Cantón Rafael, Horcajada Juan Pablo, Oliver Antonio, Garbajosa Patricia Ruiz, Vila Jordi
Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Unidad de Resistencia a Antibióticos y Virulencia Bacteriana, Consejo Superior de Investigaciones Científicas, Madrid, Spain.
Enferm Infecc Microbiol Clin. 2013 Sep;31 Suppl 4:3-11. doi: 10.1016/S0213-005X(13)70126-5.
Hospitals are considered an excellent compartment for the selection of resistant and multi-drug resistant (MDR) bacteria. The overuse and misuse of antimicrobial agents are considered key points fuelling this situation. Antimicrobial stewardship programs have been designed for better use of these compounds to prevent the emergence of resistant microorganisms and to diminish the upward trend in resistance. Nevertheless, the relationship between antibiotic use and antimicrobial resistance is complex, and the desired objectives are difficult to reach. Various factors affecting this relationship have been advocated including, among others, antibiotic exposure and mutant selection windows, antimicrobial pharmacodynamics, the nature of the resistance (natural or acquired, including mutational and that associated with horizontal gene transfer) and the definition of resistance. Moreover, antimicrobial policies to promote better use of these drugs should be implemented not only in the hospital setting coupled with infection control programs, but also in the community, which should also include animal and environmental compartments. Within hospitals, the restriction of antimicrobials, cycling and mixing strategies and the use of combination therapies have been used to avoid resistance. Nevertheless, the results have not always been favorable and resistant bacteria have persisted despite the theoretical benefits of these strategies. Mathematical models as well as microbiological knowledge can explain this failure, which is mainly related to the current scenario involving MDR bacteria and overcoming the fitness associated with resistance. New antimicrobials, rapid diagnostic and antimicrobial susceptibility testing and biomarkers will be useful for future antimicrobial stewardship interventions.
医院被认为是筛选耐药菌和多重耐药菌（MDR）的绝佳场所。抗菌药物的过度使用和滥用被视为加剧这种情况的关键因素。抗菌药物管理计划旨在更好地使用这些化合物，以防止耐药微生物的出现，并减少耐药性的上升趋势。然而，抗生素使用与抗菌药物耐药性之间的关系很复杂，难以实现预期目标。人们提出了影响这种关系的各种因素，其中包括抗生素暴露和突变选择窗、抗菌药物药效学、耐药性的性质（天然或获得性，包括突变以及与水平基因转移相关的耐药性）以及耐药性的定义。此外，促进更好地使用这些药物的抗菌政策不仅应在医院环境中与感染控制计划相结合实施，还应在社区中实施，这也应包括动物和环境领域。在医院内部，限制使用抗菌药物、轮换和混合策略以及联合治疗已被用于避免耐药性。然而，结果并不总是理想的，尽管这些策略有理论上的益处，但耐药菌仍然存在。数学模型以及微生物学知识可以解释这种失败，这主要与当前涉及多重耐药菌的情况以及克服与耐药性相关的适应性有关。新型抗菌药物、快速诊断和抗菌药物敏感性检测以及生物标志物将有助于未来的抗菌药物管理干预。
