Tiếp cận chẩn đoán, xử trí nhiễm trùng sơ sinh sớm=Approach to early onset sepsis in neonate

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Tác giả: Ngọc Phượng Cam

Ngôn ngữ: vie

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Thông tin xuất bản: Tạp chí Y học Việt Nam (Tổng hội Y học Việt Nam), 2024

Mô tả vật lý: tr.60-67

Bộ sưu tập: Metadata

ID: 243682

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This approach updates for the diagnosis and treatment of early onset sepsis in the neonate. It is relevant to all medical, nursing and midwifery staff working with neonates in the hospital. Due to the challenges of early diagnosis and a potential fatal out come if treatment is delayed, clinicians often empirically administer intravenous (IV) antibiotics to newborns at risk or with subtle signs of early-onset sepsis (EOS). However, prolonged and unappropriated antibiotic treatment is associated with adverse effects on the individual and societal level, including frequent exposure to painful procedures, parent-infant separation and antibiotic resistance. This approach follows the current NICE guidance and uses risk factors and clinical indicators to determine risk of infection. The NICE guideline determines the risk of early onset sepsis in the neonate using a framework of risk factors and clinical indicators. Babies with ‘red flags’, multiple risk factors or abnormal clinical indicators, NICE recommends the prompt introduction of intravenous antibiotics even if adequate intrapartum prophylaxis has been given. Antibiotics should be commenced within 1 hour of decision to treat. Babies with proven sepsis will generally require a minimum of 7 days antibiotics. In cases of clinically suspected sepsis, if the blood cultures remain negative, the baby has clinically improved, and the CRP falls to below 10 mg/L, antibiotic therapy may be discontinued earlier in the course of treatment. Longer courses may be required dependent on microbiological results, or in the presence of meningitis For babies with a ‘red flag’ OR two or more risk factors or clinical indicators BUT without a strong clinical suspicion of sepsis. Antibiotics should be prescribed. Repeat CRP should be taken 18-24h later to enable a decision to be made about the need for further treatment within 36h. If both CRP tests (Baseline & 18-24h later) are <
10 mg/L AND there are no clinical signs of infection then antibiotics may be discontinued. If CRP is >
10 mg/L, the duration of treatment will be based on the results of blood cultures and/or the persistence of clinical signs. For infants without any "red flags", who have only a single risk factor or clinical indicator for sepsis, withhold antibiotics and closely monitoring the clinical condition of the infant over the first 24 hours.Tiếp cận này cập nhật hướng dẫn chẩn đoán và xử trí nhiễm trùng sơ sinh sớm. Công việc này liên quan đến toàn bộ nhân viên bác sĩ, điều dưỡng, nữ hộ sinh chăm sóc trẻ sơ sinh trong bệnh viện. Do có nhiều thách thức trong việc chẩn đoán sớm và việc xử trí chậm trễ có thể dẫn đến tử vong, các thầy thuốc lâm sàng thường điều trị kháng sinh truyền tĩnh mạch theo kinh nghiệm cho trẻ sơ sinh có nguy cơ hoặc có các dấu hiệu mơ hồ của nhiễm trùng sơ sinh sớm. Tuy nhiên, việc điều trị kháng sinh kéo dài, không phù hợp thường kèm theo nhiều tác dụng phụ cho bản thân trẻ, và cấp độ xã hội bao gồm trẻ bị tiêm đau nhiều lần, cách ly trẻ và gia đình, và đề kháng kháng sinh. Tiếp cận này áp dụng hướng dẫn hiện tại của NICE và sử dụng các yếu tố nguy cơ và các chỉ số lâm sàng để xác định nguy cơ nhiễm trùng. Hướng dẫn NICE xác định nguy cơ bằng khung các yếu tố nguy cơ và dấu hiệu lâm sàng. Trẻ có dấu “cờ đỏ”, nhiều yếu tố nguy cơ hoặc các dấu hiệu lâm sàng bất thường, NICE đề nghị nhanh chóng truyền tĩnh mạch kháng sinh ngay cả khi kháng sinh dự phòng trong khi sanh đủ. Nên bắt đầu điều trị kháng sinh trong vòng 1 giờ. Trẻ có bằng chứng nhiễm trùng huyết thường cần dùng kháng sinh ít nhất 7 ngày. Trong trường hợp lâm sàng nghĩ nhiễm trùng huyết, nhưng cấy máu âm tính, lâm sàng trẻ cải thiện, và CRP giảm dưới 10 mg/L, có thể ngưng kháng sinh sớm hơn. Thời gian điều trị kháng sinh kéo dài hơn tùy vào kết quả cấy máu, hoặc có kèm viêm màng não. Trẻ có dấu “cờ đỏ” hoặc hai hay nhiều yếu tố nguy cơ hoặc các dấu hiệu lâm sàng nhưng không nghĩ nhiều nhiễm khuẩn huyết. Nên sử dụng kháng sinh. Xét nghiệm CRP nên lặp lại sau 18-24 giờ để quyết định có tiếp tục điều trị trong 36 giờ. Nếu cả CRP (Ban đầu & sau 18-24 giờ) <
10 mg/L và lâm sàng không có dấu hiệu nhiễm khuẩn thì có thể ngưng kháng sinh. Nếu CRP >
10 mg/L, thời gian điều trị sẽ dựa trên kết quả cấy máu và/hoặc còn dấu hiệu lâm sàng. Trẻ không có dấu “cờ đỏ”, chỉ có một yếu tố nguy cơ hay một dấu hiệu lâm sàng, chưa sử dụng kháng sinh và theo dõi sát tình trạng lâm sàng trẻ trong 24 giờ đầu.

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