[转帖]克林霉素与氨基糖苷类抗生素联合应用问题

石桥wshh1975

<p><a href="http://www.dxy.cn/bbs/actions/archive/post/4040036_1.html"><font face="Times New Roman" size="4">http://www.dxy.cn/bbs/actions/archive/post/4040036_1.html</font></a></p><p><a href="http://www.dxy.cn/bbs/actions/archive/post/4207274_1.html"><font face="Times New Roman" size="4">http://www.dxy.cn/bbs/actions/archive/post/4207274_1.html</font></a></p><p><a href="http://www.dxy.cn/bbs/actions/archive/post/4207319_1.html"><font face="Times New Roman" size="4">http://www.dxy.cn/bbs/actions/archive/post/4207319_1.html</font></a></p><p><font face="Times New Roman" size="4">发一下之前DXY中关于克林霉素与氨基糖苷类抗生素联合使用的三个提问帖.</font></p><p><font face="Times New Roman" size="4">留白wrote:</font></p><p><font face="Times New Roman" size="4">卫生部颁布的《抗菌药物临床应用指导原则》指出：克林霉素主要用于厌氧菌（包括脆弱拟杆菌、产气荚膜杆菌、放线菌等）引起的腹腔和妇科感染，并常与其他抗菌药物联合。而需要联合的是能够针对G-的抗菌素，比如氨基糖苷类，喹诺酮类和第三代头孢菌素。</font></p><p><font face="Times New Roman" size="4">那么在操作过程中就会出现这样两个尴尬：<br/>1.氨基糖苷类注意事项（2）任何一种氨基糖苷类的任一品种均具肾毒性、耳毒性(耳蜗、前庭)和神经肌肉阻滞作用,因此用药期间应监测肾功能(尿常规、血尿素氮、血肌酐),严密观察患者听力及前庭功能,注意观察神经肌肉阻滞症状。林可霉素和克林霉素注意事项（3）本类药物有神经肌肉阻滞作用,应避免与其他神经肌肉阻滞剂合用。 也就是说两者不能联用！</font></p><p><font face="Times New Roman" size="4">2.喹诺酮类和第三代头孢菌素均为是繁殖期杀菌剂，克林霉素是快效抑菌药（参见：《中国临床医生》2005，7，17页），两者联用会影响喹诺酮类和第三代头孢菌素的作用。</font></p><p><font face="Times New Roman" size="4">所以综上，《抗菌药物临床应用指导原则》关于林霉素主要用于厌氧菌（包括脆弱拟杆菌、产气荚膜杆菌、放线菌等）引起的腹腔和妇科感染的提法有问题！</font></p>

石桥wshh1975

<p><font face="Times New Roman" size="4">bright007 wrote:<br/>--------------------------------------------------------------------------------<br/>&nbsp;繁殖期杀菌剂和快速抑菌剂可以联合应用，只是需要给药顺序和剂量。如青霉素和四环素，青霉素剂量足够大，或四环素剂量低于抑菌有效量或高而具杀菌活性时，则没有拮抗现象。顺序也很重要，如先用青霉素而继以四环素等，则不会出现拮抗。</font><br/></p><p><font size="4">关于克林霉素的问题，我请教了上海华山医院抗生素研究所的王明贵教授。答复如下：<br/>1. 克林霉素有神经阻滞作用，但是弱于通常所说的神经阻滞剂。<br/>2. 克林霉素在应用时应注意：①不可静脉推注，不能快速滴注②避免与神经阻滞剂合用。<br/>3.克林霉素与庆大霉素无合用禁忌。“克林霉素＋庆大霉素”是以往外科预防和治疗腹部感染的经典配伍。</font>
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[此贴子已经被作者于2007-5-14 22:03:52编辑过]

石桥wshh1975

<font size="4">To assess the potential efficacy of fleroxacin in combination with clindamycin or metronidazole in mixed aerobic and anaerobic infections, we used a rat model of intra-abdominal abscesses in which the inoculum consisted of pooled rat feces mixed with BaSO4. Two hours after bacterial challenge, antimicrobial therapy was begun intravenously with regimens designed to stimulate human pharmacokinetics. A combination of clindamycin and gentamicin was included as an established treatment regimen. After 8.5 days of therapy, final bacterial counts in abscesses showed that fleroxacin alone or combined with metronidazole or clindamycin effectively eradicated Escherichia coli, with bacterial densities of &lt; or = 2.84 +/- 0.1, &lt; or = 2.9 +/- 0.1, and &lt; or = 2.9 +/- 0.1 (mean +/- standard error of the mean) log10 CFU/g, respectively. The addition of either clindamycin or metronidazole to fleroxacin substantially enhanced the effectiveness of the regimens against Bacteroides fragilis, with bacterial counts of &lt; or = 3.0 +/- 0.1 or &lt; or = 2.9 +/- 0.1 log10 CFU/g, respectively, versus 9.2 +/- 0.2 log10 CFU/g for fleroxacin alone. The combination of metronidazole and fleroxacin also resulted in a significantly greater reduction of peptostreptococci and Bacteroides thetaiotaomicron than fleroxacin alone (&lt; or = 2.9 +/- 0.1 versus 6.1 +/- 0.9 log10 CFU/g and 3.3 +/- 0.4 versus 8.3 +/- 0.1 log10 CFU/g, respectively). Except for those of B. fragilis, counts of other anaerobes were reduced to a greater extent by metronidazole plus fleroxacin than by clindamycin plus fleroxacin, although differences were not always significant. Metronidazole plus fleroxacin was at least as active a clindamycin plus gentamicin against all species and was significantly more active against Clostridium spp. No regimen effectively eradicated enterococci from the abscesses. These results suggest that the addition of either metronidazole or clindamycin would effectively enhance the spectrum of fleroxacin for treatment of mixed aerobic and anaerobic infections.<br/>Antimicrob Agents Chemother. 1994 February; 38(2): 252–255.A Pefanis, C Thauvin-Eliopoulos, J Holden, G M Eliopoulos, M J Ferraro, and R C Moellering, Jr<br/>Department of Medicine, New England Deaconess Hospital, Boston, MA 02215<br/>氟罗沙星（一种喹诺酮类药物）与克林霉素和甲硝唑联合应用在大鼠腹腔感染模型中疗效比较，以克林霉素和庆大霉素的联合作为标准治疗方案作为对照。结果是克林霉素或甲硝唑与氟罗沙星的联合应用可以有效的扩大在其治疗需氧菌和厌氧菌混合性感染时的抗菌谱。 </font>

楚楚

<font face="楷体_GB2312" size="3">真是一个有心人呢！学习了！[</font>em17][em17][em17][em17]

木瓜

以前接受的教育是“杀菌剂和抑菌剂不宜联用”，觉得也挺有道理。今年参加上海院感知识培训，听胡教授讲“在针对不同病原体时，杀菌剂和抑菌剂是可以联用的”。现在回想起来，还正是自己平时没留心。大环内酯类是抑菌剂吧，临床上同beta-内酰胺类抗生素联用不少见吧，关键不还是象阿奇霉素可以覆盖肺部不典型病原体感染吗？我想林可霉素和氨基糖苷类联用，一个是针对厌氧菌，一个是针对革兰阴性杆菌。是这个道理吧？

水月

木瓜版主，能告诉我确切的大环内酯类跟beta-内酰胺类抗生素联用的理论依据吗？

巴斯德之徒

我觉得还是应限制一个"确切的应用范围",有违药理学常识的特殊药物的连用方法并不是能针对所有细菌,抑或所有类型的感染都能行得通.:o

    否则,这些本来行之有效的治疗方法就会为临床医生药物的滥用提供间接"理由",这样抗生素管理又会重新落入混乱当中.:@

木瓜

原帖由 水月 于 2007-7-16 23:27 发表

                               
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木瓜版主，能告诉我确切的大环内酯类跟beta-内酰胺类抗生素联用的理论依据吗？

理论依据不好找呀，可能这方面的研究不是很多，但临床上又有这样用。
β_内酰胺类与阿奇霉素联用治疗小儿肺炎的疗效评价[1].pdf (217.59 KB, 下载次数: 25335)

2007-7-17 18:53 上传

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gjs661

学习了，有病原学数据就更好了。