合理使用抗生素的基本原则

合理使用抗生素的基本原则 抗生素是治疗感染性疾 病的主要药 物，在临床 医疗 工作中占有重要地位。 由于抗生素种类较多 ，临床应用也极为广泛 ，其使用 的合理性 与患者的康复及 医院的医疗 质量密切相关 。但近年来 由于应用不合理或滥用抗生素现象 日见突出，几乎成为全球问题 ，我 国有关专家多次 呼呈 ，合理应用抗生素已成为当务之急。为了不断临床应用抗生素用药中一些基本规律 ，使抗生素 的使用达到科学合理 ，确保用药的安全性和有效性 ，更好地 发挥抗生素在救死扶伤的重要作用 ，本文就临床上合理应用抗 生素必须掌握的几个基本原则 ，与医药同行进行商讨 。 1正确选择原则 选择抗生素治疗 的前提是必须明确病 因诊断 ，目前用药偏滥、针对性差，主要是病因诊断做得不够造成的。正确估计致病菌 ，熟悉原发病 的临床 特点是合理应用抗生素的基础。对一些严重感染的患者 ，应尽一切努力寻找病原菌，在细菌培养及药敏结果未获得前 ，可根据病史和体格检查、病情变化和感染来 源作出临床诊断 ，并根据 临床经验选用抗生素。致病 菌确定后 ，应 根据药 敏试 验，及 时调整抗 生素。在选择抗生素时 ，应 了解该药 的抗菌作用、药代谢动力学及副作用，结合患者 的具体情况选用 ，有条件 poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 的医院，在治疗过程中，可测定血药杀菌浓度及进行血药浓度监测 ，以指导临床合理应用抗 生素。总之 ，只有全 面了解和分析机 体的各种状态 ，从中找出抗生素应 用中的一些基本规律，才能做到正确选药、合理应用 、安全有效的原则。 2严格掌握适应证原则 抗生素 的应用必须根据临床诊 断，严格 掌握适应证的原则，凡属可用可不 用的尽 量不 用，切忌轻率 和盲 目地应用。对发热病人不能见热 即用抗生素 ，应 区别病 因，是病毒性感染还是细菌性感染。对 已确诊 为病毒感染 者，除重症乙型脑 炎、重症肝炎 、流行 性出血热 、麻疹等与预防继 发感染而适 当用抗生素外 ，其他病毒感染一般不必用抗生素。 3熟悉与恰 当原则 熟悉药理学及体内药物代谢动力学过程 ，是合理用药的基础 ，同时要熟悉原发病的临床特点 ，注意个体差异及遗传特征差异选择用药。所谓恰当是指选择适当的剂量与给药方法。用药剂量正确与否关系甚大，用量恰 当能治病 ，用量过小达不到治疗目的 ，过大则会危害人体健康。因此 ，在临床使用抗生素 时，应尽早使用 ，剂量要恰 当，避免长期使用。特别是在肝、肾功 能减退 的情况下 ，用药 要更加慎重。给药途径的不同，不仅影响药物 的剂量 和poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 速度 ，也影 响药物疗效。总之，给药途径必须根据用药 目的、药物性质 、患者机体的生理和病理状态以及安全和经济等因素 ，全面考虑 ，作出决定 。 4灵活调整原则 所谓灵活就 是指随时调整用药剂量及用药 ，也有人称之为浮动化。在 用药过程 中要根据病情 变化，并尽可能结合药物监测来 调整用 法和用量，做到剂 量个 体化和浮动化。同时要严密观察药物进入体内的反应 ，密切注意各种药原性 疾病警告症状的出现 ，以便及早进 行适 当处理。因此 ，在临床 上既要保证药物 的疗效 ，又要 防止药物 中毒 ，除根据药物监测外 ，还要注意观察患者 治疗的反应，并根据病情变化 ，随时地调整用药剂量及治疗方法也是最重要 的治疗原则。 5慎重配伍原则 多种药的同时并用或联合用药 ，是临床较为常用的治疗方法 ，但有时 因配伍不 当，或盲目地联合用药 ，会降低疗效 ，或产生严重的不良反应，甚至导致死亡。在联合或合并用药时，要注意抗生素之 间或抗生素与其它药物之 间的配伍禁忌问题 。如两种 以上抗 生素均需 同时静脉滴注时，不仅要看溶液的澄 明度及 颜色有 无改变 ，尚应考虑药物效价是否会降低 ，更重要的是了解两种药物配伍poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 时对抗菌 活力的影响。目前主张抗生素最好单独静脉滴注，避免与其他药物配伍。克服临床上往往只重视联合或合并用药的有益作用，而忽视不良反应的作法。医生的职责不仅要充分发挥药物的治疗作用 ，还要避免不良反应的发生 ，防止细菌耐药性的产生和传播。 6联合用药原则 抗生素联合应用 的 目的在 于获得协同作用 ，减少或防止耐药菌的产生 ，并减少联合用药中个别抗生素的用量以减少毒性反应，从而提高抑菌或杀菌效果。临床实践证 明，联合用药并不是对所有病例都 能获得所 希望的增强效果 ，甚至少数情况下疗效反而有所降低。联合用药可以发生“无关 、累加 、协 同、拮抗”4 种结果。抗 生素可分为 (见 附表)。 poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 目前临床上采用抗生素联合治疗偏 于过滥 ，无原则的联合用药不仅浪费药物 ，还会增加药物 的毒副作用，而且常使细菌不易培养 出，使临床表现不典型 而延误诊断和治疗 ，因此，必须严格掌握联合用药 的指征 :(1)单一抗生素不能控制的严重感染 ，如感染性心 内膜炎、败血症等采用杀菌剂联合治疗 ;(2)严重混合感染 ，如严重烧伤 、腹腔脏器穿孔所引起的腹膜炎等 ;(3)病 因未明且危及生命 的严重感染 ;(4)感染部位为一般抗生素不易透入者 ，如结核性脑膜炎 ，采用链霉素与易入细胞内的异烟肼合用 ，以增加疗效 ;(5)长期用药有可能产生耐药者 ，如结核病 、慢性尿路感染 、慢性骨髓炎等采用联合用药治疗。联合用药可因个体差异、药物的代谢动力学 的不 同、药物间的交互作用等因素的影响 ，而使药敏结 果与临床疗效出现较大的差异 ，同时应用抗生素 的种类越多 ，发生相poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 互作用的可能性就越大。因此联合用药较单独用药更需有 明确的指征，大多数感染用一种抗生素即可控制。联合用药仅适用少数情况;有二联即可，应用的联合药物中至少有一种须对病原菌有相当抗菌活性 。有特殊情况下也可采用三联或三联以上的药物联合 ，并宜结合 临床经验 和联合药敏结果选用。总之 ，联合用药要有联合用药 的指征 ，可用窄谱者即不用广谱抗生素 ;一种抗生素可 以控制的感染不任意采用多种抗生素治疗 ，尽量减少或避 免不必要 的联合或合并用药 ，使临床用药更趋科学 、合理、安全 、有效。 7严格控制预防用药原则 尽管抗生素 的临床适 应证 有明确规定 ，但滥用 或不合理用药状况仍十分严重 ，造成“药害”流行。例如感 冒及上呼吸道感染为病毒所引起 ，抗生素 并无疗效 ，而临床上应用者却并不少见，实属有害无益 ，若应用抗生素预防的 目的在于防止一二种特殊细菌侵入而发生的感染 ，则常劳而无功，甚至适得其反，不仅可引起感染致病菌高度耐药而且不易控制。有表明，几乎所有住院病人都用“三素”(抗生素、维生素、皮质激素 )。事实上 ，药物几乎都具有双重性 ，既可治病 ，也可致病 ，甚至有些药物既可救命 ，也可要命 。预防性使用抗生素要严格掌握，一般限于下列少数情况:(1)风湿病患者 (特别是儿童)宜较长期 应用青霉 素 G ;(2)风湿性或先poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor 天性心脏病患者在行 导管术 、口腔手术前后采用适当的抗生素 ，以防止感染性心 内膜炎的发生 ;(3)感染性肺部病变作切 除术 时，依致病 菌药敏而选用适 当的抗生素 ;(4)战伤或 复杂外 伤采用青霉素 G ，防止气质坏疽的发生 ;(5)结肠手术前应用氨基糖甙类抗生素 ，以减少肠道 内各种细菌的生长繁殖。 8强调综合治疗原则 传统的临床治疗 ，多侧重于药物观点 ，而往往忽视综合治疗 。在感染性疾病的治疗 中，抗 菌疗 法是其中最重要的一环 ，但感染的最后控制 以及致病 菌的清除 ，有赖于人体本身的防御免疫功能。因此 ，为取得最终的治疗成功 ，应采取生物 、心理 、社会医学的综合治疗措施 ，如心理治疗 ，树立乐观主义精神 ，增强人体抗病能力 ，原发病的处理、局部病灶的清除、水与电解质和酸碱平衡 的纠正 、改善微循环、补充血容量及膳食的合理调节等因素均不可忽 视，不应过分强调依赖抗生素 的功效而忽视人体 的内在 因素及其他因素，以保证药物收到预期治疗效果 ，具有重要意义。 poverty. In the area of poverty alleviation, to rely on e-commerce business park, active docking Alibaba group "rural treasure", "the stars plan" and "featured the Museum" project to accelerate the implementation of electronic commerce "hundred thousand rural village" project, free train operation staff, offering online support help for poor families, the provision of micro-credit support, helping them to use e-commerce platform to escape poverty. In poverty reduction, give a man a fish and feed him for a day, to targeted skills training and entrepreneurship training free of charge for the poor, increase employment, entrepreneurial skills, ensure the transfer of training people, poverty. In terms of student poverty, high school, vocational college students ' stipends and other costs, can be through the "one card", such as direct subsidies to households. In terms of financial poverty, in order to further increase the size of loans, expands the scope of delivery, developing industry, Enterprise provides protection for the poor. In respect of transport poverty alleviation, to solve the bottleneck in poor villages, development of transport, vigorously promoting the construction of rural roads and ordinary roads. PV poverty reduction, to support conditions of poor villages and photovoltaic system of centralized, poor construction projects, poor