Empiric therapy for bacterial meningitis.
Empiric therapy for bacterial meningitis.
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细菌性脑膜炎的经验治疗。
DOI：
10.1093/clinids/5.supplement_1.s74
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发表时间：
1983
期刊：
影响因子：
--
通讯作者：
McCabe,WR
中科院分区：
文献类型：
--
作者：
McCabe,WR
来自三个县的人口研究表明，在美国，脑膜炎每年发生的频率约为每10万人10次。根据这一流行率和2.3×108人口进行的估计表明，美国每年约有23,000例脑膜炎发作。现有研究表明，75%的脑膜炎患者可以通过脑脊液革兰氏染色、对流免疫电泳法或其他抗原检测技术，快速和相当准确地识别病原体。这些快速诊断的方法理论上每年在美国只剩下∼7,000例脑膜炎发作，其中需要经验性的治疗，而不是特定的治疗。脑膜炎病因的年龄变异显著影响治疗方案的选择。肠杆菌科和B组链球菌作为新生儿脑膜炎的主要原因，导致使用青霉素(通常是氨苄西林)和氨基糖苷进行经验性治疗。持续较高的发病率和死亡率，特别是在由肠杆菌科引起的新生儿脑膜炎中，一直被认为是氨基糖苷类药物对脑脊液渗透不足的反映，但对鞘内和脑室内氨基糖苷类药物的仔细前瞻性随机研究未能证明治疗效果有任何改善。对于年龄较大的儿童，氨苄西林似乎是经验性治疗的理想药物，在这些儿童中，脑膜炎通常是由致病嗜血杆菌引起的，肺炎链球菌和脑膜炎奈瑟菌较少被认为是致病因素。β-内酰胺酶介导的氨苄西林耐药发生率高达15%。在Jluenzaee导致联合使用氨苄西林和氯霉素治疗儿童脑膜炎。临床上重要的氨苄西林和氯霉素之间的拮抗作用的证据使这一方法变得复杂。由于几乎所有其他健康成年人的社区获得性脑膜炎都是由脑膜炎双球菌和肺炎双球菌引起的，青霉素仍然是首选药物。相比之下，在中枢神经系统和老年人的创伤和手术后，脑膜炎通常是由革兰氏阴性杆菌和其他不寻常的微生物引起的；这一组的治疗问题与新生儿脑膜炎的治疗问题相似。
Population studies from three counties indicate that meningitis occurs with a frequency of approximately 10 episodes per 100,000 population annually in the United States. Estimates based on this prevalence and a population of 2.3 × 108suggest that approximately 23,000 episodes of meningitis occur annually in the United States. Available studies indicate that rapid and reasonably accurate identification of the etiologic agent can be made in ⩾75% of patients with meningitis by gram-staining of the cerebrospinal fluid, counterimmunoelectrophoresis, or other antigen detection techniques. These means of rapid diagnosis theoretically leave only ∼7,000 episodes of meningitis annually in the United States in which empiric, as opposed to specific, therapy is necessary. Age-dependent variation in etiologic agents of meningitis markedly influences selection of therapeutic regimens. The preponderance of Enterobacteriaceae and group B streptococci as causes of meningitis in neonates has resulted in utilization of a penicillin (often ampicillin) combined with an aminoglycoside for empiric therapy. Continued high morbidity and mortality, especially in neonatal meningitis caused by Enterobacteriaceae, have been felt to reflect inadequate penetration of aminoglycosides into the cerebrospinal fluid, but careful prospective randomized studies of intrathecal and intraventricular administration of aminoglycosides failed to demonstrate any enhancement of therapeutic results. Ampicillin appeared to be an ideal agent for empiric therapy in older children, in whom meningitis is usually caused byHaemophilus injluenzae, withStreptococcus pneumoniaeandNeisseria meningitidisbeing less frequently implicated as etiologic agents. The occurrence of β-lactamase-mediated resistance to ampicillin in as high as 15% of isolates ofH. inJluenzaehas resulted in combined use of ampicillin and chloramphenicol for meningitis in children. This approach is complicated by evidence of clinically important antagonism between ampicillin and chloramphenicol. Since almost all community-acquired meningitis in otherwise healthy adults is caused by meningococci and pneumococci, penicillin remains the agent of choice. In contrast, meningitis following trauma to and surgery involving the central nervous system and in the elderly is often caused by gram-negative bacilli and other “unusual” organisms; therapeutic problems in this group parallel those observed in neonatal meningitis.