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本帖最后由 蓝鱼o_0 于 2011-4-1 09:44 编辑
众所周知，MDRO产生的重要原因是因为抗生素的选择压力，因而通过对抗生素的合理化管理就能够从源头上降低MDRO的产生。
但是我一直有个疑问：
在面临一些危重病例，通常需要经验性预防抗生素给药，以达到争取黄金抢救时间。然而带来的的潜在问题就是，一部分人也许就没有细菌感染，或者抗生素未必真的对治疗有效，在此就有可能导致
病原抗力累计，最终导致MDRO的产生，MDRO产生率增加继而导致HAIs发生率增加，而MDRO引起的HAI的管理重要办法就是抗生素管理。这与一开始"预防性给药"抢救策略之间矛盾，
而预防性给药也会导致恶性循环，催化新的耐药菌产生。
而如果严格控制预防性给药和抗生素管理，又会导致危重病患的死亡率增加。（纠结！）
那么再面临这种矛盾时候，临床医生，感控专家应该如何应对？是不是我们的指导原则忽略了这类矛盾的存在，缺陷或者不足？
在《Lancet Infect Dis. 》最新的一篇personal view上面，一个专家也探讨了这个问题，他探讨的是HAP和VAP的指导原则问题，
链接：http://www.ncbi.nlm.nih.gov/pubmed?term=Guidelines%20for%20hospital-acquired%20pneumonia%20and%20health-care-associated%20pneumonia%3A%20a%20vulnerability%2C%20a%20pitfall%2C%20and%20a%20fatal%20flaw
题目：Guidelines for hospital-acquired pneumonia and health-care-associated pneumonia: a vulnerability, a pitfall, and a fatal flaw. 出处： Lancet Infect Dis. 2011 Mar;11(3):248-52.
The 2005 American Thoracic Society and Infectious Disease Society of America's guidelines for pneumonia introduced the new category of health-care-associated pneumonia, which increased the number of people to whom the guidelines for multidrug-resistant pathogens applied. Three fundamental issues inherent in the definition of hospital-acquired pneumonia and health-care-associated pneumonia undermined the credibility of these guidelines and the applicability of their recommendations: a vulnerability, a pitfall, and a fatal flaw. 【笔者的观点】The vulnerability is the extreme heterogeneity of the population of patients. The fatal flaw is the failure to accurately diagnose hospital-acquired pneumonia and ventilator-associated pneumonia; inability to distinguish colonisation from infection in respiratory-tract cultures renders the guidelines inherently unstable. The pitfall is spiralling empiricism of antibiotic use for severely ill patients in whom infection might not be present. A vicious circle of antibiotic overuse leading to emergence of resistant microflora can become established, leading to unnecessary use of empirical broad-spectrum combination antibiotics and increased mortality. Controlled studies now show that administration of broad-spectrum combination antibiotic therapy can lead to increased mortality in uninfected patients. Proposed solutions include the use of individualised assessment of patients. Health-care-associated pneumonia should be broken down into several distinct subgroups so narrow-spectrum antibiotic therapy can be used. 【结论】Emphasis should be placed on defining the microbial cause of the pneumonia rather than reflex administration of empirical combination therapy.
笔者在最后强调，应该加强肺炎病原的关注，而不是经验性抗生素治疗的反射管理。
他提出的观点主要从微生物检验的角度考虑，尽管未必一定正确，但是也确实反映了现实问题。
这个疑虑困扰我很久，我虽然是个医师但却不做临床，发现问题，认识事件的层次尚不够。希望有识之士能给予指导，授业解惑！ | 
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发表于 2011-3-31 19:40
发表于 2011-3-31 21:21
发表于 2011-3-31 21:48
发表于 2011-4-1 07:46