胆道感染外科论文

抗菌兽药合理应用的基本原则是：

（1）有严格的适应证不同的抗菌兽药各有其不同的适应证。青霉素类、四环素类、酰胺醇类、红霉素等主要对革兰氏阳性菌引起的疾病，如猪丹毒、破伤风、炭疽、马腺疫、链球菌性炎症、败血症等有效；氨基糖苷类、酰胺醇类等对革兰氏阴性菌引起的疾病，如巴氏杆菌病、肠炎、泌尿道炎症的效果不错；耐酶青霉素对耐青霉素G金黄色葡萄球菌所引起的呼吸道感染、败血症为首选药物；庆大霉素、多黏菌素类等对绿脓杆菌引起的创面感染、尿路感染、肺炎、败血症等有效。磺胺类主要对大多数革兰氏阴性、阳性细菌如链球菌、肺炎球菌、沙门氏菌、化脓棒状杆菌等均有较高的抑制作用。

（2）选择合适的剂量和疗程抗菌兽药在使用时，一定要选择好所用的剂量和适宜的疗程。一般开始治疗时可选用较大剂量，使血液药物浓度达到较高程度后，再根据病情酌减剂量。药物的疗程可视疾病类型和患畜病况而定。急性感染的病例其疗程不宜过长，可在感染控制后3日左右停药。对于一些慢性感染的则应适当延长疗程，以巩固疗效。否则盲目加大使用剂量会造成药物和经济上的损失，还可使患畜产生不良反应。若用量不足或疗程过短，则起不到治疗作用而使细菌产生耐药性。

（3）联合应用的抗菌兽药之间可发生协同、累加或颉颃作用联合用药如果选择得好即可获得协同和累加作用，以提高疗效，减少抗菌药物用量、减小毒性反应；如果选择得不好则可能出现颉颃作用。所以，联合应用应选择最佳的药物联合。一般情况下应用两种抗菌兽药联合应用，特殊情况下选三种或三种以上的药物联合应用。但在联合用药时，应注意可能出现的配伍禁忌：

①在输液中，有些药物混合后常出现混浊、变色、沉淀及降低抗菌活性。如青霉素G不宜与四环素类、氨基糖苷类、多黏菌素E、两性霉素B、磺胺药钠盐及碳酸氢钠、氨基酸、维生素C、去甲肾上腺素、氯丙嗪等联合静脉注射。

②四环素类与多种药物都有配伍禁忌，适宜单独静脉注射给药。不宜与含铁、钙、铝、镁、铋等药物或饲料同服，因可形成不易溶解的复合体而影响吸收；也不宜与碳酸氢钠同服，因后者可使pH升高而降低其溶解度。

③两种药物合用时，会引起毒性加剧。如氨基糖苷类与头孢菌素类联合，可引起急性肾小管坏死；庆大霉素与速尿合用，会增强耳毒性等。

（4）要有明确的临床指征，避免滥用抗菌兽药根据临床的诊断、患畜的全身状况及感染的轻重选择合适的抗菌兽药，应注意以下几点：

①诊断为病毒病或已被病毒感染者不宜应用。因一般抗菌兽药特别是抗生素都无抗病毒作用。

②患畜发热原因不明者不宜应用。因使用后可使病原微生物不易被检出，使临床表现不典型而影响正确诊断或延误及时治疗。

③尽量避免皮肤、黏膜等局部应用。防止发生过敏反应或引起耐药菌产生。

（5）意外情况的处理如发生过敏反应等意外情况，应沉着冷静，选用适合的药物来解救。

2 results infections formation rates 181 examples liver cirrhosispatient merges infects 101 examples, the infection formation , in the courtyard the infection percentage is . infections has the spot 101 examples infections altogether to haveeach kind of infection example order is 133. 4 examples are 3 spotsinfect, 24 examples are 2 spots infect Other 73 examples are a spot infect. The infection spotaccording to has the frequency height is in turn: Primary peritonitis59 examples, the intestinal tract infects 15 examples, on The respiratory tract infects 12 examples, bacteriemia 9examples, the lungs infection and pleurisy each 8 examples. Thebiliary duct infects, the urine road infection and the oral cavityinfects each 5 examples The skin soft tissue infects 4 examples, infectiousness is inshock 3 examples. has the infection correlation factor infections and liver function child - pugh graduationrelational infection group 101 examples. A, B and the C level patientpopulation respectively is 11 examples, 41 examples and 49 Example. The non- infection group 80 examples, A, B and the Clevel patient population respectively is 26 examples, 39 examples and15 examples. In liver cirrhosis merge infection group child - pugh Clevel The patient counts obviously are many to the non- infectiongroup, two groups compare the difference to be extremely remarkable(x2=, P < ) see Table 1. Two groups of liver function child - pugh graduation comparison (X2) Group other A B C grand total Infection group 11 () 41 () 49 () 101 Non- infection group 26 () 39 () 15 () 81 Amounts to 378064181 Note: In the parenthesis the data is various numbers theorynumber (T) In courtyards infects with is hospitalized the timerelations to be hospitalized the time > in January, 1/2 ~ in Januaryand < 1/2 month courtyard 内感 dyes the formation rate respectivelyis , , . The liver cirrhosis patient is hospitalizedwhen > January has the opportunity which in the courtyard infectsobviously to be higher than < January (P < ) to see Table 2. In the courtyard infects with is hospitalized the time relations Is hospitalized the time infection example number infectionpercentage < 1/2 5 1/2 ~ in January 13 > In January 31 In courtyards the infection and in the attack operationrelational 133 examples infection, accepts the attack operationpatient person sequence to the first 3 distinctions is: 25 examples Before the infection accepts the deep vein to set at the tubetechnique, 14 examples abdominal cavities puncture method, 4 exampleschest cavities puncture method. Question supplement that, etiology bacilliculture examined thebacterium includes: Large intestine Egypt hopes the fungus (ascites);假单胞菌 (ascites); Smelly nose 克雷 伯氏 fungus ( The blood, the phlegm, the bedsore pus fluid), Purey Mao theSi sand mold (blood, neck vein inserts a tube), epidermis grape fungus(phlegm), white rosary fungus (phlegm, excrement, Swallows 拭子), pulls west west the peduncle the fungus(phlegm), ear grape fungus (urine). revolutions turn over to have the infection to die of illness 29examples, the mortality rate are ; Has not had the infection todie of illness 2 examples, the mortality rate . Other 72 examplesinfection The reasonable use antibiotic and guarantees treatment and soon liver, diuresis in the etiology examination foundation, maintainsthe patient oral cavity and the whole body skin cleanly in order tohelp the control infection and so on Under nurses all good extension to leave the hospital, equallyis hospitalized the number of days is days. Under has not had theinfection other 78 examples reasonably to treat and to nurse all goodextension to leave the hospital, even Is hospitalized the number of days is days. The livercirrhosis merge infection mortality rate obviously is higher than thenon- infection. (X2= P < ) see Table 3 The infection compares with the non- infection mortality rate The group other death example number change for the betterexample number equals Infection group 29 () 72 () 101 Non- infection group 2 () 78 () 80 Amounts to 31150181 Two groups of differences have 显著性 the significance

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The result � Infect with 181 cirrhosises of the occurrence rate sufferer the merger infects with 101, infecting with of the occurrence rate, the infection rate inside the hospital is .� Infection occurrence the part 101 infections totally take place a time of various infection is among those exampleses infect with for 3 parts,24 the examples infect with for 2 parts, Rest 73 the examples infect with for a with the part press occurrence the 频 degree is high and low one by one in order is:At first the peritonitis 59 times of hair, the bowel way infects with 15, topBreathe the way infects with 12 times, the disease 9 times of the germ blood, an infection of lung and pleuritis 8 for each infection of 胆 , urine the road infects with to infect with 5 for each time with mouth cavity, The soft organization of skin infects with 4 times, the shock 3 times of infection.� Occurrence related factor � of the A 101 of the relation infection of the infection and the liver function child- pugh , B and the C class sufferer's numbers distinguish to 11,41 example and with 80 of set not, A, B and the C class sufferer's numbers distinguish to 26,39 examples and cirrhosis merger infects with the C class of child- pugh in setThe number of the sufferer is obvious and precious sight more to infect with the set not, two relatively differ to show the 著 ( x2=, P<) to see the table very much 1.�Two livers function child- pugh ratings compare( X2)Set do not the A B C is totalInfect with the set 11()41()49()101Infect with the set not 26()39()15()81Total 378064181Note:The data inside the brackets counts for the theories of each number( T) Hospital inside infection and hospitalization time relation hospitalization time> January,1/2-1 months and<1/ February hospital inside infection the occurrence rate is respectively, the sufferer of the cirrhosis stay in the hospital> January the opportunity of the infection inside the occurrence hospital is obvious high in< the of January sees the table 2. Hospital inside infect with and stay in the hospital the horary relationStay in the hospital the time infection number infection rate<1/ of 1/2-1 months> of Infection inside the hospital with encroach upon sex operation to relate to in 133 infections, accept to encroach upon sex to operate sufferer's number before list on 3 respectively is:25 exampleThe infection accepted the deep vein to place to take care of the 术 before,14 belly cavities wore to stab the 术 ,4 chests wore to stab the 术 .�Problem complement: The cause learns the germs that the germs development have already examine to have:Rare germ( the stomach water) of the large intestine 埃 ;False single afterbirth germ( the stomach water);Smelly nose gram thunder 伯 surname germ(Blood, phlegm, the bedsore 脓 liquid), 普 in the hair 斯 sand fungi( the blood, the neck vein puts the tube), the epidermis grape germ( phlegm), white beads germ( phlegm, muck,Swallow to wipe the son), pull the surname west germ( phlegm), the ear grape germ( urine).� The one who turn return to take place the infection dies of illness 29, the death rate is ;Don't the one who take place infection die of illness 2, death rate 72 infectionsLearn to examine the foundation in the cause up the reasonable usage antibiotics and protect the liver, the benefit urine etc. treatment, keep patient's mouth cavity and the whole body skin to sweep for the convenience of control infection descend all turn for the better the hospital discharge, the average hospitalization number is not take place the infection of other 78 example at reasonable treatment and nursing under all turn for the better the hospital discharge, evenAll stay in the hospital the day to count to merger infection death rate obvious high in not the one who infect with.( X2= Ps<) see 3 �s of tableInfect with with not infect with death rate compareThe set do not die the number amendment number to add upInfect with the set 29()72()101Infect with the set not 2()78()80Total 31150181Two differences show the 著 meaning

3 讨论 本组肝硬化患者感染发生率，肝硬化肝功能失代偿child—pugh C级患者合并感染者明显增多。院内感染总发生例次率，住院时间超过1月者发生院人感染机会明显增加，住院期间由于诊冶需要而行各种创伤性操作也增加了医源性感染的机会。肝硬化验室患者肠道内菌群上移，而小肠段肠壁较薄，门脉压增高使肠壁淤血，淋巴流量增多，导致肠壁水肿，致使肠壁屏障被破坏〔3〕。肝硬化患者肝细胞坏死、纤维化的同时，肝脏的单核—巨噬细胞系统功能亦显著受损，使来自肠腔的细菌不能被清除，易发生肠源性感染。本资料已培养检测到的细菌以条件致病菌居多，治疗选用抗菌药物最多的是甲硝唑和头孢第三代类。本组发生感染者病死率％，明显高于无合并感染者的病死率％。提示肝硬化合并感染是造成病情加重，导致死亡的重要原因。这主要与机体免疫功能低下，高胆红素血症、白蛋白明显下降及肝功能衰竭有关。而感染又常诱发生上消化道出血，肝性脑病及肝肾综合征等严重并发症，使肝硬化进展为慢性重型肝炎、肝功能衰竭甚至多脏器功能衰竭而死亡，病死率明显增高。因此，肝硬化患者住院后应抓紧时间检诊，在诊治过程中加强消毒隔离，严格无菌操作及掌握各种侵袭性操作的适应症，尽量减少医源性感染的诱因。对肝功能child—pughC级患者采取绝对卧床休息、给予高热量、适量蛋白质(以植物蛋白为主)、丰富维生素等易消化饮食，并应细嚼慢咽，绝对戒烟酒，加强口腔及皮肤护理，病情稳定后尽早出院。发现感染征兆如不明原因的持续低热，黄疸明显升高，顽固性腹胀、腹痛、腹泻、腹水量明显增多或利尿剂无效等，应及早作细菌培养，合理应用抗菌药物，加强支持利退黄治疗，积极预防和控制感染及严重并发症的发生