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CHI TIẾT
Phân tích tính hợp lý trong việc lựa chọn doripenem điều trị viêm phổi bệnh viện tại Khoa Hồi sức tích cực, Bệnh viện Bạch Mai
The use of Doripenem for treatment of hospital-acquired pneumoniae in Deparment of Intensive Care Medicine, Bach Mai Fospital (Hanoi)
Vũ Đình Hòa, Nguyễn Thị Phương Dung, Đỗ Thị Hồng Gấm, Vương Xuân Toàn, Đào Xuân Cơ, Đặng Quốc Tuấn, Nguyễn Thị Tuyến, Nguyễn Hoàng Anh, Nguyễn Gia Bình
Số: 518 - Tháng 6/2019 - Trang 8-13

Viêm phổi bệnh viện (VPBV) bao gồm viêm phổi liên quan đến thở máy là một trong những nguyên nhân hàng đầulàm gia tăng gánh nặng bệnh tật và tử vong. Việc lựa chọn kháng sinh kinh nghiệm phù hợp bao phủ các tác nhân gây VPBV góp phần cải thiện kết quả điều trị của bệnh nhân, do đó kháng sinh phổ rộng thường được khuyến cáo sử dụng. Doripenem là kháng sinh phổ rộng trong nhóm carbapenem mới được đưa vào sử dụng tại một số nước trên thế giới, trong đó có Hoa Kỳ và các nước Châu Âu. Cơ quan Quản lý Dược phẩm Châu Âu và Cục Quản lý Dược Việt Nam đã cấp phép cho chỉ định sử dụng doripenemtrong điều trị VPBV/viêm phổi thở máy (VPTM). Một thử nghiệm lâm sàng công bố năm 2012 cho thấy tỷ lệ tử vong trong 28 ngày của nhóm dùng doripenem cao hơn so với nhóm dùng imipenem ở bệnh nhân VPTM và nghiên cứu này đã phải dừng trước thời hạn. Do vậy, Cơ quan Quản lý Dược phẩm Hoa Kỳ (FDA) cảnh báo không sử dụng doripenem trong điều trị VPTM và không phê duyệt chỉ định điều trị VPBV của kháng sinh này. Khác với quan điểm của FDA, Cơ quan Quản lý Dược phẩm Châu Âu (EMA) cho rằng không thể kết luận chính xác từ nghiên cứu này đồng thời việc sử dụng doripenem trong thời gian ngắn (7 ngày) là yếu tố quan trọng dẫn đến kết cục lâm sàng của bệnh nhân xấu hơn khi so sánh với nhóm đối chứng. Vì vậy, EMA khẳng định lợi ích của doripenem vẫn vượt trội hơn nguy cơ nếu sử dụng liều cao hơn và thời gian điều trị dài hơn ở VPBV có kèm theo thở máy hoặc nhiễm vi khuẩn đa kháng. Tại Việt Nam, doripenem mới được đưa vào sử dụng và thông tin sử dụng trong VPBV còn rất hạn chế. Trong khi đó, meropenem hiện nay đang là kháng sinh thuộc nhóm carbapenem phổ biến được dùng rộng rãi trong điều trị VPBV/VPTM tại các đơn vị điều trị tích cực. Do đó, tiến hành nghiên cứu này nhằm phân tích việc sử dụng của doripenem trong phác đồ điều trị VPBV tại Khoa Hồi sức tích cực, Bệnh viện Bạch Mai và so sánh hiệu quả với phác đồ có chứa meropenem.

Đối tượng: Hồ sơ bệnh án (HSBA) được chẩn đoán VPBV.

Phương pháp: Nghiên cứu hồi cứu mô tả có so sánh hiệu quả điều trị giữa hai nhóm doripenem và meropenem.

Kết luận

Bệnh nhân được sử dụng doripenem trong cả phác đồ kinh nghiệm và phác đồ thay thế trong điều trị VPBV và hiệu quả điều trị cho thấy không khác meropenem.Có thể cân nhắc sử dụng doripenem trong các phác đồ phối hợpưu tiên áp dụngchế độ liều dựa trên các dữ liệu dược động học và dược lực học để đảm bảo để tối ưu hóa hiệu quả điều trị. Cần tiếp tục theo dõi, đánh giá và thu thập thông tin để hoàn thiện dữ liệu lâm sàng từ thực tế điều trị VPBVcủa doripenem trên.

Viewing carbapenems including doripenem as backbone antimicrobial agents for hospital-acquired pneumonia (HAP) commonly involving multidrug resistant pathogens, the use of doripenem was investigated to compare the treatment outcomes of doripenem-based and meropenem-basedregimens in HAP by retrospective study of medical records of patients diagnosed with HAP and admitted to Department of Intensive Care Medicine, Bach Mai Hospital from March 2017 to January 2018. A. baumannii, P. aeruginosa and K. pneumoniae were common  isolated pathogens. Doripenem was most commonly indicated in empirical therapy (57.0 %), both as monotherapy and in combination with quinolon, colistin or glycopeptid. With microbiological confirmation, doripenem combined with colistin was used in up to 81.0 % of the cases. No significant difference was observed in clinical success rate between doripenem-based and meropenem-based regimens (45.7 % and 44.3 %, respectively) with ORa = 1,087; 95 % CI, 0.579 - 2.039. These findings suggested the high efficacy of doripenem as empirical or microbiologically confirmative regimens in HAP, where the clinical outcome appeared closely similar to meropenem. Doripenem in combination therapy with an optimized dosing strategy and a rational treatment duration should be considered to improve clinical efficicacy of HAP treatment.

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