1Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia. 2Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia. 3Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia. 4Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia. 5Sections of Critical Care Medicine and Infectious Diseases, Health Sciences Centre/St. Boniface Hospital, Departments of Medicine, Medical Microbiology and Pharmacology, University of Manitoba, Winnipeg, Manitoba, Canada.
Crit Care Med. 2017 Feb;45(2):331-336. doi: 10.1097/CCM.0000000000002210.
Drugs are key weapons that clinicians have to battle against the profound pathologies encountered in critically ill patients. Antibiotics in particular are commonly used and can improve patient outcomes dramatically. Despite this, there are strong opportunities for further reducing the persisting poor outcomes for infected critically ill patients. However, taking these next steps for improving patient care requires a new approach to antibiotic therapy. Giving the right dose is highly likely to increase the probability of clinical cure from infection and suppress the emergence of resistant pathogens. Furthermore, in some patients with higher levels of sickness severity, reduced mortality from an optimized approach to antibiotic use could also occur. To enable optimized dosing, the use of customized dosing regimens through either evidence-based dosing nomograms or preferably through the use of dosing software supplemented by therapeutic drug monitoring data should be embedded into daily practice. These customized dosing regimens should also be given as soon as practicable as reduced time to initiation of therapy has been shown to improve patient survival, particularly in the presence of septic shock. However, robust data supporting these logical approaches to therapy, which may deliver the next step change improvement for treatment of infections in critically ill patients, are lacking. Large prospective studies of patient survival and health system costs are now required to determine the value of customized antibiotic dosing, that is, giving the right dose at the right time.
药物是临床医生对抗重症患者严重疾病的重要武器。抗生素尤其常用，能显著改善患者的预后。尽管如此，仍有很大机会进一步降低感染性重症患者持续不良预后的风险。然而，要采取这些措施来改善患者的护理，就需要采用新的抗生素治疗方法。给予正确的剂量极有可能提高感染临床治愈的概率，并抑制耐药病原体的出现。此外，在一些病情较重的患者中，通过优化抗生素使用方法降低死亡率也可能发生。为了实现优化给药，应将基于证据的给药图表或最好通过使用补充治疗药物监测数据的给药软件等定制给药方案纳入日常实践中。这些定制的给药方案也应尽快实施，因为减少治疗开始的时间已被证明可以提高患者的生存率，尤其是在存在感染性休克的情况下。然而，支持这些治疗方法的逻辑的强有力数据，可能会为重症患者感染的治疗带来下一个改变，目前还缺乏。现在需要进行大规模的前瞻性患者生存和卫生系统成本研究，以确定定制抗生素剂量的价值，即，在正确的时间给予正确的剂量。
