amakuru

Umusonga wa Nosocomial ni indwara ikunze kwibasira nosocomial, muri yo ikaba ifata umusonga uhumeka (VAP) bangana na 40%. VAP iterwa na virusi itera indwara iracyari ikibazo kitoroshye cyamavuriro. Haraheze imyaka, umurongo ngenderwaho wasabye ko hajyaho ingamba zitandukanye (nko kwikuramo intego, kuzamura umutwe) kugirango wirinde VAP, ariko VAP ibaho ku barwayi bagera kuri 40% bafite intubation tracheal, bigatuma ibitaro bimara igihe kinini, gukoresha antibiyotike, ndetse n’urupfu. Abantu bahora bashakisha ingamba zifatika zo gukumira.

Umusonga uterwa na Ventilator (VAP) ni intangiriro nshya y’umusonga ikura nyuma y’amasaha 48 nyuma yo guterwa na tracheal kandi ni yo ndwara ikunze kwibasira kandi yica nosocomial mu gice cyita ku barwayi bakomeye (ICU). Amabwiriza y’amashyirahamwe y’abanyamerika y’indwara ya 2016 yatandukanije VAP n’ibisobanuro by’umusonga wanduye ibitaro (HAP) (HAP bivuga gusa umusonga ubaho nyuma yo gushyirwa mu bitaro udafite umuyoboro wa tracheal kandi ntaho uhuriye no guhumeka imashini; VAP ni umusonga nyuma yo guterwa na tracheal no guhumeka imashini), kandi Umuryango w’ibihugu by’Uburayi urakomeza.

Ku barwayi bahabwa imashini ihumeka, ubwandu bwa VAP buri hagati ya 9% na 27%, umubare w'abapfa bangana na 13%, kandi birashobora gutuma imiti ikoreshwa na antibiyotike yiyongera, guhumeka igihe kirekire, kuguma muri ICU igihe kirekire, no kongera ibiciro [4-6]. HAP / VAP mu barwayi badafite ubudahangarwa ikunze guterwa no kwandura bagiteri, kandi ikwirakwizwa rya virusi zisanzwe hamwe n’imiterere yabyo yo kurwanya biratandukanye bitewe n'akarere, ibyiciro by'ibitaro, umubare w'abarwayi, hamwe na antibiyotike, kandi bigahinduka uko ibihe bigenda bisimburana. Pseudomonas aeruginosa yiganjemo virusi itera VAP mu Burayi no muri Amerika, mu gihe Acinetobacter baumannii nyinshi yari mu bwigunge mu bitaro bya gatatu byo mu Bushinwa. Kimwe cya gatatu kugeza kuri kimwe cya kabiri cy’impfu zose ziterwa na VAP ziterwa n’ubwandu butaziguye, aho impfu z’indwara ziterwa na Pseudomonas aeruginosa na acinetobacter ziri hejuru [7,8].

Bitewe nuburinganire bukomeye bwa VAP, umwihariko wo gusuzuma ibimenyetso byerekana ivuriro ryayo, amashusho na laboratoire ni bike, kandi intera yo kwisuzumisha itandukanye ni nini, bigatuma gupima VAP mugihe. Muri icyo gihe, kurwanya bagiteri bitera ikibazo gikomeye cyo kuvura VAP. Bigereranijwe ko ibyago byo kwandura VAP ari 3% / kumunsi mugihe cyiminsi 5 yambere yo gukoresha imashini ihumeka, 2% / kumunsi hagati yiminsi 5 na 10, na 1% / kumunsi mugihe gisigaye. Indwara yibisanzwe ibaho nyuma yiminsi 7 ihumeka, bityo hariho idirishya rishobora kwirindwa hakiri kare [9,10]. Ubushakashatsi bwinshi bwarebye uburyo bwo kwirinda VAP, ariko nubwo hashize imyaka ibarirwa muri za mirongo ubushakashatsi no kugerageza gukumira VAP (nko kwirinda intubation, kwirinda kongera kwinjizwa mu nda, kugabanya imitekerereze, kuzamura umutwe w’igitanda kuri 30 ° kugeza 45 °, no kwita ku munwa), indwara ntabwo isa nkaho yagabanutse kandi umutwaro ujyanye n’ubuvuzi ukomeza kuba mwinshi cyane.

Antibiyotike ihumeka yakoreshejwe mu kuvura indwara zidakira zo mu kirere kuva 1940. Kuberako irashobora kugwiza itangwa ryibiyobyabwenge aho bigenewe kwandura (ni ukuvuga inzira yo guhumeka) no kugabanya ingaruka ziterwa na sisitemu, yerekanye agaciro gakoreshwa muburwayi butandukanye. Antibiyotike ihumeka ubu yemejwe n’ikigo cy’Amerika gishinzwe ibiryo n’ibiyobyabwenge (FDA) n’ikigo cy’ubuvuzi cy’uburayi (EMA) kugira ngo gikoreshwe muri fiboside ya cystic. Antibiyotike ihumeka irashobora kugabanya cyane imitwaro ya bagiteri ninshuro zo kwiyongera muri bronchiectasis itiyongereyeho ingaruka mbi muri rusange, kandi umurongo ngenderwaho uriho wabonye ko ari ubuvuzi bwa mbere kubarwayi bafite indwara ya pseudomonas aeruginosa no kwiyongera kenshi; Antibiyotike ihumeka mugihe cyo gutangira kwimura ibihaha irashobora kandi gukoreshwa nk'imiti igabanya ubukana cyangwa ikingira [11,12]. Ariko mu mabwiriza ya VAP yo muri Amerika 2016, impuguke ntizizeraga imikorere ya antibiyotike ihumeka bitewe no kubura ibigeragezo binini byateganijwe. Ikizamini cya Phase 3 (INHALE) cyasohowe muri 2020 nacyo nticyashoboye kubona ibisubizo byiza (guhumeka amikacin yafashaga antibiyotike ziva mu mitsi ya Gram-negative bacterial infection yatewe n’abarwayi ba VAP, impumyi ebyiri, impumyi, igenzurwa na perezidansi, igeragezwa ry’icyiciro cya 3, abarwayi 807, imiti itunganijwe + ifasha guhumeka amikacine mu minsi 10).

Ni muri urwo rwego, itsinda riyobowe n’abashakashatsi bo mu kigo cy’ibitaro by’ibitaro bya Kaminuza byo mu Karere (CHRU) mu Bufaransa bafashe ingamba zinyuranye z’ubushakashatsi maze bakora iperereza ryatangijwe n’iperereza, ryatangijwe na benshi, rihumye-impumyi, ryateganijwe mu buryo butemewe (AMIKINHAL). Amikacine yashizwemo cyangwa umwanya wo gukumira VAP wagereranijwe muri icus 19 mu Bufaransa [13].

Abarwayi 847 bakuze bafite imashini itera imashini hagati yamasaha 72 na 96 bahawe amahirwe 1: 1 yo guhumeka amikacine (N = 417,20 mg / kg uburemere bwiza bwumubiri, QD) cyangwa guhumeka umwanya wa (N = 430, 0,9% sodium chloride ihwanye) muminsi 3. Iherezo ryibanze nigice cyambere cya VAP kuva itangira umukoro uteganijwe kugeza kumunsi wa 28.

Ibyavuye mu igeragezwa byagaragaje ko ku minsi 28, abarwayi 62 (15%) mu itsinda rya amikacin bari barateje VAP naho abarwayi 95 (22%) mu itsinda rya placebo bakoze VAP (itandukaniro rito ryo kubaho kuri VAP ryari iminsi 1.5; 95% CI, 0.6 ~ 2.5; P = 0.004).

Ku bijyanye n’umutekano, abarwayi barindwi (1,7%) mu itsinda rya amikacin n’abarwayi bane (0.9%) mu itsinda rya placebo bahuye n’ibibazo bikomeye bijyanye n’ibigeragezo. Mu batagize imvune ikabije yimpyiko ku bushake, abarwayi 11 (4%) mu itsinda rya amikacin n’abarwayi 24 (8%) mu itsinda rya placebo bakomeretse impyiko zikomeye ku munsi wa 28 (HR, 0.47; 95% CI, 0.23 ~ 0.96).

Igeragezwa rya clinique ryari rifite ibintu bitatu byingenzi. Ubwa mbere, mubijyanye nigishushanyo mbonera cy’inyigisho, ikigeragezo cya AMIKINHAL gishingiye ku igeragezwa rya IASIS (umuntu utabishaka, impumyi ebyiri, igenzurwa na platbo, igereranya icyiciro cya 2 kirimo abarwayi 143). Kugirango dusuzume umutekano n’akamaro ka amikacine - fosfomycine ihumeka uburyo bwo kuvura indwara ya bagiteri-mbi ya bagiteri yatewe na VAP) hamwe n’igeragezwa rya INHALE kugira ngo irangize amasomo mabi yize, yibanda ku gukumira VAP, kandi yabonye ibisubizo byiza ugereranije. Bitewe nibiranga impfu nyinshi hamwe nibitaro birebire mubarwayi bafite imashini ihumeka na VAP, niba guhumeka kwa amikacin bishobora kugera kubisubizo bitandukanye cyane mukugabanya urupfu no kuguma mubitaro muri aba barwayi, bizaba bifite agaciro mubikorwa byubuvuzi. Ariko rero, ukurikije ivangura rishingiye ku gutinda no kuvurwa bitinze muri buri murwayi na buri kigo, hari ibintu byinshi bitera urujijo bishobora kubangamira ubushakashatsi, bityo rero birashobora kugorana kubona ibisubizo byiza biterwa na antibiyotike ihumeka. Kubwibyo, ubushakashatsi bwubuvuzi bwatsinze ntibusaba gusa igishushanyo mbonera cyiza cyo kwiga, ahubwo bisaba no guhitamo ibyibanze byibanze.

Icya kabiri, nubwo antibiyotike ya aminoglycoside idasabwa nkumuti umwe mumabwiriza atandukanye ya VAP, antibiyotike ya aminoglycoside irashobora kwanduza virusi itera abarwayi ba VAP (harimo pseudomonas aeruginosa, acinetobacter, nibindi), kandi kubera kwinjirira kwinshi mumyanya mito yibihaha, hamwe nuburozi buke bwa sisitemu. Antibiyotike ya Aminoglycoside itoneshwa cyane muri antibiyotike ihumeka. Uru rupapuro ruhuye nigereranya ryuzuye ryingaruka zubunini bwimikorere ya gentamicin mu ngero nto zasohotse mbere, zikaba zigaragaza hamwe ingaruka za antibiyotike ya aminoglycoside ihumeka mukurinda VAP. Twabibutsa kandi ko ibyinshi mubigenzurwa na platbo byatoranijwe mubigeragezo bijyanye na antibiotique ihumeka ni saline isanzwe. Ariko, urebye ko guhumeka atomine yumunyu usanzwe ubwayo bishobora kugira uruhare runini mukugabanya ibibyimba no gufasha gusohora, umunyu usanzwe urashobora gutera intambamyi zimwe na zimwe mu gusesengura ibyavuye mu bushakashatsi, bigomba gusuzumwa neza mu bushakashatsi.

Byongeye kandi, kurwanya imihindagurikire y’imiti ya HAP / VAP ni ngombwa, kimwe na antibiyotike ya prophylaxis. Muri icyo gihe, tutitaye ku burebure bwigihe cyintubation, ibidukikije bya ICU byaho nicyo kintu cyingenzi gishobora kwanduza bagiteri zidakira imiti myinshi. Kubwibyo, ubuvuzi bufatika bugomba kwifashisha amakuru ya mikorobi y’ibitaro byaho bishoboka, kandi ntishobora kwerekeza buhumyi umurongo ngenderwaho cyangwa uburambe bwibitaro bya kaminuza. Muri icyo gihe, abarwayi barembye cyane bakeneye guhumeka akenshi bahujwe nindwara zitandukanye, kandi mugikorwa cyo guhuza ibintu byinshi nko guhangayika, hashobora no kubaho ikibazo cya mikorobe zo munda zambukiranya ibihaha. Ubwinshi bwindwara ziterwa no guterwa imbere no hanze nabyo bigena ko kuzamura amavuriro manini ya buri gikorwa gishya ari inzira ndende.