几种常用抗生素引发肾毒性临床浅析

抗生素药物问世以来，已挽救了成千上万人的生命。随着抗生素品种的日益增多，目前临床应用甚广，在取得抗感染防治疾病的同时，随之而来的不良反应也屡见不鲜，如肾毒性就是其中之一。为了引起临床工作者对抗生素引起的肾毒性高度重视，摸索和掌握它的规律，避免或减少肾损害，达到合理安全用药之目的。笔者集多年的临床医疗实践，就几种临床上常用的抗生素引发肾毒性进行了初探、综合分析。抗生素引发肾毒性，主要是指能引起可逆性蛋白尿、血尿、管型尿、氮质血症、少尿、无尿、甚至肾小管坏死、急性肾功能衰竭的某些抗生素药物而言。如氨基糖甙类抗生素多数具有直接肾毒性，其中庆大霉素对肾脏有特殊的亲和力，肾损害发生率在西方国家约１１－２６％，北京协和医院分析了１１年的急性肾功能衰竭，由庆大霉素所致的高达３６％，两性霉素Ｂ、多粘菌素类、青霉素类、头孢菌素类及利福平等均有不同程度的肾损害，但又有各自的临床特点。故在临床上使用这些抗生素药物时务必高度警惕其对肾脏的毒性，正确掌握适应证和禁忌证，加强对肾功能的监护，及时纠正电解质紊乱和代谢异常。     

关于合理使用抗生素的几点建议

抗生素是目前世界上药品消费中消费量最大，临床使用最为广泛的一类抗生素药物。在我国用药呈上升趋势．我院也不例外。近年我院所用抗生素金额占药品消费总额的40％左右，80％的处方都开有抗生素。由于我国目前对抗生素药品应用尚无管理法规．人人均可自行购买使用抗生素，因此对它的合理使用更需值得注意。大多数抗生素对人体重要器官有潜在的毒性，对免疫系统有明显的抑制作用。如大环类、四环素类、头抱类等，可致肝脏损伤，氨基糖贰类、多肽类、头抱类等有严重的肾毒性；利福霉素能抑制巨噬细胞的吞噬功能和淋巴细胞转化，使病人免疫功…     

简述抗生素在临床应用中的几点事项

目的抗生素在临床合理使用方法及其常见的不良反应症状。方法运用青霉素类、头孢菌素类及喹诺酮类等抗生素药物在临床使用的抗菌效果。结果青霉素类、头孢菌素类及喹诺酮类等抗生素药物在杀菌方面和抑菌方面优于一些传统的抗生素。结论在临床上,能够正确地、合理地使用抗生素类药物,预防由抗生素引起的不良反应、是临床治疗疾病的根本原则。     

简述抗生素类药物不良反应

药物的不良反应是临床用药中的常见现象。它不仅指药物的副作用,还包括药物的毒性、特异性反应、过敏反应、继发性反应等。抗菌药物是临床上最常用的一类用药,包括抗生素类、抗真菌类、抗结核类及具有抗菌作用的中药制剂类。其中以抗生素类在临床使用的品种和数量最多。目前临床常用抗生素品种有100多种。抗生素挽救了无数生命,但其在临床应用也引发了一些不良反应。抗生索药物的不良反应的临床危害后果是严重的。在用药后数秒钟至数小时乃至停药后相当长的一段时间内均可发生不良反应。常见的有过敏性休克、固定型药疹、荨麻疹、血管神经性水肿等过敏性反应、胃肠道反应、再生障碍性贫血等,严重的甚至会引起患者死亡。因此,加强临床用药过程中的监督和合理使用抗生素对减少临床不良反应的发生具有特别重要的意义。     

抗生素的合理使用

抗生素(antibiotics)系指来源于各种微生物(如放线菌、真菌等),在高度稀释下对一些特异性微生物具有杀灭或抑制作用的产物及其化学衍生物;随着抗生素不断发现,现将具抗肿瘤、寄生虫等作用的微生物产物及衍生物均归于抗生素范畴。除此之外,尚有多种纯化学合成的抗菌药物,如喹诺酮类、磺胺类、吡咯类等。应用抗生素,人类战胜了许多疾病,如产褥热、肺炎、脑膜炎、败血症等曾严重威胁人类生命健康的疾病。但抗生素毕竟是药物,更不是万能药,而且是难以掌握,必须了解它的特性,合理使用,才能为人类服务,否则会造成不良反应,诱导细菌耐药。 作为合理使用抗生素基础,临床医师应注意以下几方面问题。     

抗生素治疗痤疮的临床应用进展

目的结合痤疮的发病机理，合理使用抗生素进行系统治疗。方法通过检索近年来有关抗生素治疗痤疮的文献，归纳抗生素在临床上治疗痤疮的应用情况。结果四环素类、大环内酯类等抗生素治疗痤疮都取得了显著疗效。结论抗生素治疗痤疮，疗程较长，易产生耐药性，提倡与非抗生素药物联用。     

抗生素的合理使用及相关对策

抗生素是临床上使用最广泛的药物之一，特别近年来新的抗生素不断问世，在临床上使用频率和档次较3年前有明显的升高。笔者走访了5所二级以上医院，门诊处方使用抗生素者占28％-33％，住院处方抗生素占47％，抗生素使用金额占总金额的37％以上。由于抗生素的广泛应用，为临床及时控制病情起到了至关重要的作用，但随之也产生一些不良后果，如：细菌的耐药菌株增多，菌群失调，毒副作用增加，医院感染率升高等。这一方面与药物自身有关，抗生素的不合理使用是主要原因，这偏离以患者为中心的服务宗旨。本文就此问题进行探讨，以供同行商榷。     

关于临床如何合理应用抗生素的几点建议

抗生素应用越来越广泛，它给广大患者带来了福音，使得细菌性疾病可以比较容易得到控制，这对临床医学是十分有益的。但是目前在临床上不注意合理使用抗生素的现象也普遍存在，不仅达不到良好的治疗效果，还能引起药源性疾病及诱发耐药菌的产生，不良反应明显增多，甚至危及患者的生命，给临床上治疗带来一定的困难。因此如何正确、合理、有效地使用抗生素是提高临床治疗效果的关键。     

浅谈抗生素的合理使用

半个世纪以来,抗生素为防病治病,保护人民健康作出了卓越的贡献。然而因种种因素的影响,临床上出现了使用抗生素不当或滥用现象,下面提出几点看法以供参考。1　滥用的危害性1.1　耐药菌株增加　根据抗生素对细菌的作用机制不同,可将其分为四类:一类为繁殖期杀菌剂:如青霉素类、头孢菌素类、万古霉素等;二类为静止期杀菌剂:如氨基糖苷类、多粘菌素类等;三类为快效抑菌剂:如氯霉素、四环素类、大环内酯类、林可霉素类;四类为慢效抑菌剂:如磺胺类等。它们分别作用于细菌生长的不同环节而达到杀菌或抑菌的效果。但随着时间的推移,有时可造成菌体…     

小儿临床应用抗生素应注意的问题

抗生素为临床上应用最广和最重要的一类抗感染药。自抗生素广泛应用于临床后，对治疗各种感染性疾病取得了显著疗效。但是，应用不当或滥用，不但会降低药效，反而会带来危害，甚至危及生命。某些临床医务人员对小儿用药只看到这些抗生素对感染性疾患的特效，而忽视了某些抗生素在杀伤病原微生物的同时亦产生对人体有害的毒副作用。因此，严格掌握适应证合理使用，防止不良反应和并发症的发生是十分重要的。本文就小儿临床有关抗生素的使用应注意的问题作一浅论。     

Epidemiology of resistance to antibiotics. Links between animals and humans

An inevitable side effect of the use of antibiotics is the emergence and dissemination of resistant bacteria. Most retrospective and prospective studies show that after the introduction of an antibiotic not only the level of resistance of pathogenic bacteria, but also of commensal bacteria increases. Commensal bacteria constitute a reservior of resistance genes for (potentially) pathogenic bacteria. Their level of resistance is considered to be a good indicator for selection pressure by antibiotic use and for resistance problems to be expected in pathogens. Resistant commensal bacteria of food animals might contaminate, like zoonotic bacteria, meat (products) and so reach the intestinal tract of humans. Monitoring the prevalence of resistance in indicator bacteria such as faecal Escherichia coli and enterococci in different populations, animals, patients and healthy humans, makes it feasible to compare the prevalence of resistance and to detect transfer of resistant bacteria or resistance genes from animals to humans and vice versa. Only in countries that use or used avoparcin (a glycopeptide antibiotic, like vancomycin) as antimicrobial growth promoter (AMGP), is vancomycin resistance common in intestinal enterococci, not only in exposed animals, but also in the human population outside hospitals. Resistance genes against antibiotics, that are or have only been used in animals, i.e. nourseothricin, apramycin etc. were found soon after their introduction, not only in animal bacteria but also in the commensal flora of humans, in zoonotic pathogens like salmonellae, but also in strictly human pathogens, like shigellae. This makes it clear that not only clonal spread of resistant strains occurs, but also transfer of resistance genes between human and animal bacteria. Moreover, since the EU ban of avoparcin, a significant decrease has been observed in several European countries in the prevalence of vancomycin resistant enterococci in meat (products), in faecal samples of food animals and healthy humans, which underlines the role of antimicrobial usage in food animals in the selection of bacterial resistance and the transport of these resistances via the food chain to humans. To safeguard public health, the selection and dissemination of resistant bacteria from animals should be controlled. This can only be achieved by reducing the amounts of antibiotics used in animals. Discontinuing the practice of routinely adding AMGP to animal feeds would reduce the amounts of antibiotics used for animals in the EU by a minimum of 30% and in some member states even by 50%.     

谈细菌耐药与抗菌药物的合理使用

目的 通过了解我院抗生素的使用情况和我院抗生素药物敏感试验的情况，评价抗生素应用的合理性，以供临床用药参考。方法 收集我院2005年细菌室抗生素药敏试验的数据资料和2004～2005年我院住院药房电脑显示的部分抗生素使用数据资料并进行统计分析。结果 抗生素的使用是我院用量最大、品种最多的一类药物。全年临床开展药物敏感试验比较少，凭经验用药的较多。抗生素的使用趋向第三代头孢类抗生素。结论 建议临床使用抗生素应尽量多开展药物敏感试验，有针对性用药，避免凭经验或盲目应用。以尽量减少耐药菌株的产生而发挥抗生素最大疗效。     

Antibiotic usage in animals: impact on bacterial resistance and public health.

Antibiotic use whether for therapy or prevention of bacterial diseases, or as performance enhancers will result in antibiotic resistant micro-organisms, not only among pathogens but also among bacteria of the endogenous microflora of animals. The extent to which antibiotic use in animals will contribute to the antibiotic resistance in humans is still under much debate. In addition to the veterinary use of antibiotics, the use of these agents as antimicrobial growth promoters (AGP) greatly influences the prevalence of resistance in animal bacteria and a poses risk factor for the emergence of antibiotic resistance in human pathogens. Antibiotic resistant bacteria such as Escherichia coli, Salmonella spp., Campylobacter spp. and enterococci from animals can colonise or infect the human population via contact (occupational exposure) or via the food chain. Moreover, resistance genes can be transferred from bacteria of animals to human pathogens in the intestinal flora of humans. In humans, the control of resistance is based on hygienic measures: prevention of cross contamination and a decrease in the usage of antibiotics. In food animals housed closely together, hygienic measures, such as prevention of oral-faecal contact, are not feasible. Therefore, diminishing the need for antibiotics is the only possible way of controlling resistance in large groups of animals. This can be achieved by improvement of animal husbandry systems, feed composition and eradication of or vaccination against infectious diseases. Moreover, abolishing the use of antibiotics as feed additives for growth promotion in animals bred as a food source for humans would decrease the use of antibiotics in animals on a worldwide scale by nearly 50%. This would not only diminish the public health risk of dissemination of resistant bacteria or resistant genes from animals to humans, but would also be of major importance in maintaining the efficacy of antibiotics in veterinary medicine.     

DANMAP: monitoring antimicrobial resistance in Denmark

The objectives of the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme (DANMAP) are to monitor trends in resistance among bacteria from animals, food and humans, to monitor the consumption of antimicrobial agents and to determine the association between consumption and occurrence of resistance and to model transmission of resistance from animals to humans. DANMAP is based on the examination of representative bacterial isolates of animal and human pathogens, of zoonotic bacteria and of indicator bacteria. For food animals, both diseased and the healthy populations are studied. Isolates from all three reservoirs are examined for their susceptibility to a basic panel of antibiotics that includes representatives of the major classes of compounds, making comparison of resistance levels in the reservoirs possible. Isolates are stored in a strain collection and are available for further study. The data are stored in databases as MIC values or mm inhibition zones with all identifiers. A system for recording all use of the veterinary medicines, VETSTAT, is currently under implementation. For production animals, the consumption will be recorded for each herd, providing a basis for detailed modelling of the effect of consumption on resistance.     

医院手术预防用抗菌药物及感染相关因素分析

目的 了解手术预防用抗菌药物情况及引起手术部位感染的主要致病菌及相关因素.方法 调查了2013年1-3月期间山东大学附属省立医院8个外科科室的出院病历349份,对手术预防用药情况及手术感染相关危险因素进行调查分析,依据《抗菌药物临床应用指导原则》《专项整治活动》《外科手术部位感染预防与控制技术指南》（试行）等系列文件设计调查表.结果 349例手术患者中,有283例预防性应用抗菌药物,使用率81.1％;手术感染主要危险因素主要为手术备皮情况、患者术前住院时间、细菌感染等.结论 我院手术预防性用药比例过高,还需要加大抗菌药物临床应用专项整治力度.术前住院时间、术前备皮情况不达标,存在手术部位细菌感染的风险.     

Antimicrobial growth promoter use in livestock: a requirement to understand their modes of action to develop effective alternatives

Antimicrobial agents (AMAs) have been used in agriculture since the 1950s as growth-promoting agents [antimicrobial growth promoters (AGPs)]. They have provided benefits to the agricultural industry by increasing production efficiencies and maximising livestock health, yet the potential risks surrounding resistance to AMAs in medically important pathogenic bacteria have enhanced public and government scrutiny regarding AMA use in agriculture. Although it is recognised that AGP administration can select for resistance to AMAs in enteric bacteria of livestock, conclusive evidence showing a link between resistant bacteria from livestock and human health is lacking (e.g. transmission of resistant zoonotic pathogens). Livestock production output must be increased significantly due to the increase in global population, and thus the identification of non-AMA alternatives to AGP use is required. One strategy employed to identify alternatives to AGPs is an observational empirical methodology, but this approach has failed to deliver effective alternatives. A second approach is aimed at understanding the mechanisms involved in AGP function and developing alternatives that mimic the physiological responses to AGPs. New evidence indicates that AGP function is more complex than merely affecting enteric bacterial populations, and AGPs likely function by directly or indirectly modulating host responses such as the immune system. As such, a more comprehensive understanding of the mechanisms associated with AMA function as AGPs will facilitate the development of effective alternatives.     

新手儿临床抗本抗生素敏感性分析

目的：探索新生儿感染病原菌分布及常见抗菌药物敏感性,为经验性治疗提供依据。方法：按《全国临床检验操作规程》鉴定细菌,纸片扩散法做药敏试验。结果：1987－1998年内分离出病原菌2244株。院外感染前三位是表皮葡萄球菌、腐生葡萄球菌及大肠埃希菌,院内感染前三位是大肠埃希菌、克雷白菌及绿脓杆菌。院内外感染菌株对青霉素、氨苄西林等15种抗生纱的耐药率差异显著。阿米卡星的总敏感率86．2％,与青霉素联用敏感率增至89．9％。结论：院外感染致病菌以革兰阳性菌为主,而院内感染致病菌以革兰阴性菌为主,后者对许多抗菌药物更易产生耐药性,阿米卡星联合青霉素作为第一线抗菌药物值得推广。     

282例小儿社区获得性肺炎抗菌药物使用分析

目的了解我院小儿社区获得性肺炎住院患者的抗菌药物使用情况。方法随机抽取2008年3月至2011年9月282例小儿社区获得性肺炎住院病例,对抗菌药物使用频度、联用情况、出院带药等情况进行归纳整理,并对使用合理性进行评价。结果痰培养以革兰阴性菌为主(62.09%);头孢哌酮的使用频率最高(19.86%);二联用药占大部分(56.51%);出院带药以头孢丙烯最多(24.82%)。结论临床医生在使用抗菌药物治疗小儿社区获得性肺炎时基本符合抗菌原则,但仍需进一步提高。     

金属基纳米颗粒的制备及抑菌性能

摘要：病原菌感染严重威胁着人类健康,抗生素的广泛使用导致了细菌的耐药性,而有效抑菌剂的开发远跟不上耐药菌的 繁殖速度,因此开发新型抑菌剂至关重要。随着纳米技术的不断发展,具有生物安全性和易多功能化的金属基纳米颗粒在抑菌 领域受到广泛重视。本文对银纳米颗粒、铜纳米颗粒、金纳米颗粒针对革兰菌的抑菌活性和抑菌机理进行了总结,重点综述了 采用抗生素等小分子对银、铜、金纳米颗粒表面进行修饰得到新型抑菌材料的研究进展,并展望金属基纳米颗粒在抑菌方面的 发展趋势,提出从分子层面揭示抑菌机制,可拓展金属纳米颗粒应用范围的观点     

鲍曼不动杆菌耐药性分析及用药策略

目的：分析我院鲍曼不动杆菌的耐药情况,指导临床合理使用抗菌药物。方法：回顾性对我院2008年1月～2009年2月73株鲍曼不动杆菌药敏结果采用WHONET5．4进行统计、分析。结果：鲍曼不动杆菌检出率最高的标本类型是痰,临床科室是ICU。在常用的抗菌药物中,亚胺培南的耐药率最低为12．3％,替卡西林克拉维酸次之为38．4％,其它的β-内酰胺类抗菌药物耐药率均在70％以上。氨基糖苷类药物耐药率在70％～80％之间。左氧氟沙星的耐药率为53．4％,环丙沙星为82．2％。结论：鲍曼不动杆菌耐药现象严重,临床应加强合理选用抗菌药物,减少耐药菌株的产生。