1. Carbapenem antibacterial drugs play an important role in the treatment of infectious diseases
Carbapenem antibacterial drugs have a broad antibacterial spectrum and strong antibacterial activity. They have antibacterial effects on both aerobic and anaerobic bacteria, especially against multi-drug-resistant gram-negative bacilli, such as the production of extended-spectrum β-lactamase ( ESBL) Enterobacteriaceae bacteria have strong antibacterial activity. Such drugs have a wide range of clinical indications and play an important role in the antibacterial treatment of multi-drug resistant bacteria infections, mixed infections of aerobic and anaerobic bacteria, severe infections and infections in immunodeficiency patients.
At present, there are 5 varieties of carbapenem antibacterial drugs on the market in my country: imipenem, meropenem, panipenem, biapenem and ertapenem. Ertapenem has a relatively narrow antibacterial spectrum, and has poor antibacterial effects on non-fermenting sugar bacteria such as Pseudomonas aeruginosa and Acinetobacter; the pharmacodynamic properties of the other four varieties are similar. Imipenem and panipenem are combined with cilastatin and betamirone respectively. The latter two are kidney dehydropeptidase inhibitors and proximal tubular organic anion transport system inhibitors, respectively. To antibacterial effect.
2. Problems in the clinical application of carbapenem antibacterial drugs
(1) The clinical use of carbapenem antibacterial drugs is increasing year by year. According to data from the National Antimicrobial Clinical Application Monitoring Network, since my country launched a special treatment for the clinical application of antimicrobial drugs in 2011, the use rate of antimicrobial drugs in hospitalized patients in my country has dropped from 59.4% in 2011 to 36.8% in 2017, and the intensity of antimicrobial drug use has increased over the same period. 85.1 DDDs/100 person·day decreased to 49.7 DDDs/100 person·day. The intensity of use of most types of antibacterial drugs, including third-generation cephalosporins and quinolones, showed a downward trend. During the same period, the intensity of carbapenem antibacterial drugs used by the member units of the monitoring network increased from 1.83 DDDs/100 person·day to 3.28 DDDs/100 person·day. In some areas, there are too many applications or rapid rise of individual varieties.
The main reasons for the increase in the use of carbapenem antibacterial drugs are: 1. The number of patients infected with multi-drug resistant bacteria has increased. In recent years, the resistance of clinically isolated bacteria to antibacterial drugs has been on the rise globally, so the probability of choosing such drugs has increased. 2. Increasing number of patients with immunodeficiency/immunosuppressive therapy. 3. The clinical application of some medical staff is unreasonable.
(2) The resistance of gram-negative bacilli to carbapenem antibacterial drugs is on the rise. According to the National Bacterial Resistance Surveillance Network, the average detection rate of carbapenem-resistant Klebsiella pneumoniae nationwide in 2017 was 9.0%, an increase of 2.6 percentage points from 2014, and the detection rate in individual provinces reached 26.9%. . The detection rates of carbapenem-resistant Klebsiella pneumoniae in elderly, children and adult patients were 10.2%, 9.1% and 7.8%, respectively. The detection rate of carbapenem-resistant Acinetobacter baumannii (CRAB) continues to be high. In 2017, the national average detection rate was 56.1%, and the detection rate in individual provinces reached 80.4%.
3. Expert advice on the clinical application of carbapenem antibacterial drugs
(1) Strictly grasp the indications for clinical application of drugs. "Guiding Principles for the Clinical Application of Antibacterial Drugs (2015 Edition)" clarifies the indications for the clinical application of carbapenem antibacterials: severe infections caused by multi-drug resistant but sensitive aerobic gram-negative bacilli; Bacteroides fragilis Severe patients with mixed infections of aerobic bacteria and aerobic bacteria; empirical treatment of infections in patients with severe immunodeficiency whose pathogens have not been identified. In contrast to these 3 indications, the key points of reasonable clinical application are:
1. "Severe infection" refers to patients with clinical manifestations such as hypotension, hypoxemia, and organ damage due to infection. For "critically ill patients", it is necessary to carefully identify whether there is an infection before deciding whether to use antibacterial drugs, especially carbapenem drugs.
2. Severely ill patients infected by multi-drug resistant bacteria have indications for the use of carbapenem antibacterial drugs. The diversification of antibacterial treatments for drug-resistant bacterial infections should be promoted. For some mild to moderate multi-drug resistant bacterial infections, other types of antibacterial drugs should be selected. For example, mild to moderate infections caused by ESBL-producing bacteria can also be selected based on the results of drug susceptibility. Other types of antibacterial drugs.
3. Patients with useful drug indications should emphasize pathogenic diagnosis and timely de-escalation treatment. Before applying carbapenem antibacterial drugs, specimens must be sent for pathogenic examination. When the pathogen and drug susceptibility results are clarified, the disease condition should be evaluated in time, and de-escalation treatment should be adopted reasonably.
4. Select the appropriate carbapenem species according to the type of pathogenic bacteria and the pharmacokinetic/pharmacodynamic characteristics of antibacterial drugs. ①The in vitro antibacterial activities of imipenem, meropenem, panipenem and biapenem are similar (close to the minimum inhibitory concentration), and should be guaranteed for some severe infections and extensively drug-resistant bacterial infections (such as CRE infection) Adequate dosage, choose the product with larger dosage recommended in the instructions or authoritative guidelines with evidence-based medical evidence. ② Ertapenem can be used for moderate to severe bacterial infections with a long half-life and can be administered once a day.