脓毒症的经验性抗感染治疗

严重脓毒症和脓毒性休克在重症患者中的死亡率较高。早期、合理的经验性抗感染治疗是提高患者生存的基石。然而随着耐甲氧西林金黄色葡萄球菌(methicillin-resistant Staphylococcus aureus,MRSA)及产超广谱β-内酰胺酶(extend-ed-spectrum beta-lactamases,ESBLs)菌等多重耐药菌株(multidrug-resistant organism,MDRO)的日益增多以及抗菌药物种类的限制,使经验性抗生素选择面临巨大挑战。本文将对近年来国内外脓毒症经验性抗菌药物选择方面的研究做一综述,以期为临床决策的制定提供参考。     

Pharmacological indices in antibiotic therapy

After 60 years of antibiotic treatment, attempts to rationalize it have culminated in the use of pharmacological indices. These indices facilitate comparison of the activity of different antibiotics and serve as a sound basis for antibiotic dosing. Pharmacokinetic parameters (e.g. AUC, Cmax) and pharmacodynamic parameters (mostly MIC) are used for this purpose. For the so-called concentration-dependent antibiotics, the pharmacological indices AUC/MIC and Cmax/MIC are used, whereas for time-dependent antibiotics, the pharmacological index T>MIC is used. Some authors believe that the index AUC/MIC can be used as a universal index, but, not all experts accept this generalization. As the various pharmacological indices have been defined inconsistently in the literature, the International Society for Anti-Infective Pharmacology (ISAP) has published a paper on the terminology of pharmacokinetic and pharmacodynamic parameters and the pharmacological indices. This paper will help to ensure uniform use of terminology. In addition, we point out that the use of pharmacological indices should consider the differences in pharmacokinetics (patient characteristics and localization of the infection) and the differences in pharmacodynamics of antibiotics (beyond MICs) with different pathogens (e.g. Gram-positive and Gram-negative).     

Update: antibiotic therapy

Although these new antibiotics are powerful broad-spectrum agents, the decision to use new antibiotics should be based on careful assessment of the patient's clinical status and need for therapy, the known resistance patterns of the hospital or community, and cost-benefit factors. Indiscriminate widespread use will limit or abolish their usefulness and needlessly increase the cost of hospital therapy.     

Outpatient intravenous antibiotic therapy

Outpatient intravenous antibiotic therapy is a cost-effective modality to shorten hospital stays and provide continued care to patients with infections. The recent availability of tamper-proof pumps that can deliver multiple antibiotics on independently timed regimens will further expand the use of home intravenous antibiotics. Problems with reimbursement remain, and new classes of oral antibiotics may provide alternatives to parenteral medications.     

Rational antibiotic therapy of pneumonia

The aim of the study was to analyse antibacterial treatment in patients with extrahospital pneumonians in a standard pulmonological department. The analysis covered 80 patients with EHP treated in 2000. In the 100% cases the choice of the antibiotics was random and did not depend on pneumonia severity, age, sex, occupation of the patient, concomitant pathology, the disease duration, previous treatment. Gentamycin was prescribed most frequently. The course doses of the drugs were often violated. The mean hospital stay was 22.5 days, complete resolution was observed only in 8.75% patients.     

Cost considerations in oral antibiotic therapy

The total cost of antibiotic treatment may be computed from basic treatment and indirect costs. Basic treatment costs represent the product of the per-dose acquisition cost and the number of doses. Agents with a high per-dose acquisition cost and an infrequent (eg, once daily), short duration of therapy may have lower total costs than agents with a low per-dose acquisition cost and a high-frequency (eg, four times daily), long-duration regimen. Indirect cost reflects expenditures associated with noncompliance, treatment failure, adverse events, and drug interactions. These costs result, in turn, from additional office visits, treatment with alternative or additional medications, hospitalization, and lost productivity. Older agents, though likely to have lower acquisition costs, may have reduced efficacy against clinically important pathogens, side effects, drug interactions, and the requirement for multiple daily doses and long dosage regimens--factors that may increase the probability of poor outcome and the overall treatment cost. Newer broad-spectrum agents are effective and generally well tolerated and may have fewer drug interactions; however, most require long and relatively complex dosage regimens. These limitations increase the basic treatment cost and influence indirect costs through negative effects on patient compliance. Broad-spectrum antibiotics with low acquisition costs, simple dosing regimens, and relatively favorable safety and tolerability profiles may provide benefits in the treatment of common infections.     

An overview of antibiotic therapy

Antibiotics are one of the most widely prescribed group of drugs in the UK. However, their widespread use has resulted in antibiotic resistance and unnecessary prescribing. This article provides an overview of antibiotic therapy, including the principles and modes of action of drug treatment, prescribing criteria and the issue of antibiotic resistance.