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Learning to share antibiotics
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rational use of antibiotics in one, the definition of antibiotics and related concepts
(a) of the definition of antibiotics is antibiotic
by bacteria, fungi or other microorganisms in the process of life arising with anti-pathogen or other activity of a class of substances. Such as penicillin, griseofulvin, doxorubicin.
semi-synthetic antibiotics is based on the basis of microbial synthesis of antibiotics, improved its structure gained a new class of compounds. Such as: ampicillin. Are entirely synthetic inhibition of bacteria or fungi, or kill the material, strictly speaking, only as antimicrobial agents or antifungal agents, and can not be called antibiotics. Such as: quinolone antibacterial drugs.
(b) of the related concepts
1. the meaning of rational use of antibiotics is a clear indication, the choice of appropriate antibiotics and the use of appropriate dose and duration, to achieve the kill eliminate pathogenic microorganisms and (or) the purpose of infection control, while also preventing the occurrence of various adverse reactions.
2. Evaluation of rational use of antibiotics, safe, effective, convenient, timely, rational drug economy is an international research center evaluation of rational drug use. Made this special
Second, the rational application of antibiotics
(a) a prerequisite for rational use of antibiotics
to achieve rational use of antibiotics, we must first fully understand and grasp the characteristics of the role of various antibiotics, drugs used for the targeted provide a solid theoretical basis; followed by a variety of pathogenic bacteria but also to fully understand the mechanism of resistance, especially in this region, the state unit of bacterial resistance, for the selection of antibiotic-sensitive pathogens to provide a reasonable basis.
1. antibiotics and their role in the classification of features according to the chemical structure of antibiotics and clinical use of antibiotics can be divided into β-lactams, aminoglycosides, macrolides, lincomycin, tetracycline class, chloramphenicol, and other major class of antibiotic resistant bacteria, antibiotics, anti-fungal, anti-tumor antibiotic with immunosuppressive effects of the ten categories of antibiotics. The following details the role of the characteristics of antibiotic resistant bacteria.
(1) β-lactam β-lactam antibiotics based on the characteristics of the chemical structure can be divided into penicillins, cephalosporins, cephamycins, single ring amide and other atypical β-lactam antibiotics. These antibiotics on the bacterial cell membrane with penicillin binding proteins (PBPs) and prevent bacterial cell wall with sticky peptide synthesis and cross-linking, resulting in cell wall defect, rupture and rapid death. So he was breeding bacteria have powerful role in the killing, is a reproduction of fungicides. And he also has toxic side effects on the human body benefits. The role of antibiotics characteristics shown in Table 1, Table 2, Table 3.



(2) aminoglycoside aminoglycoside (AGS) a major role in bacterial protein synthesis, cell membrane permeability of bacteria, lead to leakage of some important physiological substance, causing bacterial death. The antibiotics kill bacteria for stationary phase is stronger, as a stationary phase of the fast spectrum disinfectant. As the class of antibiotics ear, kidney toxicity and other side effects of neuromuscular blockade, is generally not clinically as a preventive medication for the treatment of serious systemic infections, often in combination with other antibiotics. The role of various common features of aminoglycoside antibiotics shown in Table 4.

(3) the role of macrolide antibiotics on the bacteria of the nuclear ribosomal 50S subunit, impeding bacterial protein synthesis,microsoft office Enterprise 2007 license, are effective antibacterial agents fast growth period, not with the β-lactam combined with fungicides such as breeding, so as to avoid antagonism.
(4) mechanism of action of lincomycin and macrolide class of the same varieties of lincomycin and clindamycin, the same antimicrobial spectrum of the two drugs, bacteria on the two between those who complete cross-resistance. Can be used in clinical Staphylococcus aureus (including enzyme production strains), Staphylococcus epidermidis, hemolytic streptococcus, pneumococcus, Streptococcus viridans and a variety of infections caused by anaerobic bacteria. This class of antibiotics in high concentrations in bone tissue; adverse reactions have pseudomembranous colitis, and cardiac toxicity (ECG changes, blood pressure, heart rate and breathing to stop).
(5) antibiotics tetracycline mechanism of action of the main bacterial 30S ribosomal subunit binding and inhibition of peptide chain growth and protein synthesis of bacteria, therefore a fast inhibitory effect agent. Species include tetracycline, oxytetracycline, doxycycline, chlortetracycline, minocycline. Broad spectrum antibiotic, but in recent years some of the high rate of resistance to common pathogens, limiting the application of this class of drugs.
(6) classes of the antibiotics chloramphenicol major role in the bacterial 70S ribosomal 50S subunit to inhibit bacterial protein synthesis, is a fast effective antimicrobial agent. Varieties of chloramphenicol and thiamphenicol. However, broad spectrum antimicrobial drug resistance has been very severe and adverse reactions (aplastic anemia and gray baby syndrome), clinical only bacterial eye infections and typhoid, paratyphoid and other salmonella bacteria, Bacillus fragilis infection.
(7) other classes (see Table 6).

2. clinical common pathogenic bacteria and their resistance mechanisms to prevent or empirical treatment of clinical infections, it is often necessary for one or a few most likely pathogens, choose the most effective antibiotic for prevention or empirical treatment. This requires medical personnel to fully understand the region and the resistance of pathogenic bacteria. Now common clinical pathogens and resistance mechanisms are listed below (Table 7):

(b) the reasonableness of antibiotic prophylaxis antibiotic prophylaxis
about the total amount of antibiotics 30% to 40%, or medical units in some areas even up to 50% to 60%. Reasonable precautions applications can usually achieve the intended purpose; but to prevent unreasonable application of, not only can not achieve the purpose of prevention, but is likely to lead to resistant infections. Therefore, prophylactic before, need to fully consider the possibility of infection,office 2010 Standard 32 bit key, prevention of drug use, drug-resistant generation, the incidence of superinfection, adverse drug reactions, drug prices, and the susceptibility of patients with a variety of factors, then decide whether to apply.
1. the principle of preventive medicine
(1) to prevent the possibility of bacterial infection medication indication is to determine the extent of whether to use preventive medication were the only indicators. It can be seen, only suitable for prophylaxis in patients not infected, while the patient if the medication is not likely to prevent infection and cause serious consequences. Therefore requested the medical personnel must be integrated into the risk factors contribute to infection, evaluation out the possibility of bacterial infection in patients with the degree of the final decision whether to use preventive medication in patients to provide evidence. Promote infection risk factors:
① patient factors such as age, immune status, with disease;
② pathogen factors, such as pollution and invasive virulence of pathogens such as;
③ environmental factors,microsoft office Professional 2010 license, such as the operating room, recovery room, intensive care unit and ward health and quarantine status;
④ other factors, such as the surgical procedure, operation duration, intraoperative blood loss and so on.
(2) Targeted prevention of drug use is often a site of infection are those few special virulent bacteria such as Staphylococcus aureus, Streptococcus and so on. Therefore, prophylaxis should be targeted, broad-spectrum antibiotics should be chosen at random or in combination with several antibiotics as a preventive medication.
(3) prevention of drug treatment to those for the sake of the advantages of growth and reproduction, resulting in severe refractory infections. Therefore, prevention should be the appropriate course of treatment.
(4) surgery, gynecology principles of perioperative prophylaxis of perioperative medicine must be based on the surgical site, hospital ward or the pathogen may be popular, the degree of pollution surgery, surgical trauma level, duration of operation and other factors, rational use of antibiotics. Prophylaxis following principles:
① clean operation can be divided into A and B categories. A such as hernia, breast, thyroid, spermatic vein, great saphenous vein and other music
Zhang, in principle, to use antibiotics. For use, 0.5 to 1 hour before surgery or in the beginning with a dose of anesthetic. Interventional therapy can also press the relevant antibiotics such treatment. B such as heart, chest, skull, bones, joints and clean an artificial implant surgery to the main first line antibiotics,home basic windows 7, the use of antibiotics to shorten the time. Such as diabetes or immunocompromised conditions such interventional therapy can be handled.
② clean but vulnerable to pollution, easy to clean contaminated surgical procedures, such as stomach, intestine, lung, gynecological, ENT, obstetrics, oral cavity, maxillofacial surgery and other surgery and open wounds In principle, the use of antibiotics the day of surgery, if necessary, extended. Such as vaginal hysterectomy, can prevent medication 2 to 3 days.
③ contaminated surgical excision of the abscess, suppurative cholangitis, abdominal puncture wound surgery secondary peritonitis, have been contaminated surgery, starting from the perioperative use of antibiotics by therapeutic principles of medicine.
④ perioperative prophylaxis should a short course of treatment usually administered intravenously 1 h before surgery. If a short half-life of drugs used, operative time more than 4 hours, can be used in the surgery plus one. After treatment by conventional methods, the general course of 3 days.
2. prevention of drug use Notes
(1) has a clear need for the simple viral infection with antibiotics.
(2) prophylactic antibiotics is the best disinfectant, also should have safe, effective and less adverse reactions, administration convenience, low prices and so on. Can not blindly use broad-spectrum antibiotics, or multiple drugs combined with a variety of bacterial multi-site infection prevention.
(3) must pay attention to sterile surgical operation should be careful to minimize blood loss and tissue damage. Well disinfection and isolation, the patient nutritional support, environmental disinfection. Application of taking preventive antibiotics.
(4) Clean shorter operation time, no need for antibiotics.
(5) pollution of the digestive tract does not absorb oral drug selection conditions, high drug concentrations within the intestine, intestinal contents affect the antibacterial activity is small, and easy shift of pathogenic Gram positive bacteria, Gram-negative bacteria, fungi and so has a strong bactericidal effect of drugs such as metronidazole, clindamycin, neomycin, erythromycin, nystatin, also useful for oral gentamicin.
3. Clinical prevention of common infectious diseases, rational drug program
(1) common clinical treatment of non-surgical infection prevention program shown in Table 8.

(2) surgery, gynecologic surgery before (in) the prevention of infection regimen shown in Table 9.

(c) a reasonable therapeutic application of antibiotics
1. therapeutic application of the basic principles of
(1) only for the treatment of infectious diseases of all antibiotics only for the treatment of bacterial, mycoplasma, chlamydia, fungi and other infectious diseases caused by non-principle, the infection with antibiotics. Although the past decade, many scholars reported a large number of macrolide non-antibacterial effect, such as for the treatment of: chronic bronchial asthma, gastrointestinal neurogenic movement disorders, such as gallbladder stones, but because of its easy to induce bacterial resistance generation, and should therefore be very careful treatment of these new uses, in principle, be used.
(2) early diagnosis of pathogenic bacteria to establish checks on the diagnosis and treatment of infectious diseases has an important role. Although many infectious diseases clinical empirical treatment can be cured, but at different times, different infections, the different medical units, pathogen species, composition, has a very different drug sensitivity. Therefore, in order to find sensitive to antibiotics, in time, infection control, should be established early diagnosis of infectious disease pathogens, and strive to be treated with antibiotics before the specimens were collected properly and timely delivery pathogenic examination and drug sensitivity test, in order to obtain scientific medicine basis. Once culture results, you should refer to test results, clinical effects, and adjust the medication regimen, the goal of treatment.
(3) specific experience in the treatment without the exact etiological diagnosis is not allowed before or delays in the case of the disease,office 2010 64bit key, the infection as soon as possible to determine the nature of the experience of the treatment can be targeted. On the light of community-acquired infections, or untreated patients may be using common antibiotics; of nosocomial infection or serious infection, refractory infection should be based on clinical presentation and site of infection, infer the possible pathogens and drug resistance, selection of wide coverage, strong antibacterial activity and safety of a good fungicide, can combination therapy. Leading to organ dysfunction, life-threatening infections should be covered by the application of antibiotics Gram-positive bacteria, Gram-negative bacteria, anaerobic bacteria, fungi.
(4) combined with clinical evaluation of the results of bacterial culture and sensitivity should be based on the clinical significance of drug effect, as soon as possible to determine the effectiveness of empirical treatment in order to refer to selected results in a targeted manner sensitive to the role of strong antibiotics. No more infected with the performance of the positive result meaningless, should be excluded from contaminating bacteria, normal flora and colonization of bacteria may be sent.
(5) selection of the role of strong, high concentrations of antibiotic the site of infection should be considered the following factors:
① basis of disease status in patients with disease types , severity, pathology, physiology, immune function and so on.
② the effectiveness of drugs, including antibiotics, antibacterial spectrum, antibacterial activity, pharmacokinetic characteristics (absorption, distribution, metabolism and excretion, such as the half-life, plasma concentration, tissue concentration, cell the concentration), pharmacodynamic characteristics and adverse reactions.
③ the region, medical institutions, drug resistance of endemic bacterial pathogens sensitive to the antibiotics used.
④ route of administration should be based on the severity of infection and pharmacokinetic characteristics determine the route of administration, mild infection try to use the bioavailability of oral preparations.
⑤ use a variety of drugs available should be based on a narrow spectrum, adverse reactions, low cost is preferred.
⑥ Other drug interactions, and supply.
(6) to note change in time according to the clinical efficacy of antibiotics or (and) to determine whether microbial test results need to be replaced by the infection with antibiotics usually medication 72 hours (severe infection 48 hours) After the basis of clinical efficacy can be used to determine the effectiveness of antibiotics.
(7) a reasonable course of treatment or general infection until the end of symptoms, signs and laboratory tests returned to normal after the improvement or continued medication 2 to 3 days, you can terminate the anti- infection treatment; special implementation of infection by a specific course of treatment, such as tuberculosis.
(8) necessary to attach importance to the comprehensive treatment of antibiotic treatment of bacterial infections in the process, must be fully aware of the importance of the human immune system, excessive reliance on the efficacy of antibiotics to the neglect of the inner body factor in the failure of antibiotic treatment is often an important factor. Therefore, in the use of antibiotics, we must make every effort to improve the situation of human body, a variety of comprehensive measures, such as correcting water, electrolyte and acid-base balance, improve microcirculation, supplementary blood volume, blood transfusion, plasma, albumin or amino acid, treatment of primary disease and local focus, are not be ignored.
(9) to try to avoid topical skin and mucous less if local infection or severe infection, but systemic administration of local infection foci in the effective concentration is difficult to achieve, consider the following topical use of local Preparation: nitrofurazone, neomycin, bacitracin, silver sulfadiazine, mupirocin, sulfonamides, sulfacetamide sodium. Will not allow unauthorized use of systemic agents in the local, in case of clinical strains resistant to commonly used drugs have.
(10) a clear indication of the joint use of antibiotics can not clear only those who cause serious infections, a variety of mixed infection caused by bacteria requires long-term medication, the bacteria could develop resistance to the joint use of antibiotics .
2. all kinds of common infectious diseases in different empirical drug of choice for the treatment of patients with different underlying diseases, different types of infection and different clinical manifestations to have different pathogens. Therefore, when the experience of treatment of infectious diseases, it should be taken into account the various influential factors, to infer the most likely one or more pathogens, and the choice of a specific or in combination with several sensitive antibiotics, in order to achieve timely and effective control of infection. Empirical treatment of various infectious diseases, drug selection Table 10.

(d) combination of antibiotics for clinical
as soon as possible to effectively control severe infection, mixed infection and to prevent bacterial resistance, often a joint program of the use of antibiotics. Combined with a reasonable solution can often achieve the desired effect; but an inadequate solution combined with drug use or abuse of this model, the waste of medical resources will inevitably lead to adverse drug reactions, and even increased the multiple drug resistance of bacteria. Therefore, when using combination therapy, the use of several drugs which combined joint is reasonable, the majority of medical personnel has always been of particular concern.
1. the principle of combination of antibiotics
(1) the purpose of joint use of combined drugs on the bacteria to be able to produce to increase treatment effect and reduce adverse reactions in patients, reducing bacterial resistance to the purpose.
(2) the type of joint application of appropriate combination of two or more generally the joint application of antibiotics, plus special circumstances, but also antifungal. Reproduction of fungicides commonly used (β-lactams, fosfomycin, vancomycin, etc.) and resting fungicides (aminoglycosides, polymyxin class) or β-lactam combined with β-lactam class enzyme inhibitor, synergistic antibacterial effect to obtain.
(3) indications for combination therapy indication for joint use of antibiotics should be more stringent than the single drug. Its clear indications as follows:
① severe infections of unknown etiology.
② single drug can not effectively control the mixed infection.
③ single drug can not effectively control a serious infection.
④ single drug resistant strains can not effectively control the infection, especially nosocomial infection.
⑤ synergistic combination therapy side effects can make one large dose of antibiotics can be reduced, thus reducing the incidence of adverse reactions.
⑥ requires long-term treatment and prevention of bacterial resistance, such as tuberculosis, treatment should be used for strengthening of the quadruple, triple, and consolidation is appropriate to the second joint.
2. relatively rational drug combinations based on in vitro susceptibility test results and the joint long-term clinical results confirmed the combination of certain drugs do have a good effect. Now a number of potentially effective antimicrobial drug combinations are listed below:
(1) of S. aureus sepsis, endocarditis, severe pneumonia (or pulmonary abscess), and other serious infections effective drugs in combination with oxacillin (or cloxacillin, dicloxacillin) + aminoglycoside; cefazolin (or cephradine) + aminoglycoside; (to A) vancomycin + aminoglycoside; (to A) vancomycin + cefazolin; cloxacillin + (to a) vancomycin; β-lactam + inhibitor; (to A) vancomycin + fluoroquinolone ; teicoplanin + aminoglycoside.
(2) of the Streptococcus viridans endocarditis and other serious infections caused by drugs in combination with penicillin effective (high dose) + aminoglycosides (AGs alone drug); (to A) vancomycin + aminoglycoside.
(3) of Streptococcus pneumoniae causing sepsis, meningitis and other serious infections combined with effective drugs (high dose) of penicillin, amoxicillin, cefuroxime, cefotaxime, A + ceftriaxone in which (to a) vancomycin; which cefotaxime (or ceftriaxone) + (to a) vancomycin has become the treatment of bacterial meningitis in children's standard of empirical program. Pay special attention to the β-lactam + inhibitor combined it invalid because the mechanism of resistance of Streptococcus pneumoniae is caused by changes in penicillin binding proteins, rather than produce β-lactamase.
(4) caused by Enterococcus endocarditis, septicemia and other serious infections combined with effective drugs penicillin (or ampicillin, amoxicillin) + netilmicin ( ordinary strain); (to A) vancomycin + aminoglycoside (generally drug-resistant strains); Daptomycin + aminoglycoside (VRE strain) should be noted that teicoplanin in Enterococcus + aminoglycoside no synergies.
(5) on a variety of serious infections caused by Pseudomonas aeruginosa and effective drugs in combination with piperacillin (or azlocillin, ceftazidime) + aminoglycoside; ceftazidime + fluoroquinolone ; cefoperazone + inhibitors; piperacillin + ofloxacin.
(6) of Klebsiella pneumoniae causing severe pneumonia or sepsis and effective drugs in combination with piperacillin + aminoglycoside; Trimethoprim + aminoglycoside; the second and third-generation cephalosporin + aminoglycosides.
(7) gram-negative bacteria to other effective drugs in combination with piperacillin + aminoglycoside; fluoroquinolones + aminoglycosides; piperacillin □ ofloxacin ; β-lactam + inhibitor.
(8) of Mycobacterium tuberculosis infection caused by an effective drug combination of rifampicin + isoniazid + streptomycin there; rifampicin + isoniazid + ethambutol; ofloxacin (600 ~ 800mg / d) + rifapentine + isoniazid.
※ Note (to A) vancomycin + aminoglycoside is only suitable for patients to β-lactam antibiotics, a high degree of allergy or severe infections caused by pathogenic bacteria to all β-lactam highly resistant to antibiotics, the case, because both drugs can produce ear, kidney toxicity, combined with post-ear, renal toxicity will increase.
Third, to strengthen macro-management of antibiotics to promote the rational use of antibiotics
to be safe, effective, economical and rational use of antibiotics, we must further increase the monitoring and management efforts. First, antibiotic use guidelines should be developed. Hospitals, the departments according to their specific circumstances, such as the common types of infectious diseases, the recent development of pathogens and drug resistance in a reasonable and applicable principles of antibiotic use, and revised periodically. At the same time to strengthen the medical staff, pharmacists in the education and training to institutionalized and standardized alternative to the traditional principles of antibiotic use, highly arbitrary treatment methods. Second, we must promote and uphold the anti-infective drug sensitivity test done before treatment and test results with reference to use of antibiotics, a definite purpose. According to the test results while also developing a treatment of choice for major pathogens, the second choice and suspension of use of antibiotics. This is not only lower health care costs, reduce the economic burden of patients with the method, but also improve the level of medical personnel and effective drug treatment measures. Third, strengthen the monitoring of adverse reactions of antibiotics. Term effect on the poor or the occurrence of serious adverse reactions to temporarily stop using antibiotics, and trace the reasons for the rational use of antibiotics to provide negative basis.
In short, the rational use of antibiotics need to be taken into account various factors, their clinical thinking and clinical practice are very complex. However, with technological development and social progress, the rational application of antibiotics will be further towards the efficient, safe, economical and reasonable direction, which is the inevitable trend of things.