血液透析患者发生头孢菌素脑病的观察和护理

目的探讨血液透析患者使用头孢菌素所致脑病的观察和护理。方法对8例血液透析治疗患者,在使用头孢菌素后出现的神经精神症状进行回顾性分析和总结。结果 8例血液透析患者均在用药3~7 d后发病,经停药、继续透析治疗等处理和相应护理后症状完全消失。结论血液透析患者在使用头孢菌素过程中应密切观察和护理,防止头胞菌素脑病的发生。     

Glucocorticoids therapy as a first line treatment in ITP

Idiopathic thrombocytopenic purpura(ITP) is an immunohematological disorder for which appropriate diagnostic and treatment strategies are unclear. In 1982 in Japan and 1996 in ASH, guideline for ITP treatment was produced, respectively. These guidelines selected the steroid for the first line treatment. Appropriate steroid treatment was recommended based on the severity or grade of bleeding and platelet counts. Patients with platelet counts above 50,000 do not require treatment ordinarily. Treatment was indicated in-patients with platelet counts under 20,000-30,000, and those with platelet counts under 50,000 with presence of bleeding tendency or risk factor for bleeding. Most ITP patients responded well with initial steroid treatment and 33% of them had a complete remission from ITP, but remaining patients decreased platelet counts with the steroid dose reduction. The management of the bleeding symptoms without the adverse effects is an important point of steroid medication in ITP after first line treatment.     

Duration of antimicrobial therapy for nosocomial pneumonia: possible strategies for minimizing antimicrobial use in intensive care units

OBJECTIVE: To review published data evaluating shorter courses of antibiotic therapy for nosocomial pneumonia and provide recommendations for minimizing antimicrobial use in intensive care units. DATA SOURCE: Literature was identified through MEDLINE (1966 through 6/2002) and a manual search of critical care, infectious disease, and pharmacy journals was conducted to identify relevant abstracts. DATA SYNTHESIS: Antibiotic use may be decreased by discontinuing therapy after 3 days in patients with low likelihood of nosocomial pneumonia. In addition, clinical guidelines or invasive diagnostic procedures may be effectively instituted to reduce duration of antibiotic therapy. CONCLUSION: Shorter-course antibiotic therapy may be beneficial in decreasing lengths of hospital and intensive care units stays, antimicrobial resistance, and total hospital costs. Further research is needed to determine the optimal duration of therapy in patients with nosocomial pneumonia.     

国产血透机与进口血透机性能比较

目的:通过多中心大量临床治疗观察,验证国产JH-2000血透机在临床过程中各部件的工作状态及临床疗效。方法:选择急慢性肾功能衰竭的住院及门诊108例患者,每周透析3次,随机分为观察组和对照组,平均透析时间(32.9±17.8)个月,各组观察1000例次。观察透析前后肌酐(Cr)、尿素氮(BUN)、电解质和临床症状改变,验证JH型血透机在临床治疗过程中各部件及系统的工作状态。结果:两组治疗前后自身对照结果显示血清BUN、Cr、K+和PO43-均有明显降低;呼吸、心率和血压改变在两组之间相比较差异无显著性;Kt/V值两组病人均在1.25以上,两组之间Cr、BUN、电解质及血压和心率的改变相比较差异无显著性(P>0.05)。结论:经JH血透机治疗后患者BUN和肌酐均有明显降低;电解质和酸碱平衡紊乱可得到明显纠正,与对照组相比差异无显著性,未发现与JH型血液透析机相关的不良反应。其不仅可与进口透析机一样用于维持性血液透析治疗,而且优于进口透析机的是可推移到病床旁做床边血液透析滤过治疗。     

水产养殖中使用抗菌药物对人类健康的影响

抗菌药物在水产养殖中的大量使用产生选择压力,使水环境成为耐药细菌和鱼类致病菌及其他细菌中可转移耐药基因的储蓄池。一些耐药的水生病原菌同样是人类病原菌或机会病原菌,可通过接触水或水生病原菌、饮水、处理使用水产品等直接由水环境传播致人类疾病;一些水环境中细菌     

Surveillance of antimicrobial use and antimicrobial resistance in intensive care units (SARI): 1. Antimicrobial use in German intensive care units

Objective To study antimicrobial use for benchmarking and ensuring quality of antimicrobial treatment and to identify risk factors associated with the high use of antimicrobials in German intensive care units (ICUs) through implementation of the SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in ICUs) system.Design Prospective, unit-based surveillance on antimicrobial use from February, 2000, until June, 2002. The data are standardised by use of the defined daily dose (DDD) for each antimicrobial defined by the WHO and by calculating use per 1000 patient days.Setting The data were obtained from 35 German ICUs and stratified by type of ICU (medical, surgical, interdisciplinary).Results To date, the project covers a total of 266,013 patient days in 744 reported ICU months and 354,356 DDDs. Mean antimicrobial use density (AD) was 1,332 DDD/1000 patient days and was correlated with length of stay. Penicillins with beta-lactamase inhibitor (AD 338.3) and quinolones (155.5) were the antimicrobial group with the highest ADs. Comparison with US ICARE (Intensive Care Antimicrobial Resistance Epidemiology)/AUR (Antimicrobial Use and Resistance) data revealed a higher AD for glycopeptides and 3rd generation cephalosporins in ICARE/AUR ICUs, but a higher AD for carbapenems in German SARI ICUs regardless of the type of ICU. In the multivariate analysis, length of stay was an independent risk factor for an AD above the 75% percentile of the total amount of antimicrobials used (OR 1.96 per day); likewise, for the AD above the 75% percentile of carbapenems (OR 1.90 per day) and penicillins with extended spectrum (OR 2.01 per day). High use of glycopeptides and quinolones (AD >75% percentile) correlated with central venous catheter (CVC) rate (OR 1.14 per CVC day per 100 patient days and 1.16, respectively).Conclusion The SARI data on antimicrobials serve ICUs as a benchmark by which to improve the quality of antimicrobial drug administration and for international comparison.Electronic Supplementary Material Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134-004-2266-9     

The guideline how to use the antimicrobial agents--the guidance how to use the antimicrobial agents

In regard to reconsider the way of antimicrobial agent, it has given the guideline which is how to use the antimicrobial agent to be protected the occurrence of drug resistant bacteria and how to use it safety. This writing omit the way of thinking about the proper use, the safety use, and the prevention for hospital acquired infections by this reference. What the proper use for antimicrobial agent is. The basic idea as the proper use for antimicrobial agent is 1. to heal a patient(individual-defense), 2. not to increase drug resistant bacteria(group-defense), 3. to be utilizable for a medical resource mostly. In the choice of antimicrobial agent for the individual situation, we have to think about 1. (to heal a patient) seriously first, and then, of course, we recognize the point of view for 2. and 3. has a good balance in this way.     

Practical considerations in the use of outpatient antimicrobial therapy for musculoskeletal infections

Successful treatment of many musculoskeletal infections often requires an extended course of outpatient antimicrobial therapy, much of which is administered parenterally outside the hospital under the guidance of an infectious disease specialist. Delivery of outpatient parenteral antimicrobial therapy (OPAT) may occur in physicians' offices, ambulatory infusion centers, or hospital clinics but most frequently is done in patients' homes, often by the patients themselves. In this article, we outline the essential elements of outpatient antimicrobial therapy for musculoskeletal infections with particular emphasis on OPAT, including patient selection and evaluation; antimicrobial administration, including the route, duration, and complications of central venous access; and clinical and laboratory monitoring of antimicrobial therapy. We believe that primary care physicians, orthopedists, and infectious disease specialists caring for patients with musculoskeletal infections should become familiar with the use of, indications for, and complications of OPAT.     

Prevalence and consequences of nonadherence to hemodialysis regimens.

Adherence to fluid restrictions and dietary and medication guidelines as well as attendance at prescribed hemodialysis sessions of a hemodialysis regimen are essential for adequate management of end-stage renal disease. A literature review was conducted to determine the prevalence and consequences of nonadherence to the different aspects of a hemodialysis regimen and the methodological obstacles in research on nonadherence. Nonadherence to the prescribed regimen is a common problem in hemodialysis and is associated with increased morbidity and mortality. Research on nonadherence is associated with 2 major obstacles: inconsistencies in definitions and invalid measurement methods. Further research is needed to validate measurement methods and to establish clinically relevant operational definitions of nonadherence.     

Photodynamic therapy based on 5-aminolevulinic acid and its use as an antimicrobial Agent

Exogenous 5-aminolevulinic acid (ALA) is taken up directly by bacteria, yeasts, fungi, and some parasites, which then induces the accumulation of protoporphyrin IX (PPIX). Subsequent light irradiation of PPIX leads to the inactivation of these organisms via photodamage to their cellular structures. ALA uptake and light irradiation of PPIX produced by host cells leads to the inactivation of other parasites, along with some viruses, via the induction of an immune response. ALA-mediated PPIX production by host cells and light irradiation result in the inactivation of other viruses via either the induction of a host cell response or direct photodynamic attack on viral particles. This ALA-mediated production of light-activated PPIX has been extensively used as a form of photodynamic therapy (PDT) and has shown varying levels of efficacy in treating conditions that are associated with microbial infection, ranging from acne and verrucae to leishmaniasis and onychomycosis. However, for the treatment of some of these conditions by ALA-based PDT, the role of an antimicrobial effect has been disputed and in general, the mechanisms by which the technique inactivates microbes are not well understood. In this study, we review current understanding of the antimicrobial mechanisms used by ALA-based PDT and its role in the treatment of microbial infections along with its potential medical and nonmedical applications.     

Role of long-acting cephalosporins in ambulatory therapy

Selected patients with community-acquired infections can be discharged from the hospital, when afebrile and stable, with parenteral antibiotic therapy continued on an ambulatory basis. This therapy is currently possible because of the availability of long-acting cephalosporins that can be administered once daily, often with substantial reductions in hospital costs. Cefonicid and ceftriaxone both have sufficiently long half-lives and either may be administered intramuscularly once daily. Their antibacterial spectra encompass many of the pathogens encountered in community-acquired infections of the lower respiratory tract, skin and soft tissue, bone, and urinary tract. Ceftriaxone, a third-generation cephalosporin, has a broader spectrum than the second-generation agent cefonicid. Ceftriaxone should generally be reserved for the treatment of gonococcal disease and of community- or hospital-acquired infections due to organisms resistant to the narrower-spectrum and less expensive long half-life agent cefonicid.     

血液透析患者静脉应用左旋肉碱(可益能)的药代动力学研究

目的 研究血液透析患者静脉应用左旋肉碱的药代动力学特点，探讨治疗肉碱缺乏的给药途径、剂量、疗程。方法 选择9例本透析中心病情稳定的患者，男5例，女4例。于每次血液透析结束回血前3分钟，静脉推注1g左旋肉碱，共用药8周(26次透析)。应用酶法检测首次给药前(0时)、给药后1．5分钟、3分钟、15分钟、30分钟、1小时、2小时、4小时、8小时、12小时、24小时肉碱的血药浓度，分析单次静脉应用左旋肉碱的药代动力学特点。另外，于首次给药、给药2周、4周、6周、8周分别检测透析前后、透析液中肉碱浓度，研究多次用药后血浆肉碱水平变化和透析液中的清除量。结果 维持性血液透析患者用药前血浆肉碱浓度大大低于正常值40—50μmol/L；首次于透析结束时静脉给予1g左旋肉碱的药代动力学符合二室开放模型。给药后血药浓度很快增加，然后迅速下降，AUC大，但半衰期与正常人接近；每次透析过程中均可清除大量的肉碱，并且随着血药浓度增加而清除增加；连续给药期6至8周后透析前后肉碱水平基本维持稳定。结论 血液透析患者外源性补充肉碱的药代动力学特点与正常人不同，透析清除是药物排泄的主要途径，因此须6—8周连续透析后补充用药，使组织及血浆肉碱水平恢复。     

Resistance of gram-negative bacilli as related to hospital use of antimicrobial agents

The development of resistance of gram-negative bacilli, which are common nosocomial pathogens, is an increasing problem. It is generally accepted that this resistance may directly reflect the frequency of use of various antimicrobial agents. Because our institution experienced in 1976 a dramatic change in the pattern of antimicrobial use, primarily a marked decrease in prescribing cephalosporins, we attempted to evaluate retrospectively the effects of this change upon the resistance of gram-negative bacilli that are common nosocomial pathogens. Susceptibilities of Klebsiella and Providencia spp., Pseudomonas aeruginosa, and Serratia marcescens were determined for the years 1975 to 1979. Not unexpectedly, we observed a substantial decrease in cephalosporin resistance. An unexpected finding was a decrease in aminoglycoside resistance, despite increased use of these agents. The possibility that decreased cephalosporin use may lead to decreased aminoglycoside resistance is an intriguing and provocative thesis which can only be speculative at this time but which would seem worthy of additional formal investigation.     

Comparative serum levels and protective activity of parenterally administered cephalosporins in experimental animals

Six cephalosporin antibiotics were administered subcutaneously to mice at a level of 20 mg/kg. The serum levels of each were determined at five time intervals ranging from 5 to 120 min after dosing. Urinary recovery and the presence of active metabolites in mouse urine were determined. The peak serum levels and serum half-lives in mice were found to be positively correlated with the mean effective dose values obtained after lethal challenge with Escherichia coli. The administration of cefazolin and cephanone resulted in the highest serum level and the best protection. Good protection was obtained with cephaloridine despite somewhat lower serum levels. The cephalosporins with the acetoxy side chain (cephalothin, cephapirin, and cephacetrile) showed lower serum levels and the poorest protection. Cefazolin, cephaloridine, and cephalothin serum levels were also determined in dogs, squirrel monkeys, and rabbits. A mixed response was obtained in these species, with cefazolin peak serum levels being highest in rabbits and cephaloridine peak highest in dogs.     

Modeling the response of pneumonia to antimicrobial therapy.

The response to antimicrobial therapy in patients with pneumonia was assessed by using a previously developed pneumonia scoring system. Patients from two different clinical trials were evaluated. The first group (n = 22) was treated with cefmenoxime. For these patients, doses were adjusted to achieve an area under the plasma concentration-versus-time curve (AUC) above the MIC of 140 microg x h/ml and pneumonia response scores were evaluated retrospectively. The second group (n = 21) were treated with either ciprofloxacin (CIP) or ceftazidime (TAZ) in a randomized clinical trial. Here, doses were adjusted to achieve AUC from 0 to 24 h/MIC values that were > 250 SIT(-1) x h (estimate of the area under the curve of inverse serum inhibitory titer versus time) and pneumonia response scoring was concurrent. In both studies eradication of the pathogen was determined by serial endotracheal cultures and clinical parameters were scored daily. A decrease in total score was indicative of an improving clinical condition. The percent change in clinical daily score was determined for each day of treatment. The rate of clinical response was determined by linear regression of the percent change in daily clinical score versus time during the course of antimicrobial therapy. Factors predictive of time to eradication were explored by interval analysis. Logistic regression was used to determine the earliest time point in therapy at which treatment scores predicted outcome. Kruskal-Wallis analysis of variance was used for statistical analysis, and significance was accepted at P < 0.05. There were no differences in baseline scores at day one for the patients treated with different antibiotics (P = 0.58). For patients with pathogen eradication, a significant difference between the two studies in time to eradication was found: 4.8 days for cefmenoxime-treated patients and 1.4 days for CIP- or TAZ-treated patients (P < 0.001). For patients experiencing bacterial eradication, the rates of clinical change for cefmenoxime and CIP or TAZ treatment were similar (P = 0.77). For patients with organisms that were not eradicated, the rates of change were similar (P = 0.14). There was a significant difference in the rate of change for patients experiencing eradication compared with that for patients in which the organism persisted (P << 0.01). Both treatment group and rate were found to be predictive of days to eradication. There was a significant difference in the percent change in clinical score on day 3 of therapy for patients with bacteria that were eradicated versus those with persistent organisms (P < 0.01). The percent change was more predictive of outcome with each subsequent day. Patients who demonstrated a > or = 10% reduction in clinical score after 72 h of treatment had an 88% probability of bacterial eradication. The clinical scoring system is a useful tool for modeling the response of pneumonia to antimicrobial therapy. The ability to predict outcome relatively early in therapy, by using a scoring system of clinical parameters which can be routinely monitored, will aid in assessing the response to antimicrobial therapy in clinical as well as in research settings.