nkhani

Chibayo cha Nosocomial ndi matenda ofala kwambiri komanso owopsa a nosocomial, omwe chibayo chogwirizana ndi mpweya (VAP) chimakhala 40%. VAP yoyambitsidwa ndi tizilombo toyambitsa matenda akadali vuto lovuta lachipatala. Kwa zaka zambiri, malangizo adalimbikitsa njira zingapo zothandizira (monga kuwongolera, kukweza mutu) kuti ateteze VAP, koma VAP imapezeka mpaka 40% ya odwala omwe ali ndi tracheal intubation, zomwe zimapangitsa kuti azikhala nthawi yayitali m'chipatala, kugwiritsa ntchito mankhwala opha maantibayotiki ambiri, komanso kufa. Anthu nthawi zonse amafuna njira zodzitetezera.

Ventilator-associated pneumonia (VAP) ndi chiyambi chatsopano cha chibayo chomwe chimayamba patatha maola 48 pambuyo pa tracheal intubation ndipo ndi matenda ofala kwambiri komanso akupha a nosocomial mu chipinda cha odwala kwambiri (ICU). The 2016 American Society of Infectious Diseases Guidelines yasiyanitsa VAP kuchokera ku tanthauzo la chibayo chopezeka kuchipatala (HAP) (HAP imangotanthauza chibayo chomwe chimachitika pambuyo pogonekedwa m'chipatala popanda chubu cha tracheal ndipo sichikugwirizana ndi mpweya wabwino; VAP ndi chibayo pambuyo pa tracheal intubation and mechanical ventilation), ndipo European Society HAP idakali yapadera [3] mtundu wa VAP ndi China.

Odwala omwe amalandira mpweya wabwino wa makina, chiwerengero cha VAP chimachokera ku 9% mpaka 27%, chiwerengero cha anthu omwe amafa chimafika pa 13%, ndipo zingayambitse kuwonjezereka kwa maantibayotiki, kutulutsa mpweya wabwino kwa nthawi yaitali, kukhala ICU kwa nthawi yaitali, ndi kuwonjezeka kwa ndalama [4-6]. HAP / VAP mwa odwala omwe alibe chitetezo chamthupi nthawi zambiri amayamba chifukwa cha matenda a bakiteriya, ndipo kugawidwa kwa tizilombo toyambitsa matenda ndi kukana kwawo kumasiyana ndi dera, kalasi yachipatala, chiwerengero cha odwala, ndi maantibayotiki, ndikusintha pakapita nthawi. Pseudomonas aeruginosa ankalamulira tizilombo toyambitsa matenda a VAP ku Ulaya ndi America, pamene Acinetobacter baumannii ambiri anapezeka m'zipatala zapamwamba ku China. Gawo limodzi mwa magawo atatu mpaka theka la imfa zonse zokhudzana ndi VAP zimayambitsidwa mwachindunji ndi kachilomboka, ndipo chiwerengero cha anthu omwe amafa chifukwa cha Pseudomonas aeruginosa ndi acinetobacter ndi apamwamba [7,8].

Chifukwa cha kusiyanasiyana kwa VAP, chidziwitso chodziwikiratu cha mawonetseredwe ake azachipatala, kujambula ndi kuyesa ma laboratory ndi otsika, ndipo mitundu yosiyanasiyana ya matendawa ndi yotakata, zomwe zimapangitsa kuti zikhale zovuta kudziwa VAP panthawi yake. Panthawi imodzimodziyo, kukana kwa mabakiteriya kumabweretsa vuto lalikulu pa chithandizo cha VAP. Akuti chiopsezo chokhala ndi VAP ndi 3%/tsiku m'masiku 5 oyamba kugwiritsa ntchito mpweya wabwino, 2%/tsiku pakati pa masiku 5 mpaka 10, ndi 1%/tsiku kwa nthawi yonseyi. Zomwe zimachitika pachimake nthawi zambiri zimachitika pakadutsa masiku 7 a mpweya wabwino, kotero pali zenera momwe matenda angapewedwe msanga [9,10]. Maphunziro ambiri ayang'ana kupewa kwa VAP, koma ngakhale kuti zaka makumi ambiri zafukufuku ndikuyesera kuteteza VAP (monga kupeŵa kulowetsedwa, kuteteza kubwezeretsanso, kuchepetsa kutsekemera, kukweza mutu wa bedi ndi 30 ° mpaka 45 °, ndi chisamaliro chapakamwa), zochitikazo sizikuwoneka kuti zachepa ndipo katundu wachipatala wogwirizana amakhalabe wokwera kwambiri.

Maantibayotiki okometsedwa akhala akugwiritsidwa ntchito pochiza matenda amtundu wapanjira kuyambira m'ma 1940. Chifukwa chitha kupititsa patsogolo kuperekedwa kwa mankhwala kumalo omwe akukhudzidwa ndi matenda (mwachitsanzo, njira yodutsa mpweya) ndikuchepetsa zotsatira zoyipa, zawonetsa kufunika kogwiritsa ntchito matenda osiyanasiyana. Maantibayotiki okometsedwa tsopano avomerezedwa ndi US Food and Drug Administration (FDA) ndi European Medicines Agency (EMA) kuti agwiritsidwe ntchito mu cystic fibrosis. Maantibayotiki opumira amatha kuchepetsa kuchuluka kwa mabakiteriya komanso kuwonjezereka kwapang'onopang'ono kwa bronchiectasis popanda kuchulukitsa zovuta zonse, ndipo malangizo apano adawazindikira ngati chithandizo choyambirira kwa odwala omwe ali ndi matenda a pseudomonas aeruginosa komanso kuwonjezereka pafupipafupi; Maantibayotiki opangidwa ndi mpweya panthawi ya opaleshoni ya kupatsirana m'mapapo angagwiritsidwenso ntchito ngati mankhwala adjuvant kapena prophylactic [11,12]. Koma mu 2016 US VAP malangizo, akatswiri analibe chidaliro pa mphamvu ya adjuvant inhaled maantibayotiki chifukwa cha kusowa kwakukulu kwa mayesero olamulidwa mwachisawawa. Mayesero a Phase 3 (INHALE) omwe adasindikizidwa mu 2020 adalepheranso kupeza zotsatira zabwino (inhale amikacin adathandizira maantibayotiki a Gram-negative bacteria omwe amachititsidwa ndi odwala a VAP, osawona, osasinthika, oyendetsedwa ndi placebos, kuyesa kwamphamvu kwa gawo 3, odwala 807, mankhwala okhazikika + othandizidwa ndi kupuma kwa masiku 10).

M'nkhaniyi, gulu lotsogozedwa ndi ofufuza a Regional University Hospital Center of Tours (CHRU) ku France adatengera njira yofufuzira yosiyana ndipo adachita kafukufuku wofufuza, wochuluka, wakhungu, wakhungu, wopangidwa mwachisawawa (AMIKINHAL). Amikacin yopumira kapena placebo pofuna kupewa VAP inafaniziridwa mu 19 icus ku France [13].

Odwala achikulire 847 omwe ali ndi mpweya wabwino wapakati pa maola 72 ndi 96 adapatsidwa 1: 1 kuti apume amikacin (N= 417,20 mg/kg kulemera kwa thupi, QD) kapena kupuma kwa placebo (N = 430, 0.9% sodium chloride yofanana) kwa masiku atatu. Mapeto omaliza anali gawo loyamba la VAP kuyambira pachiyambi cha ntchito yosasinthika mpaka tsiku la 28.

Zotsatira za mayeserowa zinasonyeza kuti pa masiku a 28, odwala 62 (15%) mu gulu la amikacin adapanga VAP ndi odwala 95 (22%) mu gulu la placebo adapanga VAP (kusiyana kochepa kwa moyo wa VAP kunali masiku 1.5; 95% CI, 0.6 ~ 2.5; P = 0.004).

Pankhani ya chitetezo, odwala asanu ndi awiri (1.7%) mu gulu la amikacin ndi odwala anayi (0.9%) m'gulu la placebo adakumana ndi zovuta zokhudzana ndi mayesero. Pakati pa omwe analibe kuvulala kwakukulu kwa impso pa randomisation, odwala 11 (4%) mu gulu la amikacin ndi odwala 24 (8%) mu gulu la placebo anali ndi vuto lalikulu la impso pa tsiku la 28 (HR, 0.47; 95% CI, 0.23 ~ 0.96).

Chiyeso chachipatala chinali ndi mfundo zitatu. Choyamba, ponena za mapangidwe a maphunziro, mayesero a AMIKINHAL amachokera ku mayesero a IASIS (mayesero osasinthika, akhungu awiri, olamulidwa ndi placebo, ofanana ndi gawo lachiwiri la odwala 143). Kuwunika chitetezo ndi mphamvu ya amikacin - fosfomycin inhalation systemic treatment of gram-negative bacterial infection chifukwa cha VAP) ndi kuyesa kwa INHALE kuti athetse ndi zotsatira zoipa zomwe zaphunziridwa, zomwe zimayang'ana pa kupewa VAP, ndikupeza zotsatira zabwino. Chifukwa cha makhalidwe omwe amafa kwambiri komanso kukhala m'chipatala kwa nthawi yayitali kwa odwala omwe ali ndi mpweya wabwino ndi VAP, ngati kupuma kwa amikacin kungathe kukwaniritsa zotsatira zosiyana kwambiri ndi kuchepetsa imfa ndi kukhala m'chipatala mwa odwalawa, zidzakhala zofunikira kwambiri pazochitika zachipatala. Komabe, chifukwa cha kusiyanasiyana kwa chithandizo chochedwa ndi chisamaliro kwa wodwala aliyense ndi malo aliwonse, pali zinthu zingapo zosokoneza zomwe zingasokoneze phunzirolo, kotero zingakhalenso zovuta kupeza zotsatira zabwino zomwe zimachitika chifukwa cha mankhwala ophera tizilombo. Choncho, kafukufuku wachipatala wopambana amafunikira osati kokha kamangidwe kabwino ka phunziro, komanso kusankha mfundo zoyenera zoyambira.

Chachiwiri, ngakhale kuti maantibayotiki a aminoglycoside savomerezedwa ngati mankhwala amodzi m'mabuku osiyanasiyana a VAP, maantibayotiki a aminoglycoside amatha kuphimba tizilombo toyambitsa matenda mwa odwala a VAP (kuphatikizapo pseudomonas aeruginosa, acinetobacter, etc.), komanso chifukwa cha kuchepa kwawo m'maselo a epithelial a m'mapapo, ndende yapamwamba pa malo a poizoni, ndi otsika kwambiri. Maantibayotiki a Aminoglycoside amakondedwa kwambiri pakati pa maantibayotiki omwe amakokedwa. Pepalali likugwirizana ndi kuyerekezera kokwanira kwa kukula kwa intracheal kasamalidwe ka gentamicin m'masampuli ang'onoang'ono omwe adasindikizidwa kale, zomwe zikuwonetseratu zotsatira za mankhwala ophera aminoglycoside popewa VAP. Tiyeneranso kudziwa kuti zowongolera zambiri za placebo zomwe zasankhidwa m'mayesero okhudzana ndi maantibayotiki okokedwa ndi mchere wabwinobwino. Komabe, poganizira kuti kupuma kwa maatomu a saline wamba kumatha kukhala ndi gawo lina pakuchepetsa sputum ndikuthandizira expectorant, saline wabwinobwino angayambitse kusokoneza pakuwunika zotsatira za kafukufukuyu, zomwe ziyenera kuganiziridwa mozama mu kafukufukuyu.

Kuphatikiza apo, kusintha kwamankhwala kwa HAP/VAP ndikofunikira, monganso ma antibiotic prophylaxis. Nthawi yomweyo, mosasamala kanthu za kutalika kwa nthawi yolowera, chilengedwe cha ICU yakomweko ndichofunikira kwambiri pachiwopsezo chokhala ndi mabakiteriya ambiri osamva mankhwala. Choncho, chithandizo chamankhwala chiyenera kutchula zambiri za microbiology m'zipatala zam'deralo momwe zingathere, ndipo sangatchule mwachimbulimbuli malangizo kapena zochitika zachipatala chapamwamba. Panthawi imodzimodziyo, odwala omwe akudwala kwambiri omwe amafunikira mpweya wabwino wamakina nthawi zambiri amaphatikizidwa ndi matenda amitundu yambiri, ndipo pansi pa kuphatikizika kwa zinthu zambiri monga kupsinjika maganizo, pangakhalenso chodabwitsa cha tizilombo toyambitsa matenda m'matumbo kupita m'mapapo. The heterogeneity mkulu wa matenda chifukwa cha superposition mkati ndi kunja kumatsimikiziranso kuti chipatala chachikulu kukwezedwa kwa njira yatsopano iliyonse ndi njira yayitali yopitira.