98
Suy gim min dch lin quan n bnh c tnh, gim bch cu ht, dng
corticoid
hay thuc c ch ty lu di, hoc nhim HIV c th chim n 57% bnh
nhn.
Khong 81% biu hin ging nh m t c in: bnh khi pht t ngt vi lnh
run theo bi st, au ngc, v ho khc m nht m.
Triu chng thay i ty tui, c iu tr khng sinh trc, v nng ca
bnh.
Mt s triu chng khng phi h hp gm mt mi, bing n, m hi v bun
nn. Triu chng h hp v khng phi h hp t thy nhm tui gi hn. Th
nhanh (>2430 /pht) thng thy nhm tui gi hn. Nghe phi c rale
(khong
78%), du ng c (khong 29%).
Bch cu thng 15.00035.000/mm3, gim BC c th gp v l du tin lng
xu. CRP tng 50100mg/L thy sm. m c v m, c th mu g st, nhum
Gram thy nhiu Neutrophile v vi khun, thng c mt mm bnh tri
nht.
Phim phi thy nhng vng tn thng nhu m, thng vi tin trnh lp y
ph
nang. Ngay c vi nhng xt nghim y , ch 2070% c chn on vi sinh.
S. pneumoniae cn l nguyn nhn chnh. Mt s gy ra do H. influenzae.
S t do
S. aureus gy vim phi ngi gi v nhng ngi mc bnh cm. Phn cn li
do vi khun Gram m hiu kh (ngoi tr H. influenzae) v cc vi khun k
kh v
hiu kh hn hp. Mt na trc khun Gram m l Pseudomonas aeruginosa,
nghi
ng bnh nhn cng mc bnh phi v mi nhp vin.
Ngoi ra, cn gp vim phi do Legionella spp., c biu hin lm sng khc
vim
phi do cc vi khun khc. St cao > 40oC, nam gii, iu tr lactam,
tn
thng nhiu thy bt thng, Xquang din tin nhanh, cn chm sc c bit,
bt
thng d dy rut v thn kinh, men gan v creatinine tng kt hp vi vim
phi
Legionella. Moraxella catarrhalis cng gp, l mm bnh quan trng ngi
gi
c COPD, v cc th suy gim min dch khc.
2. VPC ngi gi
Biu hin lm sng khng r nh ngi tr, vi khi pht t t hn, st v
nhng triu chng c in ca vim phi. St t xy ra, cng nh n lnh v
rt
run. Trong mt na ngi gi, c th khng c ho v kh th. t thy th
nhanh
(nhp th > 2430 ln/pht). Thng nghe c rale, mc du nhng hi
chng
ng c t tm thy.
Cc triu chng khng phi h hp c th l biu hin chnh. Biu hin u tin
c
th gm gim tng trng, yu, thay i nh tm trng, bing n v au bng.
ngi gi thng b nhim trng huyt, nhim trng di cn v t vong cao
hn.
3. VPC. nh
Thng iu tr ngoi tr, do cc tc nhn gy bnh thng gp: S.
pneumoniae,
H. influenzae, S. aureus, M. pneumoniae, v cc loi virus (thng gp
Influenzae
A v B, Parainfluenzae, Adenovirus v RSV).
4. VPC. nng
Khong 10% VPC cn sn sc c bit/thng kh c hc.
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Gio trnh Bnh nhim
99
- S. pneumoniae v L. pneumophila thng gp nht.
- Klebsiella spp. ngh n khi c bnh quan trng trc nh COPD, tiu
ng, nghin ru.
- M. pneumoniae,
Th nhanh (> 30 ln /pht), huyt p tm trng < 60mmHg v BUN
> 7mmol /L
thng dn n t vong. Cc tnh cht khc lm tng t l t vong gm c bnh
nng trc, bnh c tnh, trn 60 tui, khng au ngc mng phi, thay i tm
tr,
suy h hp cp cn h tr thng kh, tn thng phi hai bn, nhim trng
huyt,
N < 3.500/mm3, protein huyt thanh < 45g/L, creatinin huyt
>15mg/L, c sc,
iu tr khng sinh lc u khng , X quang chng t bnh ang lan rng,
v
vim phi do S. aureus hoc trc khun Gram m.
5. VPC. chm khi
c nh ngha khi gim < 50% bt thng X quang 2 tun v cha sch
ht
khi n 4 tun. Cc yu t k ch nh > 50 tui, ung ru, c bnh nng
trc
(COPD, tiu ng, suy tim huyt, hen ph qun, c tnh) kt hp vi vim
phi
chm khi. Mc khi cng ty thuc tc nhn gy bnh, vi S. pneumoniae
thng
cn n 6 tun, Legionella 26 thng, Mycoplasma vi tun.
Khi vim phi chm khi, cn xem c th: tc nhn gy bnh khng thuc,
chn
on mm bnh sai, hoc chn on vim phi khng ng. Cn chn on phn
bit vim phi vi bnh c tnh, vim mch mu, xut huyt phi, v vim
phi
tng bch cu i toan.
6. Hi chng vim phi khng in hnh
Nguyn nhn quan trng nht l: M. pneumoniae, Chlamydophila
(Chlamydia)
pneumoniae, v L. pneumophila. Tc nhn gy bnh khc gm:
Chlamydophila
(Chlamydia) psittaci, Francisella tularensis, M. tuberculosis,
Coxiella burnetii, v
mt loi virus h hp (Adenovirus, ). bnh nhn AIDS, Pneumocystis v
cc
Mycobacteria non-tuberculous cng l nhng tc nhn gy bnh.
Phn bit VPC do vi khun in hnh v cc tc nhn khng in hnh khng r
rng.
Trong th c in, nhim Mycoplasma biu hin nhng triu chng c nng
v
tin trin t ng h hp trn xung di. Thng bt u au hng. Khi c vim
mng nh bng nc (5%), ngh n nhim Mycoplasma. Triu chng chnh l
st,
kh chu, s mi, nhc u v ho. t thy au ngc, kh th v suy h hp. C
th
nghe ran n hoc m. Khc m bin thin, trng hp c th c nh m.
Tn thng phi trn X quang thng lan rng hn khm thc th: thm nhim
mt hoc hai bn mt hay hai phn phi, thng thy di, phn b theo ph
qun hoc quanh ph qun. Him thy tn thng thy trn v trn dch. Hu
ht
din tin lnh tnh. Triu chng c nng bin mt trong tun 1 v 2, mc d ho
v
cc thay i X quang c th ko di vi tun. Thnh thong, nhim M.
pneumoniae
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Gio trnh Bnh nhim
100
cn sn sc c bit. Mt s ln c biu hin ngoi phi gm tn thng da, h
thn kinh trung ng, mu v thn.
- Chlamydophila pneumoniae gy vim phi khng in hnh, cng l mt
ng
sinh bnh quan trng, thng kt hp vi S. pneumoniae. Bnh thng l t,
mc
d ghi nhn c xy ra dch. a s khng triu chng hoc nh. Bt u au
hng
v khan ting, nhng din tin chm hn trong vim phi Mycoplasma v
virus.
Ho c th bt u sau vi ngy n hng tun, ngh n mt bnh c hai thi k.
Khan ting v au xoang thng hn trong bnh nhn nhim Mycoplasma
hoc
virus. Bch cu mu him khi cao. Bnh thng nh, mc d c th chm khi
hn. Ho v kh chu c th ko di hng tun n hng thng. Biu hin ngoi
phi
gm vim tai, vim xoang, vim mng ngoi, mng trong v c tim.
- Chlamydia trachomatis gy bnh vi ho khc, au c v st, kt hp vi
thm
nhim lan ta.
Tc nhn virus ngi ln thng nht l Influenzae A v B, Adenovirus type
3,
4 v 7, Parainfluenzae, v RSV. c im bnh s kh kh v khm nghe ran
rt.
- Legionella c th gy VPC khng hoc in hnh, trong L.
pneumophila
chim 80%. Mc d kh chu, au c, nhc u, ho khan ging hi chng siu
vi,
thng triu chng h hp v st tng i cao c gi tr. Kt hp vi cc triu
chng ngoi phi gm: thay i tm tr, phn lng hoc tiu chy, nhc u,
tim
chm. Biu hin X quang kh phn bit, c im l thm nhim m k, hoc nt
c th tin trin nhanh d iu tr , trn dch c th ghi nhn n bnh
nhn.
7. Vim ph qun-phi (VPQ-P)
a s do virus, ngoi tr ngi c bnh ph qun mn.
7.1. Do virus: RSV c th gy dch trong tp th tr nh, vi nguy c nng
tr s
sinh v nh nhi. Tng t nh Myxovirus parainfluenzae I, II, III. Phn
nh do
mc si hoc thy u nng.
7.2. Do vi khun: thng l bi nhim.
- S. pneumoniae cn l mm bnh thng nht.
- H. influenzae tr em, gy tn thng lan ta, kt hp vi vim mng no,
vim
tai, hoc vim np thanh qun.
- S. aureus ngi ln, tin trin nhanh n to pxe v trn m mng phi.
tr
nh nhi, bnh cnh thng m h, vi triu chng bng, tng trng thay i
sm
v nng vi nguy c suy h hp. Din tin ch bi xut hin hnh nh bng
hi,
thnh mng, gy ngt th v nguy c v vo mng phi.
- Pseudomonas aeruginosa xy ra ngi VPQ mn, iu tr nhiu khng
sinh,
bnh nhn suy gim min dch c tin cn nhp vin.
- Bordetella pertussis gy bnh ho g.
7.3. Do vi nm: xy ra nht l ngi suy gim min dch.
8. Vim phi m k
8.1. Do virus
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Gio trnh Bnh nhim
101
Thng xy ra dch theo ma (cm v RSV trong ma lnh).
Adenovirus thng nht ngi tr, thng kt hp vi vim kt mc hai bn,
hch c to, pht ban dng si, ngay c tiu chy.
CMV thng gy bnh ngi suy gim min dch.
8.2. Do vi khun
- M. pneumoniae: bnh bt u t t vi st < 39oC, ho khan, tng cn
bui ti.
Triu chng ngoi phi gm: au c, vim ngoi b quanh cc l t nhin. X
quang ngc thy cc hnh hn hp vi sang thng m k tri nht trn hnh
ph
nang (nhiu nht y phi). Bng dng cm tri y phi.
- Chlamydia psitttaci: c tip xc vi vt, b cu, vt, g li. Bnh phi
khng in
hnh vi mch khng tng, kh th v cc triu chng ngoi phi (au c
quanh
dy tht lng, hch trung tht, lch to v hoi t t bo gan). C.
pneumoniae gy
nhim ng h hp trn v di, ly t ngi sang ngi.
- Coxxiella burnetii: ly qua ngi theo ng khng kh t cc cha mm
bnh
loi gm nhm, cu, d, b, th n tht trong nh. Bnh bt u t ngt, st
cao
nguyn 3940oC, au c lan ta, gan lch thng to.
8.3. Do k sinh trng
Pneumocystis carinii, Toxoplasma gondii, thng xy ra ngi suy
gim
min dch. Bnh thng bt u t t, tn thng lan ta.
VI. CHN ON
1. Chn on xc nh
Da trn bnh s, cc biu hin lm sng v xt nghim.
1.1 Vim phi gm mt nhm triu chng (st, lnh run, ho, au ngc
mng phi, khc m, tng hoc gim nhit, nhp th nhanh, g c, rale
ph qun, rale n, ting c mng phi), kt hp vi t nht mt bng m
trn X quang ngc.
Vim phi do vi khun v khng do vi khun biu hin lm sng khc
nhau.
Vim phi khng do vi khun thng xy ra nht tr ln v ngi ln cn
tr. Bnh nhn vim phi do virus, Mycoplasma, hoc Chlamydiae
thng
than phin ho khan nng, nhng khc m tht s bt thng. Bnh nhn
vim phi vi khun khc m nhiu, cng nh khi pht bnh t ngt, st
cao, lnh run, v pht trin trn dch ng k. Khm thc th, thng thy
du hiu ng c phi hoc t nht l nhng rale khu tr. Tng phn vi
bnh nhn vim phi khng do vi khun, ch thy t rale nh, v thng,
du thc th t lan rng hn cc bt thng trn X quang.
Chn on vim phi da trn lm sng c nhy 4769% v chuyn
bit 5875%.
1.2 X quang ngc, khng nhy n 100%. Xquang ngc thy ng c
mt phn, hoc mt thy phi, pxe phi, hoc trn dch mng phi ng
-
Gio trnh Bnh nhim
102
k, c th l vim phi do vi khun hn. Trong khi thm nhim lm m,
khng u, m k tht s ngh n nguyn nhn khng phi vi khun.
Bng 2. Yu t k ch kt hp vi mm bnh vim phi chuyn bit
TNH TRNG BNH NHN VI SINH VT LIN I
Nghin thuc l tch cc/COPD Streptococcus pneumoniae, Haemophilus
influenzae,
Legionella pneumophila
Sng nh an dng S. pneumoniae, trc khun gramm, H. influenzae,
Staphylococcus aureus, Chlamydia pneumoniae, vi khun
k kh, lao
Nghin ru
S. pneumoniae (k c dng khng thuc), trc khun gram
m, vi khun k kh, lao
Ht nng/ b rng xu km Vi khun k kh
Du lch n Ty nam Hoa k Coccidioides immitis
Tip xc vi di Histoplasma capsulatum
Tip xc vi loi chim Cryptococcus neoformans, C. psittaci, H.
capsulatum
Tip xc vi th Francisella tularensis
Tip xc vi cc ng vt trang tri Coxiella burnetii (Q fever)
Bnh cm Influenza, S. aureus, S. pneumoniae, H. influenzae
Gin ph qun, X ha nang
Pseudomonas aeruginosa, P. cepacia, S. aureus,
Aspergillus spp., Mycobacterium avium complex
Dng thuc tim mch S. aureus, vi khun k kh, lao, P. carinii
Tc ni ph qun Vi khun k kh
iu tr khng sinh mi y S. pneumoniae khng thuc, P. aeruginosa
Adapted from American Thoracic Society: Guidelines for
management of adults with
community-acquired pneumonia: Diagnosis, assessment of severity,
initial antimicrobial therapy,
and prevention. Am J Respir Crit Care Med 2001:163:17301754.
1.3 CT rt hu ch vi nhim trng hn hp. CT thnh thong tm thy
nhng m m phi trn nhng bnh nhn c triu chng nghi vim phi, nhng
hnh X quang khng chng t vim phi. Nu lm sng nghi nhiu n vim
phi,
m phim ngc u tin khng thy m m, cn chp X quang lp li trong
2448
gi hoc chp CT. Cn phn bit vi xp phi.
VIM PHI THY LAO PHI
-
Gio trnh Bnh nhim
103
Thnh thong, mt chn on nguyn nhn ngh n trn hnh X quang ngc. V
d, sang thng c hang thy trn c l do lao phi, v c bu kh ngh n
vim phi do Staphylococcus aureus. Mc nc hi do pxe phi, thng
do
nhiu vi khun. ngi suy gim min dch, du li lim ngh n vim phi
do
Aspergillus.
VIM PHI DO
S. AUREUS
PXE PHI (T) VIM PHI DO ASPERGILLUS
2. Chn on nguyn nhn
Mm bnh gy vim phi c th nhn bit t cy mu, m, dch mng phi, m
phi, hoc cht tit trong ph qun ly t pht hay ra ph qun. Cc phng
php
khc xc nh nguyn nhn vim phi gm pht hin p ng IgM hoc hiu
gi khng th vi khng nguyn ca mt vi sinh c bit tng gp 4 ln v tm
thy
khng nguyn trong nc tiu, huyt thanh, hay dch mng phi. Trong vi
trng
hp, khuch i DNA hoc RNA ca mt mm bnh h hp t mt trong cc bnh
phm trn hoc t cht pht hu hng c th dng cho mc ch ny.
2.1. Cy mu
Cng thc mu trong vim phi do vi khun, c th c tng bch cu a nhn
trung tnh.
bnh nhn iu tr ngoi tr, cn ly mu cy khi c mt trong du hiu
sau:
thn nhit >38.5C, hoc
-
Gio trnh Bnh nhim
104
Kt qu cy phi lun tng quan vi nhum. Vi mm bnh phn lp trong m
nn lun xem l gy bnh gm: M. tuberculosis, Legionella spp., B.
dermatitidis,
H. capsulatum, v C. immitis.
Cn kho st xm ln bnh nhn suy gim min dch, bnh nguy kch, tht
bi
vi iu tr thng thng. Bin php gm ht qua kh qun, soi ph qun (i
khi
cn sinh thit), pht ph qun, BAL, hoc ly mu phi xuyn qua da, sinh
thit
phi m.
Bng 3. Phn loi chn on nguyn nhn vim phi
Xc nh
(Definition)
Mm bnh tm thy t mu, dch mng phi, hoc m phi.
Legionella spp. hoc M. tuberculosis phn lp t m.
Th nghim khng nguyn Legionella trong nc tiu dng tnh.
C nhiu kh nng
(Probable)
Phn lp bt c vi sinh no sau y t mu m m, vi hnh dng
tng t trn nhum Gram s ln hoc va: Staphylococcus aureus,
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis, Pseudomonas aeruginosa.
Hiu gi khng th vi mm bnh h hp tng 4 ln hoc hn gia
mu huyt thanh thi k hi phc v cp tnh.
Th nghim khng nguyn S. pneumoniae trong nc tiu ngi
trng thnh dng tnh.
C th
(Possible)
Nhum Gram mt mu m c th chp nhn chng t Song cu
trng gram dng (S. pneumoniae), T cu gram dng (S. aureus),
hoc Trc cu trng gram m (H. influenzae) chim u th.
Phn lp mt mm bnh t mu m m trong khi nhum Gram tng
ng khng thy.
Hiu gi n c hoc khng thay i cao vi Legionella pneumophila
(=1:1024) hoc Mycoplasma pneumoniae (=1:64).
2.3. Tm khng nguyn ca mm bnh phi trong nc tiu
Khng nguyn L. pneumophila serogroup 1 c th tm thy trong nc tiu
bnh
nhn mc bnh do vi khun ny bi th nghim ELISA.
ELISA cn tm khng nguyn S. pneumoniae trong nc tiu bnh nhn
vim
phi ph cu nhim trng huyt. tr em, mang mm bnh S. pneumoniae
trong
hu hng c th cho kt qu dng tnh.
2.4. Huyt thanh hc
Tm thy khng th IgM hoc chng minh hiu gi khng th vi mt tc nhn
c
bit, tng 4 ln mu huyt thanh thi k hi phc so vi thi k cp tnh
thng
chng t tc nhn ny l nguyn nhn gy vim phi. Cc tc nhn gy bnh
sau
y thng chn on bng xt nghim huyt thanh: M. pneumoniae, C.
pneumoniae, Chlamydia psittaci, Legionella spp., C. burnetii,
Adenovirus, Para
v Influenza virus A.
-
Gio trnh Bnh nhim
105
Cc xt nghim huyt thanh gm: gn b th, min dch hunh quang gin tip,
v
ELISA. Th nghim tm khng th IgM v IgG tch bit c th thc hin vi 2
th
nghim sau. Kh khn l c huyt thanh hc ca p ng khng th n dng i
vi mt tc nhn.
2.5. PCR
Nhiu phn ng cho php tm DNA ca Legionella spp., M. pneumoniae,
C.
pneumoniae. Th nghim ny t tin v khng lm thng qui.
Nhn dng tc nhn gy bnh vim phi nn phn loi l tc nhn xc nh, c
nhiu kh nng, hoc c th, ty thuc ngun vi sinh hoc th nghim dng
khm ph. Phn loi chn on nh vy hu ch khng nhng trong nghin cu
so
snh v nguyn nhn vim phi, m cn trong cch tip cn bnh nhn vim
phi.(Bng 3)
3. Chn on phn bit
3.1 Bnh khng phi do nhim trng:
Vim ph qun dng hen.
Vim phi qu mn.
COPD, k c kh ph thng v dn ph qun (bronchiectasis).
Xp phi, nhi mu phi, ph phi v bu phi.
Phn ng qu mn v c t do thuc hoc ha cht dng phun, ung chch.
Vim phi do tia bc x, bnh sarcoidosis, vim mch mu, vim phi do
urhuyt xut huyt phi, vim phi tng bch cu i toan.
3.2 Bnh nhim trng:
Vim ph qun cp (c th phi hp/do cng tc nhn gy bnh).
VII. IU TR
V nguyn nhn vim phi thng khng bit, iu tr khng sinh ban u
thng
theo kinh nghim v cn c trn bnh s, biu hin lm sng, kiu bt thng
trn
X quang phi, cc kt qu soi m hoc cc dch th khc, v mu nhy cm
hin
nay ca mm bnh nghi ng i vi khng sinh.
Chn khng sinh phc tp do tn xut khng thuc ca ph cu, cn kim sot
c
mm bnh khng v in hnh v d kin ngh iu tr phi hp.
Penicillin cn c vai tr quan trng trong iu tr VPC. Vi ph cu khng
nhy,
dng liu cao hn hoc khong cch gia cc liu ngn hn c th iu tr
hiu
qu nhng mm bnh khng thuc tng i. Cc loi Penicillin ung nh
Amoxicillin v Amoxicillinclavulanic acid c th to c tc dng ny
ngay
c i vi vi mm bnh khng Penicillin.Trong cc Cephalosporin ung,
Cefuroxime c li nht, nhng ch i vi dng ph cu nhy va vi
Penicillin.
Penicillin liu cao v Cephalosporin th h th III nh Ceftriaxone v
Cefotaxime
khng ch ngay c nhng dng khng thuc. Cc loi khc nh Ceftazidime
v
Ceftizoxime t mnh hn.
-
Gio trnh Bnh nhim
106
Mt s Quinolone ng h hp (Levofloxacin, Moxifloxacin,
Gemifloxacin,
Gatifloxacin) c tc dng chng a s cc tc nhn in hnh v khng in
hnh
gy nhim trng h hp di. Nhng dng ph cu khng vi cc Quinolone
ng h hp cng tng trnh, s tht bi trong iu tr nhim ph cu bng
Quinolone do khng thuc rt bt thng.
C tc dng hip ng gia lactam v Macrolide, nht l Azithromycin.
Phi
hp iu tr vi cc khng sinh ny lm gim t l t vong v thi gian nm
bnh
vin ca nhng ngi bnh gi mc VPC v vim phi c chng minh do ph
cu, gm c trng hp nhim trng huyt.
Telithromycin l mt thnh phn th nht ca loi Ketolide nghin cu lm
sng
c tc dng tt chng nhng dng ph cu, H. influenzae, v Moraxella spp.
nhy
v khng vi Penicillin.. N cng tc dng chng dng ph cu khng
Macrolide.
Ch cn c vo tui, thng khng nh hng n chn thuc. Ni m nguy c
ph cu khng thuc thp, chn lactam (Amoxicillinclavulanic acid,
Cefuroxime axetil), Macrolide/Azalide (Erythromycin,
Azithromycin, hoc
Clarithromycin), hay Fluoroquinolone ng h hp ung.
bnh nhn m nguy c tng do tui hoc bnh c sn, hay nguy c nhim ph
cu khng thuc, Fluoroquinolone ng h hp l khng sinh c l hiu qu
nht.
Chng c tc dng chng tt c dng ph cu, k c dng khng Penicillin, v
cn
tc dng chng mm bnh khng in hnh.
Khi mm bnh c phn lp, chn theo khng sinh , ph cng hp cng tt.
Bnh nhn cn nhp vin, nn iu tr bng thuc chch khng ch nhng mm
bnh c th. Nn chn Fluoroquinolone ng h hp, hoc Ceftriaxone phi
hp
vi Azithromycin.
Trong thi gian c dch cm, nghi ng vim phi do t cu khng
Methicillin, c
th dng Vancomycin, Linezolid, hoc Quinupristin/Dalfopristin.
Nghi vim phi do ht, dng khng sinh chng vi khun k kh ming, gm
Ampicillinsulbactam hoc Clindamycin.
Nu nghi trc khun gram m, c th nhim Pseudomonas aeruginosa, iu
tr
bng lactam chng pseudomonas (nh Cefepime,
Piperacillintazobactam,
imipenem, hoc meropenem). Nu loi tr Pseudomonas, dng
Cefotaxime,
Ceftriaxone. Phi hp lactam vi Aminoglycoside hoc Quinolone iu
tr
vim phi gram m cn bn ci. Bnh nhn d ng vi Penicillin, c th
dng
Aztreonam vi Fluoroquinolone ng h hp, thm Aminoglycoside hay
khng.
Sau y l hng dn chn khng sinh iu tr VPC theo kinh nghim ca Hi
Lng ngc, Hi Bnh truyn nhim Hoa K. (bng 4)
-
Gio trnh Bnh nhim
107
Bng 4. Hng dn chn khng sinh theo kinh nghim iu tr bnh nhn b
VPC
TNH TRNG BNH NHN LA CHN IU TR THCH HP
Khng iu tr khng sinh mi y C iu tr khng sinh mi y Khng iu tr khng
sinh mi y C iu tr khng sinh mi y Nhim trng nghi do ht phi Cm c bi
nhim vi khun
Ngoi tr
Khe mnh trc y Macrolide1 hoc Doxycycline Fluoroquinolone h hp3 n
c, hoc Macrolide mi + Amoxicillin (hay Amoxicillinclavulanate) liu
cao C sn bnh COPD, tiu ng, suy tim/thn, c tnh Macrolide mi2 hoc
Fluoroquinolone h hp Fluoroquinolone h hp n c, hoc Macrolide mi +
lactam Amoxicillinclavulanate hoc Clindamycin lactam, hoc
Fluoroquinolone h hp
Khng iu tr khng sinh mi y C iu tr khng sinh mi y Khng do nhim
Pseudomonas Do nhim Pseudomonas
Ni tr
Khoa Ni Fluoroquinolone h hp n c, hoc Macrolide mi + lactam
Macrolide mi + lactam, hoc Fluoroquinolone h hp n c (chn ty khng
sinh dng mi y) Khoa Sn sc c bit lactam + Macrolide mi, hoc +
Fluoroquinolone h hp (D ng lactam: Fluoroquinolone h hp
Clindamycin) Thuc chng pseudomonas4 + Ciprofloxacin, hoc Thuc chng
pseudomonas + Aminoglycoside + Fluoroquinolone h hp hoc Macrolide
(D ng lactam: Aztreonam + Levofloxacin, hoc Aztreonam +
Motifloxacin hoc Gatifloxacin Aminoside)
ang iu tr nh iu dng
nhp vin
Nh iu dng
Fluoroquinolone h hp n c, hoc
Amoxicillinclavulanate + Macrolide mi
iu tr nh Khoa Ni v Khoa Sn sc c bit 1 = Erythromycin,
Azithromycin, hoc Clarithromycin. 2 = Azithromycin, hoc
Clarithromycin. 3 = Motifloxacin, Gatifloxacin, Levofloxacin, hoc
Gemifloxacin. 4 = Piperacillin, Piperacillintazobactam, imipenem,
meropenem, hoc Cefepime.
Data from Mandell LA, Bartlett JG, Dowell SF, et al. Update of
practice guidelines for the management of community-acquired
pneuminia in immunocompetent adults. Clin Infect Dis.
2003:37:1405-1433.
V mt lch s, tin trnh iu tr vim phi l 1014 ngy, ty thuc bnh nhn
c
cn phi nhp vin khng, c lc ca tc nhn gy bnh, s hin din ca
nhng
-
Gio trnh Bnh nhim
108
bnh i km, v mc p ng. Azalide, Ketolide, v Quinolone dng liu
cao
v/hoc iu tr thi gian ngn 57 ngy vi thnh cng ban u. Hin nay, iu
tr
1014 ngy cho bnh nhn nhp vin dng nh thch hp nht.
VIII. PHNG BNH
Tt c nhng ngi nghin thuc l b vim phi nn khuyn b thuc.
Chch nga cm v ph cu.
Khi b ht phi (aspiration) dch hoc kh, cn c bin php phng nga
vim
phi.
TI LIU THAM KHO
1. Gerald R. Donowitz, Gerald L. Mandell. Acute pneumonia. In
Mandell,
Douglas and Bennetts Principle and Practice of Infectious
Diseases, 6th edition,
2005, Chapter 61 (Pages 819839).
2. APPIT. Pneumonies communautaires. Dans Maladies Infectieuses
et Tropicales,
E. Pilly, 17 dition, 2M2, 2000, Chapitre 20 (Pages 154164).
3. Thomas J. Marrie, G. Douglas Campbell, David H. Walker,
Donald E. Low.
Pneumonia. In Harrisons Principle of Internal Medicine, 16th
edition, 2005,
Chapter 239 (Pages 15821595).
4. Andrew H. Limper. Overview of pneumonia. In Cecil Textbook of
Medicine,
22nd edition, 2004, Chapter 92 (Pages 462 465).
5. Harvey B. Simon. Pulmonary infections. In The Clinician's
Guide to Diagnosis,
Treatment, and Prevention, 2004. Chapter 6 (Pages 5156).
6. INFECTIOUS DISEASES AND ANTIMICROBIALS NOTES. Pneumoniae
(Page 216). Copyright PDA Medical Solutions, All Rights
Reserved. Last
Revised on July 2002. Type: PDB File. Modified: 8/12/2005.
CU HI TRC NGHIM
1. Mt tr, ng kinh, suy tim huyt, bnh mch mu no, ht thuc,
nghin
ru, v bnh phi tc nghn mn tnh (COPD) l nhng yu t nguy c vim
phi do ph cu, trong ht thuc l nguy c mnh nht mc bnh ph cu
xm ln.
A. ng
B. Sai
2. Hai tc nhn gy vim phi thng gp nht l:
A. S. aureus v H. influenzae
B. Staphylococci v trc khun gramm
C. S. pneumoniae v H. influenzae
D. C. pneumoniae v P. carinii
-
Gio trnh Bnh nhim
109
3. Chn cu sai khi ni v sinh bnh hc ca vim phi:
A. Khim khuyt cc c ch bo v k ch l nguyn nhn ca hu ht vim
phi
B. Ly lan thng nht l theo ng mu n phi
C. Thay i dn lu khph qun dn n thi tr mm bnh v hiu nh
vim ph qun mn, gin ph qun
D. p ng vim c th gy tn hi m, h hng tc dng ca nhung mao, v
ngn cn thc bo
4. Biu hin lm sng in hnh ca vim phi:
A. Bnh c th khi pht t ngt v nguy kch hoc t t.
B. St km n lnh, ho khan hoc khc m, au nhi ngc, v kh th
C. Triu chng thc th gm th nhanh, g c, rung thanh tng, rale n
D. C a, b, v c
5. VPC ngi gi:
A. Khi pht t ngt hn, vi st v nhng triu chng c in ca vim phi
B. Cc triu chng khng phi h hp c th l biu hin chnh, gm gim
tng trng, yu, thay i nh tm trng, bing n v au bng
C. Thng thy th nhanh (nhp th > 2430 ln/pht)
D. Thng khng nghe c rale, mc du nhng hi chng ng c thng
tm thy
6. Chn on vim phi:
A. Chn on vim phi da trn lm sng, cn xc nh bi hnh chp X
quang ngc
B. Xquang ngc thy ng c mt phn, hoc mt thy phi, pxe phi,
hoc trn dch mng phi ng k, c th l vim phi do vi khun hn
C. Mm bnh gy vim phi c th nhn bit t cy mu, m, dch mng
phi, m phi, hoc cht tit trong ph qun
D. Xt nghim m l chnh chn on nguyn nhn. Ra ph qunph
nang (BAL) hiu qu tm tc nhn gy bnh hn
E. Tt c cc cu trn
P N: 1. A 2. C 3. B 4. D 5. B
6. E