Phn tch thc trng:

S dng khng sinh v khng khng sinh Vit Nam

Nhm Nghin cu Quc gia ca GARP-Vit Nam TS. Nguyn Vn Knh, Ch tch

Thng 10- 2010

Nhm nghin cu quc gia GARP-Vit Nam (NWG)

TS. BS. Nguyn Vn Knh. Ch tch. Gim c Bnh vin Bnh Nhit i Trung ng TS. BS. Lng Ngc Khu. Cc trng Cc Qun l khm, cha bnh. B Y t TS. DS. Trng Quc Cng. Cc trng Cc Qun l Dc. B Y t TS. BS. L Ngc Knh. Cc Qun l khm, cha bnh. B Y t ThS. DS. Ng Th Bch H. Chuyn vin chnh. Cc Qun l khm, cha bnh. B Y t BS. Hong Thanh Mai. Phng Qun l thng tin v Qung co. Cc Qun l Dc. B Y t ThS. BS. Nguyn Hng H. Ph Gim c NHTD. H Ni PGS. TS. BS. Nguyn V Trung. Trng khoa xt nghim. NHTD Ph Ch nhim B mn Vi sinh. i hc Y H Ni PGS. TS. BS. Phm Vn Ca. Ph Trng khoa xt nghim. NHTD PGS. TS. DS. Nguyn Th Kim Chc. Ging vin chnh. Ph Ch nhim B mn Y hc Gia nh. i hc Y H Ni TS. BS. on Mai Phng. Ph Trng khoa Vi sinh. BV Bch Mai. H Ni TS. BSTY. Nguyn Quc n. Ph Trng phng Qun l Thuc. Cc th y. B Nng nghip v Pht trin Nng thn GS. TS. BS. Trn Tnh Hin. Ph Gim c Nghin cu Lm sng. n v Nghin cu lm sng i hc Oxford. Thnh ph H Ch Minh BS. Peter Horby. Gim c. n v Nghin cu Lm sng i hc Oxford

Cn b GARP- Vit Nam

TS. BS. Heiman Wertheim. GARP-Vit Nam gim st. Chuyn gia vi sinh lm sng. n v Nghin cu Lm sng i hc Oxford ThS. DS. Th Thu Nga. GARP-Vit Nam. iu phi vin Quc gia. n v Nghin cu Lm sng i hc Oxford

Th k CDDEP/RFF GARP
TS. BS. Ramanan Laxminarayan. Sng lp GARP. Chuyn gia cp cao kim gim c. Trung tm Nghin cu Bin ng Bnh dch, Kinh t v Chnh sch. T chc Ngun lc cho Tng lai ThS. Hellen Gelband. iu phi vin chng trnh. Trung tm Nghin cu Bin ng Bnh dch, Kinh t v Chnh sch. T chc Ngun lc cho Tng lai GARP-VN Phn tch thc trng

Mc lc
Li ni u, TS. Nguyn Vn Knh...................................................................................................... I Tng kt..................................................................................................................................................... III I. Cc ch s c bn v kinh t v y t ...................................................................................................1 1.1. Gii thiu.........................................................................................................................................1 1.2. Cu trc ca h thng chm sc sc kho.............................................................................4 1.3. Chng nhim khun.....................................................................................................................9 1.4. Gnh nng bnh tt ................................................................................................................... 11 II. H thng cung ng v qun l khng sinh.................................................................................. 17 2.1. C cu lp php chi phi s phn phi, lu thng khng sinh .................................... 17 2.2. Chui cung ng .......................................................................................................................... 21 2.3. S dng khng sinh ti cc tuyn c s.............................................................................. 25 2.4. S dng khng sinh khng hp l ........................................................................................ 26 2.5 C ch khuyn khch ................................................................................................................. 27 2.6. Cc v d v mc s dng khng sinh trn ngi............................................................ 28 2.7. Chi ph cho khng sinh ti cc bnh vin............................................................................ 31 2.8. Gim st khng khng sinh..................................................................................................... 32 2.9. Khng sinh s dng trn ng vt ....................................................................................... 33 III. nh gi s b, xut chnh sch v gii php can thip .................................................. 36 3.1. nh gi s b............................................................................................................................ 36 3.2. Phn tch chnh sch................................................................................................................. 37 3.3. Cc c hi nghin cu .............................................................................................................. 39 Ti liu tham kho.................................................................................................................................. 41

GARP-VN Phn tch thc trng

Li ni u
Vn v thc trng khng khng sinh mang tnh ton cu v c bit ni tri cc nc ang pht trin vi gnh nng ca cc bnh nhim khun v nhng chi ph bt buc cho vic thay th cc khng sinh c bng cc khng sinh mi, t tin. Cc bnh nhim khun ng tiu ho, ng h hp, cc bnh ly truyn qua ng tnh dc v nhim khun bnh vin l cc nguyn nhn hng u c t l mc v t l t vong cao cc nc ang pht trin. Vic kim sot cc loi bnh ny v ang chu s tc ng bt li ca s pht trin v lan truyn tnh trng khng khng sinh ca vi khun. C th ni rng, vi khun cng phi nhim nhiu vi khng sinh th sc p v thuc cng lncc chng khng thuc cng c nhiu c hi pht trin v ly lan. Mc d khng khng sinh l vn cn bn thuc v y t, trong sc p v thuc l yu t ni ti quan trng nht thc y s pht trin v gia tng tnh trng khng khng sinh. Tuy nhin, vn ny cn chu s chi phi ca nhiu lnh vc khc bao gm cc yu t v sinh thi hc, dch t hc, vn ho-x hi v kinh t. Ngi bnh, cc nh lm sng, bc s th y, cc phng khm t, bnh vin v doanh nghip dc t qui m nh n ln u c rt t ng thi (v mt kinh t hoc cc kha cnh khc) nhm nh gi nhng nh hng bt li ca vic s dng khng sinh i vi cc i tng lin quan hoc hu qu ca nhng nh hng i vi th h tng lai. Nhng hot ng nh tng cng gim st, cc chin dch thng tin i chng v mi him ha ca tnh trng khng khng sinh l mt phn cn thit trong k hoch i ph ton din c th em li tc ng rt hn ch. em li hiu qu cao, cc gii php chnh sch cn c s thay i v mt cu trc cc bin php khuyn khch i vi bnh nhn, cc nh lm sng v cc i tng khc trong h thng chm sc sc khe, ng thi cc chnh sch ny phi c vn hnh trong mi quan tm cao nht ca x hi. nh gi cc gii php chnh sch phi bao gm nhng hiu bit ca cng ng v bnh nhim khun. Trc ht cn nghin cu, vch ra cc gii php chnh sch c th v trng tm c th em li cc tc ng c ngha i vi tnh trng khng khng sinh. Tip theo , cn phi bin gii php chnh sch thnh hnh ng. Khng khng sinh khng nm trong danh sch cc vn c u tin ca mi quc gia cng nh khng c c cc xut chin lc nhm thu ht cc mi quan tm t chnh ph. gii quyt vn mt cch ng n, kim sot khng khng sinh nn tp trung vo mt s cc bin php can thip trng im v mt y t c kh nng thc s em li hiu qu kinh t. Bo co ny phn tch, nh gi mt cch chi tit v tnh hnh s dng khng sinh v thc trng khng khng sinh ti Vit Nam. Bn bo co s dng cc ngun thng tin thu thp t cc bo co GARP-VN Phn tch thc trng I

trong v ngoi nc ng thi phn tch, tng hp cng nh tham kho kin ng gp ca cc chuyn gia trong cc lnh vc lin quan nhm xy dng bn bo co phn tch mt cch tng quan v chi tit. T xut cc gii php can thip nhm kim sot tnh hnh s dng thuc khng hp l v thc trng khng khng sinh nh hin nay ti Vit Nam.

TS. Nguyn Vn Knh Ch tch. i din Nhm nghin cu Quc gia. GARP Vit Nam

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Tm tt

p tc ton cu v khng khng sinh (GARP) nhm hng ti gii quyt cc thch thc ca tnh trng khng khng sinh bng cch xy dng cc xut chnh sch hnh ng ti Vit Nam v bn nc c thu nhp thp v trung bnh nh: Trung Quc, n , Kenya v Nam

Phi. GARP s xy dng cc bng chng khoa hc cho chng trnh hnh ng khng khng sinh ti Vit Nam v nhn bit cc chnh sch c tc ng mnh lm gim s pht trin v ly lan tnh trng khng thuc. K t sau i mi ca nn kinh t nm 1986, Vit Nam c nhiu chuyn bin ng k: tng thu nhp bnh qun u ngi, tng tui th trung bnh, gim t l t vong tr em v ci thin kh nng tip cn dch v chm sc sc khe v thuc k c thuc khng sinh. Vic ci thin kh nng tip cn vi thuc khng sinh ng thi cng em li mt v khch khng mi m n: khng khng sinh. Nh bn Phn tch thc trng cho thy, khng khng sinh gia tng, nhng cc c hi nhm bo tn gi tr ca thuc khng sinh v ci thin trin vng iu tr i vi bnh nhn vn cn b ng. Nm 1996, B Y t ban hnh chnh sch Quc gia v thuc, trong c nu r chnh sch v thuc khng sinh nh sau: Thuc khng sinh c vai tr rt quan trng trong iu tr, c bit i vi tnh hnh bnh tt ca mt s nc kh hu nhit i nh nc ta. Do , cn phi chn chnh vic k n v s dng khng sinh, kim sot tnh trng khng khng sinh ca mt s vi khun gy bnh thng gp, ng thi ci thin kh nng chun on ca cc phng xt nghim vi sinh lm sng. Chnh sch ny thm ch cn ph hp hn vi tnh hnh hin nay, nm 2010.

Vn ton cu v khng khng sinh

Trn th gii, nhiu chng vi khun gy bnh tr nn ngy cng khng thuc khng sinh. Cc khng sinh th h mt gn nh khng c la chn trong nhiu trng hp. Cc khng sinh th h mi t tin, thm ch c mt s khng sinh thuc nhm la chn cui cng cng ang mt dn hiu lc. Bng chng mi y nht l s ly lan ca chng vi khun khng carbapenem (ndm-1) mt s quc gia Chu u v Chu . Hiu lc ca khng sinh nn c xem nh mt loi hng ha c bit, cn c bo v v qu trng, khng nn lng ph vo cc trng hp khng cn thit. Mc tiu lm th no khng sinh ch c s dng cho cc trng hp nhim khun l cc trng hp c th iu tr bng thuc khng sinh, khng phi cho cc trng hp s khng c li t vic s dng khng sinh.

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Khng khng sinh Vit Nam

Tnh trng khng khng sinh Vit Nam mc cao. Trong nhng nm gn y, mt s nghin cu cho thy: Vit Nam, cc chng Streptococcus pneumoniae - mt trong nhng nguyn nhn thng gp nht gy nhim khun h hp- khng penicillin (71.4%) v khng erythromycin (92.1%) c t l ph bin cao nht trong s 11 nc trong mng li gim st cc cn nguyn khng thuc Chu (ANSORP) nm 2000-2001. 75% cc chng pneumococci khng vi ba hoc trn ba loi khng sinh. 57% Haemophilus influenzae (mt cn nguyn vi khun ph bin khc) phn lp t bnh nhi H Ni (2000-2002) khng vi ampicillin. T l tng t cng c bo co Nha Trang. Vi khun phn lp t tr b tiu chy c t l khng cao. i vi hu ht cc trng hp, b nc v in gii l bin php x tr hiu qu nht i vi bnh tiu chy, khong s tr c ch nh khng sinh trc khi a n bnh vin. Cc vi khun gram m a s l khng khng sinh (enterobacteriaceae): hn 25% s chng phn lp ti mt bnh vin Thnh ph H Ch Minh khng vi khng sinh cephalosporin th h 3, theo nghin cu nm 2000-2001. Theo bo co ca mt nghin cu khc nm 2009 cho thy, 42% cc chng vi khun gram m khng vi ceftazidime, 63% khng vi gentamicin v 74% khng vi acid nalidixic ti c bnh vin v trong cng ng. Xu hng gia tng ca tnh trng khng khng sinh cng th hin r rt. Nhng nm 1990, ti thnh ph H Ch Minh, ch c 8% cc chng pneumococcus khng vi penicillin. n nm1999-2000, t l ny tng ln 56%. Xu hng tng t cng c bo co ti cc tnh pha bc Vit Nam. Do t l khng khng sinh cao, nhiu liu php khng sinh c khuyn co trong cc ti liu hng dn iu tr khng cn hiu lc. Do cc bnh nhim khun vn l cc bnh ph bin Vit Nam, vic tip cn vi cc khng sinh c hiu lc gi vai tr rt quan trng. T l khng khng sinh gia tng nh hin nay l mi him ha i vi hiu qu ca cc liu php iu tr bng khng sinh.

Cc nguyn nhn dn n tnh trng lm dng khng sinh v khng khng sinh
C th ni rng, cng lm dng khng sinh, cc chng vi khun khng thuc cng c c hi pht trin v ly lan. Khng sinh b lm dng c trong cng ng-do ngi dng t chn on v iu tr hoc theo li khuyn ca ngi cung cp dch v y t- v trong bnh vin, ni m khng sinh c th thay th kim sot nhim khun tt hn, ni cc khng sinh ph rng c s dng thay th cho cc khng sinh ph hp, v cng l ni bnh nhn thng c cung cp cc loi bit dc mi, t tin hn thay v cc thuc th h c. GARP-VN Phn tch thc trng IV

Cc nguyn nhn dn n vic s dng khng sinh khng hp l vn cn cha r, tuy nhin c th xc nh mt s nhn t quan trng i vi thc trng ti Vit Nam. Cc nhn t ny c tho lun di y.

Trong cng ng
Chi ph chm sc sc khe t tin ti ngi bnh: Vic p dng cc hnh thc chi tr t ngi bnh ti cc bnh vin cng lp, m hnh chi tr bng bo him y t, thng mi ha ngnh dc, v bi b qui nh v kinh doanh nh l i vi thuc em li nhiu ci thin ng k v cht lng v kh nng tip cn cc dch v chm sc sc khe. Tuy nhin, cc yu t ny cng dn n vic tng t trng chi ph y t t tin ti ngi bnh nhn trong tng chi ph y t. Chi ph t tin ti ngi bnh cao khuyn khch ngi bnh mua thuc bao gm c thuc khng sinh trc tip, m khng cn cc chn on ph hp. Tng doanh thu thuc gn nh tng gp ba v gi tr gia nm 2001-2008, t 500 triu la M ln 1400 triu la M. Hin ti khng c s liu thng k ring cho thuc khng sinh, tuy nhin y l nhm thuc c s dng rng ri nht, v thng khng hp l. Mua thuc khng c n: Mc d c qui nh v k n v bn thuc theo n, ngi bnh vn c th mua thuc khng sinh v nhiu loi thuc khc trc tip t cc nh thuc v cc quy thuc bn l. T iu tr l tnh trng kh ph bin, mc d t chn on thng rt thiu chnh xc. Theo mt nghin cu cng ng nm 2007, 78% khng sinh c mua ti cc nh thuc t nhn m khng cn n. Mua thuc trc tip l hnh thc tit kim c v kinh ph v thi gian so vi vic i khm bc s. Thiu kin thc v s dng khng sinh hp l: Theo bo co ca nghin cu thc hin nm 2007 nhm nh gi kin thc v s dng khng sinh khu vc nng thn Vit Nam cho thy, mc d c cc ti liu hng dn, kin thc v s dng khng sinh vn cn rt hn ch v cc cn b cung cp dch v chm sc sc khe thng cung cp khng sinh mt cch khng cn thit cho cc trng hp cm cm thng thng. Khi khng sinh c s dng, loi, liu dng, thi gian iu tr thng khng tun th theo hng dn.

Ti Bnh vin
Cng tc kim sot nhim khun cn yu v tnh trng qu ti: Kim sot nhim khun tt l cng vic cn thit nhm ngn chn s ly lan ca vi khun khng thuc. Cc bnh vin lun trong tnh trng qu ti, tnh trng ngi bnh phi nm ghp ging thng xuyn xy ra. Hn na, vic qun l rc thi cng cn nhiu hn ch.

GARP-VN Phn tch thc trng

Thiu cc dch v v vi sinh: Hu ht cc bnh vin khng c phng xt nghim vi sinh. Ngay c vi cc phng xt nghim hin c, cng khng c yu cu v vic nh gi cht lng. Hn na, thiu i ng cc nh vi sinh lm sng c trnh nhm ci thin cht lng phng xt nghim. Do , cc d liu v khng khng sinh cng khng th xem l chnh xc i vi Vit Nam. Thiu Hi ng Thuc v iu tr hot ng c hiu qu: Nm 1997, B Y t yu cu tt c cc bnh vin thnh lp Hi ng Thuc v iu tr nhm thc hin cc hng dn lin quan n vic s dng thuc, a ra cc li khuyn v liu php khng sinh hp l, xy dng danh mc thuc ch yu s dng trong bnh vin, thng bo cho cc cn b y t a phng v s dng thuc hp l v t chc gim st, bo co v khng thuc khng sinh. Hin nay, hu ht cc bnh vin tuyn trung ng u c hi ng ny, tuy nhin mt s bnh vin tuyn c s th vn cn thiu v yu. i vi mt s bnh vin tuyn qun/huyn, thnh phn hi ng thng thiu dc s hoc chuyn gia vi sinh v ngun lc cho hi ng hot ng.

Trong nng nghip

Khng sinh c s dng rng ri trong chn nui v nui trng thy sn vi mc ch kch thch tng trng, phng bnh v iu tr. Chn nui ln v gia cm thng c b sung khng sinh nh tetracycline v tylosin. Trong nui trng thy sn, tm, cua v c thng c nng d lng khng sinh nhm quinolones v sulfonamides gp vi ln so vi cc quc gia khc. D lng khng sinh cng thng c pht hin trong mu t v nc ng con ging, mc d hu ht cc trng hp pht hin d lng ca cc khng sinh c php s dng v cng nm trong gii hn cho php. Tuy nhin, vn c nhiu trng hp d lng khng sinh vt qu gii hn. Mt nghin cu gim st cho thy, thc phm, bao gm tht v c, pht hin nhim Salmonella a khng khng sinh. Campylobacter phn lp t g tht cng c mc khng cao: 90% khng vi nalidixic acid, 89% vi tetracycline v 82% vi ciprofloxacin.

Nghin cu ca GARP-Vit Nam

Mt trong nhng mc tiu ca GARP-Vit Nam l nhm b p cc thiu ht v thng tin. Sau y l mt s nghin cu m nhm nghin cu quc gia GARP-VN hin ang trin khai: 1. Xy dng mt mng li v s dng khng sinh v khng khng sinh: thit lp cc knh chia s thng tin gia mt s bnh vin hng u ng thi hp tc vi Cc Qun l khm cha bnh nhm xy dng v cng b cc bo co nh k v s dng khng sinh v khng khng sinh.

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2. Nghin cu nh gi gnh nng ca tnh trng khng khng sinh: bng chng thuyt phc nht i vi cc nh hoch nh chnh sch l ch ra c cc tn tht do khng khng sinh gy ra v vic qun l khng sinh c th em li hiu qu kinh t ng thi cu c mng sng ngi bnh. Nghin cu s tin hnh nh gi mc khng hin ti ca mt s vi khun thng gp phn lp t bnh phm mu v dch no ty. nh gi gnh nng ca tnh trng khng thuc do cc cn nguyn ny gy ra trn c s so snh chi ph iu tr bng khng sinh cho cc trng hp khng thuc v chi ph iu tr khng sinh mc tiu chun cho cc trng hp cha khng thuc. 3. nh gi cu trc cc nhn t tc ng v kinh t: i vi vic bn khng sinh trong cng ng ti cc c s bn l dc phm bng b cu hi v trc tip quan st vic bn thuc ti 15 nh thuc khu vc ni thnh v 15 nh thuc ti khu vc ngoi thnh H Ni. nh gi t trng li nhun do thuc khng sinh em li.

CC C HI NHM KIM SOT KHNG KHNG SINH

La chn chnh sch Tng cng cng tc qun l nh nc v khng khng sinh Thuc khng sinh l thuc k n Cc bnh vin cn c Hi ng Thuc v iu tr hot ng c hiu qu (D&TCs) Hnh ng Xy dng K hoch Hnh ng Quc gia v Khng Khng sinh. Hiu lc ha cc qui ch v qui nh hin hnh. p ng yu cu ca Hi ng, xc nh cha nng v tiu chun ca Hi ng, xy dng v thm tra c ch hot ng. Cung cp cho Hi ng cc cng c/hng dn lm th no xy dng Hng dn Qun l Khng sinh tt cho cc bnh vin. ng thi bo co cho hi ng cc s liu cp nht v ng tin cy v tnh hnh khng khng sinh. Cung cp kinh ph hot ng cho cc hot ng ca hi ng v nng cp c s h tng. Xy dng cc ch s chun nhm gim st tin nh: t l nhim khun bnh vin theo tng khoa v s tun th v sinh bn tay. Chun ho d liu bng cch p dng trn ton quc cc ti liu hng dn xt nghim bao gm c kim sot cht lng. Cung cp kinh ph cho th nghim mc khng khng sinh, kim sot cht lng, tp hun v bo co. Xy dng cc bo co hng nm v tnh hnh s dng khng sinh v thc trng khng khng sinh. Chun ho cc ch s v mc s dng khng sinh theo n v quc t, v d nh liu ch nh hng ngy (DDD) trn 100 ging-ngy. Xy dng cc bo co hng nm v s dng khng sinh v khng khng sinh trong cng mt bn bo co. Tng thi thi lng chng trnh ging dy v s dng khng sinh v khng khng sinh. m bo tnh chnh xc v cp nht ca cc ti liu hng VII

Cc bnh vin cn c hi ng chng nhim khun

Chng trnh gim st khng khng sinh quc gia

Chng trnh gim st v s dng khng sinh ti cc bnh vin Chng trnh ging dy trong cc trng y, dc Hng dn iu tr GARP-VN Phn tch thc trng

Trung tm cnh gic Dc Chin lc gio dc truyn thng cng ng Cc chng trnh tim chng Quc gia Chng trnh nng cao nng lc phng xt nghim vi sinh lm sng Nng nghip

dn iu tr i vi cc bnh nhim khun. Thu ht s tham gia ca trung tm cnh gic Dc vo vic kim sot tnh trng k n khng sinh bt hp l. Tng cng nhn thc v gio dc cho cng ng v s dng khng sinh hp l v khng hp l bng cc chin dch lin kt. m bo t l tim chng cao cho cc bnh truyn nhim cn iu tr bng khng sinh. m bo cht lng cc xt nghim vi sinh lm sng, Xem xt vic xy dng mt trung tm chun quc gia v xt nghim chn on vi sinh lm sng. Xy dng mng li nhm chia s thng tin (d liu, hng dn, kin ca cc chuyn gia). Hiu lc ho qui ch, qui nh hin hnh Xy dng chng trnh gim st ton quc v s dng khng sinh v khng khng sinh trn ng vt Xy dng bo co hng nm v tnh hnh s dng khng sinh v mc khng khng sinh trn ng vt Qui nh v thi gian dng s dng thuc khng sinh trc khi thu hoch sn phm t ng vt.

Vit Nam c rt nhiu con ng nhm kim sot v o chiu tnh trng khng khng sinh. Cc c hi s c phn tch y trong bo co cui cng ca GARP-VN, d kin hon thnh vo u nm 2011. Mt s cc la chn chnh sch c lit k di y. V l thuyt, tt c cc la chn ny u c th kh thi, tuy nhin mt s c trin vng hn so vi cc la chn cn li. Nhm nghin cu quc s phn tch nh gi tng la chn bng cch c lng v chi ph, ngun lc, v cc iu kin thun li v mt k thut, khung thi gian thc hin, v quan trng hn c l tc ng m la chn em li ( cc mc thnh cng khc nhau) trong bi cnh c th ca Vit Nam. Danh sch c la chn s c xut cho cc la chn chnh sch c trin vng nhm xy dng hnh ng. Bn bo co u tin ny v phn tch thc trng khng khng sinh Vit Nam nhm chuyn ti vn quan trng ny n tt c cc i tc c lin quan, bao gm chnh ph, dc s, bc s, cc c s khm cha bnh, ngnh dc, v ngi bnh. Tt c chng ta u c trch nhim phi hp hnh ng nhm duy tr hiu lc ca khng sinh ng thi m bo kh nng tip cn vi cc thuc cu cha bnh bt c u v bt c khi no ngi bnh cn.

Thay mt Nhm nghin cu Quc gia, TS. Nguyn Vn Knh. Ch tch Gim c Bnh vin Bnh Nhit i Trung ng
GARP-VN Phn tch thc trng VIII

H Ni, Vit Nam

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I. Cc ch s c bn v kinh t v y t 1.1. Gii thiu

Phn I phn tch khi qut v h thng chm sc sc khe ca Vit Nam, t phn tch, nh gi thc trng khng khng sinh trong s chi phi ca bi cnh tng th. ng thi, cng cp n cc vn c bn ca cc chnh sch quc gia v y t, c cu t chc hot ng ca h thng chm sc sc khe, c hi tip cn vi cc dch v chm sc sc khe v thuc cha bnh. Cc ch s v a l, y t cng nh t l mc v t vong do nguyn nhn cc bnh nhim khun cng c trnh by s lc trong phn ny.

Hnh 1. Vit Nam

1.1.1. S lc v a l, dn s
Nm trn bn o ng dng, Vit Nam c bin gii gip Trung Quc, Lo v Campuchia, vi din tch khong 331.000 km. Vi hn 88 triu dn, Vit Nam l nc ng th 13 v dn s trn th gii, vi mt dn s xp x 265 ngi/km. Dn s tng i tr so vi cc nc pht trin vi tui trung bnh l 27 tui trong khi cc nc Chu u l 39-41 tui. Tc tng dn s gim trong vng 20 nm qua vi t l trung bnh 1,98 tr/m (Bng 1). Xp x 28% dn s sng ti thnh th vi tc th ho khong 3,1% mi nm. Tr em Vit Nam c tip cn tt vi gio dc, t l bit ch t 90%. Tnh n cui nm 2005, 81% cc h gia nh c in. Mc tiu ca chnh ph l n nm 2010, 95% h gia nh c s dng in1. Nm 2010, chnh ph hy vng 85% dn s c s dng nc sch. Tuy nhin, qu trnh trin khai cn kh chm v khng th t mc tiu 70% nm 20102. Ngun: n v nghin cu lm sng H Oxford. s dng phn mm AcrGIS

GARP-VN Phn tch thc trng

1.1.2. Tnh hnh pht trin kinh t v t l ngho

Trong thp k qua, Vit Nam l mt trong nhng nc trn th gii c s pht trin ng k v kinh t. Tng sn phm quc ni GDP bnh qun t 7,3% mi nm trong giai on 1995-2005 v thu nhp bnh qun u ngi tng 6,2% mi nm. Vit Nam nhanh chng hi phc v kinh t sau tc ng bt li ca 2 i dch SARS v cm gia cm. Thu nhp bnh qun u ngi/nm tng t 260 USD trong nm 1995 v t mc 835 USD vo nm 2007. D tnh, n nm 2010, thu nhp bnh qun u ngi/nm t 1000 USD v do Vit Nam s tr thnh nc c mc thu nhp trung bnh trn th gii3. Vit Nam ang trong qu trnh cng nghip ha. Gia giai on 1995-2005, t l ng gp ca ngnh nng nghip vo tng sn phm quc ni gim t 27% xung cn 21%, trong khi , cng nghip tng t 29% ln 41%. Nm 2007, Vit Nam chnh thc tr thnh thnh vin ca T chc Thng mi Th gii. Vit Nam cng thnh cng trong chin dch xo i gim ngho. T l h ngho gim t 58,1% nm 1993 xung 22% nm 2007. Tc tng trng kinh t cao v tc xo i gim ngho nhanh dn n s phn cp trong x hi. T l cc h i ngho cao nht cc vng GARP-VN Phn tch thc trng

trung du v min ni pha Bc v thp nht ng nam v cc khu th ln. Tuy nhin, phn tch v mt cc h ngho ch ra rng, hu ht dn ngho khng sng cc khu vc ngho nht m ch yu tp trung 2 khu vc chu th, ni m t l h ngho mc trung bnh (Hnh 2). Hnh 2. Tnh hnh phn b cc h ngho Vit Nam4

Ngun: Bn i ngho v an ton thc phm4 Vit Nam trin khai l trnh pht trin mt s mc tiu pht trin thin nin k (MDGs). 5 trong s 10 mc tiu MDGs c ra cho giai 2

on n nm 2015 c hon thnh trong k c mc tiu xo i gim ngho.

a vo chng trnh tim chng m rng m vn ang l sn phm thng mi ti Vit Nam. Dinh dng l mt ch tiu sc khe quan trng khc. Mt trong cc ni dung trng im

1.1.3. Cc ch s c bn v y t
Tui th trung bnh ca Vit Nam kh cao so vi cc quc gia ang pht trin, bnh qun xp x 69 tui i vi nam v 74 tui n. Tui th ny tng t Brazil v Hy Lp. Xu hng bnh tt v t vong gim i vi cc nhm dn s c bit nh ph n v tr em. T l t vong tr gim t 53 trn 1000 tr sng nm 1990 xung cn 22 trong nm 20085. T l m t vong tng i thp vi khong 150 trn 100.000 tr sng nm 2005, so snh vi mt s nc trong khu vc nh Campuchia, t l ny ln ti 540/100.0006.

ca MDGs l xo i n na u nm 2015, chng trnh ny vt mc ch tiu trc nm 2006. Tng t nh cc ch tiu khc, dinh dng vn cn l vn kh ph bin vng su, vng xa v cc vng dn tc thiu s ni m t l cc h ngho cn cao v cc iu kin v kinh t cn rt thiu thn. Chnh ph cn quan tm hn na v cng cuc ci thin iu kin sng v tnh hnh y t vng su, vng xa. Bng 1: Nhng ch s pht trin c bn v cc ch s y t ca Vit Nam Ch s Dn s (triu) Tc tng dn s (%) Tc th ho (%) Nm 2009 2009 20002008 2008 S lng 88,6 1,14 3

Cc ch s khc v sc kho tr cn cp gm c ch s v tim chng v dinh dng. Chnh ph Vit Nam ti tr 88% cho chng trnh tim chng m rng vi cc vc xin trong chng trnh. Kt qu l, 90% tr c tim chng cc vc xin trong chng trnh tim chng m rng bao gm, lao, bch hu, ho g, un vn, vc xin vim gan B, bi lit v si. Vc xin Haemophilus influenzae B chnh thc c trin khai v a vo chng trnh tim chng m rng k t nm 2009. Tuy nhin t l tim chng cn thp vng su, vng xa7. n nay, vc xin phng bnh do ph cu vn cha c

Tui th (Nam/N) 69/74 Bnh qun GDP 2008 2.600 (USD) T sut cht s sinh 22,3 (trn 1.000 tr 2008 sng) T sut cht m (trn 2005 150 100.000 tr sng) T l ngho 2007 22 (%<1,25$/ng) S dng nc sch 2006 92 (%) iu kin v sinh (%) 2006 65 T l bit ch ngi 200390 ln (%) 2008 Ngun: Ngn hng th gii. CIA S kin th gii. UNICEF Vit Nam6, 8, 9

GARP-VN Phn tch thc trng

1.2. Cu trc ca h thng chm sc sc kho

1.2.1. Gii thiu
25 nm trc, h thng chm sc sc kho Vit Nam ch c h tr bi chnh ph v cc c s cng lp l n v duy nht cung cp cc dch v y t. Vo thi im , thuc men rt khan him. Nhm to thm nhiu c hi tip cn cc dch v chm sc sc khe, k t sau 1986, chnh ph thi hnh mt s bin php nh: ngi bnh ng vin ph ti cc bnh vin cng, p dng m hnh bo him y t, hp php ho ngnh cng nghip dc, bi b qui nh v kinh doanh nh l i vi dc phm10. iu gp phn chuyn i h thng chm sc sc kho ca Vit Nam thnh mt h thng Hnh 3. H thng chm sc sc khe11
Tuyn Trung ng B Y t
Bnh vin tuyn trung ng Cc vin v sinh dch t Trng Y Trng Dc C s khm cha bnh Doanh nghip Dc Tnh Bnh vin tuyn tnh Trng cao ng Y Trung tm v sinh phng dch Qun/ Huyn X Bnh vin tuyn qun/huyn Trm v sinh phng dch Trm y t x Bnh x (khu vc)

phi hp gia cc n v cng lp v t nhn, trong hu ht cc loi thuc u sn c trn th trng vi mc gi tng i thp.

1.2.2. T chc v phn b cc dch v y t

H thng chm sc sc khe cng lp c chia thnh bn cp t trung ng n x (Xem hnh 3). Mi cp li bao gm mt s n v nh chu trch nhim v cc lnh vc khc nhau trong h thng chm sc sc kho bao gm: iu tr, phng bnh, o to, nghin cu v phn phi thuc.

B ngnh khc
BV qun i BV B cng an BV B nng nghip BV Bu in

C s t nhn

BV Giao thng-Vn ti

Formatted: Font: (Default) Arial, 8.5 pt

Phng khm t Nh thuc t Bnh vin t

GARP-VN Phn tch thc trng

Ngun: Thun, N.T., Lofgren, C., Lindholm, L. &Chc, N.T.K. Choice of healthcare provider folloing reform in Vietnam. BMC Health Serv Res 8, 162 (2008).

GARP-VN Phn tch thc trng

C s vt cht
Mc d vi s pht trin nhanh chng ca cc loi hnh chm sc sc kho t nhn, cc n v cng lp vn gi vai tr quan trng trong y t d phng, nghin cu v o to. Trong tng s 961 bnh vin trn ton quc, Vit Nam c 41 bnh vin cp trung ng, cn li l cc bnh vin tuyn tnh, huyn. Hu ht cc bnh vin trung ng u nm trn a bn th H Ni. Tuyn di, c 609 bnh vin tuyn huyn v 10.866 trm y t x 12. Cc trm y t x v phng khm a khoa khu vc l c s khm cha bnh ban u v cng l a ch u tin ngi bnh tip cn vi c s khm cha bnh cng lp, tr trng hp cp cu. Cc n v ny cung cp cc dch v phng v cha bnh cng nh chuyn ngi bnh ln tuyn trn trong trng hp iu kin c s tuyn di khng p ng c yu cu chn on v iu tr. Cc trm y t x/phng chu s qun l ca trung tm y t huyn/qun.

ti cng vic l tnh trng kh ph bin i vi cc cn b y t c bit l mt s bnh vin cng lp do ngi bnh khng khm bnh y t c s. Nghin cu ct ngang, thc hin ti phng khm ngoi tr ti 6 bnh vin thnh ph H Ch Minh (TPHCM) trn 2.587 phiu iu tra t 2001 n 2006. Kt qu cho thy, bnh nhn n khm ngoi tr ti cc bnh vin chuyn khoa ngy cng tng v l do n khm a s l nhng bnh thng thng (44,0%-85,1%) trong khi tuyn y t c s c th iu tr c (67,7%). Bnh nhn n bnh vin a s l vt tuyn hoc t n (85,5%) dn n tnh trng qu ti bnh nhn cc phng khm ngoi tr ti cc bnh vin tuyn trn, vt cng sut s dng ging (107,8%130,0%) v vt ch tiu khm cha bnh ngoi tr (114,4%-145,0%). Mi ngy mt bc s c th khm t 50-100 bnh nhn, dn n vic gim cht lng ca cng tc khm cha bnh14. Ngoi ra, iu kin xt nghim chn on

Theo thng k ca B Y t, nm 2008, cng sut s dng ging bnh ti cc bnh vin cng lp l 128,52% i vi bnh vin tuyn trung ng v 126,66% i vi cc bnh vin tuyn tnh12. T l ny c th ln n trn 200% mt s bnh vin ln tuyn trung ng, nht l trong thi im bng n dch bnh. in hnh nh, bnh vin Nhi ng I, thnh ph H Ch Minh, t l ny c khi ln ti 285% 13. Qu GARP-VN Phn tch thc trng

ti cc c s khm cha bnh tuyn di cn rt hn ch, hoc nu c, ngi bnh phi t chi tr cho chi ph ca cc xt nghim chn on. Bnh vin a khoa c xu hng u t cho cc xt nghim chn on em li li nhun cao, cc xt nghim chn on bnh nhim khun mt mt i hi u t trang thit b t tin cng nh yu cu i vi c s h tng, mt khc li nhun thu c li khng 5

cao, do thng t c quan tm u t so vi cc xt nghim chn on khc. Sc p v mt thi gian v phng tin chn on l mt trong nhng l do dn n vic k n khng sinh mt cch thng xuyn. T khi chuyn i sang c ch th trng, gn 80 bnh vin t, 30.000 phng khm t v 21.600 c s kinh doanh, phn phi dc phm t nhn c hnh thnh. Theo thng k t cc bo co v Cc Qun l Khm cha bnh - B Y t ca 731 bnh vin nm 2007, cng sut s dng ging bnh ti cc bnh vin t nhn l 67,8% nm 2006 v 74,7% nm 2007. Ngi bnh iu tr ni tr ti cc bnh vin t chim t l tng i nh trong tng s ngi bnh iu tr ni tr ti cc bnh vin cng lp (ch chim 1,9% nm 2006 v 2,2% nm 2007)15.

B Y t nm 2009, Vit Nam mi t t l 1,5 dc s/10.000 dn. 52% s dc s tt nghip i hc ch yu tp trung hai thnh ph ln l H Ni v thnh ph H Ch Minh dn n cng trm trng hn tnh trng thiu nhn lc dc tuyn c s v vng su, vng xa 19. Bng 2: Nhn lc ngnh y t nm 2005200816 Phn loi 2005 Cn b ngnh Y Bc s (k c TS. 48.215 ThS) Y s 48.059 Y t (H. TH. SH) 49.536 N h sinh (H. TH. 17.610 SH) KTV Y 8.771 Lng y 293 S bc s cho 10.000 5,88 dn Cn b ngnh Dc Dc s (k c TS. 6.360 ThS) Dc s TH v KTV 10.424 Dc Dc t 8.298 S dc s cho 0,78 10.000 dn Ngun: Thng k Y t 2008 (B Y t) 2008 56.208 49.213 67.081 22.943 11.586 882 6,52

10.524 15.748 9.726 1,22

Nhn lc
Tnh trng thiu ht nhn lc trong ngnh y t l kh ph bin vi t l kh thp t y t n bc s, thiu cc chuyn gia v nhng nh qun l c trnh , tnh trng thiu ht ny c bit trm trng vng su v vng xa (Xem bng 2)16. in hnh nh, khu vc chu th sng Mekong, t l nhn vin y t c trnh i hc (bc s-dc s) l 4,3 bc s/10.000 dn v 0,2 dc s/ 10.000 dn17. Ngc li, cc thnh ph ln, con s ny cao hn r rt vi 9 bc s/10.000 dn18. Theo thng k ca GARP-VN Phn tch thc trng

Ti chnh
Do c s chuyn i trong nn kinh t th trng, h thng ti chnh y t cng c thm nhiu ngun lc mi. Hu qu ca nhng hn ch v mt ti chnh v nhu cu ci thin vic tip cn cc dch v chm sc sc kho. Chnh ph quyt nh thi hnh mt s bin php bao gm: thu vin ph ti cc bnh vin cng 6

lp, m hnh bo him y t, hp php ho cng nghip dc v xo b cc qui nh i vi kinh doanh dc phm nh l10. Nhng thay i ny c th em li nhng ci thin ng k v cht lng v s tip cn cc dch v y t ti Vit Nam. Tuy nhin, ng thi cng dn n vic tng chi ph ca ngi bnh, h phi t chi tr cho cc dch v chm sc sc kho v chim t l kh cao trong tng chi ph v y t. V tng s, chi ph cho y t Vit Nam, tng v t mc xp x 5-6% tng sn phm quc ni15. Con s ny tng i cao so vi mt s nc trong khu vc nh Trung Quc (4,7%),

v Thi Lan (3,5%)20. Tuy nhin, chi ph t cc ngun cng lp ch chim 31% trong tng s chi ph cho y t nm 2006 (Hnh 4), mc chi ph ny tng i thp so vi cc nc c mc thu nhp thp v trung bnh khc, vi t l xp x 45%15. 69% ca tng chi ph y t c chi tr bi cc ngun t nhn, trong , 61% l chi ph t tin ti bnh nhn v 8% c h tr bi cc t chc phi chnh ph (Xem hnh 4)21. Chi ph t tin ti c nhn nh vy l kh cao so vi cc nc ang pht trin trong khu vc, nh Trung Quc (38,8%) v Malaysia

(44,8%)15.

Hnh 4: C cu chi ph y t 200615.

8% 11%

2%

Out-of-pocket Tin ti MoH sch nh nc Ngn budget Health insurance Bo him y t

Phi chnh ph Non governmental

18%

61%

Vn nc ngoi Foreign aid

Ngun: B Y t. Ti khon Y t quc gia 2000-2006 (H Ni. 2008)

Bo him y t

Ngn sch nh nc cng c dng chi tr chi ph ca bo him y t i vi cc

GARP-VN Phn tch thc trng

nhm i tng c bit, v d nh cc i 7

tng ngi ngho v ngi ngh hu. Cc dch v y t c min ph cho cc i tng tr em di 6 tui c p dng k t nm 2005. Trong cu trc cc ngun chi tr ca ph bo him i vi nhm bo him y t bt buc v bo him y t t nguyn cho thy, nh nc chi tr phn ln nht cho bo him y t, chim 64,5% trong tng s ngn sch ca bo him y t. Cui nm 2007, xp x 42% dn s c bo him y t (Xem bng 4). Bo him y t l bt buc i vi ngi lao ng. Mc ng bo him y t bt buc c qui nh tr gi 3% mc lng c bn, trong , 1% c tr bi ngi lao ng v 2% t ngi s dng lao ng15. i vi nhng ngi khng c thu nhp t lng, vic ng bo him y t l t nguyn v mc ph tng ng 3% ca mc lng ti thiu. Bo him y t yu cu ngi bnh ng chi tr 20% chi ph (tr trng hp mc chi

di 100.000 VND i vi bnh nhn ngoi tr v di 200.000 VND i vi bnh nhn ni tr)22. i vi cc dch v k thut cao, mc chi tr ngi bnh c thanh ton t bo him khng vt qu 20.000.000 VND15. Hin nay, c mt s bnh vin t nhn ng k khm bo him y t. Chnh ph chi tr 64,5% tng ngn sch ca bo him y t15. c hon tr cc chi ph cho cc dch v chm sc sc kho, bnh nhn phi n khm bnh ti c s y t ni h ng k khm dch v bo him y t. Trong trng hp ngi bnh chuyn vin, cn phi c giy chuyn vin c hon tr mt phn vin ph trong phm vi t 30% n 70% tu thuc vo cp bnh vin. Ngi bnh s khng c hon tr chi ph chm sc sc kho t bo him y t nu ngi bnh chuyn vin m khng c giy php t c s y t tuyn di22.

Bng 3. S ngi tham gia bo him y t trn ton quc, 2005-200715 2005 Thnh vin 9.154.308 4.726.324 9.133.134 23.013.766 % 39,8 20,5 39,7 100 2007 Thnh vin 11.606.569 15.498.284 9.379.349 36.484.742 % 31,8 42,5 25,7 100

Bt buc T nguyn Tng s

Khng ngho Ngho

1.2.3. Tip cn dch v chm sc sc kho v thuc

Vit Nam c mt h thng trm y t rng khp c nc vi t nht ba nhn vin y t GARP-VN Phn tch thc trng

mi c s. cc khu vc thuc vng su, vng xa, s lng trm y t c php cao hn cc khu vc khc v mt mt nhm tit kim thi gian di chuyn v nhng vng ny iu kin c s h tng v phng tin i li cn rt 8

kh khn. Hn na, i tng ngi ngho v i tng khm bo him y t l hai i tng s dng loi hnh trm y t nhiu hn so vi ngi c iu kin v kinh t. Cc h gia nh c iu kin tt hn v kinh t s dng cc dch v chm sc sc khe nhiu hn so vi cc h ngho v do mc ng gp ca h trong tng chi tr t tin ti cng ln hn. V d nh, cc h c iu kin v kinh t d dng tip cn vi bnh vin ln cp trung ng23. Cc dch v chm sc sc kho ngy cng phong ph, do vic tm kim v tip cn cc dch v y t cng thay i r rt: Nhiu c s khm cha bnh t nhn cung cp cho ngi bnh kh nng tip cn dch v y t cng nh cht lng dch v tt hn rt nhiu so mt s c s khm cha bnh cng lp. Tuy nhin nhiu ngi bnh t iu tr hoc tm n cc hiu thuc t nhn. T iu tr l bin php r tin v tit kim thi gian hn nhiu so vi vic i khm bnh ti cc c s y t. Mt nghin cu ch ra rng, chi ph trung bnh ca h gia nh cho mt t iu tr l 19.616 , i vi loi hnh chm sc sc kho t nhn l 35.206 , v vi loi hnh dch v cng lp l 95.795 . iu ny gii thch ti sao ngi bnh thng c xu hng la chn phng thc t iu tr, kt qu l dn n tnh trng s dng thuc khng hp l ngy cng ph bin. Theo qui nh ca qui ch k n v bn thuc theo n, tt c cc khng sinh u phi bn theo GARP-VN Phn tch thc trng

n nhng thc t th hu ht cc loi khng sinh u mua c ti cc ca hng thuc m khng cn n. Mc d cc loi thuc khng sinh b cm bn khi khng c n thuc, thc trng v vic bn thuc khng sinh khng n ch r s khng tun th cc qui nh c ra10.

1.3. Chng nhim khun

Mi y, B Y t tin hnh vic sa i, b sung qui ch c ban hnh nm 1997 v vic chng nhim khun vi h tr v mt k thut t T chc Y t th gii. Thng t Hng dn trin khai cng tc chng nhim khun ti cc c s khm cha bnh c B Y t thng qua, v c hiu lc t thng 12 nm 200924. Thng t ny l mt n lc ca B Y t nhm ci thin kh nng ca quc gia trong cng tc chng nhim khun v do tng cng cng tc bo v an ton cho ngi bnh cng nh cn b y t v ngi nh bnh nhn. Cc hng dn ny c p dng c c s cng lp v t nhn trong bao gm rt nhiu mt ca cng tc chng nhim khun: v sinh bn tay, kh khun, cc cnh bo chun, cch ly, gim st nhim khun bnh vin, v sinh mi trng, qun l cht thi, an ton thc phm, git l, x l t thi. Mt nhm ch o trin khai vic thc hin thng t theo hng dn c thnh lp nhm m bo vic hiu v thc hin ng v ng b trn qui m ton quc v cng tc chng nhim khun. iu 9

ng ch theo Thng t ny l, vic gim st nhim khun bnh vin tr thnh nhim v bt buc i vi cc c s y t. Hn na, cng tc ny c h tr bi T chc Y t th gii trong chng trnh: Nhng thch thc mang tnh ton cu v an ton cho ngi bnh, nm 2009. Mt nghin cu gn y ti 51 bnh vin thuc khu vc Bc b, Vit Nam v cng tc kim sot nhim khun ti bnh vin nm 2007 v so snh vi kt qu kho st nm 2003 c thc hin25. c mt s ci thin ng k, vi nhng khc bit r rt gia bnh vin tuyn trung ng v tuyn a phng. cc bnh vin tuyn a phng, iu kin vt cht cn ngho nn v hn ch cc c hi o to lin tc cho cc cn b y t. Hu ht cc bnh vin tuyn huyn c hi ng chng nhim khun trc nm 2007, tuy nhin nhn lc cn thiu v do hiu qu hot ng ca hi ng cha cao. Hn na, mt s hng dn thiu tnh cp nht do khng cn ph hp v mt ni dung25. Thc trng ca cng tc chng nhim khun c bit gp nhiu kh khn hu ht cc bnh vin Vit Nam vi c s h tng tr nn qu c v tnh trng qu ti ti cc bnh vin ny. Cng sut s dng ging bnh c th vt qu 100%, c ngha l t nht 2 ngi bnh phi s dng chung mt ging. Tnh trng ny thng xuyn xy ra trong cc GARP-VN Phn tch thc trng

v dch nh t, st xut huyt, cm. Hn na, ngi nh bnh nhn cng cn cng gip chm sc ngi bnh v v sinh v n ung, dn n tnh trng qu ti cng nghim trng. Nghin cu v thc trng v sinh bn tay c thc hin ti 29 khoa lm sng bao gm cc khoa Ngoi, Sn, Hi sc cp cu ca mt bnh vin trung ng v 8 bnh vin tuyn tnh/TP khu vc pha Bc26. Kt qu cho thy s v tr VSBT/100 ging bnh rt thp: 10,3. T l nhn vin y t nhn thc tt v v sinh bn tay l 41,2%. T l tun th VSBT tnh chung l 13,4%26. T l tun th VSBT nhn vin y t bnh vin trung ng l 17,7% cao hn so vi nhn vin y t bnh vin tnh/TP: 10,7%26. Mt s yu t nh hng n thc hnh VSBT ca nhn vin y t gm: thiu phng tin, khng c trang b cn kh khun tay, nhn vin y t nhn thc khng tt v VSBT, mt c hi cn VSBT/gi thp, khi Ngoi khoa, hc vin v t l

NVYT/ging bnh<126. Mt nghin cu khc tin hnh ti mt s bnh vin khu vc pha Bc Vit Nam cho thy phng tin v sinh bn tay cn thiu nh: nc, x phng, hoc khn lau dng mt ln27. Ch c khong 1/3 bnh vin t tiu chun v s v tr v sinh bn tay27. Bung bnh c bn ra tay ch t cha n 40%28. Vic qun l cht thi t bnh vin cng l vn ng ch Vit Nam. Mt d n v 10

iu kin v sinh bnh vin v vic qun l cht thi c tin hnh 12 bnh vin khu vc pha Bc (2006) cho thy, tnh trng kh ph bin khi nc thi t bnh vin c thi trc tip ra ng rung m khng c qua qu trnh x l29. Mt kh khn nghim trng

T l t vong l mt ch s y t quan trng nhm nh gi v tnh hnh sc kho ca ngi dn v s pht trin ca mi quc gia. Vit Nam, cha c s liu mang tnh h thng v chnh xc v t l t vong. Theo thng k ca B Y t, mt s nguyn nhn gy t l t vong cao nht ti Vit Nam c trnh by trong bng 5. Mt nghin cu ch ra rng, bnh l tim mch l nguyn nhn hng u gy t l t vong cao, tip n l nguyn nhn bnh nhim khun. iu chng t Vit Nam c s pht trin ng k v mt dch t hc trong vic phng v iu tr bnh nhim khun32. Bng 4. Mt s nguyn nhn gy t l t vong cao nht ti Vit Nam12 Nguyn nhn t vong Chn thng s no Hi chng suy gim min dch mc phi Vim phi Xut huyt no Tai nn giao thng Nhi mu c tim cp T l (trn 100.000 dn) 2,53 2,43 2,34 1,27 1,10 0,85

khc l hu ht cc bnh vin thiu nc cho cng tc v sinh. Cc theo di khc nh: cc loi rc thi bnh vin vt ba bi gn ngun nc, khng c hp ng xilanh qua s dng, iu kin v sinh ngho nn30. Theo bo co mi y, mi ngy, cc bnh vin trong khu vc thnh ph H Ch Minh thi khong 14.000m3 nc khng qua x l vo cc dng sng v cng sinh hot31.

1.4. Gnh nng bnh tt

nhng nc m bnh truyn nhim chim mt t l ln trong c cu bnh tt th vic tip cn vi thuc khng sinh mt cch hiu qu ng mt vai tr rt quan trng trong vic gim t l mc v t l t vong do cc bnh nhim khun. Do , s gia tng ca tnh trng khng khng sinh c th c nh hng nghim trng i vi sc kho ln kinh t ca ngi dn cc nc ny. Phn ny nh gi mt cch tng quan gnh nng bnh tt Vit Nam v cc cn nguyn vi khun ph bin gy nhim khun mc phi bnh vin.

Ngun: Thng k Y t 2008 (B Y t)

1.4.2. Gnh nng bnh tt do nguyn nhn vi khun

Cc bnh nhim khun vn l nguyn nhn ch yu gy t l mc v t l t vong cao Vit Nam. Hu ht d liu da trn cc nghin cu ca bnh vin, cha c d liu chung v t l mc v t vong ngoi bnh vin ni thiu cc iu kin chn
11

1.4.1. Cc ch s trn ton quc

GARP-VN Phn tch thc trng

on. Nhng hn ch v mt d liu i hi cn c mt s hiu bit su sc v tc ng v dch t hc ca cc bnh nhim khun phi iu tr bng khng sinh.

cu c trin khai nhm nh gi tnh hnh nhim Hib tr di 5 tui Vit Nam t cc ca vim mng no. Trn ton quc, mi nm c 5.107 ca nhp vin v vim phi do H. influenzae tr di 5 tui36. Mt nghin cu

Gnh nng ca cc bnh truyn nhim c th phng bnh bng vc xin

Mi y theo thng k t UNICEF cho thy, Streptococcus pneumoniae l nguyn nhn gy ra 50% cc ca t vong do vim phi tr trn ton th gii. Gim st cc trng hp tr nhp vin c lin quan n cn nguyn ph cu khun ti tnh Khnh Ho, Vit Nam (nm 2005-2006) cho thy t l mc vim phi xm ln (IPD) l 48,7/100.000 tr33. 69% cc ca tr nhp vin v vim phi do ph cu, v 11% v vim mng no do ph cu33. Mt nghin cu khc trn i tng bnh nhn l tr di 5 tui, vim ng h hp cp ti bnh vin Saint Paul, H Ni (2003), vi khun phn lp c vi t l cao nht l S. pneumoniae (35,8%)34. Hin ti cha c gim st da trn cng ng v bnh vim phi xm ln v hin ti vn cha c k hoch v vic a vc xin ph cu vo Vit Nam. Trc khi trin khai vic a vc xin phi hp Hemophilus influenza tup B (Hib) vo chng trnh tim chng m rng, theo thng k, trn th gii c khong 600.000 ca t vong hng nm do cn nguyn Hib35. Mt vi nghin GARP-VN Phn tch thc trng

khc ch ra rng, Hib l cn nguyn gy t l vim mng no xm ln do vi khun tr di 5 tui: 22,9 ca trn 100.000 tr33. Nhm tui c t l mc bnh do Hib cao nht l tr s sinh (87,9/100.000 tr) v tr di 2 tui (32,9/100.000)33. Nghin cu dch t hc vim mng no xm ln do Hib ti H Ni t 2000-2002, t l vim mng no do Hib tr 5 tui l 12 ca trn 100.000 tr v 26 ca trn 100.000 tr tr di 2 tui36. Vim mng no do Hib tr di 2 tui chim khong 88-94% s trng hp vim mng no do vi khun tr di 5 tui35. Mt nghin cu khc tin hnh vi cc bnh phm dch no tu thu thp t bnh nhn nhp vin vo vin Nhi trung ng t 2001 n 2005. Kt qu cho thy 129/529 (24%) cc mu bnh phm dch no ty (CSF) nui cy dng tnh vi Hib, trong 59,7% (77/129) cc chng khng vi amoxicillin37. Mt nghin cu khc ch ra rng Hib l cn nguyn ph bin th 2 gy ra t l mc bnh nhim khun xm ln tr di 5 tui: 22,9/100.000. T l mc Hib c bo co trong nghin cu ny cao hn t l mc c bo co trc vi t l t 12 n 18/100.000 trong 2 phn 12

tch khc33. Vic a vc xin Hib vo chng trnh tim chng s gip gim t l mc bnh nhim khun xm ln tr. Trong mt thi gian di, Salmonella typhi thng c phn lp t bnh phm mu ca bnh nhn c triu chng st. Chng trnh tim chng cng vi cng tc ci thin iu kin v sinh em li nhng thay i ng k v mt dch t hc ca S. typhi Vit Nam. Vit Nam v ang s dng vc xin cha Vi polysaccharide chng li st thng hn cc vng c t l mc cao vi i tng tr t 3 n 10 tui38.

tr vim mng no ti Vit Nam, nghin cu nh gi mc khng khng sinh i vi khng sinh ny (t nm 1996 n nm 2005) cho thy: Trong s 55 chng S. pneumoniae, 50 (90,9%) chng nhy cm vi ceftriaxone v 5 (9,1%) chng khng trung gian vi khng sinh ny40.

Nhim khun huyt

Phn lp cc tc nhn gy nhim khun huyt ti mt bnh vin tuyn trung ng: t l dng tnh l 8% nm 200941. Cc vi khun thng gp l: K. pneumonia (18,3%), E. coli (17,6%), Staphylococcus aeruginosa aureus (11,9%), v

Vim mng no
Vit Nam, nguyn nhn gy bnh vim mng no vi khun ch yu do H. influenzae v S. pneumoniae nh c cp trn y. ngi ln, yu t dch t hc c s khc bit. V d, Streptococcus suis l nguyn nhn gy vim mng no do vi khun ph bin nht: 26% tt c cc chng vi khun nui cy39. S. suis l mt vi khun t ln truyn nhim sang ngi do tip xc v n cc sn phm t tht ln khng m bo an ton thc phm. Cn nguyn vi khun quan trng khc gm S. pneumoniae (11,1%), N. meningitidis (2,4%), Klebsiella (2,7%), E. coli (1,8%), S. aureus (0,7%) v Haemophilus influenzae (0.9%)39. Ceftriaxone c s dng ph bin trong iu GARP-VN Phn tch thc trng

Pseudomonas

(5,9%)

Acinetobacter baumannii (4,4%). Mc khng khng sinh ln lt l: K. pneumoniae ESBL (+) 16,2%; E. coli ESBL (+) 21,5%; S. aureus (MRSA) khng methicillin 13,6%; S. aureus khng trung gian vancomycin (VISA) v S. aureus khng vancomycin (VRSA) 6,1%42. Theo bo co ca Bnh vin Bnh Nhit i Trung ng, cc cn nguyn vi khun gy bnh thng gp t 2008 n 2009 l: E. coli (19,3%), K. pneumoniae (15,2%), S. aureus (13,8%), v S. suis (9,7%)43. Ti thnh ph H Ch Minh, cc cn nguyn vi khun thng phn lp c l: E. coli, S. typhi, Klebsiella pneumoniae v Streptococcus spp44. Cc cn nguyn gy bnh quan trng khc nui cy phn lp t mu Vit Nam l: Burkholderia 13

pseudomallei, nguyn nhn gy melioidosis, nm Penicillium marneffei v Cryptococcus neoformans bnh nhn nhim HIV.

sinh m bo. Mc d vy, trong nm 2007 vn xy ra v dch t cc tnh pha Bc Vit Nam46. Nghin cu H Ni t 3/2001 n 4/2002, trn 587 tr b tiu chy, cn nguyn vi khun gy bnh phn lp c vi t l 67,3%, bao gm: rotavirus (47%), E. coli (23%), Shigella spp. (5%), v Bacteroides fragilis (7%). Khng phn lp c Salmonella spp hoc phy khun t 47. E. coli v Shigella spp. c mc khng khng sinh cao vi ampicillin, chloramphenicol, v trimethoprim/ sulfamethoxazole. E. coli khng cao vi ampicillin (AMP), chloramphenicol (CHL), v trimethoprim/sulfamethoxazole

Vim ng h hp cp (ARI)
ARI l mt trong nhng nguyn nhn ch yu nht gp phn gy ra gnh nng v bnh truyn nhim. Vim phi l nguyn nhn ph bin th hai gy t l t vong. Theo bo co t cc trm y t x, ARI l bnh ph bin nht ti cc c s ny v khng sinh thng c ch nh trong iu tr45. Mt iu tra nghin cu ch ra rng, s dng khng sinh khng y trong trng hp kh th (mt trong nhng triu chng in hnh ca vim phi), v vic lm dng khng sinh iu tr cm lnh v ho ca cn b y t, cc b m v cc i tng hnh ngh y dc t nhn l kh ph bin11.

(SXT), vi t l khng tng ng l 86.4%, 77.2%, v 88.3%. Khong 89% cc chng Shigella khng vi

trimethoprim/sulfamethoxazole, 75% khng ampicillin, v 53.6% khng chloramphenicol47. Tr nhp vin vi cc triu chng st (43,6%), nn (53,8%), v mt nc (82,6%). Trc khi nhp vin, 162/587 (27,6%) tr dng khng sinh. Hu ht cc ca tiu chy c bn t cc h gia nh c iu kin v sinh km47.

Cc nguyn nhn chnh ca ARI v bn cht l vi rt nh rhinovirus, vi rt RS, influenza, v cc cn nguyn khc [s liu cha cng b, OUCRU]. Cn nguyn vi khun bao gm: S.pneumoniae, K. pneumonia, H. infuenzae, Moraxella catarrhalis, v S. aureus. ng ch l, K. pneumoniae l mt nguyn nhn ch yu gy vim phi mc phi cng ng ngi ln [S liu cha cng b OUCRU-NHTD].

Bnh truyn nhim qua ng tnh dc (STI)

Sau ca nhim HIV u tin c bo co Vit Nam vo nm 1990, con s cc ca nhim HIV v AIDS gia tng nhanh chng tt c

Bnh tiu chy

Gnh nng ca bnh tiu chy Vit Nam gim ng k nh vic ci thin iu kin sng, nh s dng nc sch v h thng v GARP-VN Phn tch thc trng

cc tnh/thnh ph48. Tng s trng hp nhim HIV tnh n cui nm 2008 l 179.735 14

ngi12. Tnh hnh nhim HIV Vit Nam vn gia tng v din bin phc tp, ch yu tp trung nhm i tng s dng ma ty, gi mi dm v quan h tnh dc ng tnh nam gii49. Cc nhm i tng khc chim khong 0,53%49. Tnh n nay, c nc c khong

Hin nay c rt t s liu v gnh nng ca nhim khun bnh vin Vit Nam. Nh trnh by phn trn, cng tc chng nhim khun bnh vin Vit Nam gp nhiu tr ngi do thiu iu kin v sinh (x phng, nc sch hp ng cht thi sc nhn, h thng qun l cht thi), v sinh bn tay khng y , tnh trng qu ti v thiu nhn lc. Hin ti, khng c s liu ton quc v t l mc v gnh nng ca nhim khun bnh vin Vit Nam. Ti liu hng dn mi ca B Y t yu cu tt c cc c s y t phi ghi li cc s liu v nhim khun bnh vin trong thi gian sp ti. Mt s nghin cu v nhim khun bnh vin Vit Nam, ch yu c thc hin bnh vin Bch Mai v bnh vin Ch Ry. Gim st c tin hnh bnh vin Bch Mai v hiu qu iu tr v chi ph cho nhim khun bnh vin do nhim khun vt m (SSI). Kt qu cho thy nhim khun vt m lm tng chi ph iu tr v tng thi gian nm vin. C th l tng thi gian nm vin ln 8,2 ngy, chi ph iu tr khong 110 USD 51. Nghin cu 36 bnh vin cc tnh pha Bc Vit Nam trong nm 2006-2007 bao gm 2 bnh vin trung ng, 17 bnh vin tuyn tnh v 17 bnh vin tuyn huyn cho thy 553/7571 (7,8%) bnh nhn mc nhim trng

15.007 trng hp t vong do AIDS49. 63 tnh/thnh trn ton quc u c ngi nhim HIV, t l nhim 96% ti 659 qun v hn 66% 10.732 trm y t phng/x49. Nhim HIV

ch yu tp trung nhm i tng t 20-39 tui chim 78.9%, trong nam gii chim 85.2%49. T l nhim HIV nhm i tng tr

tui v quan h tnh dc ng gii ngy cng gia tng49. Trong mt nghin cu vng nng thn Vit Nam, 37% gi mi dm mc bnh truyn nhim qua ng tnh dc hoc mc bnh vim ng sinh dc50. Cc nhim khun thng gp

l candidiasis (26%), vi khun m o (11%), tip n l vim gan B (8,3%), Chlamydia trachomatis (4,3%), trng roi m o (1%), Neisseria gonorrhoeae (0,7%), v mn cc m o (0,2%)50. Khng pht hin trng hp no

nhim HIV v giang mai, 50% cc ca STI khng c triu chng50. Yu t lin quan n chlamydia STI l nhm i tng c iu kin kinh t cao50.

Nhim khun bnh vin

bnh vin (HAIs)27. Cn nguyn gy nhim khun bnh vin thng gp l: vim phi

GARP-VN Phn tch thc trng

(41,9%), nhim khun vt m (27,5%), nhim 15

khun tiu ho (13,1%). Cc vi khun thng gp l Pseudomonas aeruginosa (31,5%), Acinetobacter baumanii (23,3%), v Candida spp (14,4%). Ch yu, HAIs xy ra khoa phu thut27. Mt nghin cu ct ngang Bnh vin Bch Mai nm 2006 cho thy, t l cc trng hp nhim khun bnh vin tng i thp: 5.9%. C 3 loi nhim khun chnh: nhim khun h hp (75%), nhim khun tit niu (10%) v nhim khun tiu ho (5%). Cn nguyn chnh l P. aeruginosa (28,6%), A. baumanii (23,8%), K. pneumoniae (19%) v Candida spp (14,3%)52. 48,5% bnh nhn c iu tra s dng khng sinh trc khi chn on mc HAIs53. Nghin cu khc bnh vin

Ch Ry cng ch ra rng, cn nguyn thng gy HAIs l trc khun Gram m bao gm: K. pneumoniae (25%), P. aeruginosa (24%), A. baumani (18%). v E. coli (19%)54. HAIs do S. aureus khng ng vai tr quan trng Vit Nam. Mt nghin cu khc khoa cp cu hi sc, khoa phu thut v khoa sn ca 3 bnh vin tnh bao gm Qung Ninh, Ha Bnh, in Bin nm 2004 cho thy, t l mc nhim khun bnh vin tng i cao: 17,3%55. T l cao nht khoa cp cu hi sc. Nhim khun ph bin nht l nhim khun vt m (55%), nhim khun tit niu (21%) v vim ng h hp di (17%)55.

GARP-VN Phn tch thc trng

16

II. H thng cung ng v qun l khng sinh

Ni dung phn II trnh by v h thng qun l v phn phi khng sinh Vit Nam, ng thi cung cp cc thng tin lin quan n cc chnh sch qui ch quc gia lin quan n s cung cp v phn phi thuc, tm quan trng ca khng sinh trong cc ti liu hng dn iu tr, qui nh phn b v thc trng qun l dc phm.

lnh vc dc, s ng k lu hnh thuc; giy php xut nhp khu thuc v cc lnh vc qun l khc c lin quan. Cc Qun l Khm, cha bnh tham mu gip B trng B Y t qun l nh nc v lnh vc khm, cha bnh; qun l bnh vin; iu dng; phc hi chc nng; gim nh (bao gm gim nh y khoa, gim nh y php) i vi ton b h thng y t nh nc, bn cng v t nhn trong phm vi c nc; Ch o, hng dn s dng thuc an ton, hp l, hiu qu. Chm sc v bo v sc

2.1. C cu lp php chi phi s phn phi, lu thng khng sinh

Mt s V, Cc trc thuc B Y t c chc nng, nhim v iu hnh cc hot ng ca cc c s y dc cng lp v t nhn. C th l, Cc Qun l Dc gip B trng B Y t thc hin chc nng qun l Nh nc v thc thi php lut, iu hnh cc hot ng chuyn mn, nghip v v lnh vc dc v m phm trong phm vi c nc. Nhim v: Xy dng chin lc, chnh sch, quy hoch, k hoch pht trin ngnh Dc Vit Nam; Ch o, hng dn, kim tra vic thc hin cc vn bn quy phm php lut, quy ch, ch qun l v dc, m phm trong phm vi c nc; Ch tr hoc phi hp vi cc c quan lin quan trong vic qun l thng tin, qung co thuc, m phm; T chc thc hin v quyt nh theo thm quyn vic cp, nh ch, thu hi giy chng nhn t tiu chun thc hnh tt v GARP-VN Phn tch thc trng

kho cn b. Ch o cc c s y t thc hin khm cha bnh, iu dng, phc hi chc nng cho ngi bnh c th bo him y t. Thanh tra B Y t c chc nng thc hin thanh tra chuyn ngnh y t trong phm vi c nc trong bao gm: T chc thanh tra vic chp hnh nhng quy nh ca php lut, cc quy ch, quy trnh chuyn mn, k thut trong khm cha bnh, iu dng, phc hi chc nng trong phm vi c nc bao gm c t chc v c nhn nc ngoi ti Vit Nam; T chc thanh tra vic chp hnh nhng quy nh ca php lut v dc trong phm vi c nc bao gm c t chc v c nhn nc ngoi ti Vit Nam. n nm 2006, c nc c 230 thanh tra y, vi s h tr ca khong 1000 cng tc vin trong tng khu vc c th v 30 cn b tuyn trung ng56. Trc thuc B Nng nghip v Pht trin Nng thn, Cc Th y gip B trng thc hin 17

chc nng qun l Nh nc v cng tc phng chng dch bnh cho ng vt, kim dch v kim sot thuc th y trong phm vi c nc. Ngoi ra, Cc Qun l Cht lng Nng lm Thu sn gip B thc hin chc nng qun l nh nc v cht lng, v sinh an ton thc phm i vi nng, lm, thy sn trong qu trnh sn xut n khi thc phm c a ra th trng ni a hoc xut khu, trong phi k n chng trnh gim st d lng cc cht b hn ch hoc cm s dng trong chn nui v nui trng thu sn, k c thuc khng sinh. Nm 1996, B Y t ban hnh chnh sch Quc gia v thuc, trong c nu r chnh sch v thuc khng sinh nh sau: Thuc khng sinh c vai tr rt quan trng trong iu tr, c bit i vi tnh hnh bnh tt ca mt s nc kh hu nhit i nh nc ta. Chn chnh vic k n v s dng khng sinh, xc nh tnh khng khng sinh ca mt s vi khun gy bnh, to iu kin cc c s iu tr c kh nng lm khng sinh . Ngnh y t cng vi B Nng nghip v Pht trin Nng thn ban hnh quy nh s dng khng sinh cho sc vt nhm trnh s gia tng tnh khng khng sinh i vi mt s vi khun gy bnh cho ngi. Hin nay, ch c cc bnh vin tuyn trung ng hoc cc bnh vin ln tuyn tnh c kh nng tin hnh nui cy vi khun, nh danh v GARP-VN Phn tch thc trng

xc nh mc nhy cm khng sinh. Cho n nay, hu ht cc phng xt nghim vi sinh lm sng ti cc bnh vin khng t tiu chun c th tin hnh v cho kt qu ng tin cy ca cc xt nghim vi sinh. Trong chng trnh ASTS (Nghin cu th nghim nhy cm khng sinh) cht lng v tin cy ca cc xt nghim vi sinh l mt vn . V d, Pseudomonas aeruginosa trong mt s bo co cho thy kt qu nhy cm vi cotrimoxazole, trong khi vi khun ny v bn cht khng vi cc khng sinh ny. Nm 1997, B Y t c vn bn yu cu cc bnh vin thnh lp Hi ng Thuc v iu tr. Thnh vin ca Hi ng gm c bc s lm sng, dc s v chuyn gia vi sinh. Mt trong nhng nhim v ca HT&T l thc hin cc hng dn ca B Y t v vic s dng thuc, a ra cc li khuyn v mt chuyn mn nhm gip ci thin vic s dng thuc hp l, an ton v hiu qu. Ngoi ra, Hi ng cn c nhim v tham vn gip xy dng danh mc thuc ch yu s dng ti n v ca h. Mt s loi thuc khng sinh nht nh, v d nh meropenem, trc khi s dng trong iu tr phi tham kho kin t vn ca Hi ng. Mt nhim v khc ca Hi ng l ch o tuyn cho cc cn b y t a phng v vic s dng thuc hp l v t chc cc hot ng gim st v bo co v tnh trng khng khng sinh khng sinh. Hin ti, gn 100% cc bnh vin c hi ng thuc v iu tr. Cc bnh 18

vin tuyn huyn tn ti tnh trng thiu nhiu nhn lc dc c trnh v cc chuyn gia vi sinh. B Y t trin khai nhiu hot ng nhm tip tc thc hin ch th 05/2004/CTBYT v vic chn chnh cng tc cung ng, s dng thuc trong bnh vin. C th nh sau: Xy dng hng dn s dng thuc hp l, an ton; Tp hun tng cng s dng thuc hp l; Kim tra hot ng ca Hi ng thuc v iu tr; Hot ng h tr s dng khng sinh hp l; Cung ng qun l thuc; s dng thuc trong bnh vin; Hot ng s dng thuc hp l trong bnh vin v tng cng hot ng ca nh thuc bnh vin57. Tuy nhin, nhng thnh tu v tc ng do Ch th ny em li cha c nhn bit r rng. Trong quy nh ca Lut Dc c ban hnh nm 2005 c ghi r: nghim cm: Bn l thuc k n khng c n thuc; Khi s dng thuc theo n thuc, ngi s dng thuc phi thc hin theo ng hng dn ghi trong n thuc; Khi s dng thuc, nu c th c nhng du hiu khng bnh thng, ngi s dng thuc cn thng bo ngay cho c s y t gn nht, ngi k n thuc hoc ngi bn l thuc bit c bin php x l kp thi; Ngi k n thuc, ch c s bn l thuc c trch nhim thng bo vi c quan y t c thm quyn v nhng du hiu khng bnh thng ca ngi s dng thuc. Ngi k n phi chu trch nhim v n thuc k; GARP-VN Phn tch thc trng

Thuc k n khng c qung co cho cng chng di mi hnh thc. Mc d vy, hu ht cc hiu thuc vn bn thuc khng n mt cch t do m khng phi chu bt k hnh pht no58. L do dn n tnh trng ny c th l v cho n nay, vn cha c cc ch ti c th p dng i vi cc c s kinh doanh dc phm khng tun th theo qui nh. Quy ch K n thuc trong iu tr ngoi tr (ban hnh km theo Quyt inh s 04/2008/Q- BYT ngy 1 thng 2 nm 2008 ca B trng B Y t :Quy nh thuc phi k n: Theo quy nh ti Danh mc thuc phi k n do B Y t ban hnh; iu kin i vi ngi k n thuc phi l ngi c bng i hc y ang lm vic ti c s khm cha bnh hp php hoc i vi cc tnh vng su vng xa. Y s c th c ch nh thay th bc s. ng ch l, trong qui ch ny cng qui nh v vic khng c k n theo yu cu khng hp l ca ngi bnh. n thuc c gi tr mua thuc trong thi hn 05 ngy k t ngy k n v c mua ti tt c cc c s bn thuc hp php trong c nc. Quyt nh s 11/2007 ca B Y t va ban hnh v vic thc hnh tt qun l nh thuc (Good Pharmacy Practice - GPP) a ra cc nguyn tc, tiu chun c bn trong thc hnh ngh nghip ti nh thuc ca dc s v nhn s dc trn c s t nguyn tun th cc tiu chun o c v chuyn mn mc cao hn nhng yu cu php l ti thiu. 19

GPP bo m thc hin cc nguyn tc sau: t li ch ca ngi bnh v sc kho ca cng ng ln trn ht; Cung cp thuc bo m cht lng km theo thng tin v thuc, t vn thch hp cho ngi s dng v theo di vic s dng thuc ca h; Tham gia vo hot ng t iu tr, bao gm cung cp thuc v t vn dng thuc, t iu tr triu chng ca cc bnh n gin; Gp phn y mnh vic k n ph hp, kinh t v vic s dng thuc an ton, hp l, c hiu qu. Theo bo co ca 37 tnh, thnh ph (tnh n 31.3.2009) c 5% nh thuc t nh thuc t GPP59.

ca cc loi thuc trn th trng; cung cp t vn v ph bin cc thng tin v thuc, cnh gic Dc cho cc c s y t, cn b y t v cng ng; xy dng mng li thng tin thuc v cnh gic Dc trn ton quc v thit lp mi quan h vi cc trung tm thng tin thuc v cnh gic dc khu vc v trn th gii. Trung tm ny c th ng gp mt vai tr quan trng trong vic tip cn cc chnh sch v thc hnh k n trong h thng y t. Cho n nay, Vit Nam s dng 2 danh mc thuc l danh mc thuc thit yu v danh mc thuc ch yu. Danh mc thuc thit yu l danh mc gm c s thuc cn c ti cc c s khm cha bnh. Danh mc thuc ch yu c xy dng da trn danh mc thuc thit yu v bao gm cc thuc c th c Bo him y t chi tr. Danh mc ny c th iu chnh cho ph hp vi iu kin ca tng bnh vin. Hin nay, cc bnh vin s dng danh mc thuc ch yu (ban hnh nm 2008 vi hn 750 thuc trong c 141 thuc khng sinh) c xy dng da trn danh mc thuc thit yu quc gia. Danh mc ny l c s cc c s khm cha bnh la chn, m bo nhu cu iu tr v thanh ton cho cc i tng ngi bnh, bao gm c ngi bnh c bo him y t. Trong danh mc ny, c 44 khng sinh ch c s dng cc bnh vin hng hai tr ln, 16 loi khng sinh cn phi c Hi ng thuc v iu tr thng qua trc khi k n. Mt s loi khng sinh nn 20

Tp trung trin khai vi i tng cc nh thuc bnh vin. Khuyn khch cc doanh nghip t chc chui nh thuc t GPP vi nhiu chnh sch u i nh chnh sch v thu, trc tip nhp khu, cung ng thuc cho bnh vin. Theo d kin cc nh thuc khng trin khai thc hin l trnh s ch c php bn thuc OTC. Nhm tng cng hiu qu trong s dng thuc Vit Nam, mi y B Y t chnh thc thnh lp Trung tm Quc gia v thng tin thuc quc gia v theo di phn ng c hi ca thuc (DI&PV). Mc tiu ca trung tm l nhm xy dng mt h thng DI&PV ton din nhm m bo an ton thuc Vit Nam. Mc tiu c th bao gm, xy dng mt c s d liu thng tin v thuc k c thng tin v cnh gic Dc; h tr cc c quan qun l nh nc trong vic nh gi, thng tin v nhng nguy c v li ch GARP-VN Phn tch thc trng

hn ch s dng bao gm cephalosporins th h 3, 4 (cefepim, cefoperazon, cefotiam, v ceftriaxone), ertapenem), carbapenems piptazobactam, (khng k

nc chim khong 46,5% tng s vn iu l, nhn vin ca doanh nghip gi 38,1% v thnh phn ngoi doanh nghip gi 15,4%60. S liu nm 2008 cho thy, sn phm thuc ni a chim 50,2% trong tng s tt c cc thuc trn th trng Vit Nam (Ngun: B Y t). Tng gi tr thuc sn xut trong nc nm 2008 l 715.435 triu la M, tng ng k so vi nm 2007 (600.630 triu la M USD, xem hnh 1, s liu t B Y t). Cc cn b y t cng c khuyn khch s dng cc thuc sn xut trong nc nu c th. Hnh 5. Doanh thu ca thuc sn xut trong nc v thuc ni chung ti Vit Nam (triu la M) t 2001 n 200861.
la M Tng doanh thu DT thuc ni

netilmicin,

azithromycin, fluorquinolones (levofloxacin, lomefloxacin, v moxifloxacin), v vancomycin.

2.2. Chui cung ng

2.2.1. Nh sn xut
Hin nay, c 93 doanh nghip trong nc sn xut dc phm. Trong s , 53 c s t tiu chun thc hnh tt sn xut thuc ca T chc Y t th gii (GMP WHO) v 24 c s t tiu chun GMP ASEAN. Hu ht cc c s sn xut trong nc v c bn ch yu nhp bn thnh phm v ng gi mt s loi thuc bao gm c mt s thuc khng sinh thng thng nh beta-lactams, tetracycline, chloramphenicol v gentamicin, t bn thnh phm nhp khu. Cc nguyn liu sn xut ch yu nhp khu t Trung Quc, Singapore v n . Mt s doanh nghip sn xut ni a cng tham gia vo qu trnh cung ng thuc cho cc bnh vin v cc c s bn bun (c bit n nh mt s ch thuc ln) hoc thm ch cc doanh nghip ny cng s hu cc nh thuc hot ng trong lnh vc kinh doanh. C 4 doanh nghip dc phm ln chi phi hot ng sn xut, nhp khu, cung ng thuc v chim lnh th trng. Cc doanh nghip ny trc y l doanh nghip c 100% vn nh nc, hin nay tr thnh cc cng ty c phn vi vn nh GARP-VN Phn tch thc trng

Nm

Ngun: Cc Qun l Dc (B Y t)

2.2.2. Nh phn phi

21

Knh phn phi dc phm trn th trng Vit Nam c chia lm 2 th phn: iu tr (37%) v thng mi (63%)62. u thu v bn thuc qua h thng bnh vin thuc v knh iu tr, trong khi vic kinh doanh qua h thng nh thuc c hiu l knh thng mi. Li nhun trong knh iu tr thp hn knh thng mi do gi thuc trong bnh vin thng thp hn gi th trng. Hn 370 doanh nghip nc ngoi v 93 doanh nghip sn xut trong nc cung ng thuc khng sinh cho th trng thuc Vit Nam qua mt h thng phn phi phc tp, trong ring doanh s ca mt vi cng ty phn phi nc ngoi chim gn 50% th trng. Trong h thng cung ng thuc Vit Nam c khong 800 cng ty phn phi dc phm v 39.016 i l (nh thuc, hiu thuc, quy thuc) nm 200863. Qun l gi v cht lng thuc trong chui cung ng cn rt yu. V d, khng sinh phi qua rt nhiu khu trung gian mi n c tay ngi bnh dn n tnh trng tng gi thuc gi to. Mc d tp trung ch yu ti TP. H Ch Minh v H Ni, cc ca hng bn bun v cng ty trch nhim hu hn chi phi kh ln vo cc khu vc phn phi thuc trn ton quc. Cc doanh nghip ny c u th l rt linh hot tm ngun hng cung ng, giao nhn hng v thanh ton. GARP-VN Phn tch thc trng

2.2.3. Bnh vin

Tt c cc bnh vin u c nh thuc chu trch nhim vic cung ng v phn phi thuc trong bao gm thuc khng sinh cho cc i tng bnh nhn ni tr v ngoi tr c n thuc. Mi nm khoa dc bnh vin d tr danh mc v s lng thuc thit yu s dng cho mt nm, t chc u thu cho cc cng ty phn phi dc phm. Cc tiu chun la chn nh phn phi ch yu da trn gi c, cht lng thuc, uy tn ca cng ty phn phi v li ch bnh vin nhn c. Theo kt qu thanh tra mi y ca Cc Qun l Dc ti 6 nh thuc bnh vin v 8 nh thuc khu vc gn bnh vin cho thy, gn 98% cc loi thuc ti nh thuc bnh vin c bn vi gi thp hn so vi cc nh thuc ngoi bnh vin58. Tuy nhin, mt s nghin cu khc li chng minh kt qu ngc li, gi thuc ti nh thuc trong bnh vin t hn gi bn l bn ngoi. Bo co mi y ca T chc y t th gii v gi thuc ti Vit Nam cng nhn nh rng, gi thuc ti khu vc cng lp cao hn so vi khu vc t nhn64.

2.2.4. Hiu thuc

y l a ch u tin ngi bnh tm n khi au m vi mc tiu tit kim thi gian v chi ph. Hin nay, trn th trng Vit Nam c hn 39.000 hiu thuc. Hu ht cc thuc

c bn khng c n thuc km theo65. 22

Ngi bnh m t triu chng bnh, v ngi bn thuc vi kin thc hn ch v y, dc, s a ra cc hng dn la chn. Sau thi gian 5 nm thc hnh ti c s Dc, dc s c quyn xin cp giy php hnh ngh Dc t nhn, v phi c mt ti c s kinh doanh dc m h ng tn, tuy nhin tnh trng cc dc s cho thu bng l kh ph bin trong khi vn lm vic ton b thi gian c s khc. Hu ht bnh nhn mua thuc khng sinh iu tr trong mt thi gian ngn, khong 3 ngy. Khng sinh thng c bn km vi vitamin, thuc h st v mt s thuc nhm steroids [S liu cha cng b OUCRU-HMU].

bi B Y t (Xem bng 6)66. Hin cha c s liu ng tin cy v tng chi ph cho khng sinh trn ton quc Vit Nam. cc c s cng lp, khng sinh chim khong 40-50% tng chi ph cho thuc ni chung. Trong s 100 dc phm c doanh thu cao nht ti th trng Vit Nam nm 2002, 21 thuc l khng sinh, chim 29% tng gi tr67. Do li nhun t khng sinh em li chim t trng kh ln trong tng s li nhun m c s kinh doanh thu c68.

2.2.6 Kim sot gi thuc

Cc Qun l Dc phi hp vi B Ti chnh chu trch nhim thi hnh v thit lp h thng kim sot gi thuc. Hi ng ny cn hoch nh cc hot ng v t chc hp nh k. Cc Qun l Dc cn thiu bng chng y thit lp h thng gi thuc. T chc y t th gii h tr trong vic thu thp d liu v tin hnh cc nghin cu gim st v gi thuc cng nh cc cu thnh ca gi thuc. C ch hin ti vn cha t c cc mc tiu mong mun v gi thuc Vit Nam vn cao hn gi thuc th gii64. Hin ti, Cc Qun l dc thu thp gi CIF ca tt c cc thuc nhp khu v yu cu cc nh sn xut cng b gi bn bun trc khi cp s ng k. Tuy nhin, khng c gii hn trn i vi gi bn bun. Chnh ph cng khng c bin php no thng lng v gi bn bun. Thm ch c so snh gi CIF vi gi bn bun th gi bn 23

2.2.5. Gi thuc cc cp khc nhau trong knh phn phi

Mt kho st nh ti ch thuc H Ni v mt s nh thuc ti a bn xung quanh bnh vin Bch Mai cho thy, gi thuc khng sinh bn l thng cao hn gi bn bun khong 15-20% (Xem bng 5). Gi thuc trong bnh vin thng thp hn gi thuc bn bun khong 15-20% do gi thuc trong bnh vin l gi thuc trng thu, c n nh vo u nm, khi cc hp ng u thu c k kt. Trong khi , gi thuc bn bun c th tng do c ch th trng. Gi thuc trong bnh vin ch p dng cho bnh nhn ni tr. i vi bnh nhn ngoi tr, c th mua thuc t nh thuc bnh vin, vi gi bn l c qui nh GARP-VN Phn tch thc trng

bun vn c php cao hn gi CIF. Cc bnh

vin c yu cu mua thuc qua qu trnh

Nm

GARP-VN Phn tch thc trng

24

Bng 5: Gi ca mt s khng sinh cc cp khc nhau Khng sinh Augmentin 625mg (Amoxicillin + Acid Clavulanic) Unasyn (Ampicillin+Sulbactam) Cefalexine 500mg Cng ty GSKEngland Pfizer-Italy n v vin l Bnh vin 0,58 3,56 Gi bn bun (USD) 0,79 4,26 Gi bn l (USD) 0,89 4,96

Traphacovin 0,025 0,035 0,042 Vietnam MekofarmCefaclor 125mg vin 0,36 0,48 0,55 America RotexCefuroxim 750mg l 2,43 2,81 3,24 Germany BayerCiprofloxacin 500mg vin 0,67 0,76 0,89 Germany Ngun: kho st ti ch thuc Ngc Khnh. H Ni v mt s hiu thuc xung quanh bnh vin Bch Mai. u thu theo gi bn bun. Gi bn bun cao, kt hp vi vic cc nh thu y gi cao n mc ti a dn n gi thuc cao ti khu vc cng lp. Gi bn l c th trng qui nh, tuy nhin th trng c xu hng bn thuc bit dc hn l thuc gc gi r64. Vi cc chnh sch hin nay, cc nh cung cp d dng iu chnh tng gi v chnh ph khng th kim sot. Mt s quc gia c c ch kim sot gi c cht ch hn, vi chnh sch thuc gc mnh m, phi hp vi h thng mua bn hp l nhm h gi thnh ca thuc. Bng 6. Gi thuc bn l v nh nc qui nh mc gi thng d cho nh thuc bnh vin Gi gc/n v (USD) 1 0,054 2 0,054-0,27 3 0,27-5,41 4 5,41-54,05 5 >54,05 GARP-VN Phn tch thc trng STT Thng d ti a (%) 20 15 10 7 5 Ngun: Qui nh v t chc v hot ng ca Nh thuc bnh vin (Ban hnh km theo Quyt nh s: 24/2008/Q-BYT. ngy 11/7/2008 ca B trng B Y t)

2.2.7. Thuc gi
Mt s khng sinh gi thng gp th trng Vit Nam gm c: ampicillin.

Amoxicillin, chloramphenicol, erythromycin and tetracycline69. Hu ht cc loi thuc ny c bn ti cc c s kinh doanh khng c giy php. Cc bo co v thuc b thu hi cho thy trong 5 nm tr li y s lng thuc b thu hi gim ng k, v c th s tip tc gim trong thi gian sp ti, khi m l trnh GPP c trin khai vi tt c cc c s kinh doanh dc phm hp php. ngi dn s khng phi mua thuc t cc c s khng ng k cp giy php kinh doanh69. Theo B Y t, nm 2008, 25 24

l thuc khng sinh trong tng s 94 thuc b thu hi do khng t tiu chun v cht lng70.

Nm 2008, c s gia tng t l thuc gi c pht hin do tng cng hot ng gim st v s phi hp gia cc ban ngnh (Bng 7)71.

Bng 7. Thuc gi c pht hin qua cc nm71

Nm 2000 2001 2002 2003 T l (%) 0.06 0.05 0.03 0.06 Ngun: Cc Qun l Dc B Y t Vit Nam71 2004 0.06 2005 0.09 2006 0.13 2007 0.17 2008 0.21

2.3. S dng khng sinh ti cc tuyn c s

Vi s h tr ca T chc Y t Th gii WHO v UNICEF, B Y t xy dng cc hng dn iu tr i vi cc bnh thng gp tr bao gm bnh vim ng h hp cp (ARIs), vim mng no, tiu chy, cm, vim phi mc phi cng ng, v tiu chy do l trc khun72. Hng dn iu tr cc bnh nhim khun thng gp (B y t, 2006) bao gm cc hng dn c th v liu php khng sinh (tn, liu, thi gian iu tr) da trn cp ca c s khm cha bnh, triu chng, tnh trng bnh, cn nng v la tui, v la chn theo cn nguyn gy bnh73. ng thi, hng dn cng a ra nhng khuyn co v vic gim st c tnh ca thuc trn bnh nhn (v d theo di c tnh trn thn vi khng sinh nhm aminoglycosides). Ti cng ng, hng dn ca B Y t khuyn co dng penicillin hoc amoxicillin cho trng hp vim phi cha r nguyn GARP-VN Phn tch thc trng

nhn. Amoxicillin phi hp axit clavulanic hoc khng sinh cephalosporin th h 2, 3 c th dng thay th. i vi trng hp nghi vim phi khng in hnh, khng sinh nhm macrolide c th c la chn b sung trong liu php iu tr. Vi tnh trng khng khng sinh hin ti ca S. pneumoniae v H. influenzae, khuyn co s dng penicillin hoc amoxicillin c th khng hiu qu74. Thc t, ampicillin hoc cephalexin (cephalosporin th h 1) thng c ch nh trm y t x. Ti cc tuyn bnh vin, bnh nhn mc vim phi cng ng c ch nh amoxicillin (n hoc phi hp vi axit clavulanic) hoc

cephalosporin th h 2, 3 v mt khng sinh nhm macrolide. i vi vim mng no, hng dn khuyn co dng khng sinh ng tim vi la chn ban u l ceftriaxon. Ch nh ph thuc vo i tng tr em hoc ngi ln v cn nguyn gy bnh. ng ch l, mt cn nguyn quan trng gy vim mng no ngi ln thng 25

gp Vit Nam, Streptococcus suis, khng c cp trong hng dn. Hn na, hng dn cng khuyn co dng penicillin ng tnh mch i vi vim mng no do ph cu, mc d trn thc t mc khng vi khng sinh ny tng i cao. Trovafloxacin cng c khuyn co s dng trong iu tr vim mng no trong khi thuc ny b cm s dng trong nhiu nm do c tnh cao vi gan. i vi l trc khun gy tiu chy c ln mu tr, hng dn khuyn co b sung nc v in gii phi hp vi amoxicillin hoc cotrimoxazole. i vi ngi ln, khuyn co dng ORS phi hp vi mt khng sinh nhm fluorquinolone (v d ciprofloxacin). Hn na, cc bnh vin tuyn di khng c php ch nh khng sinh cho cc bnh nhn nghi vim mng no vi khun. n v c nhim v thc hin vic chuyn bnh nhn ln tuyn trn chn on v iu tr73. Hng dn x l lng ghp cc bnh thng gp tr (B Y t, 2006) ch yu hng dn cc b m chm sc tr ti nh hoc a tr n trung tm y t trong trng hp bnh nng. Trong ti liu ny, khi qut nh gi, phn loi v iu tr bnh thng gp tr bao gm vim phi v tiu chy. Hng dn khuyn co dng cotrimoxazole, amoxicillin, hoc erythromycin i vi cc trng hp vim ng h hp nng. ng cng khuyn co khng s dng khng sinh trong trng GARP-VN Phn tch thc trng

hp tr ho hoc cm lnh khng c triu chng vim phi. Tr c du hiu tin lng bnh nng, phi c tim bp mt liu

chloramphenicol v sau a tr i bnh vin. Mt nghin cu c tin hnh nm 2007 nhm nh gi kin thc s dng khng sinh khu vc nng thn Vit Nam cho thy mc d c cc ti liu hng dn iu tr, mt nghin cu cng ng ti khu vc nng thn Vit Nam cho thy, kin thc v s dng khng sinh khng tun th theo cc hng dn ny dn n tnh trng x l vim ng h hp cp khng hp l ca cc cn b y t 74. Khng sinh thng c ch nh iu tr cm lnh v ho thng thng. Ngoi ra, liu dng v qu trnh iu tr cng thng khng tun th theo hng dn75.

2.4. S dng khng sinh khng hp l

Trong chng trnh o to ti cc trng Y, dc, thi lng ging dy v khng sinh, khng khng sinh v cch k n chim t l rt nh. Mt nghin cu da trn cng ng c tin hnh nm 2003 bo co rng, 78% khng sinh c mua ti cc nh thuc t nhn m khng c n67, 67% tham kho t vn dc s trc khi s dng v 11% t quyt nh v vic dng thuc; ch c 27% nhn vin dc c kin thc ng v khng sinh v khng khng sinh. 26

 c cc qui ch v vic cm bn thuc khng sinh khng c n, tuy nhin cc qui ch ny n nay vn cha c hiu lc. i vi tr bnh, cc b m thng t k n, 82% tr c t nht mt triu chng vim ng h hp cp (ARI) c iu tr vi khng sinh. Nm 1999 khng sinh c s dng ph bin nht bao gm: ampicillin hoc amoxicillin erythromycin (86%), (5%), penicillin tetracyclin (12%), (4%) v

phi t chi tr chim t trng ln trong tng chi ph y t, do ngi dn c xu hng tm kim cch thc r nht cho vic chm sc sc kho.

2.5 C ch khuyn khch

Nh bo co ca Cc Qun l Khm Cha bnh nm 2009, chi ph cho khng sinh chim trn 30% tng chi ph ca bnh vin cho thuc v ho cht. Mt phn ln kinh ph c chi cho cephalosporins th h 3 (ceftriaxone. cefoperazone), quinolones (levofloxacine) v carbapenem (imipenem). Bng 8 lit k mt s li ch vt cht c s dng nhm khch l vic k n v s dng thuc khng sinh t cc bo co c trnh by ti hi tho nm 2009 [Ngun: Bo co hi tho khoa hc ln th nht ca GARP]. bnh vin tuyn di, c bit i vi bnh nhn khm bo him y t, cc khng sinh r thng c la chn v d nh amoxicillin. Trong khi , cc phng khm t nhn, bc s thng c xu hng chn cc khng sinh mnh nh cephalexin, zinnat, hoc augmentin. Hn na, cc cng ty dc phm thc y vic tiu th sn phm bng cc chnh sch khuyn khch bc s k n. Bng 8. Khuyn khch cho vic s dng khng sinh Phn loi Khuyn khch Bc s c Chia s gi thuc, tham s cng lp gia hi tho, qu tng Tho mn mong i ca bnh nhn C th tit kim thi 27

streptomycin (2%). Khng sinh c dng khong 3 ngy, qu ngn cho iu tr vim phi do vi khun vi thi gian iu tr ti thiu c khuyn co l 5 ngy. Nm 2007, xu hng s dng khng sinh thay i, cephalosporins ng ung c dng ph bin i vi cc bnh c triu chng nng. Cc khng sinh thng dng l: ampicillin hoc amoxillin (49%), cephalosporin th h 1, ng ung (27%), cotrimoxazol (11%), macolides (3%), loi khc (2%) 76. Cng ging nh mt s nc khc, mt trong nhng nguyn nhn ca tnh trng s dng khng sinh khng hp l l do ngh ca bnh nhn, p lc v thi gian thm khm, thiu kin thc, thiu kh nng chn on, li nhun kinh t i vi ngi k n [Ngun: Bo co hi tho khoa hc ln th nht ca GARP]. Mt thch thc ln l xc nh v thay i cu trc khuyn khch i vi vic k n khng hp l. Hn na, chi ph m ngi bnh GARP-VN Phn tch thc trng

gian Bc s c Chia s gi thuc s t nhn Tho mn mong i ca bnh nhn Phng khm H tr v c s vt t cht, v d nh iu ho nhit nh, TV, vv, Bnh vin Chia s gi tr hp ng u thu thuc, h tr v c s vt cht Cc chng trnh Nh khuyn mi, gim gi thuc/Hiu Chia s li nhun da thuc trn chnh sch gi Bnh nhn Mong mun c ch nh thuc mnh nh khng sinh Cn tc v y ny, v khng kh nng chn on xc nh cn nguyn vi khun gy bnh T iu tr r hn v thun tin hn l i khm bc s

thuc bn l v bnh vin

(Hnh 1).

Cephalosporins ung (J01D01) l khng sinh ph bin nht c 2 c s y t ni trn, tip n l penicillins ph rng (J01C01),

macrolides v fluoroquinolones. S khc bit ng k gia nh thuc v bnh vin l cc khng sinh tim ch yu c dng bnh vin hn l bn l nh thuc. Do , cc khng sinh aminoglycosides v carbapenems tim thng c dng ch yu bnh vin, him khi bn nh thuc bn l. Cc khng sinh th h c nh chloramphenicol ch yu c bn hiu thuc bn l v t dng bnh vin. Doanh s ca polymyxins (v d colistin) rt thp v nhng thuc ny cha c ng k Vit Nam trong iu tr cc cn nguyn nhim trng khng khng sinh, mc d vy, cc khng sinh ny vn c lit k trong danh mc thuc ch yu s dng trong bnh vin. S liu tng t ti M cho thy, khng sinh tim cng c chim t trng ln trong kinh ph iu tr. Cephalosporins tim c doanh thu cao nht trong bnh vin, tip theo l carbapenems. hiu thuc bn l, cc khng sinh cephalosporins tim cng tr nn ngy cng quan trng. Mt nghin cu th im ti NHTD (20082009) nh gi mc s dng khng sinh thng qua liu xc nh hng ngy trn 100

2.6. Cc v d v mc s dng khng sinh trn ngi

IMS l mt t chc thng mi nghin cu v th trng dc phm Vit Nam theo 2 knh chnh: nh thuc bn l v nh thuc bnh vin. S liu ca nh thuc bn l s dng y c thng k t 439 nh thuc khng bao gm cc c s bn bun. S liu v nh thuc bnh vin c thng k t 62 bnh vin trong khu vc 5 thnh ph: H Ni, thnh ph H Ch Minh, Hi Phng, Nng v Cn Th. S liu v doanh thu trong vng 1 nm: t u qu 4 nm 2008 n ht qu 3 nm 2009. Con s thng k cho thy, cc khng sinh c doanh thu cao tng t nh nhau gia nh GARP-VN Phn tch thc trng

ging-ngy (DDD/100 ging-ngy). S liu ca khoa Dc cho thy, c 44 loi khng sinh 28

c s dng [s liu cha cng b NHTD]. Cc khng sinh c gi tr DDD /100 ging-ngy cao nht trong nm 2009 ln lt l levofloxacine (104,73), ceftriaxone (85,93), doxycyclin (62,58), ampicillin (sulbactam) (tng ng l 48,86 v 45,36), azithromycine (42,59), imipenem (22,58), cefoperazone

nm 2008. V d, fluoroquinolones tng t 76,5 DDD/100 ging-ngy n 125,6 v

cephalosporins th h 3 t 63,4 n 124,5 DDD/100 ging-ngy. ng ch l,

meropenem tng khong 8 ln nm 2009 (7,8 DDD/100 ging-ngy) so vi nm 2008 (0,9/100 ging-ngy). Cc khng sinh th h c nh amphenicols v cephalosporins th h 1 hoc 2, t c s dng trong iu tr (Xem hnh 3). Hnh 4 ch ra khng sinh s dng nhiu nht vo cc thng 6, 7 v 11 nm 2009.

(22,14) v streptomycine (21,9). Mc tiu th ca levofloxacin l cao nht tip theo l ceftriaxone, azithromycin v doxycyclin (Xem hnh). 7 khng sinh c mc tiu th cao nht tng gn gp i trong nm 2009 so vi s liu

Hnh 6. S liu v doanh thu ca khng sinh ti Vit Nam.

S lng tiu th hng nm/nh thuc

Doanh thu trung bnh hng nm/nh thuc ( la M)

Doanh thu trung bnh hng nm/bnh vin ( la M)

S lng tiu th hng nm/bnh vin

S lng trung bnh thuc khng sinh c bn ca nh thuc t (trn) v bnh vin (di). Doanh thu trung bnh hng nm tnh theo la M t khng sinh ca nh thuc t (trn) v bnh vin (di).

GARP-VN Phn tch thc trng

29

Hnh 7: DDD trn 100 ging ngy ca cc loi khng sinh nm 2008-2009
J01A-Tetracyclines J01B-Amphenicols J01CA-Penicillins with expanded spectrum J01CE-Beta lactam sensitive Penicillines J01CF-Beta lactam resistance Penicillines J01CG-Sulbactam J01CR-Beta-lactam and Inhibitors
Khng sinh

J01DB-First gen. Cephalosporins J01DC-Second gen. Cephalosporins J01DD-Third gen. Cephalosporins J01DE-Forth gen. Cephalosporins J01DH-Carbapenem J01FA-Macrolides J01FF-Lincosamides J01G-Aminoglycosides J01M-Fluoroquinolones J01X-Others 0 20 40 60 80 100 120 140
Nm 2009 Series2 Nm 2008 Series1

DDD trn 100 ging-ngy

Ch : Khng sinh khc bao gm Vancomycin, Fosfomycin, Rifampicin, Metronidazole, Tinidazole.

GARP-VN Phn tch thc trng

30

Hnh 8: DDD trn 100 ging-ngy theo thng ca 7 loi khng sinh c mc tiu th cao nht nm 2009
25

DDD trn 100 ging-ngy

20 Doxycylin J01AA02 15 Ampicilline J01CA01 Ceftriaxone J01DD04 Cefoperazone J01DD12 10 Azithromycin J01FA10 Streptomycin J01GA01 Levofloxacin J01MA12 5

0 1 2 3 4 5 6 7 8 9 10 11 12 Thng

2.7. Chi ph cho khng sinh ti cc bnh vin

B Y t thu thp cc bo co v tnh hnh s dng thuc ti bnh vin. Theo thng k t cc bo co ny, khng sinh chim khong 36% tng chi ph cho thuc v ho cht (khong gii hn t 3% n 89%, xem bng 9). Trong s 100 bnh vin chn ngu nhin, bnh vin tuyn trung ng (12%) chi khong 26% (gii hn 10-45%) cho thuc khng sinh trong tng kinh ph cho thuc ni chung. Bnh vin tm thn c mc chi ph cho khng sinh thp nht (3%). T l cao nht c bo co ti bnh vin nhi thnh ph H Ch Minh (89%). Bnh vin bnh nhit i trung ng, bnh vin u ngnh v bnh truyn nhim, chi 35% cho GARP-VN Phn tch thc trng

thuc khng sinh. Trong s 4 nhm bnh vin, th bnh vin a khoa tuyn tnh/thnh ph c mc chi trung bnh cho khng sinh l cao nht (43%)77. Bng 9. Chi ph bnh vin cho khng sinh nm 2009 (s liu: B Y t) Khng S Phn loi bnh vin lng bnh vin sinh /Tng chi ph cho thuc (%) Bnh vin a khoa tuyn trung ng Bnh vin chuyn khoa 12 21 10-45 5-89 26 28 31 Trung bnh (%)

tuyn trung ng Bnh vin a khoa tuyn tnh Bnh vin chuyn khoa tuyn tnh Ngun: B Y t

Di y l mt s bo co v khng khng sinh c cng b, thng tin tham 52 15 6-88 3-66 43 34 kho xem thm phn ph lc A.

Streptococcus pneumoniae
Mc khng penicillin ca S. pneumoniae tng ng k. Mt nghin cu TP H Ch Minh cho thy, trong 10 nm, t l cc chng pneumococcus khng penicillin phn lp t mu v dch no ty tng t 8% (1993-1995) ln 56% (giai on 1999-2002)78. Nm 20002001, Vit Nam c t l khng penicillin cao nht trong 11 nc khu vc Chu (71.4%)79. Mc khng penicillin ca tr thnh th cao gp 22 ln so vi tr nng thn80. Trong chng trnh nghin cu quc gia v khng khng sinh (ANSORP), Vit Nam c mc khng cao vi penicillin (71,4%) v

2.8. Gim st khng khng sinh

Hin nay, Vit Nam cha c chng trnh gim st quc gia v khng khng sinh qui m ton quc. C quan hp tc pht trin quc t Thy in (SIDA) v B Y t phi hp h tr chng trnh gim st khng khng sinh trong vng hn 10 nm tnh n nm 2006, c bit n vi tn gi Chng trnh gim st mc nhy cm vi khng sinh (ASTS). Cc bnh vin trng im trn ton quc tham gia vo chng trnh ny xy dng c cc bo co hng nm. Tuy nhin, tc ng ca cc bo co ny, cng nh thnh tu ca ton b chng trnh vn cha c nh gi mt cch ton din v r rng. n nay, c 8 bnh vin tip tc ng ti d liu WHO-NET ln trung tm d liu do Khoa vi sinh Bnh vin Bch Mai- l mt trong nhng bnh vin a khoa u ngnh tuyn trung ng. Mi y, B Y t cng mi xy dng chng trnh gim st khng khng sinh mi nhm thu thp cc bo co v tnh hnh s dng thuc cng nh khng khng sinh t 20 bnh vin khc nhau c cc phng xt nghim vi sinh lm sng. GARP-VN Phn tch thc trng

erythromycin (92,1%)79. Hn na, 75% ph cu khun khng vi t nht 3 loi khng sinh tr ln. Hu ht cc chng ph cu vn nhy cm vi ceftriaxon44.

Haemophilus influenza
Hib phn lp t tr vim mng no m H Ni (2000-2002) cho thy 57% cc chng sinh men -lactamase dn n khng

ampicillin81. Mc khng tng t cng c ghi nhn tr vim ng h hp trn Nha Trang82.

32

Enterobacteriaceae
Theo bo co ca Bnh vin chn thng chnh hnh thnh ph H Ch Minh (2004) cho thy, trong s cc chng Gram m phn lp c, 14,7% sinh ESBL. Trong s cc chng sinh ESBL, 70% khng gentamicin v 72,5% khng ciprofloxacin83. Tnh trng khng

Vit Nam, t l cc chng S. typhi a khng khng sinh vn chim t l tng i cao vi khong 50% nm 2004. Mc khng axit nalidixic tng r rt trong vng 12 nm, t 4% ln 97% nm 2005
89.

Mt bo co khc cho

thy hn 80% cc chng S. typhi phn lp c khng vi khng sinh axit nalidixic 90.

cephalosporins ph rng l kh ph bin trong s cc chng E. coli, K. pneumoniae v Proteus mirabilis t 2000-2001 thnh ph H Ch Minh: hn 25% khng vi cephalosporins th h 3 v 16% khng vi cefoperazone84. Mt nghin cu khc cng thnh ph H Ch Minh cho thy 42% cc chng Enterobacteriaceae khng ceftazidime, 63% khng vi gentamicin v 74% khng axit nalidixic. T l khng cao cng c ghi nhn ngi kho mnh trong cng ng85.

2.9. Khng sinh s dng trn ng vt 2.9.1. Xu hng s dng

Mt lng ln dc phm c s dng trn ng vt bao gm khng sinh, vitamin v cc thuc dit k sinh trng. Trong , khng sinh chim phn ln nht (70% trong tng s thuc) c s dng trn ng vt91. 77% cc thuc dng cho ng vt l thuc sn xut trong nc v 23% l thuc nhp khu. Cha c s liu chnh thc v lng khng sinh s dng trong nui trng thu sn, tuy nhin vic s dng ngy cng rng ri trong lnh vc ny cng c nhn thc r rng. Theo bo co t chnh ph H Lan c khong 700 g khng sinh c s dng trn mi tn c trong nui trng thu sn Vit Nam, cao gp 7 ln so vi cc quc gia khc [Bo co t Cc Qun l Thc phm, H Lan, 2009, m

Shigella
T l khng cao cng c ghi nhn, c th l: trimethoprim-sulfamethoxazole (74%), ampicillin (81%), (53%),
86. 87.

tetracycline

ciprofloxacin (10%), v ceftriaxone (5%) Hn 75% cc chng a khng khng sinh

Mt nghin cu khc ti khu vc pha Nam Vit Nam (2006-2008) ch ra rng 15,3% khng ceftriaxone88.

VWA/BuR/2009/13186]. C 11 nhm khng sinh c s dng trong nui trng thu sn trong bao gm c cc loi khng sinh c s dng trong iu tr bnh nhim khun trn

Salmonella typhi

GARP-VN Phn tch thc trng

33

ngi. Cc khng sinh c s dng gm: lactams, tetracycline, polymyxins aminoglycosides, (fluoro)quinolones, (colistin), macrolides, Phenicols,

nui ln tht tnh ng Nai v Bnh Dng cho thy tnh trng nhim khng sinh kh ph bin: 52% nhim tylosin, 41% nhim

pleuromutilins,

tetracycline, 7% nhim oxytetracycline v 2% nhim chlotetracyclin. Mt s mu cng vt qu ngng gii hn cho php91. Quinolone v sulfonamide c s dng rng ri trong nui trng thu sn. Theo bo co hng nm ca Cc Qun l Cht lng Nng lm Thu sn cho thy, d lng ca mt s khng sinh hn ch s dng c pht hin trong nui trng thu sn: quinolone v sulfonamide. Hu ht cc mu pht hin d lng u nm trong gii hn cho php. Tuy nhin, c mt s mu thu sn pht hin quinolone vt qu gii hn cho php 18 ln92. Cc khng sinh b cm s dng trong nui trng thu sn t b pht hin d lng, iu chng t, cc qui nh v xut khu to ra nhng khuyn khch ng k trong vic s dng khng sinh. Tuy nhin, chloramphenicol vn pht hin c s dng trong nui trng thu sn. Mt nghin cu cho thy, t l cao ca cc mu nc ng nhim chloramphenicol, chng t khng sinh ny vn c s dng mc d b cm s dng trn ng vt91. Xem ph lc C (Bng 12).

lincosamides, sulfamides, diaminopyrimidine (trimethoprim)91. Gim st c hai lnh vc chn nui v nui trng thu sn cho thy, tt c cc trang tri chn nui u s dng khng sinh. Cc khng sinh c amoxicillin s dng l: tylosin gentamicin (16%), (9%),

(12%),

enrofloxacin (7%), penicillin (6%), lincomycin (6%), tiamulin (6%), colistin (5%), (5%), v

streptomycin tetracyclin

(5%), (4%),

norfloxacin ampicillin (4%)

florphenicol (3%). Theo bo co ca B Nng nghip, tnh hnh s dng khng sinh trong chn nui cha hp l. Vic la chn khng sinh v liu dng c quyt nh ch yu da trn kinh nghim ca ch h (44%), 33% theo hng dn ca bc s th y, 17% theo hng dn ca nh sn xut. Cc ch h chn nui khng tun th theo qui ch v vic ngng s dng khng sinh trc khi thu hoch sn phm t ng vt92. Gim st tnh hnh s dng khng sinh ti 30 tri ln tht v 30 tri nui g tht trn a bn tnh Hng Yn v H Ty cho thy 60% mu ln tht v 70% mu g tht nhim tetracyclins hoc tylosins91. Mt s mu vt qu nng cho php. Gim st 55 trang tri GARP-VN Phn tch thc trng

2.9.2. L do/khuyn khch i vi vic s dng khng sinh trong nng nghip
34

Trong nng nghip, khng sinh c s dng rng ri vi mc ch kch thch tng trng, hoc phng bnh v iu tr. Khng sinh c s dng vi mc ch kch thch tng trng theo khuyn co ca FDA. Theo Cc th y quc gia (NOAH, 2001), khng sinh c s dng vi mc ch kch thch tng trng nhm gip ng vt tiu ho thc n d dng, gip pht trin khe mnh93. Thc n chn nui ln v g tht c b sung khng sinh tetracycline v tylosin91. Tm, cua v c cng phi nhim vi quinolone v sulfonamide92. Trong nng nghip, chn nui v nui trng thu sn ang ngy cng tr thnh mt ngnh cng nghip quan trng Vit Nam v khng sinh c s dng rng ri. T khi Vit Nam gia nhp T chc thng mi th gii, cc qui nh v s dng khng sinh trn ng vt cng cht ch hn v mt s khng sinh b cm s dng. Tuy nhin, gim st d lng khng sinh tht v c cho thy nhng vi phm trong vic tun th qui ch v s dng khng sinh. Cc trang tri b pht hin d lng ca khng sinh cm vt qu gii hn cho php s b cm thu hoch, ch bin v xut khu sn phm cho n khi khng pht hin vi phm. Bng 10 trnh by cc bin php khuyn khch vic s dng khng sinh trong nng nghip. Bng 10: Cc khuyn khch i vi vic s dng khng sinh trong nng nghip GARP-VN Phn tch thc trng

Khuyn khch S dng Khng s dng - p dng cc bin - Kch thch tng php thay th trng (tng sn tng sn lng lng) - Ci thin cht lng - Gim p lc v khng khng sinh sn phm i vi c ngi v ng vt - Tng kim ngch xut - Tun th cc qui nh ca th trng khu M v Chu u - Kim sot bnh dch - Khng phi gim st d lng khng sinh - Tit kim v mt kinh - Quan tm v sc khe t

2.9.3. Khng khng sinh trong cng nghip thc phm

Cc bnh lin quan n thc phm l mt trong nhng nguyn nhn quan trng dn n t l mc v t vong trn th gii. Thc n nhim vi khun khng khng sinh c th l mi him ho ln i vi sc kho cng ng. Trong mt nghin cu kho st mc ph bin ca tht nhim Salmonella spp v E. coli ti cc ch khu vc thnh ph H Ch Minh (2004) cho thy t l nhim kh cao (Salmonella spp: 60,8% sn phm tht v 18,0% mu c v hn 90% tt c cc mu thc phm nhim E. coli. Khong 50% cc chng Salmonella v 84% E. coli phn lp c l khng vi t nht mt khng sinh, v Salmonella a khng khng sinh cng c phn lp tt c cc mu94, 95. Mt nghin cu Bc Ninh cho thy tt c cc chng campylobacter phn lp t g tht khng vi cephalothin, axit nalidixic (89,9%), 35

tetracyclin (88,6%) v ciprofloxacin (82,3%)96. Mc khng ca Salmonella t thc n ti khu vc ng bng Nam b, Vit Nam c

iu tra tnh khng khng sinh vi 10 loi khng sinh, 21,3% khng khng sinh97.

GARP-VN Phn tch thc trng

36

III. nh gi s b, xut chnh sch v gii php can thip 3.1. nh gi s b

T khi Vit Nam chuyn sang nn kinh t th trng, th trng dc phm tr nn phong ph v sn c ng ngha vi vic tng c hi tip cn thuc qua h thng nh thuc. Kh nng v c hi tip cn vi khng sinh gp phn tng hiu qu iu tr bnh nhim khun ng thi cng dn n gia tng tnh trng s dng thuc khng hp l. Kin thc gii hn ca ngi dng, ngi bn v dc s v gi tr v nguy c ca khng sinh l mt phn ca vn , tuy nhin c nhng khuyn khch v ti chnh i vi vic bn khng sinh v li ch gin tip trong vic s dng khng sinh l gnh nng i vi x hi. Thm ch trong lnh vc chm sc sc kho, nhng hn ch v kin thc trong vic s dng khng sinh trong iu tr, v kh nng chn on phng xt nghim xc nh cn nguyn gy bnh v cc khuyn khch i vi vic k n dn n s gia tng tnh trng s dng khng sinh khng hp l. Hin nay c cc qui nh v kim sot s dng khng sinh tuy nhin s tun th cc qui ch ny vn cn cha hiu lc do cha c cc ch ti c th. Tnh trng ph bin ca vi khun khng khng sinh Vit Nam mc bo ng. GARP-VN Phn tch thc trng

l kt qu ca vic s dng khng sinh ba bi trong cng ng. Mt khc, vic s dng khng sinh trn ng vt cng ngy cng rng ri, l mt trong nhng nguyn nhn quan trng vn cha b pht hin v vai tr ca n i vi tnh trng khng khng sinh ca cc cn nguyn gy bnh trn ngi. Hu qu tt yu ca tnh trng khng khng sinh gia tng l nhiu khng sinh vn c khuyn co s dng trong cc ti liu hng dn iu tr nhng thc t khng cn hiu qu trn lm sng. Mc d c nhiu n lc trong vn v khng khng sinh, thc trng ny vn gy ra nhng nh hng tiu cc v y t v kinh t quc gia. Bng 11. Thch thc v c hi trong kim sot khng khng sinh C hi Thch thc Cng ng Cng ng Thnh vng hn Thun tin hn khi Truyn thng tt hn n hiu thuc (internet v in thoi Kin thc ngho di ng c s nn dng rng ri) C hi tip cn Yu cu cao hn i thng tin cn hn vi vic chm sc ch sc kho H thng Dc H thng dc Thay i thi lng Khch l i vi ging dy v khng cung ng sinh v khng khng Kin thc hn ch sinh trong cc trng C hi tip cn chuyn ngnh thng tin cn hn Trin khai GPP ch Trung tm cnh gic Thi lng ging dc dy v khng sinh v khng khng sinh trong trng qu hn ch H thng y t H thng y t Tng gi ging trong Khch l i vi 36

trng Tng kh nng chn on Trin khai chng nhim khun Sn sng ci tin Chng trnh tng cng nng lc phng th nghim

ngi k n Kinh ph cho gim st rt hn ch Nng lc chn on yu Kin thc hn ch C hi tip cn thng tin hn ch Cc hng dn khng cp nht Thi lng ging dy v khng sinh v khng khng sinh trong trng qu hn ch

nh c ro cn no dn n s km hiu lc ca cc qui ch lin quan n vic ci thin tnh hnh s dng khng sinh v chng nhim khun (v d nh. thiu ht v kinh ph, thiu nhn lc v cc khuyn khch v mt ti chnh). ng thi, tin lng hu qu ca vic hiu lc ho cc chnh sch ny s c th dn n nhng bt li v mt li nhun i vi cc c s y dc cng nh c hi tip cn cc dch v chm sc sc kho. Nm bt c iu ny s c th ci thin vic thi hnh cc chnh sch mt cch hiu qu. Hn na, cn nhn nh r qui m p dng trng im ca cc qui ch, nu khng cc mc tiu s b phn tn v km kh thi. Mt trong nhng nguyn nhn dn n s thiu hiu qa ca cc qui ch c th l do vic bi b cc qui ch ca cc c s chm sc sc khe, dn n vic lm mt hiu lc ca cc qui ch i vi vic kim sot tnh hnh s dng khng sinh. Bn cnh , chi ph t tin ti bnh nhn ng mt phn ln trong tng chi ph y t c th l nguyn nhn dn n tng nhu cu ca ngi bnh i vi cc dch v chm sc sc kho v suy gim quyn hn ca nh nc i vi th trng y, dc. Cc chnh sch gim chi ph t tin ti bnh nhn qua h thng bo him y t c th gim vai tr ca

3.2. Phn tch chnh sch

S cn thit ca cc chnh sch lin quan n vic s dng khng sinh c cc nh lnh o v hoch nh chnh sch trong lnh vc y t nhn thc mt cch r rng, v thc t c rt nhiu iu lut v chnh sch c ban hnh nhm gim thiu vic s dng khng sinh khng hp l (Xem bng 12). Tuy nhin, thc t cho thy vic thc hin cc iu lut v qui nh vn cha thc s em li hiu qu. Vic ngi dn t do mua thuc khng sinh khi au m l tnh trng kh ph bin, t l s dng khng sinh trong bnh vin cao v tnh trng khng khng sinh ngy cng gia tng r rt. Mc d c khng t cc chnh sch c ban hnh, thc trng khng khng sinh Vit Nam vn ngy cng nghim trng. Phn ln cc xut chnh sch hng ti vic ban hnh cc qui ch, trong khi th trng y, dc lun tm cch bi b hiu lc ca cc qui ch ny. Quan trng l cn phi xc GARP-VN Phn tch thc trng

khch hng i vi th trng y, dc v do c th tng cng vai tr ca nh nc. Ngoi cc php ch trc tip tn ti, cc cng c chnh sch khc c th em li hiu 37

qu. Nhng bin php iu chnh mt cch mm do v linh hot c th em li hiu qu, v d nh. khuyn khch c ch th trng t iu ho phi hp vi cc qui tc thc hnh. Cc cng c kinh t, v d nh chnh sch tr cp v thuc, v ang c p dng rng ri nhm ci thin chnh sch gi v cc u i ca thuc, to thun li i vi ngi tiu dng, ng thi khng gy ra nhng cn tr v mt th trng i vi cc mt hng dc phm , v d nh, p thu i vi a s cc khng sinh ph rng, ngc li, chnh sch tr cp ch p dng i vi mt s lng gii hn cc khng sinh c th. H thng thng tin, gio dc v cc bng chng in hnh cng c th l cng c hu hiu gip em li nhng thay i v mt quan

im. Cc phng php qung co tng em li nhng thay i trong thi ca cc i tng cung cp dch v y t. nh hng t pha cc nh lnh o v cc chuyn gia trong lnh vc y, dc cng c th em li thay i nh vo cc bng chng in hnh trong thc tin. Ch trng hn na vic ghi nhn cc sn phm thuc bt buc bn theo n c th s em li nhng hiu qu tim nng i vi cc c nhn v ton x hi v vic s dng khng sinh khng hp l. Tt c cc xut v chnh sch ny cn c xem xt ht sc cn thn v tnh kh thi, kh nng cng nh nhng tc ng bt li m cc chnh sch ny c th em li. s l ti nghin cu trong giai on tip theo trong chng trnh hot ng ca GARP-Vit Nam.

Bng 12. Danh sch cc chnh sch hin c lin quan n vic s dng khng sinh v thc trng khng khng sinh ti Vit Nam v nhng xut Lut/Chnh sch xut Thuc khng sinh l thuc k Hiu lc ho qui ch n Thnh lp Hi ng Thuc v Cung cp cho hi ng cc cng c/quyn ch o nhm iu tr ti tt c cc bnh xy dng cc hng dn kim sot khng sinh hiu qu ti vin t tuyn trung ng n cc bnh vin. ng thi bo co cho hi ng cc s liu c s cp nht v ng tin cy v tnh hnh khng khng sinh, Thnh lp Hi ng chng Cung cp kinh ph hot ng cho cc hot ng ca hi nhim khun ti tt c cc ng v nng cp c s h tng. Xy dng cc ch s chun bnh vin t tuyn trung nhm gim st tin nh: t l nhim khun bnh vin theo tng khoa v s tun th v sinh bn tay, ng n c s Chng trnh gim st khng Chun ho d liu bng cch p dng trn ton quc cc ti khng sinh quc gia liu hng dn xt nghim bao gm c kim sot cht lng. Cung cp kinh ph cho th nghim mc khng khng sinh, kim sot cht lng, tp hun v bo co. Xy dng cc bo co hng nm v tnh hnh s dng khng sinh v thc trng khng khng sinh. Chng trnh gim st v s Chun ho cc ch s v mc s dng khng sinh theo dng khng sinh ti cc bnh n v quc t, v d nh liu ch nh hng ngy (DDD) trn vin 100 ging-ngy. Xy dng cc bo co hng nm v s GARP-VN Phn tch thc trng 38

Chng trnh ging dy trong cc trng y, dc Hng dn iu tr Trung tm cnh gic Dc Chng trnh nng cao nng lc phng xt nghim vi sinh lm sng Nng nghip: Qui ch v vic ngng s dng khng sinh trc khi thu hoch sn phm t ng vt

dng khng sinh v khng khng sinh trong cng mt bn bo co. Tng thi lng chng trnh ging dy v s dng khng sinh v khng khng sinh, m bo tnh chnh xc v cp nht ca cc ti liu hng dn iu tr i vi cc bnh nhim khun. Thu ht s tham gia ca trung tm cnh gic Dc vo vic kim sot tnh trng k n khng sinh bt hp l. m bo cht lng cc xt nghim vi sinh lm sng. Xem xt vic xy dng mt trung tm chun quc gia v xt nghim chn on vi sinh lm sng. Xy dng mng li nhm chia s thng tin (d liu, hng dn, kin ca cc chuyn gia). Hiu lc ho qui ch. Xy dng chng trnh gim st ton quc v s dng khng sinh v khng khng sinh trn ng vt Xy dng bo co hng nm v tnh hnh s dng khng sinh v mc khng khng sinh trn ng vt 1. Xy dng mng li thng tin v vic s dng khng sinh v tnh hnh khng khng sinh: thit lp cc knh chia s thng tin gia mt s bnh vin tiu biu nh Bnh vin Bch Mai, Bnh vin Bnh Nhit i Trung ng, Bnh vin Nhit i TP H Ch Minh v Bnh vin Ch Ry. Cng vi s hp tc ca Trung tm Quc gia v Thng tin thuc v theo di phn ng c hi ca thuc, mng thng tin s xy dng v cng b cc bo co nh k v s dng khng sinh v tnh hnh khng khng sinh. Hn na, cc hng dn cp nht cng nh cc ti liu lin quan s c lu

3.3. Cc c hi nghin cu
c cc d liu y c th kt lun v mc ng bo ng ca tnh hnh s dng khng sinh v thc trng khng khng sinh. Tuy nhin, cc thng tin hin c khng c so snh v tuyn truyn rng ri. Cn phi c ting ni mnh ng h cho chin dch i ph vi tnh trng s dng khng sinh khng hp l hin nay. Thiu cc d liu v gnh nng y t v kinh t dn n cha kh nng thuyt phc cc nh hoch nh chnh sch. Cn xc nh r c ch khuyn khch cho vic k n khng sinh s gp phn h tr thit k cc can thip mt cch hiu qu. Da trn bn phn tch thc trng v nhng thiu ht v thng tin quan trng c xc nh, 3 nghin cu c xut nh sau:

hnh rng ri trn mng ni b. 2. Nghin cu v gnh nng ca khng khng sinh: xc nh c cc c im c bn ca cc cn nguyn gy

GARP-VN Phn tch thc trng

39

bnh thng gp ti mt s bnh vin tiu biu v nh gi gnh nng ca khng khng sinh. Cn thuyt phc cc nh hoch nh chnh sch ch ra nhng tn tht v kinh t v y t m vn khng khng sinh gy ra, ng thi vic qun l khng sinh v kim sot khng khng sinh c th gip gim thiu nhng tn tht ny. Do , nghin cu nh gi gnh nng ca khng khng sinh l ht sc cn thit Vit Nam. Nghin cu xut: nh gi mc khng khng sinh ca 5 cn nguyn vi khun thng gp nht t cc bnh phm: mu, dch no ty, v dch h hp, ng thi nh gi mc ph hp ca cc hng dn iu tr. nh gi s khc bit v gi ca cc thuc c th s dng theo hng dn iu tr v chi ph cc thuc thay th dng trong iu tr i vi bnh nhn khng khng sinh. 3. Cu trc khuyn khch v kinh t, can thip da trn cng ng, ti cc hiu thuc bn l c cung ng thuc khng sinh. thnh cng trong vic thay i thi quen ca ngi bn thuc, trc tin phi hiu cu trc khuyn khch. Li nhun mang li t khng sinh chim t l cao, do nu cc i tng kinh doanh dc phm t nhn thc hin vic bn khng sinh mt cch hp l

th s gim ng k li nhun thu c. Lm th no c th to ra thay i? Nghin cu xut: nh gi doanh thu do khng sinh mang li ti mt s hiu thuc. T chc cc cuc tho lun nhm vi dc s, nhn vin bn thuc tm ra nguyn nhn thc y vic bn khng sinh ngoi yu t li nhun. nh gi cu trc khuyn khch, kin thc h c th cn h tr to ra thay i. Cc thiu ht khc c lit k di y. Ngn sch hin c khng tin hnh cc nghin cu gip b p cc thiu ht. 1. Lng ln khng sinh s dng Vit Nam khng phi trn ngi m c th l trn ng vt. Cn c nhng thng tin ng tin cy xy dng chnh sch. Nghin cu xut: nh gi thc trng s dng khng sinh ti cc trang tri chn nui: ln, g v nui trng thy sn c/tm, mi lin quan n khng khng sinh trn ngi v sn phm tiu th trn th trng. 2. Thi lng chng trnh ging dy v khng sinh cho bc s v dc s trong trng cn rt thiu ht. Nghin cu xut: nh gi chng trnh o to cho bc s/dc s v khng sinh, s gi, ni dung. So snh vi cc nc khc, bc s v dc s thc s hiu v khng sinh nh th no.

GARP-VN Phn tch thc trng

40

3. Bnh nhn-i tng quan trng nht trong vic s dng khng sinh: c thc s mun dng khng sinh khng?, nu c, ti sao mun dng khng sinh, hiu bit v khng sinh. Xc nh r ngha

ca triu chng Vim. Cn thng tin g thuyt phc ngi bnh khng dng khng sinh? Nghin cu xut: kho st cng ng v tho lun trng tm nhm.

GARP-VN Phn tch thc trng

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Ti liu tham kho

1. 2. 3. 4. 5. 6. 7. 8. 9. Vietnam and Energy: Improving Rural Electricity Power Service Quality (http://go.worldbank.org/O0RRQJ9RH0). (2010). ADB Helps 350,000 people in central region access to clean water and sanitation (http://www.rwssp.org.vn/EN/?Tabid=KMN1A1&ID=59&CID=64&IDN=569). (2010). Vietnam-country overview (http://siteresources.worldbank.org/INTVIETNAM/Resources/VietnamCountryOverview.pdf) . (2008). Minot, N. Spatial patterns of poverty in Vietnam and their implications for policy. Viet Nam and the MDGs (http://www.undp.org.vn/mdgs/viet-nam-and-themdgs/?languageId=4). Maternal Mortality in 2005 (Estimates developed by WHO, UNICEF, UNFPA and The World Bank, http://www.who.int/whosis/mme_2005.pdf). (2005). Minh Thang, N., Bhushan, I., Bloom, E. & Bonu, S. Child immunization in Vietnam: situation and barriers to coverage. J Biosoc Sci 39, 41-58 (2007). CIA Factbook (https://www.cia.gov/library/publications/the-world-factbook/geos/vm.html). Development Progress in Vietnam (The World Bank: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/EASTASIAPACIFICEXT/VIET NAMEXTN/0,,contentMDK:22539306~pagePK:1497618~piPK:217854~theSitePK:387565, 00.html). Thuan, N.T., Lofgren, C., Lindholm, L. & Chuc, N.T. Choice of healthcare provider following reform in Vietnam. BMC Health Serv Res 8, 162 (2008). Hoa, N.Q., Ohman, A., Lundborg, C.S. & Chuc, N.T. Drug use and health-seeking behavior for childhood illness in Vietnam--a qualitative study. . Health Policy 82, 320-329 (2007). Health Statistics Yearbook 2008 (Ministry of Health). (2009). Annual Report of Hospital's activities (Medical Services Administration-Ministry of Health). (2009). Cu, N.V. A study to find out the causes of patients that not go to their local medical stations Journal of Medicine Ho Chi Minh city 14, 213-216 (2010 (http://tcyh.yds.edu.vn/2010/Chuyen%20de%20KHCB/NGHI%C3%8AN%20C%E1%BB%A 8U%20T%C3%8CM%20NGUY%C3%8AN%20NH%C3%82N%20B%E1%BB%86NH%20N H%C3%82N.htm)). Joint Annual Health Review 2008: Health financing in Vietnam (Ministry of Health, Health Parnership Group). (2008). Health Statistic Yearbook (Ministry of Health). (2008). Health care workforce: increase number help increase quality? (http://www.ykhoanet.com/thoisu/nhanlucyte/080612_ykhoanet_nhanlucnganhyte.htm). (2008). "Chy mu cht xm nhn lc ngnh y t" (http://www.tinmoi.vn/ldquoChay-mau-chatxamrdquo-nguon-nhan-luc-y-te-0413612.html). (2010). Potential pharmaceutical industry (http://www.hieuhoc.com/tiemnangnghenghiep/chitiet/tiem-nang-nganh-duoc-2009-12-16). (2009). Phuong, N.K. Review of Financing of Health-care, including Health Promotion. Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region. (2008). Nguyen, K.P. Review of Financing of Health-care, including Health Promotion. Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region. (2008). 41

10. 11. 12. 13. 14.

15. 16. 17. 18. 19. 20.

21.

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22. Ngh nh sa i, b sung mt s iu ca iu l Bo him y t ban hnh km theo Ngh nh s 63/2005/N-CP ngy 16/5/2005 ca Chnh ph. 23. Adam, S.J. Vietnam's Health Care System: A Macroeconomic Perspective. (2005). 24. Circular No 18/2008/TT-BYT: regulation on infection control in healthcare institutions (MoH). (2009). 25. Ohara, H., Hung, N.V. & Thu, T.A. Fact-finding survey of nosocomial infection control in hospitals in Vietnam and application to training programs. J Infect Chemother 15, 384-389 (2009). 26. Hung, N.V. A cross-sectional study on equipment for knowledge and practice of health care workers on hand hygiene at home hospitals in the north of Vietnam, 2005. Journal of clinical medicine (2008). 27. Nguyen V. Hung; T.A.T., L.T.T.T., Nguyen T. Nga, Vu V. Giang, Nguyen V. Ha, Pham L. Tuan, Tran Quy. Prevalence of and relative factors for nosocomial infections in some hospitals in the north of Vietnam, 2006-2007. Journal of clinical medicine 6 (2008). 28. Evaluation of comprehensive preventive practice in some health facilities (WHO and Bach Mai hospital). (2004). 29. Health Care Waste Management in Bac Giang Province-Vietnam 2006-2008. 30. Hospital waste water ends up in the rice fields (http://www.dhigroup.com/News/2008/06/13/HospitalWasteWaterEndsUpInTheRiceFields.a spx). (2008). 31. New technologies for hospial wastewater treatment (National Center of Science and Technology Information). (2007). 32. Huong, D.L., Minh, H.V. & Byass, P. Applying verbal autopsy to determine cause of death in rural Vietnam. Scand J Public Health Suppl 62, 19-25 (2003). 33. Anh, D.D. et al. Surveillance of pneumococcal-associated disease among hospitalized children in Khanh Hoa Province, Vietnam. Clin Infect Dis 48 Suppl 2, S57-64 (2009). 34. Anh, D.D. The infection rate of H. Influenzae, S. pneumoniae and respiratory viruses in patients under 5 years old with acute respiratory infection. Journal of Preventive Medicine 14, 14-22 (2004). 35. Phan L. T. Huong, D.D.A., Vu T.T.Huong, Ngo T.Thi, Tran Q.Canh, Mayumi Matsuoka, Kazunari Kamachi, Tsutomu Yamazaki, Yoshichika Arakawa, Tsuguo Sasaki. Genetic and Phenotypic Characterization of Heamophilus influenzae Type b Isolated from Children with Meningitis and Their Family Members in Vietnam. . Journal of Infectious Diseases 59, 111116 (2006). 36. Anh, D.D. et al. Haemophilus influenzae type B meningitis among children in Hanoi, Vietnam: epidemiologic patterns and estimates of H. Influenzae type B disease burden. Am J Trop Med Hyg 74, 509-515 (2006). 37. Phan L. T. Huong, D.D.A., Vu T.T.Huong, Ngo T.Thi, Tran Q.Canh, Tsuguo Sasaki. Haemophilus influenzae Type b: Molecular Biological Characteristics, Familial Contagious Source. . Journal of Preventive Medicine 15 (2005). 38. Ochiai, L. "Typhoid Vaccines: Current availability, programmatic issues, costs and vaccine pipeline" (Meeting on Typhoid Vaccination in the Asia-Pacific Region). (2009). 39. Mai, N.T.H. et al. Streptococcus suis Meningitis in Adults in Vietnam. Clinical Infectious Diseases 46, 659-667 (2008). 40. Nguyen, T.H. et al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med 357, 2431-2440 (2007). 41. Phuong, D.M. The feature of pathogens causing bacteremia in Bach Mai hospital-2008 Journal of clinical medicine 48, 32-38 (2010). 42. Phuong, D.M. Quality issues in resistance testing and data in Vietnam (Presentation in the 1st GARP's workshop). (2009). GARP-VN Phn tch thc trng 42

43. Report positive blood culture results National Hospital of Tropical Diseases, 2008-2009. 44. Diep, T.S. Antibiotic resistance in Hospital Tropical Disease (Presentation in the 1st GARP's workshop). (2009). 45. Hoa, N.Q. et al. Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers' knowledge, practical competence and reported practice. Trop Med Int Health 14, 546-555 (2009). 46. Nguyen, B.M. et al. Cholera outbreaks caused by an altered Vibrio cholerae O1 El Tor biotype strain producing classical cholera toxin B in Vietnam in 2007 to 2008. J Clin Microbiol 47, 1568-1571 (2009). 47. Vu Nguyen, T., Le Van, P., Le Huy, C., Nguyen Gia, K. & Weintraub, A. Etiology and epidemiology of diarrhea in children in Hanoi, Vietnam. Int J Infect Dis 10, 298-308 (2006). 48. South East Asia HIV & AIDS Statistics (http://www.avert.org/aids-hiv-south-east-asia.htm). 49. The third country report on following up the implementation to the declaration of commitment on HIV and AIDS. (2008). 50. Lan, P.T. et al. Reproductive tract infections including sexually transmitted infections: a population-based study of women of reproductive age in a rural district of Vietnam. Sex Transm Infect 84, 126-132 (2008). 51. Nguyen V. Hung, T.A.T., Nguyen Q. Anh. Clinical and economic outcomes of surgical site infections in Bach Mai hospital. Journal of clinical medicine 6, 79-83 (2008). 52. Nguyen V. Hung; T.A.T., L.T.T.T., Nguyen T. Nga, Vu V. Giang, Nguyen V. Ha, Pham L. Tuan, Tran Quy. Prevalence of and relative factors for nosocomial infections in some hospitals in the north of Vietnam, 2006-2007. Tp ch y hc Lm sng (2008) 53. Truong A. Thu, N.V.H. Prevalence of nosocomial infections and its relative factors in Bach Mai hospital in 2006. Journal of clinical medicine 6, 51-56 (2006). 54. Le Thi Anh Thu, V.T.C.M., Nguyen Phuc Tien, Dang Thi Van Trang. Resistance evaluation of pathogens causing HAIs. Journal of practice medicine 594, 19-23 (2008.). 55. Vu V. Giang, T.A.T., Nguyen V. Hung. Prevalence of Nosocomial Infection in the General Dien Bien, Hoa Binh and Quang Ninh hospital in 2005. Journal of clinical medicine 6, 46-50 (2008). 56. Vietnam Health Information System Review and Assessment (Ministry of Health). (2006). 57. Ch th ca b trng B Y t v vic chn chnh cng tc cung ng, s dng thuc trong bnh vin (Instruction No 05/2004/CT-BYT, Ministry of Health). (2004). 58. Chuc, N.T.K. Joint Annual Health Review, Chapter 5.1: Drugs, vaccines, blood and blood derived (Draft report). (2010). 59. Mai, H.T. Regulation of antibiotic registration and antibiotic monitoring in Vietnam (Presentation in the 1st GARP's workshop). (2009). 60. State share in joint-stock companies (http:vietbao.vn). 61. Total and domestic made drug sales in Vietnam (Drug Administration of Vietnam-Ministry of Health). 62. Vinh, N.T. Vietnam Pharmaceutical Industry-Investment strategy (Presentation: http://www.slideshare.net/vinhfc/vietnam-pharmaceutical-industry-and-investment-strategypresentation). (2008). 63. Hung, N.X. FIP Global Pharmacy Workforce Report 2009. 69-74 (2009). 64. Medicine prices: Make people seeker and poorer (WHO). 65. Vietnam Pharmaceuticals & Healthcare Report Q3 2009. (2009). 66. Regulation about organization and operation of Hospital's pharmacies (Ministry of Health). (2008). 67. Larsson, M. Antibiotic use and resistance: Assessing and improving utilisation and provision of antibiotics and other drugs in Vietnam. PhD Thesis (2003). GARP-VN Phn tch thc trng 43

68. Larsson, M. Antibiotic use and resistance: Assessing and improving utilisation and provision of antibiotics and other drugs in Vietnam. (2003). 69. Vietnam second in Southeast Asia in counterfeit drugs (http://english.vietnamnet.vn/social/2008/09/804985). Vietnamnet (2008). 70. Cuong, T.Q. Overview of the Vietnam pharmaceutical sector in 2008 operations of foreign enterprises in Vietnam, state management orientation in the sector in 2009 (Presentation). (2009). 71. Cuong, T.Q. Overview of the Vietnam Pharmaceutical sector in 2008 operations of foreign enterprises in Vietnam, state management orientation in the sector in 2009 (Ministry of Health, Drug Administration of Vietnam). (2009). 72. Handbook of Integrated Management for common childhood illness (Ministry of Health). (2006). 73. Treatment Guideline (Ministry of Health). (2006). 74. Hoa, N.Q. et al. Decreased Streptococcus pneumoniae susceptibility to oral antibiotics among children in rural Vietnam: a community study. BMC Infect Dis 10, 85 (2010). 75. Larsson M, K.G., Chuc NTK, Karlsson I, Lager F, Hanh HD, Tomson G and Falkenberg T. Antibiotic medication and bacterial resistance to antibiotic: a survey of children in a Vietnamese community. . J Trop Med Int Health. 5, 711-721 (2000). 76. Hoa, N.Q. et al. Unnecessary antibiotic use for mild acute respiratory infections in 28-day follow-up of 823 children under five in rural Vietnam. Journal of Antimicrobial Chemotherapy (2007). 77. Annual Report of Hospital's Pharmacy Department (Ministry of Health). (2009). 78. Parry, C.M. et al. Emergence in Vietnam of Streptococcus pneumoniae resistant to multiple antimicrobial agents as a result of dissemination of the multiresistant Spain(23F)-1 clone. Antimicrob Agents Chemother 46, 3512-3517 (2002). 79. Song, J.H. et al. High prevalence of antimicrobial resistance among clinical Streptococcus pneumoniae isolates in Asia (an ANSORP study). Antimicrob Agents Chemother 48, 21012107 (2004). 80. Parry, C.M. et al. Nasal carriage in Vietnamese children of Streptococcus pneumoniae resistant to multiple antimicrobial agents. Antimicrob Agents Chemother 44, 484-488 (2000). 81. Phan, L.T. et al. Genetic and phenotypic characterization of Haemophilus influenzae type b isolated from children with meningitis and their family members in Vietnam. Jpn J Infect Dis 59, 111-116 (2006). 82. Gotoh, K. et al. Prevalence of Haemophilus influenzae with resistant genes isolated from young children with acute lower respiratory tract infections in Nha Trang, Vietnam. J Infect Chemother 14, 349-353 (2008). 83. Jones, S.L., Nguyen, V.K., Nguyen, T.M. & Athan, E. Prevalence of multiresistant Gramnegative organisms in a surgical hospital in Ho Chi Minh City, Vietnam. Trop Med Int Health 11, 1725-1730 (2006). 84. Cao, V. et al. Distribution of extended-spectrum beta-lactamases in clinical isolates of Enterobacteriaceae in Vietnam. Antimicrob Agents Chemother 46, 3739-3743 (2002). 85. Le, T.M. et al. High prevalence of plasmid-mediated quinolone resistance determinants in commensal members of the Enterobacteriaceae in Ho Chi Minh City, Vietnam. J Med Microbiol 58, 1585-1592 (2009). 86. Kuo, C.Y. et al. Antimicrobial susceptibility of Shigella isolates in eight Asian countries, 2001-2004. J Microbiol Immunol Infect 41, 107-111 (2008). 87. Nguyen, T.V., Le, P.V., Le, C.H. & Weintraub, A. Antibiotic resistance in diarrheagenic Escherichia coli and Shigella strains isolated from children in Hanoi, Vietnam. Antimicrob Agents Chemother 49, 816-819 (2005). GARP-VN Phn tch thc trng 44

88. Vinh, H. et al. Rapid emergence of third generation cephalosporin resistant Shigella spp. in Southern Vietnam. J Med Microbiol 58, 281-283 (2009). 89. Chau, T.T. et al. Antimicrobial drug resistance of Salmonella enterica serovar typhi in asia and molecular mechanism of reduced susceptibility to the fluoroquinolones. Antimicrob Agents Chemother 51, 4315-4323 (2007). 90. Le, T.A. et al. Clonal expansion and microevolution of quinolone-resistant Salmonella enterica serotype typhi in Vietnam from 1996 to 2004. J Clin Microbiol 45, 3485-3492 (2007). 91. An, N.Q. Report of antibiotic use in animal in Vietnam (Presentation in the 1st GARP's workshop). (2009). 92. Monthly Report of Antibiotic Residue in Aquaculture (National Agro-Forestry-Fisheries Quality Assurance Department). http://www.nafiqad.gov.vn/d-chuong-trinh-giam-sat/a-duluong/. (2009). 93. Hughes, P. & Heritage, J. Antibiotic Growth-Promoters in Food Animals (http://www.fao.org/DOCREP/ARTICLE/AGRIPPA/555_EN.HTM). (2002). 94. Van, T.T., Moutafis, G., Tran, L.T. & Coloe, P.J. Antibiotic resistance in food-borne bacterial contaminants in Vietnam. Appl Environ Microbiol 73, 7906-7911 (2007). 95. Van, T.T., Moutafis, G., Istivan, T., Tran, L.T. & Coloe, P.J. Detection of Salmonella spp. in retail raw food samples from Vietnam and characterization of their antibiotic resistance. Appl Environ Microbiol 73, 6885-6890 (2007). 96. Huong, L.Q., Hanh, T.T., Ngoc, P.T. & Giang, T.T.H. Antibiotic resistance of Campylobacter spp. from chicken carcass in Bac Ninh province (unpublished). 97. Ogasawara, N. et al. Antimicrobial susceptibilities of Salmonella from domestic animals, food and human in the Mekong Delta, Vietnam. J Vet Med Sci 70, 1159-1164 (2008).

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45

Danh sch cc bng

Bng 1: Nhng ch s pht trin c bn v cc ch s y t ca Vit Nam Bng 2: Nhn lc ngnh y t nm 2005-2008 Bng 3. S ngi tham gia bo him y t trn ton quc, 2005-2007 Bng 4. Mt s nguyn nhn gy t l t vong cao nht ti Vit Nam Bng 5: Gi ca mt s khng sinh cc cp khc nhau Bng 6. Gi thuc bn l v nh nc qui nh mc gi thng d cho nh thuc bnh vin Bng 7. Thuc gi c pht hin qua cc nm Bng 8. Khuyn khch cho vic s dng khng sinh Bng 9. Chi ph bnh vin cho khng sinh nm 2009 (s liu: B Y t) Bng 10: Cc khuyn khch i vi vic s dng khng sinh trong nng nghip Bng 11. Thch thc v c hi trong kim sot khng khng sinh Bng 12. Danh sch cc chnh sch hin c lin quan n vic s dng khng sinh v thc trng khng khng sinh ti Vit Nam v nhng xut Bng 13. T l E. coli v K. pneumoniae sinh ESBL mt s bnh vin Bng 14. Mc khng Carbapenem ca P. aeruginosa v A. baumannii 6 bnh vin nm 2008 Bng 15. Gi tr MIC i vi Vancomycin ca Staphylococcus aureus phn lp Bch Mai v Ch Ry nm 2008 Bng 16: D lng khng sinh trong nui trng thu sn

Danh sch cc hnh

Hnh 1. Vit Nam Hnh 2. Tnh hnh phn b cc h ngho Vit Nam Hnh 3. H thng chm sc sc khe Hnh 4: C cu chi ph y t 2006 Hnh 5. Doanh thu ca thuc sn xut trong nc v thuc ni chung ti Vit Nam (triu la M) t 2001 n 2008 Hnh 6. S liu v doanh thu ca khng sinh ti Vit Nam Hnh 7: DDD trn 100 ging ngy ca cc loi khng sinh nm 2008-2009 Hnh 8: DDD trn 100 ging-ngy theo thng ca 7 loi khng sinh c mc tiu th cao nht nm 2009

GARP-VN Phn tch thc trng

46

Ph lc A
S liu v khng khng sinh Vit Nam: bnh vin
Kho st 4 cn nguyn thng gp thuc nhm vi khun Gram m c bnh vin a khoa v chuyn khoa tuyn trung ng bao gm E. coli, K. pneumonia, P. aeruginosa v A. baumannii cho thy tnh trng khng khng sinh ngy cng gia tng. Mc sinh ESBL cc chng E. coli v K. pneumonia nm 2005 l khong 34% i vi c 2 loi cn nguyn ny. bnh vin Bch Mai, t l K. pneumonia v E. coli tng t 20% nm 2005 n 34% nm 2008, v t 18% nm 2005 n 42% nm 2008, tng ng vi 2 loi vi khun (Xem bng 13)42. Bng 13. T l E. coli v K. pneumoniae sinh ESBL mt s bnh vin K.pneumoniae E. coli ASTS 7,7 program 23,7 (n = 485) MOH (n = 548) (2004) Bnh vin 51,6 61,7 (87/141) Ch Ry (145/281) (2005) Bnh vin 34,2 39,3 (55/140) Vit c (66/193) (2005) Bnh vin 36,2 19,6 (29/148) Bnh nh (51/141) (2005) Bnh vin 36,1 25,7 (09/35) Vit Tip (22/61) (2005) Bnh vin 18,5 Bch Mai 20,1 (37/184) (28/151) (2005) GARP-VN Phn tch thc trng

Bnh vin 21,5 28,7 (99/347) Bch Mai (77/359) (2006) Bnh vin 32,5 41,2 Bch Mai (105/323) (136/330) (2007) Bnh vin 42,2 Bch Mai 33,6 (85/253) (97/231) (2008) Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam42 Hai cn nguyn gy nhim khun bnh vin thng gp l: P. aeruginosa v A. baumannii, c nh gi mc khng carbapenem nm 2008. 20% cc chng P. aeruginosa v gn 50% cc chng A. baumanii khng carbapenem (Xem bng 14)42. Bng 14. Mc khng Carbapenem ca P. aeruginosa v A. baumannii 6 bnh vin nm 2008 P.aeruginosa A.baumannii (%) (%) Meropenem 18 46,2 Imipenem 25 47,1 Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam42 nh gi tnh ph bin ca cc chng S. aureus mt trong nhng cn nguyn Gramdng gim nhy cm vi vancomycin trong s cc chng khng methicillin S. aureus (MRSA) v S. aureus nhy cm methicillin (MSSA) Vit Nam. 200 chng phn lp t lm sng MSSA v MRSA thu thp t 2 bnh vin trung ng nm 2008 c th nghim xc nh gi tr MIC ca Vancomycin. Kt qu cho thy bt u ni ln tnh khng trung gian v/hoc 47

khng vancomycin ca cc chng S. aureus c 2 nhm MSSR v MRSA vi t l 3% ca MSSA v 5% ca MRSA (Xem bng 15)42.

22 bnh vin trn ton quc t nm 1988 n 2004 bao gm S. aureus, E. coli, Salmonella, Shigella, Enterobacteriaceae, S. pyogenes, S. pneumoniae, H. influenzae, Enterococcus,

S liu ASTS
Chng trnh ASTS v gim st tnh khng khng sinh ca mt s cn nguyn thng gp phn lp t bnh nhn ni tr v ngoi tr t

Klebsiella pneumonia, P. aeruginosa v A. baumannii. V tnh thiu chc chn ca s liu nn cc t l khng khng sinh khng c cp trong bn bo co ny.

Bng 15. Gi tr MIC i vi Vancomycin ca Staphylococcus aureus phn lp Bch Mai v Ch Ry nm 2008
Chng Tng s N Mean SD Geometric mean 1,57 1,47 1,67 1,39 1,27 1,57 1,77 1,79 1,75 % VSSA (MIC 2mg/L) 96% 97% 95% 100% 100% 100% 92% 93% 91%

S. aureus 200 1,63 0,41 MSSA 100 1,55 0,44 MRSA 100 1,72 0,36 BV Bch Mai S. aureus 100 1,47 0,43 MSSA 57 1,34 0,42 MRSA 42 1,63 0,39 BV Ch Ry S. aureus 100 1,80 0,32 MSSA 43 1,81 0,31 MRSA 57 1,78 0,33 Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam42

Ch : MSSA: S. aureus nhy cm Methicillin ; MRSA: S. aureus khng Methicillin

GARP-VN Phn tch thc trng

48

Ph lc B
Bng 16: D lng khng sinh trong nui trng thu sn 2007 2008 Sn Sn Nc Nc phm phm (%) (%) (%) (%) Khng sinh cm Chloramphenicol Semicarbazide Malachite Green Tetracyclin Sulfonamide Khng sinh gii hn s dng 0,9000 0,7000 0,3000 0,0038 0,0035 (vt qu gii hn: 0,0017) 0,1250 0,1163 (vt qu gii hn: 0,007) 0,0004 19 0,5 0,4 0,3 0,000 1,460 14,430 2009 Sn phm (%) Khng c s liu 0,002 no data no data Khng c s liu 0,011 0,09 (vt qu gii hn: 0,009) Khng c s liu Nc (%) 2 mu

Quinolone Enrofloxacin /Ciprofloxacin Trimethoprim

0,120 0,094

1,850

Ngun: Bo co hi tho khoa hc ln th nht GARP-Vit Nam91

GARP-VN Phn tch thc trng

49