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BAI DOMI, DjCH HUT DOfM QUA MUI, D|CH HUT RUTA PHE QUAN QUA N0I SOI VA CAY DOM, BENH PHAM CHUTA DOM m MUC TIEU Hiidng ddn diidc lam sang cho chi dinh dung, cung nhii hiidng dan diidc lam sang hay benh nhan lay dung cac loai benh pham nhd biet diidc cac chi dinh, phiidng phap vd thdi diem de lay mdu ddm vd cac benh pham cd ddm khao sat vi sinh hoc Danh gid diidc mdu ddm vd cac benh pham co ddm nhd vay cd the loai bo, khong tien hanh nuoi cay cac mdu khong cd gid tri, tranh diidc cac ket qua xet nghiem mdu ddm khong hUu dung cho lam sang Trien khai sit dung diidc cac phiidng tien thich hdp nhat vd day du nhat de cd the phan lap diidc dung cac vi khuan gay benh cd mdu ddm vd cac benh pham co ddm, du la cac vi khuan kho moc nhat, nhd biet diidc qui trinh xet nghiem vi sinh lam sang mdu ddm vd cac benh pham cd ddm CHiOjNH - Cac trUdng hdp viem nhiem dtfdng ho hap dudi nhii viem phoi, viem phe quan cap, cdn cap cua viem phe quan man - Nen cho chi dinh lay mau cac trUdng hdp benh nhan co mot cac trieu chiing sau: ho co mau hay ho nhieu, dau ngiic, kho thd, co dau hieu dac phoi nhii co ran am va rft; giam tieng ri rao phe nang; go due kham phoi; phim phoi co tham nhiem; co nang, co mu THOI DIEM LAY MAU - Cang d giai doan sdm cua benh cang tot Nghia la tien hanh lay mau sau co chan doan lam sang - Nen lay mau trUdC benh nhan dung khang sinh he thong 67 CACH LAY MAU 3.1 Ddm - Triidc het cho benh nhan sue mieng sach, khong sue mieng bang niidc sue mieng co chat sat trung - Hufdng d^n benh nhan hit that sau vao roi hay co khac ddm Co the giup benh nhan khac ddm bang each vo nhe vao liing Benh nhan khac ddm vao lo vo trung, rong mieng, nap chat (dung lo vo trung lay mdu) Tranh lan nUdc bot 3.2 Djch hut ddm tren quan qua dudng mui (Naso-Tracheal-Aspirate) - Triidng hdp benh nhan khong the khac dUdc ddm, nhu d tre em - Dung dung cu dac biet goi la bo hut quan (tracheal suction set), la mot ong nghiem gan vdi mot nap van tren co voi, mot noi vdi mot ong thong mem, mot noi vdi may bdm chan khong dang hoat dong va tren voi c6 mot van hong dang met TrUdc het ngUdi me hay than nhan benh nhi am ngiia be vao long, giii dau hdi ngiia sau Dua ong thong qua mui benh nhi cho den dau ong cham vao phan tren quan, luc benh nhi se c6 phan xa ho Ngay luc benh nhi ho, dung tay bit chat van hong lai, nhd vay ddm dUdc hut vao ong thong Sau rut ong thong khoi mui benh nhi, roi cho dau ong thong vao mot lo chiia 5ml nUdc muoi sinh ly vo trung Nude muoi sinh ly se riia dam dinh d ong thong vao ong nghiem Tat may bdm, thao nap co voi khoi ong nghiem roi day chat ong nghiem bang mot nap van khac co bo dung cu Gui mau den phong thi nghiem - Neu khong co dung cu nay, co the dung ong chich 60ml, noi mot dau vdi ong thong mem de lay ddm theo cach nhu tren, nhung thay vi dung bdm chan khong, hut ddm bang tay vdi ong chich tren 3.3 Djch hut phe quan qua noi soi (BW = Broncho-Washing) Do bac si chuyen khoa lay dang noi soi, cho vao tube vo trung nap chat roi giii den phong thi nghiem 3.4 Cac benh pham khac Nhii dich hut xuyen quan, choc hut phoi, cac bac si chuyen khoa lay va giii den phong thi nghiem de khao sat DANH GlA MOT m Au CO GlA TRj DE KHAO SAT VI KHUAN HOC - Vi ddm cung nhii dich hut ddm tren quan qua diidng mui (NTA) hay dich rUa phe quan qua noi soi (BW) co the bi ngoai nhiem bdi cac vi khuan thiidng tru vung hong, do can phai danh gia trudc tien hanh nuoi cay 68 - Tot nha't cac m lu sau nhan phai dUdc tien hanh khao sat ngay, khong cham tre Neu vi mot ly gi chtia the khao sat dtidc, co the giul mku tu lanh, nhung khong qua gid 4.1 Khao sdt dai the mau ddm Ghi nhan tinh chat dai the cua mSu ddm, cac tinh chat sau: - Co nhieu nUdc hot khong? - Co mu (purulent) khong, thudng mau xanh hay vang due? - Co mu nhay (muco-purulent) khong? - Co nhay (mucoid) khong? Mau co lan nhieu nUdc hot la mau khong thich hdp de ca'y 4.2 Khao sat vi the - Dung mot que tre, go, vong ca'y, hay pipet Pasteur la'y mot it ddm tii vung nhay mu, trai deu mot phet x cm tren mot ta'm lam De kho tii nhien, sau gan nhe tren ltia ThUc hien phet nhuom gram - Khao sat dudi kinh hien vi, trtidc het dudi quang trtidng xlOO (vat kinh xlO) Tim vung nhay nhdt roi ghi nhan so' liidng te bao v&y (squamous cells) la cac te bao CO goc canh va te bao bach cau hay te bao mu (leukocyt hay purulent cells) la cac te bao tron nho hdn va an dam mau toan te bao Bang 8.1: Thang diem Barlett dung danh gia mau ddm Tinh chat dai /vi the Diem Mau ddm - bach cau +1 > 25 bach cau +2 Nhay, mu, mu nhay +1 10 - 25 te bao vay -1 > 25 te bao vay -2 M lu ddm hut qua mui (NTA=nasal tracheal suction ), noi soi phe quan 10 - 25 bach cau +1 > 25 bach cau +2 Te bao tru +1 10 - 25 te bao vay -1 > 25 te bdo vay -2 69 - Mau khong thich hdp la m lu co so ltfdng te bao v&y mot quang triidng xlOO qua 25 te bao Mau tin cky nhat la mSu co nhieu bach c&u hay tf> bko m u , qua 25 te bao mot quang trtidng xlOO Noi chung, m iu tin cfiy la mSu co nhieu te bao bach c iu (> 25), it te bao vay (= 10), ty le te bao bach cau/vay tot nhat la > 2,5 - De de dang va khach quan, dung thang diem Barlett danh gia m lu ddm, ket hdp ca quan sat dai the lan vi the de cho diem Thang diem de danh gia la cong tat ca cac diem lai roi danh gia nhu sau: < khong tin cay de cay 1-2 tin cay vtia > rat dang tin cay Ddn gian hdn, co the danh gia dua vao so' ltidng te bao vay va te bao bach dlu tren mot quang trUdng xlOO Mau hoan toan tin cay de ca'y co > 25 bach c4u va < 10 te bao vay Mau hoan toan khong tin cay co < 25 bach clu va >10 te bao vay, day la mau chi la nUdc bot hay dich tiet vung hau hong Mau tin cay vtia co co > 25 bach cau va > 10 te bao vay, day la mau bi ngoai nhilm nUdc bot hay dich tiet vung hau hong Sau danh gia, chuyen sang vat kinh dau (xlOO), quan sat vung nhay nhdt va quanh te bao bach cau de ghi nhan sU hien dien cac vi khuan theo nhu bang 8.2 Bang 8.2: C ac ti'nh ch a t vi the cua cac loai vi khuan dich co th e quan sat dUdc phet nhuom vi the Nghi VK dich Tinh chat Cau khuan gram [+] xep chum Staphylococci Cau khuan gram [+] xep doi Pneumococci Cau khuan gram [+] xep chuoi Streptococci Cau khuan gram [-] xep doi M catarrhalis Trife khuan gram [-] nho Haemophilus True khuan gram [-] I6n _ True khuan gram [-] de moc Tinh chat Nghi VK dich CAY PHAN LAP VI KHUAN GAY BENH - Tat ca cac mau ddm sau danh gia neu tin cay thi tien hanh nuoi ca'y Cac mau khong tin cay thi khong tien hanh nuoi cay ma yeu cau lam sang lay mau lai Rieng cac m lu tin cay vtia, co the yeu cau la'y mau lai hay cung co the tien hanh nuoi ca'y nhung phai co lay mam ca'y la vung ddm mu, tranh lay nhdt hay nUdc bot de nuoi ca'y - Moi mot mau ddm phai diidc tien hanh nuoi cay chieu tren cac moi trUdng phan lap du kha nang de cay dtidc cac vi khuan gay benh du kho moc Trinh bay dudi day la cac moi trUdng phan lap can phai dUdc sti dung de cay ddm va cac benh pham co ddm 70 5.1 Phan lap c iu khuan Gram [+] - Thach mdu ciCu (BA) phan lltp khong chon loc (ca vi khuan gram [+] lln vi khu&n gram [-] deu moc dUdc), hay thach mdu co nalidixic acid (BANg) de phan l^p chon loc c£u khu^n gram [+] - Hay co the them thach mdu co gentamicin (BAGe) de phan lap chon loc S pneumoniae 5.2 Phan lap H influenzae va M catarrhalis - Thach nau mau ngUa (CAXV) phan lap khong chon loc H influenzae va M catarrhalis - Hay co the dung thach nau mdu ngiia bo sung Bacitracin (CAHI) de phan lap chon loc cac vi khu&n 5.3 Phan lap true khuan dudng ruot va khong dudng ruot - Thach Mac Conkey (MC) dung phan lap chon loc trUc khu&n dudng ruot hay khong dUdng ruot - Hay co the dung cac hop thach phan lap khac co cung muc dich - Co mot so' trtic khu&n khong dtidng ruot khong moc tren MC, nhung cac trtidng hdp nay, vi khuan co the phan lap dtidc tti thach mau Cac hop thach mau hay thach nau dUdc u tu am 35-37°C va giti binh nen hay tu C Thach MC hay loai ttidng dUdng thi khong c&n u C Sau u qua dem, quan sat cac hop thach phan lap de tim cac khom vi khu&n gay benh Tien hanh dinh danh va khang sinh de co the tra ldi ket qua den lam sang vao hom sau Cac trUdng hdp khong phat hien dUdc vi khuan gay benh thi co the tra ldi cho lam sang CAC VI KHUAN GAY BENH CO T H i TIM THAY TRONG MAU DOM, NTA VA BW Thtidng mau tin cay, vi khuan phan lap dUdc tren mat cac hop thach phan lap rat phu hdp vdi ket qua khao sat trtic tiep qua phet nhuom gram Sau day la cac vi khuan la tac nhan gay benh co the phan lap tti mau 6.1 Th u d n g gap n h iim trung cong dong - H influenzae - S pneumoniae - M catarrhalis - S aureus - K pneumoniae 71 6.2 Th u d n g gap nhiem trung benh vien - S aureus - P.aeruginosa - K pneumoniae - Cac trUc khu^n gram [-] d i moc khac Cac Enterobacteriaceae khac C A Y DOM V A BENH PHAM C H lfA DOM - C A C C A U HOI T H U O N G G A P 7.1 De lay ddm lam xet nghiem vi sinh lam sang tim cac vi khuan ga y nhiem trung ho hap dudi, thdi diem tot nhat co phai la va o luc sang sdm khong? - Lay ddm vao sang sdm la lay ddm de khao sat tim vi khu^n gay benh lao v& xet nghiem benh nhan lay ddm vao ng&y lien tiep de giii den phong xet nghiem lao moi Tai phong thi nghiem, m lu ddm dUdc ti£n hanh nhuom khang acid (acid fast staining) va co the dUdc lam thu&n nhat de cay vao moi trUdng cay lao - De lam xet nghiem vi sinh lam sang phat hien cac vi khuan gay nhiem trung ho hap dudi, phai tien hanh lay ddm sau co ch£tn doan va trudc cho benh nhan dung khang sinh Lam sang phai hudng dan benh nhan cach lay ddm vi neu khong, rat nhieu benh nhan khong biet cach khac ddm ma chi khac nUdc bot va nhu vay thi khong co gia tri de lam xet nghiem 7.2 Tai co nhieu ket qua xet nghiem vi sinh lam sang khong phu hdp vdi hieu qua dieu trj khang sinh tren benh nhan? V i du cay vi khuan P aeruginosa khang rat nhieu khang sinh chi dieu trj benh nhan bang Augm entin hay cephalosporin the' he benh nhan van cai thien dUdc lam sang? - Ddm la mot benh pham rat co gia tri de tti co the phat hien dUdc tac nhan vi khan gay nhilm trung cap dtidng ho hap dudi, nhung cung co the la benh pham khong co gia tri gi neu nhu chung ta khong lay dUdc ddm that sti ma benh pham gtii den phong thi nghiem chi la nUdc bot hay la benh ph§m ddm nhUng lai tap nhiem qua nhieu nUdc bot vung hau hong - TrUdng hdp ke tren thudng la benh pham gtii den phong thi nghiem chi la nUdc bot hay tap nhilm nhieu nUdc bot ma phong thi nghiem khong danh gia va v ln tien hanh nuoi ca'y Chinh vi vay vi khu&n phan lap dUdc khong phai la vi khuan gay benh ma chi la vi khu&n thudng tru hay tam tru tren vung hau hong ma thoi 72 - Cung c6 the co mot ly ntia la phong thi nghiem khong dung moi trtidng CA mau ngtia (CAXV) va BA mau ctiu, chinh vi vay khong co kha nang phan lftp dUdc S pneumoniae, H influenzae va M catarrhalis la cac vi khu^n ra't thiidng gap (>50% tac nhan gay nhilm trung ho ha'p dtidi la cac tac nhan nay) nhUng lai rat kho moc va kho nhan dien tren cac moi trUdng thong thtidng khac cua nhieu phong thi nghiem hien nhti BA mau ngtidi va MC Chinh vi chi dung cac moi trtidng nen phong thi nghiem chi phan lap dUdc cac tac nhan vi khu^n d i moc, la trtic khuan dudng ruot hay khong dudng ruot ma cac vi khuEtn co chi la vi khuan tap nhiem tti h£u hong i 7.3 Nhieu tren hop thach phan lap chi thay lien cau tan huyet alpha, nhung khong co dac diem cua cac khuan lac S pneumoniae Trudng hop chung ta co tien hanh tiep drnh danh va lam khang sinh de tra ldi ket qua cho lam sang khong? - Gan nhti 90% cac mau ddm la co lien cau tan huyet alpha khong phai S pneumoniae moc tren cac hop thach phan lap Da so" cac trUdng hdp la tap nhiem vi khuan lien cau tti vung hau hong - Tuy nhien trUdng hdp mau co gia tri va tren thach mau hay thach nau chi thay toan la lien cau tan huyet alpha khong phai S pneumoniae thi chung ta phai tien hanh dinh danh va lam khang sinh de tra ldi cho lam sang vi day rat cd the la vi khuan gay benh cd nguon goc tti vi khuan thudng tru vung hau hong nhung lan xuong dtidng ho hap dudi de gay benh 7.4 Xin cho biet cach nhan dang cac khom S pneumoniae, H influenzae va M catarrhalis? - Khom vi khuan S pneumoniae moc tren thach mau ctiu cho tan huyet alpha (tren mau ngUdi lai cho tan huyet beta nen rat d i nham vdi lien cau tan huyet beta), tren thach nau cho mot vong mau vang ttidi quanh khom (bieu hien tan huyet alpha tren thach nau) Khom vi khuan thudng det, khong loi, va d gitia khom thtidng bi lom xuong vi khuan bi tti tieu - Tren thach mau, khom vi khuan H influenzae chi co the moc cac khom li ti ve tinh quanh cac khom vi khuan khac nhti Staphylococci, Streptococci hay Bacillus Tren thach nau (CAXV hay CAHI), H influenzae moc cac khom due nhe, hdi det, dudng kinh #lm m rat de nhan dien - Khom vi khuan M catarrhalis moc tren thach mau hay thach nau thtidng hdi loi, co mau trang hay mau vang, dudng kinh 25 te bao bieu mo va khong co te bao bach cau, (B) mau bi tap nhilm ni/6c bot vi co > 25 te bao bieu mo va > 25 bach cau (C,D) m lu hoan toan tin cay vi co 25 bach cau Ket qua quan sat m lu ddm tin cay qua phet nhuom gram quang tri/dng x 1000: (E) song cau gram [+] nghi S.pneumoniae, (F) song cau gram [-] nghi M.catarrhalis, (G.H) trUc khuan gram [-] nho va ngan nghi H.influenzae 75 CAU HOI O N T A P a Cho biet cac chi dinh lam sang va thdi diem tot nhat de lflTy ddm va cac benh pham chtia ddm de lam x6t nghiem vi sinh lam s&ng b Hay cho biet cac lay va chuyen chci ddm va cac loai benh pham c6 ddm den phong thi nghiem de lam xet nghiem vi sinh lam sing c Hay cho biet cach danh gia mot mSu ddm nhti the nao la co gia tri de nuoi ca'y d Hay cho biet qui trinh x6t nghiem vi sinh lam sang thtic hien tai phong thi nghiem do'i vdi dcJm va cac benh phjim chtia ddm e Hay cho biet phUdng tien thich hdp nha't de lam x6t nghiem vi sinh lam sang mSu ddm va cac benh pham co ddm f 76 Hay cho biet cac vi khu^n gay benh c£n phai phan lap ddm va cac benh phgLm chtia ddm Bing 20.4: Bang danh gia mtic phu hop cua hai thti nghiem di/a theo he so kappa He so kappa Mure phu hdp 0,0-0,2 Qua thap ,2 -0 ,4 Thap 0,4-0,6 VC/a He sd kappa ,6 Mure phu hop 0,8 Kha ,8 - 1,0 Cao - Sau day la cach tim he so kappa: • Phu hdp quan sat diidc, tinh nhu sau: (a+d) x 100 Phu hop ngau nhien, tinh nhu sau: *\ (c+d) (b+d) * < f ! l xioo i X - - L x 100 Phu hop hoan toan, gia dinh ca hai phu hcfp hoan toan vdi nhau, tri so' se la 100 • Phu hop thtfc tai, tmh nhu sau: Phu hop quan sat - Phu hdp nglu nhien • Phu hop tiem an, tmh nhu sau: Phu hop hoan toan - Phu hop ngau nhien Tii cac gia tri tren, he so' kappa dtfdc tinh theo cong thiic sau: Phu hop thtfc tai He so kappa =- Phu hop tiem an Trong vi du trinh bay bang 20.4, sau co dtfdc cac gia tri cua phu hcfp ngau nhien (62,5), phu hdp quan sat (100), phu hop thtfc tai (17,5) va phu hop tiem an (37,5); he so' kappa se la: 17.5 Kappa =■ 37.5 = 0,47 Vdi gia tri cua he so' kappa tinh dtfdc, chung ta co the ket luan ELISA va LAT phat hien khang the dac hieu M tuberculosis co phu hdp d mtic vtia Ngoai ra, chung ta co the phan tich phu hdp dtidng, ttic la ty le % ca hai thti nghiem deu cho ket qua [+] tong so' cac ket qua giong cua hai xet nghiem; va phu hdp am la ty le % ca hai thti nghiem deu cho ket qua 135 [-] tong so cac ket qua giong cua ck hai x6t nghiem Trong vi du tren, chung ta thay: • Do phu hdp dtfOng cua ELISA va LAT la: a 65 a+d 65+15 = 81% Do phu hdp am cua ELISA va LAT la: d 15 a+d 65+15 = 19% DO LAP LAI CUA XET NGHIEM Do lap lai cua ket qua dinh ltfOng cua xet nghiem lam nhieu lan tren cung mot mau benh pham dtfdc goi la lap lai cua x6t nghiem Thong so' noi len lap lai cua mot xet nghiem dtfdc goi la he so' bien thien (CV = Coefficient o f variation) cua ket qua xet nghiem Tren cung mot m lu benh pham, neu chung ta chia de lam cung mot x6t nghiem, va cac ket qua dinh ltfdng se la A „ A2, A3, A4 A„ Chung ta se tinh dtfdc ket qua trung binh A va lech chuan a nhtf sau: A1+A2+A3+A4+ +An A= N a= I (A- A)2 N He so bien thien chinh la ty le phan tram cua lech chuan so vdi so' trung binh, dtfdc tinh theo cong thtfc sau: cv= 100x —- — % He so' bien thien dtfdc goi la he so' phan tan, cho biet lap lai cua mot thti nghiem co tot hay khong Thtidng mot thti nghiem dtfdc danh gia co lap lai tot CV < 10% CAU HOI ON TAP 136 a Cho biet chuan vang la gi? y nghla cua chuan vang danh gia mot xet nghiem b Hay cho biet cach tinh nhay cam va dac hieu cua mot xet nghiem y nghla cua hai thong so' danh gia xet nghiem Vdi mot xet nghiem dang sti dung, lam the nao de nang cao nhay cam hay d§c hieu cua x6t nghiem do? c Hay cho biet cach tmh gia tri tien doan dtfOng va gia tri tien doan am cua mot x6t nghiem Doi v6i bac si dieu tri thi phai lam the nao de gia tri tien doan dtfOng va gia tri tien doan am cua mot xet nghiem co gia tri cao nghla la x6t nghiem se hiiu dung cao doi v6i lam sang? d Cho biet cach nao de co the tim dtfdc phu hop cua hai x6t nghiem dtfdc sti dung cho cung mot muc dich phat hien tac nhan vi sinh vat gay benh? e Cho biet cach nao de co the danh gia lap lai cua mot xet nghiem? 137 BAI 21 TRANG Bj CO BAN CHO M0T PHONG THI NGHIEM VI SINH LAM SANG ■ THIET Bj CO BAN - Mot tu lanh ngan 180L den 240L, dung de dtfng cac moi trtfdng, va cac thuoc thit che san can phai ltfu trtf d 4°C - Mot tu am co dung tich 80L den 100L, dieu chinh dtfdc nhiet ttf nhiet +5 hay +10 tren nhiet phong den 100°C dung de lam tu u vi khuan - Mot tu cay vi sinh tinh co den neon va d6n UV, kich thtfdc 0,6 x 1,2m - Mot kinh hien vi quang hoc thtfdng mat cua Olympus, Nikon, hay cua mot hang co uy tin ttf Nhat/Au My - Mot may ly tam ban co rotor ttfOng thich cho cac tube thi nghiem hay tube Falcon 15ml (co the dung may ly tam Trung Quoc) - Mot may cach thuy co the dieu chinh nhiet ttf 30°C den 100°C - Mot may vi tinh co kem may in dung de cai dat phan mem quan ly xet nghiem vi sinh lam sang (phan mem SCM cua Pham Thai Binh) Tram duoc dong bang ki'nh ly Mat nghieng trudc cua tram dupe thiet k£ c o canh tr^n, g in ban 16 de c o th6 de dang m d lau chui, vfi sinh toan tram v i ch o thi£t bi vao Hinh 21.1: Mo hinh mot tu cay vi sinh tinh Kich thirdc chieu cao 0,8m, chieu sau 0.6m Rieng kich thi/dc chieu dai thi thuoc vao ban de tu cay, trung binh la 1,2m 138 DUNG CV CO BAN - Kim c&y, vong cay, va vong c&y dinh liidng; m6i loai can cai - Micropipet dieu chinh dtfdc the tich ttf l-10pl, 20-200pl, 50-1000pl Moi loai mot cay - Mot but ngoi thep viet len kinh - Hai kep mui nhon de gSp dia khang sinh - Mot thtfdc dtfdng kinh vong vo khu&n - Hai hop dtfng lam - Hai den - Dau soi kinh hien vi - Mot binh thuy tinh mieng rong co n§p, dung tich 3-5L lam binh nen - Mot gia nhuom va khay nhuom - Hai ca nhtfa 2L co n&p de dtfng vat lieu ban sau dung xong - Hai binh tia dung tich 0,5L de dtfng rtia tay - Gia nhtfa dtfng ong nghiem thuy tinh va nhtfa cac loai - Dung cu huy kim - Binh dtfng 20L - Mot thung dtfng rac y te - Mot thung dtfng rac thong thtfdng - Hai keo cSt giay hay nylon VAT LIEU TIEU HAO 3.1 Loai thong thudng - Pipet Pasteur nhtfa vo trung - Cac hop dau cone dung cho micropipet, gom cac loai cone trang l-20pl, cone vang 20-200jil, cone xanh 50-1000pl Tat ca deu dtfdc vo trung - Lam va lamel soi kinh hien vi - Giay lau kinh hien vi, loai khong co bui giay - Bao nylon mau den dtfng rac y te - Bao nylon dtfng rac thong thtfdng - Bang keo giay 139 - But aceton - Tam bong vo trung lam khang sinh 3.3 Cac bo thuoc nhuom - Bo thuoc nhuom gram - Bo thuoc nhuom khang acid - Bo thuoc nhuom Methylen Blue kiem - Bo thuoc nhuom Nigrosin - Bo thuoc nhuom Giemsa 3.4 Cac vat lieu lay va chuyen chd benh pham - Tam bong vo trung lay mau - Tam bong manh vo trung lay mku - Tam bong que dai vo trung lay mau quet co tti cung - Tube dua moi trtfdng Stuart -Am ies - Tube dua moi trtfdng Cary —Blair - Lo nap van chat lay mau tap nhiem - Lo nap van chat vo trung lay mau khong tap nhiem ' - Lo nap van chat co mai cheo - Lo nap van chat co mai cheo va co ttii F2M - Tube 1,8ml nap van vo trung - Tube 5ml nap van vo trting - Tube 15ml nap van vo trting - Tube Eppendorf biopure - Tube lay mau khong khang dong - Cac loai tube lay mau khang dong EDTA, citrat, heparin 3.4 Cac moi trudng phong phu, tdng sinh thong thudng va che sin - GN broth - Pepton kiem - Loeffler (huyet ttidng dong) - 140 Chai cay mau pha - Chai mSt thach CA c&y dich khong tap nhilm - Chai mat thach BANg vk MC c&y niidc tieu - Ong moi trtfdng BHI -XV (tube 5ml n ip van) 3.5 Cac mdi trudng phan lap thong thudng va che san - BA mau ctfu - BANg* - CAXV - CAHI - CATM* - MC (hay EMB) - SS (hay XLD, hay HE) - MEA (hay TCBS)* - BA co tellurite * - BAYK** - Campy-BAP*** 3.6 Cac kit dinh danh - IDS 14GNR, hay mot so" cac dia giay sinh hoa le, hay mot so' ong moi trtfdng sinh hoa le - SAU-latex - Dia bacitracin - Dia optochin - Que X, V, XV - Dia novobiocin - Dia oxidase - H20 3% - Bile Esculin - TSB co 6,5% NaCl - RNIS dinh danh Neisseria - Tube KIA hay TSI 141 3.7 Cac moi trudng lam khang sinh - MHA - MHBA - HTM* M iy lanh trdn trtin Tu cay vi sinh tTnh Kinh hien vi mat Lavabo rCra tay va nhuom lam May cach thuy May ly tam ban Tu aim 80-100L Tu lanh 180-200L May vi tinh May in 10 Tu dung ho so 11 Ke da co ngSn tu ben di/di Hinh 21.2: Mo hinh mot phong thi nghiem vi sinh lam sang tai benh vien (kich thifdc 3-4m x 4-5m) 3.8 Cac phUdng tien lam khang sinh - Lo niidc muoi sinh ly vo trung (2-3ml) - Cac orig due chuan 0,5 McF - Cac dia khang sinh lam khang sinh - Dia nitrocefin tim [3-lactamase 3.9 Cac vi khuan chuan va tham chieu de kiem tra chat luong - S aureus ATCC 25923 - E coli ATCC 25922 - E coli ATCC 35218 - P aeruginosa ATCC 27853 - S faecalis ATCC 29212 - S pneumoniae ATCC 49619 - H influenzae ATCC 49247 - H influenzae ATCC 49278 142 - N meningitidis group B - S typhi, Shigella flexneri - K pneumoniae, Proteus vulgaris - N gonorrhoeae, M catarrhalis - V cholerae 3.10 Cac moi trudng luu chung tam thdi - Ong thach NA nghieng tube nhtfa 5ml nap van chat - Ong thach CAXV nghieng tube nhtfa 5ml nap van chat - Cryotube chiia BHI co 20% glycerol TAI LIEU THAM KHAO ■ Bailey & Scott’ s Diagnostic Microbiology 11th Edition Betty A Forbes, Daniel F Sahm, Alice S Weissfeld Mosby 2002 Bacterial Pathogenesis - A Molecular Approach Abigail A Salyers and Dixie D Whitt ASM Press 1994 Clinical Bacteriology J Keith Struthers, Roger P Westran Manson Publishing 2003 Color Atlas and Textbook of Diagnostic Microbiology 5th Edition Elmer W Koneman, Stephen D Allen, 'William M Janda, Paul C Schreckenberger, Washington C Winn, Jr Lippincott 1997 Immunobiology - the immune system in health and disease 6th Edition Charles A Janeway, Jr., Paul Travers, Mark Walport, Mark J Shlomchik Churchill Levingstone 2005 Jawetz, Melnick, & Adelberg5 s Medical Microbiology 23th Edition Geo F Brooks, Janet S Butel, Stephen A Morse Me Graw Hill 2004 Manual of Clinical Microbiology 6th Edition Patrick R Murray, Ellen Jo Baron, Michael A Pfaller, Fred C Tenover, Robert H Yolken ASM Press 1995 Microbial Life Jerome J Perry, James T Staley, Stephen Lory Sinauer 2002 Mims’ Pathogenesis of Infectious Disease 4th Edition Cedric Mims, Nigel Dimmock, Anthony Nash, John Stephen Academic Press 1997 10 Problem-Oriented Clinical Microbiology and In fe c tio n Hilary Humphreys, William L Irving Churchill Livingstone 1996 13 P H U• L U• C A Bang tra cum cac sd va qui trinh lam xet nghiem vi sinh lam sang cac benh pham khac SO doI Ndi dung Trang Qui trinh vi sinh lam sang cay mau vdi chai cay mau hai pha Qui trinh vi sinh lam sang cac mau mu va chat djch Qui trinh vi sinh lam sang khao sat mau phan Qui trinh vi sinh lam sang khao sat m lu ni/dc tieu Qui trinh vi sinh lam sang mau djch nao Qui trinh vi sinh lam sang khao sat mau quet hau hpng tim lien cau tan huyet beta Qui trinh vi sinh lam sang m lu mu tai, mu xoang, djch rCfa xoang Qui trinh vi sinh lam sang mau ddm/djch hut ddm tren - quan/dich afa quan qua noi soi Cach pha loang va cay djnh lupng mau ddm tren cac hop thach Qui trinh vi sinh lam sang cac mau lay tC/di/dng sinh due Qui trinh vi sinh lam sang cac m lu khao sat ky 17 24 30 42 52 58 66 10 11 77 79 91 100 P H U LUC B Bang tra curu cac hinh anh minh hoa Hinh Ndi dung Trang Hinh ve minh hoa cau tao chai cay mau hai pha 14 Hinh anh chai cay mau pha co vi khuan moc va chifa cay benh pham 16 Hinh anh chai cay mau An Do 16 Hinh anh tam bong vo trung lay benh pham 22 Hinh anh cap tam bong vo trung va tam bong manh vo trung kem vdi tube moi trudng chuyen chd Stuart -Amies 22 Hinh anh lo lay mau phan ti/di dung khao sat vi khuan 29 Hinh anh Ip lay m lu phan co F2M de tim ky sinh trung dudng ruot 29 Hinh anh cap tam bong vo trung kem vdi tube moi trudng chuyen chd Cary -Blair 29 Hinh anh gram vi khuan C jejuni 33 10 Hinh anh khom vi khuan C jejuni moc tren moi trudng phan lap 33 11 Hinh ve minh hoa cau tao chai cay nUdc tieu mat thach 39 12 Hinh anh cac mCfc vi khuan moc tren mat thach cua chai cay nUdc tieu 40 13 Hinh anh chai n ip vo trung lay benh pham 40 14 Hinh anh chai cay nUdc tieu hai mat thach 40 15 Cac hinh anh khao sat true tiep mau djch nao nhin qua kinh hien vi 47 16 Hinh ve minh hoa cau tao chai mat thach de cay djch nao 48 17 Hinh ve minh hoa cach lam thir nghiem vdi bo thuoc thir MENINGITEX phat hien khang nguyen hoa tan cac vi khuan thudng gay VMNM 50 18 Hinh anh chai mat thach de cay djch nao 51 19 Hinh anh cac loai vat lieu vo trung nen dUdc dung de lay djch nao hay cac dich khong tap nhiem khac 51 20 Hinh ve minh hoa cach quet hpng de lay mau 57 144 21 22 Hinh anh gram vi khuan bach hau Hinh ve minh hoa nguyen t ic cua thuf nghiem m iln dich sac ky phat hien vi khuan Streptococci tan huyet beta nhom A ti/ quet hong 57 56 23 Hinh anh tam bong manh vo trung nen dung de lay cac quet tai -mui-hong 65 24 Hinh anh cac tube nap van chat chtfa 5ml BHI co bd sung XV 65 25 Hinh anh cac dung cu nen dung va khong nen dung de lay m lu ddm 74 26 Hinh anh cac dung cu co the dung de lay dam qua dudng mui 74 27 Hinh anh nhuom gram ma dtfa vao co the danh gia tin cay mau ddm 75 28 Hinh anh khom vi khuan moc tren cac mat thach cay dinh ltfdng m lu ddm 83 29 Hinh anh gram phet mu nieu dao co N gonorrhoeae 90 30 Hinh anh gram phet can lin g ntfdc tieu co N gonorrhoeae 90 31 Cac hinh anh khao sat trtfc tiep quet am dao hay cd tif cung co G vaginalis 90 32 Hinh ve minh hoa phtfdng phap tao trtfdng ky bang phtfdng phap thay 96 33 Hinh anh thiet bi Axonomat Mark II de cay ky 97 34 35 Cac hinh anh khao sat trtfc tiep b ln g phtfdng phap soi ttfdi Hinh ve minh hoa cac btfdc thtfc hien phtfdng phap nhuom gram 104 107 36 Hinh anh bo thuoc nhuom gram 108 37 Hinh anh ket qua quan sat mot phet nhuom gram 108 38 Hinh anh bo thuoc nhuom Methylen Blue kiem 100 39 Hinh anh bo thuoc nhuom khang acid 113 40 Hinh anh ket qua quan sat phet nhuom khang acid 114 41 Hinh anh bo thuoc thCf lam thuan nhat va loai ta/tap nhiem m lu ddm 115 42 Hinh anh ket qua cac phet nhuom khang the huynh quang 128 43 Hinh ve minh hoa cau tao mot buong cay vi sinh 138 44 _ Hinh ve minh hoa cach bd tri cac thiet bi va dung cu can thiet cho mot phong thi nghiem vi sinh lam sang tai cac benh v i e n _ 142 PHU LUC C: Bang tom tat cac vat lieu lay mau va moi trirdng phan lap ti/dng urng cho cac benh pham khac Benh pham Mau Mu Vat lieu lay mau Moi trtfdng phan lap Chai cay mau (hinh 1.1, trang 14, hinh 1.2, trang 16) CA mau ngtfa (tot nhat) ± MC Tam bong vo trung lay m lu (hinh 2.1, trang 22) ± Moi trtfdng chuyen chd Stuart Amies (hinh 2.2, trang 22) hay Co the cay vao ong Thioglycollat hay BHI giau XV (hinh 7.2 trang 64) de Itfu m lu , phong trtfdng hdp tren cac mat thach phan lap khong co vi khuan moc Tam bong manh vo trung lay mau (hinh 7.1, trang 65) ± moi trtfdng chuyen chd Stuart Amies (hinh 2.2, trang 16) hay BA m iu ctfu + MC ± Sabouraud Agar, hay Lo lay mau vo trung nap -van chat (hinh 3.1, trang 29) hay tube Eppendorf biopure, hay tube 1,8ml vo trung, hay tube 5ml vo trung F2M (hinh 5.5, trang 51) hay Pipet Pasteur nhtfa vo trung, hay ong chich nhtfa vo trung Day la cac loai phtfdng tien de lay cac m lu mu ap xe BA mau ctfu ± MC ± MSA BANg -t MC ± MSA ± Sabouraud Agar, hay Chai mat thach CAXV cay dich khong tap nhiem (hinh 5.2, trang 48) nhtf cay mu ao xe phien trtfc khong co vi sinh 145 Phan Lo lay m lu phan khong co F2M (hinh 3.2 trang 29) dung lay mau phan tuoi -cay ngay,hay Tam bong vo trung lay mau (hinh 2.1, trang 22) dung lay phan tifdi hay quet hau mon cay ngay, hay n £ u KHONG c A y NGAY THI DUNG TAM BONG VO TRUNG l A y MAU + Moi trtfdng chuyen chd Cary -Blair (hinh 3.3, trang 29) N6n c3y phong phii vao GN broth ± Pepton kiem cho Vibrio ± Campy-thio cho C jejuni MC (hay EMB) ♦ SS (hay XLD hay HE) ± TCBS/MEA cho Vibrio ± Campy-BAP cho C jejuni Ntfdc tieu Lo lay mau vo trung n ip -van chat (hinh 3.1, trang 29) BA ± MC hay EMB, hay Dich nao Tube 1,8ml vo trung n ip vang (hinh 5.5 trang 51) Tube Falcon 15ml vo trung n ip xanh (hinh 5.5 trang 51) BANg + MC hay EMB, hay Chai mat thach BANg va MC (hinh 4.4, trang 40) cay nubc tieu ph*en true CAXV ± MC, hay Chai mat thach CAXV cay dich khong tap nhiem (dung cay DNT ph*en tnX) Tube 5ml vo trung n ip (hinh 5.5 trang 51) Tube Eppendorf biopure (hinh 5.5 trang 51) Quet hau hong Tai, m it, mui, xoang Tam bong vo trung lay mau (hinh 2.1, trang 22) ± Moi trtfdng chuyen chd Stuart Amies (hinh 2.2 trang 29) BA, hay BAGe, hay BA-tellurite ± Loeffler (neu muon phan lap bach hau), hay CAHI (neu muon phan lap H influenzae), hay CATM (neu muon phan lap N gonorrhoeae) Tam bong vo trung lay m lu (hinh 2.1, trang 22) ± Moi trtfdng chuyen chd Stuart Amies (hinh 2.2, trang 22) hay Trong trtfdng hdp quet mu m it, nen tang sinh vao BHI giau XV (hinh 7.2 trang 64) trtfdc cay vao moi trtfdng phan lap Tam bong manh vo trung lay mau (hinh 7.1 trang 64) ± Moi trtfdng chuyen chd Stuart Amies (hinh 2.2, trang 22) hay BA hay BANg hay BAGe + MC + CAXV Lo lay mau vo trung n ip -van chat (hinh 3.1 trang 29) hay tube Eppendorf biopure hay tube 1,8ml vo trung, hay tube 5ml vo trung (hinh 5.5 trang 51) Ddm va cac benh pham co ddm Sinh due Lo lay mau vo trung n ip -van chat (hinh 3.1 trang 29) hay BA hay BANg hay BAGe + MC ♦ CAXV Bo lay ddm qua ong thong mui (hinh 8.2 trang 74) Tam bong vo trung lay mau (hinh 2.1 trang 22) ± moi trtfdng chuyen chd Stuart Amies (hinh 2.2 trang 22) hay CATM ± BA hay BANg ± MC (neu cd yeu cau cay vi khuan khac ngoai vi khuan lau) Tam bong manh vo trung lay m iu (hinh 7.1 trang 64) ± moi trtfdng chuyen chd Stuart Amies (hinh 2.2 trang 22) hay Lo co F2M de lay mau (hinh 3.2 trang 29) de soi ttfdi tim T vaginalis Cay yem Tam bong vo trung lay mau (hinh 2.1 trang 22) ± moi trtfdng chuyen chd yem Carryport, hay Chai cay mau yem C)ng chich nhtfa, loai ong chich insulin vo trung de hut lay mu 146 BAYK de cay yem + cac mo< ta rin g cay hieu mau mu (BA + MC) NHA XUAT BAN Y HOC KY THUAT XET NGHIEM VI SINH LAM SANG m ■ Chju trach nhiem xuat ban HOANG TRONG QUANG Bien tap: NGUYEN TIEN DUNG Site ban in: NGUYEN TIEN DUNG Trinh bay bia: CHU HUNG K tvitin h : BUI HUE CHI In 1000 cuon, kho 19 x 27cm tai Xuong in Nha xuat ban Y hoc So dang ky ke hoach xuat ban: 23 - 2006/CXB/36 - 271/YH In xong va nop luu chieu quy II nSm 2006 ... cho vao 10ml ntidc thi nUdc se tham dan vao hai vien hoa chat de co mot vien sinh C va mot vien sinh H2 Khi H2 sinh se nhd chat xuc tac (la cac vien da pallidium -aluminium gan tren nap binh,... qua tren hop thach MCI la 20 0 khom, liidng vi khuin K pneumoniae 1ml ddm la 40000 CFU/ml (2x200xl 02) ; tren hop thach MC2 la 15, lUdng vi khuin/m l ddm la 30000 CFU/ml (2 x l5 x l0 3); va tren hop... loai khom vi khuan moc tren cac hop thach Hop thach M lu ddm pha loang Vong cay djnh lUdng The tich ddm di/cJc cay So vi khuan dupe dinh li/dng 1 /2 10^1 1 /2 V 5nl 2N x 1 02/ ml 0,5|il 2N x 103/ml