Routes of antibiotic administration. V

Generally preferred oral route of administration. Parenteral therapy is necessary in cases where the patient has a poorly functioning digestive tract, low blood pressure, it is necessary to immediately create a therapeutic concentration of the antibiotic in the body (for example, in life-threatening infections), or when taken orally, the antibiotic is not absorbed in quantities sufficient to create a therapeutic concentration at the site of infection. Topical antibiotics are indicated for some local infections (eg, bacterial conjunctivitis).

There are a number of important factors to consider before making a choice. These factors include the following:
activity against the pathogen(s), but this information may not be available at the time when treatment is needed;
the ability to reach the focus of infection at a therapeutic concentration. To do this, you need to know whether the antibiotic should have bacteriostatic or bactericidal properties against a known or suspected pathogen, because. with certain infections, only bactericidal action is necessary;
available routes of administration for a particular patient;
profile of side effects, their impact on the existing disease and possible drug interactions;
the frequency of drug use, which is of particular importance for outpatients, for whom the administration of the drug more than 1-2 times a day can create difficulties;
when using an antibiotic in liquid form (mainly for young children), you should find out if it is palatable and to what extent it is stable at different temperatures. Suspensions of some antibiotics should be refrigerated for preservation;
the cost of treatment; it is about the true cost of treatment, which includes the price of the drug, administration fees, monitoring and complications, including the lack of effect of treatment and the cost of retreatment.

The following classes are distinguished:
inhibitors of bacterial cell wall synthesis;
inhibitors of bacterial cell membrane functions;
synthesis inhibitors;
bacterial RNA synthesis inhibitors;
difficult to classify antibiotics (mixed class);
topical antibiotics;
antibiotics to treat mycobacterial infections.

Each class is described below and some of its constituent antibiotics. After a discussion of the chemical nature of each class, pharmacological information is given in terms of the mechanisms of antibacterial action, the spectrum of activity, as well as other pharmacological effects. The therapeutic use of antibiotics, pharmacokinetic characteristics, side effects and toxicity were analyzed.

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Antibacterial therapy N.V. Beloborodova
Moscow Children's City Clinical Hospital N13 im. N.F. Filatov

The article presents the author's position on the problem of the most rational approach to the use of injectable and oral forms of antibiotics in children. It has been shown (including on the basis of the author's data) that often, without proper reason, the injection route of antibiotic administration is used in the treatment of common infectious diseases (acute bacterial infections of the respiratory system, etc.), and antibiotics are also used, the spectrum of action of which does not include the most common pathogens of these diseases. Specific recommendations for optimizing empiric antibiotic therapy are given.

The most common diseases in children, as you know, are diseases of the nasopharynx and upper respiratory tract (otitis media, sypusitis, pharyngitis, bronchitis, pneumonia), as well as infections of the skin and soft tissues. In this regard, special attention should be paid to the rational use of antibiotics, since they are etiotropic drugs and are prescribed most often. The correct choice of antibiotic determines the effectiveness of treatment, the elimination of the pathogen and the speed of recovery. The antibiotic is most effective when administered at the onset of the disease, so it is most often chosen empirically, without microbiological data. With an irrational choice of a "starting" antibiotic, the course of the infectious process is delayed, complications or superinfections may develop, repeated courses of treatment or hospitalization are required.

It is no secret that the pain of antibiotic injections is one of the factors that injure the baby's unstable and vulnerable psyche. In the future, this may lead to a number of undesirable features of the behavior of the "difficult child." Most of our babies, in addition to all the troubles associated with diseases, are doomed from early childhood to experience the dubious "pleasure" of intramuscular injections. At the same time, this procedure is so painful that even many adult men hardly agree to it, and some refuse altogether.

Meanwhile, no one asks a small child whether he agrees to be treated in this way. Loving parents cannot protect the baby either, since they are absolutely helpless in front of the arguments of the local pediatrician, such as: the child fell ill again, he is weakened, the temperature is high, pills do not help, antibiotic injections are indicated. Sometimes it even seems that it doesn't matter which antibiotic to use - the main thing is that in injections, as it is reliable and effective!

We must admit that we are in captivity of ideas formed a long time ago, which today absolutely do not correspond to reality. At the same time, we mislead parents who are blinded by fear for the child and have little or no say. Are we taking advantage of the helplessness of little sufferers who have no other arguments than huge eyes filled with tears? We have to deceive them ("It won't hurt!"). So they grow up intimidated, distrustful, shrinking into a ball at the mere sight of a white coat. Can it be good that hurts?! But this is not only painful, but also unsafe. Post-injection infiltrates and abscesses today look like harmless complications in comparison with transfusion infections - hepatitis, AIDS, etc.

Of course, all this could be neglected if the goal justified our actions, but this is not so. Here are just two of the most common misconceptions.

A serious infection can only be cured with injections. But the effect of treatment does not depend on the method of administration of the drug, but on the spectrum of its activity and compliance with the characteristics of the pathogen. So, for example, penicillin, ampicillin or oxacillin will not be effective either in tablets or injections if the respiratory tract infection is caused by mycoplasmas (macrolides are needed) or microflora that produces beta-lactamase enzymes (co-amoxiclav or 2nd generation cephalosporins are needed). For the same reason, injections of kefzol or cefamezin will not help either. The child may eventually recover on his own, despite treatment, having mobilized his defenses, but recurrence of the infection is highly likely. Then what, injections again?

When administered intramuscularly, the drug acts more efficiently. This statement was true many years ago, before the advent of modern oral antibiotics for children with absorbability up to 90-95%. Numerous studies and clinical experience have shown that, when taken orally, modern antibiotics create sufficiently high concentrations in all tissues and organs, repeatedly blocking the minimum inhibitory concentrations for major pathogens. Thus, in terms of pharmacokinetic parameters, they are not inferior to injectable forms, but in terms of the spectrum of action they have significant advantages in relation to many modern pathogens.

In addition, a number of drugs, including those indicated for pneumonia, exist generally only in oral form (for example, new macrolides - azithromycin, roxithromycin, etc.) and are successfully used throughout the world. Moreover, in the vast majority of Western European countries, outpatient injections are extremely rare. Injections at home relate only to serious diseases that are treated on an outpatient basis after a previous hospitalization (for example, bacterial endocarditis, etc.). As for infections of the respiratory tract and ENT organs, especially in children, only oral antibacterial drugs are used in the treatment, including in a hospital setting. In the most severe cases, in children hospitalized in a state of severe intoxication, refusing to eat, with indomitable vomiting, the principle of stepwise therapy is used, when intravenous infusion therapy is prescribed for 2-3 days, which is more sparing than intramuscular, and then, as the condition stabilizes, - children's oral forms of an antibiotic. This avoids unnecessary stress and unnecessary pain.

What do we have? According to a selective study, in Moscow, antibiotic injections are prescribed to children in 56% of cases with bronchitis, in 90-100% of cases with pneumonia. In the hospital, in the treatment of ENT infections in young children, injectable antibiotics also predominate (up to 80-90%).

It is impossible not to mention an even more dangerous trend that characterizes the domestic practice of outpatient antibiotic therapy. In addition to the widespread use of injections, injectable antibiotics are often prescribed, which are not intended for the treatment of infections of the respiratory tract and ENT organs. Moreover, not only not shown, but also forbidden! First of all, we are talking about two drugs - gentamicin and lincamycin.

It is well known that aminoglycosides are intended for the treatment of gram-negative infections in a hospital under careful laboratory control due to potential oto- and nephrotoxicity, and in our country gentamicin is often prescribed by the local pediatrician. This does not take into account that gentamicin (like all other aminoglycosides) does not include pneumococci in its spectrum of activity. Therefore, it has never been offered anywhere as a drug for the treatment of outpatient infections of the respiratory tract and ENT organs. Apparently, this is not accidental, because pediatricians cannot treat contrary to common sense if there is no result. Gentamicin gained popularity when strains of Haemophilus influenzae resistant to ampicillin but sensitive to gentamicin spread among pathogens that cause respiratory diseases in Russia. Empirically, pediatricians began to prescribe aminoglycosides at home, although there is a more rational solution to the problem - the use of oral "protected" penicillins (amoxicillin with clavulanic acid) and 2nd generation cephalosporins.

Lincomycin, a drug with very narrow indications and low efficacy, should be prescribed in a hospital only in case of microbiologically confirmed sensitivity of an isolated pathogen to it, in particular staphylococcus, and is not suitable for outpatient practice, where treatment is always carried out empirically. Inactive on pneumococcus, it does not include Haemophilus influenzae in its spectrum of activity at all. In addition, lincomycin has another significant drawback: it has the most pronounced property to suppress the bifido- and lactoflora necessary for the child, lead to dysbiosis and impaired colonization resistance of the gastrointestinal tract. (In this respect, only clindamycin and ampicillin are similar to it.) It is not difficult to understand why many Russian pediatricians prescribe gentamicin and lincomycin to children at home: doctors prefer injections to oral drugs, so as to ensure the correct frequency of administration of beta-lactam antibiotics (penicillins or cephalosporins) 3 -4 times a day on an outpatient basis is impossible due to organizational difficulties. In the West, it is considered unjustified wastefulness for a procedural nurse to visit a patient at home 4 times a day and give injections. We do not feel sorry for anything for children, but there are not enough nurses. Pediatricians came to a compromise solution: to prescribe injections of those antibiotics that can be administered only 2 times a day, i.e. lincomycin and gentamicin. As a result, the child loses: he is in pain, and the treatment is ineffective and unsafe.

In a selective study conducted by the author, it turned out that among 108 children hospitalized with a respiratory tract infection (38 with bronchitis, 60 with pneumonia), 35% were young children. A careful survey of parents revealed that almost 90% of children had previously received antibiotics, and the following drugs were prescribed with the highest frequency on an outpatient basis. (See Table 1.)

Table 1. Frequency of use of some antibiotics in outpatient practice

For the drugs listed in Table. 1, the following should be noted.

• Penicillin and ampicillin are inactive against many modern pathogens of respiratory infections, as bacteria are destroyed by enzymes.
• Lincomycin does not include Haemophilus influenzae in its spectrum of activity at all, and gentamicin has no effect on pneumococcus.
• Ampicillin and lincomycin are known to suppress bifido- and lactoflora, with the highest rate of dysbiosis in young children.
• Gentamicin, a potentially nephrotoxic aminoglycoside, should never be used on an outpatient basis as it requires inpatient laboratory monitoring.

There is no doubt that in each case these drugs were prescribed with good intentions, but the first consequence of the irrational use of antibiotics - a repeated and serious illness that required hospitalization - is obvious. The long-term consequences are generally unclear: how many children in the future will have hearing impairments, impaired renal function or chronic dysbacteriosis, no one has analyzed.

Why do we have such a vicious practice when children from an early age not only receive painful and unnecessary injections, but they are also given antibiotics that are not the ones that are necessary and possible? The reason, apparently, is that in our country the policy of antibiotic therapy, including in outpatient pediatrics, has always developed spontaneously, during the years of drug shortages, and was not regulated by law by anyone. In Western countries, unlike in Russia, there are documents that regulate the rules of antibiotic therapy and are constantly updated.

Historically, in the previous (pre-perestroika) years, "protected" penicillins and cephalosporins of the 2nd generation were not available to our doctors and patients. When infections caused by beta-lactamase-producing flora became more frequent, and the "pills" really became ineffective, all hopes began to be associated only with injections. But, as already mentioned, not being able to provide the required frequency of administration of beta-lactam antibiotics, antibiotics with a 2-fold dosing regimen began to be preferred, despite the shortcomings in their spectrum and side effects.

Dear pediatricians! Let's leave all the problems in the past and state the fact that today our little patients live in a new Russia, in new conditions, where we cannot complain about the lack of information or the lack of medicines. Now we have all the conditions and opportunities to treat children no worse than abroad. Antibiotics from both European and American pharmaceutical companies are represented on the domestic market. It remains only to abandon the old idea of ​​​​the benefits of injections and, in each case, make the right choice of the pediatric form of the oral drug. The urgency of the above problem is beyond doubt, since irrational antibiotic therapy adversely affects the health of children and their further development. Therefore, in 1998, on the basis of the Children's Clinical Hospital. N.F. Filatov (chief physician G.I. Lukin), on the initiative of the department of medical care for children and mothers (head of department V.A. Proshin) of the Moscow Health Committee, the Cabinet of Rational Antibiotic Therapy was created. Patients are often referred to the Cabinet with the consequences of inadequate and excessive antimicrobial therapy at an early age, which leads to their allergization, dysbiotic disorders, the development of a syndrome of fever of unknown etiology and other diseases.

The primary task of the Cabinet is to optimize antibiotic therapy in outpatient pediatric practice. It was proposed to prohibit district pediatricians from using injections of gentamicin and lincomycin. In addition, guidelines have been developed that focus on effective and safe oral antibiotics for infections of the respiratory tract and ENT organs in children. These guidelines are summarized in tables for brevity. (See Table 2-4.)

Table 2. Modern oral antibiotics for outpatient treatment of respiratory infections in children

Group	Subgroup	chemical name	Trade name for pediatric oral form
Beta-lactam antibiotics - penicillins	Penicillins	Phenoxymethylpenicillin	Ospen, V-penicillin
	Semi-synthetic penicillins	Oxacillin, Ampicilpine	Oxacillin, Ampicillin
	"Protected" penicillins - combined with clavulanic acid	Amoxicillin/clavulanate, or co-amoxiclav	Amoxiclav, Augmentin
Beta-lactam antibiotics - cephalosporins	1st generation cephalosporins	cefadroxil, cephalexin	Duracef, Cefalexin
	2nd generation cephalosporins	Cefuroxime, Cefaclor	Zinnat, Tseklor
Macrolides	Macrolides	Azithromycin, Roxithromycin, Erythromycin	Sumamed, Rulid, Erythromycin

Table 3. Differentiated approach to the initial choice of antibiotic for respiratory infections in children, depending on the localization of the process

Table 4. Algorithm for choosing a drug for prolonged and recurrent respiratory infections of the nasopharynx and respiratory tract in children, depending on previous antibiotic therapy

	Pharyngitis, Tonsillitis	Otitis media, sinusitis	Bronchitis	Pneumonia
Previous antibiotic		Recommended Antibiotic
Ospen, V-penicillin		Semi-synthetic or "protected" penicillins	Macrolides
Oxacillin, Ampicillin	Cephalosporins 1-2nd generation	Macrolides, 1st generation cephalosporins or "protected" penicillins	Macrolides	2nd generation cephalosporins
Amoxiclav, Augmentin	Fusidin (Exclude mushrooms!)	Fusidin (Exclude mushrooms!)	Macrolides	Macrolides or 2nd generation cephalosporins
Duracef, Cefalexin	"Protected" penicillins	"Protected" penicillins	Macrolides	"Protected" penicillins or 2nd generation cephalosporins
Zinnat, Tseklor	Fusidin (Exclude mushrooms!)	Fusidin (Exclude mushrooms!)	Macrolides	Macrolides
Sumamed, Rulid Erythromycin	Cephalosporins 1-2nd generation	"Protected" penicillins	"Protected" penicillins	2nd generation cephalosporins or "protected" penicillins

For practice, it is very important that most oral antibiotics for children (cephalosporins, macrolides, "protected" penicillins) be included in the List of free or subsidized drugs, as is reasonably done in Moscow. It should be noted that the implementation of the proposed recommendations promises not only children's gratitude, but also significant economic benefits. Foreign studies and our randomized comparative studies conducted in real Russian conditions have proved that the use of seemingly more expensive imported drugs (modern macrolides, oral cephalosporins, "protected" penicillins) ultimately gives a significant economic effect due to the quality of treatment , reducing the duration of courses, the absence of additional costs associated with injections, hospitalization, complications, etc. . With the correct targeted administration of oral drugs, compared with traditional parenteral drugs (in a hospital), the savings reach 15-25%.

Thus, at present, there is a real opportunity to almost completely abandon the injection of antibiotics on an outpatient basis due to the wide choice of oral pediatric forms of modern antibiotics, which in most cases are more effective than traditional parenteral ones. In a hospital, the so-called stepwise therapy should be considered a modern sparing regimen for children, when in the first days, in a serious condition of the child, an injectable antibiotic is prescribed to him, and after 2-3 days they switch to the oral children's form of the drug.

In order to increase the level of knowledge of pediatricians in the field of modern possibilities of rational antibiotic therapy, for the second year in Moscow, a permanent school-seminar has been functioning, organized by the Cabinet of Rational Antibiotic Therapy at the Children's City Clinical Hospital. N.F. Filatov. The number of students at the school is growing from seminar to seminar, and we consider it appropriate to recommend this form of information assistance to pediatricians in other regions of Russia as well.

We call on healthcare organizers, administrators and practitioners not only in Moscow but also in other regions of Russia to declare war on conservatism and join the movement under the slogan "Happy childhood - without injections!"

Literature

1. Beloborodova N.V. Optimization of antibiotic therapy in pediatrics - current trends, Russian Medical Journal, 1997, v. 5, N24, pp. 1597-1601.
2. Materials of the symposium "Experience in the use of Sumamed in pediatric practice", Moscow, March 18, 1995, 112 p.
3. Beloborodova N.V., Polukhina G.M. Benefits of oral cephalosporin Cefaclor in the treatment of pneumonia in children (comparative randomized trial with pharmacoeconomic analysis), Pediatrics, 1998, N1, pp. 49-54.
4. Samsygina G.A., Bratnina N.P., Vykhristyuk O.F. Rulid (roxithromycin) in the outpatient treatment of diseases of the respiratory tract in children, Pediatrics, 1998, N1, S. 54-58.
5. Beloborodova N.V., Sorokin G.V. Clinical and pharmacoeconomic efficacy of amoxicillin/clavulanate (Amoxiclav) in pediatric otorhinolaryngology, Bulletin of Perinatology and Pediatrics, 1998, vol. 43, N5, pp. 49-56.
6. Strachunsky L.S., Rozenson O.L. Step therapy: a new approach to the use of antibacterial drugs, Clinical pharmacology and pharmacotherapy, 1997, vol. 6, N4, pp. 20-24.

You can “direct” the antibiotic to places where microbes accumulate in different ways. You can smear an abscess on the skin with an antibiotic ointment. Can be swallowed (tablets, drops, capsules, syrups). You can prick - into a muscle, into a vein, into the spinal canal.

The route of administration of the antibiotic is not of fundamental importance - it is only important that the antibiotic is in the right place and in the right amount on time . This is, so to speak, a strategic goal. But the tactical question - how to achieve this - is no less important.

Obviously, any pill is clearly more convenient than injections. But... Some antibiotics are destroyed in the stomach, for example, penicillin. Others are not absorbed or hardly absorbed from the gut, such as gentamicin. The patient may be vomiting, he may even be unconscious. The effect of a drug swallowed will come later than from the same drug administered intravenously - it is clear that the more severe the disease, the more reason for unpleasant injections.

WAYS OF ANTIBIOTIC OUT OF THE BODY.

Some antibiotics, such as penicillin or gentamicin, are excreted unchanged in the urine. This allows, on the one hand, to successfully treat diseases of the kidneys and urinary tract, but, on the other hand, with a significant disruption of the kidneys, with a decrease in the amount of urine, it can lead to excessive accumulation of the antibiotic in the body (overdose).

Other drugs, such as tetracycline or rifampicin, are excreted not only in the urine, but also in the bile. Again, the obvious effectiveness in diseases of the liver and biliary tract, but be especially careful in liver failure.

SIDE EFFECTS.

There are no drugs without side effects. Antibiotics are no exception, to put it mildly.

Allergic reactions are possible. Some drugs cause allergies often, such as penicillin or cephalexin, others rarely, such as erythromycin or gentamicin.

Certain antibiotics have a damaging (toxic) effect on some organs. Gentamicin - on the kidneys and auditory nerve, tetracycline - on the liver, polymyxin - on the nervous system, chloramphenicol - on the hematopoietic system, etc. After taking erythromycin, nausea and vomiting often occur, large doses of levomycetin cause hallucinations and decreased visual acuity, any broad-spectrum antibiotics contribute to the development of dysbacteriosis ...

Now let's think!

On the one hand, the following is obvious: taking any antimicrobial agent requires mandatory knowledge of everything that was listed above. That is, all the pros and cons should be well known, otherwise the consequences of treatment can be the most unpredictable.

But, on the other hand, swallowing biseptol on your own, or, on the advice of a neighbor, putting an ampicillin tablet into a child, did you give an account of your actions? Did you know all this?

Of course they didn't know. They didn’t know, they didn’t think, they didn’t suspect, they wanted the best ...

Better to know and think...

What you need to know.

– Any antimicrobial agent should be prescribed only by a doctor!

– It is unacceptable to use antibacterial drugs for viral infections, ostensibly for the purpose of prevention - in order to prevent the development of complications. It never succeeds, on the contrary, it only gets worse. First, because there will always be a microbe that survives. Secondly, because by destroying some bacteria, we create conditions for the reproduction of others, increasing, rather than reducing, the likelihood of the same complications. In short, an antibiotic should be given when a bacterial infection is already present, and not to supposedly prevent it. The most correct attitude to prophylactic antibiotic therapy lies in the slogan put forward by the brilliant philosopher M.M. Zhvanetsky: "Troubles must be experienced as they come!"

Prophylactic antibiotic therapy is not always a bad thing. After many operations, especially on the abdominal organs, it is vital. During a plague epidemic, massive intake of tetracycline can protect against infection. It is only important not to confuse such concepts as prophylactic antibiotic therapy in general and the prophylactic use of antibiotics for viral infections in particular.

- If you are already giving (taking) antibiotics, in no case do not stop treatment immediately after it becomes a little easier. The required duration of treatment can only be determined by a doctor.

– Never beg for something more powerful.

The concept of the strength and weakness of an antibiotic is largely arbitrary. For our average compatriot, the strength of an antibiotic is largely due to its ability to empty pockets and purses. People really want to believe in the fact that if an antibiotic, for example, "tiens" is 1000 times more expensive than penicillin, then it is a thousand times more effective. It wasn't here...

In antibiotic therapy, there is such a thing as " antibiotic of choice ". Those. for each infection, for each specific bacterium, the antibiotic that should be used first is recommended - this is called the antibiotic of choice. If this is not possible, for example, an allergy, second-line antibiotics are recommended, etc. Angina - penicillin, otitis media - amoxicillin, typhoid fever - chloramphenicol, whooping cough - erythromycin, plague - tetracycline, etc.

All very expensive drugs are used only in very serious and, fortunately, not very frequent situations, when a particular disease is caused by a microbe that is resistant to most antibiotics, when there is a pronounced decrease in immunity.

- Prescribing any antibiotic, the doctor cannot predict all the possible consequences. There are cases individual intolerance specific person specific drug. If this happened and, after taking one tablet of erythromycin, the child vomited all night and complained of pain in the abdomen, then the doctor is not to blame. You can treat pneumonia with hundreds of different drugs. And the less often an antibiotic is used, the wider the spectrum of its action and, accordingly, the higher the price, the more likely it will help. But, the greater the likelihood of toxic reactions, dysbacteriosis, suppression of immunity. Injections are more likely and faster to lead to recovery. But it hurts, but suppuration is possible in the place where they pricked. And if you have an allergy - after the pill they washed the stomach, and after the injection - what to wash? Relatives of the patient and the doctor must necessarily find a common language. Using antibiotics, the doctor always has the opportunity to play it safe - injections instead of pills, 6 times a day instead of 4, cephalexin instead of penicillin, 10 days instead of 7 ... But the golden mean, the correspondence between the risk of failure and the likelihood of a quick recovery is largely determined by the behavior of the patient and his relatives . Who is to blame if the antibiotic did not help? Is it just a doctor? What kind of organism is this, which even with the help of the strongest drugs cannot cope with the infection! Well, what kind of lifestyle had to be organized in order to bring immunity to the extreme ... And I don’t want to say at all that all doctors are angels, and mistakes, unfortunately, are not uncommon. But it is necessary to shift the emphasis, because for a particular patient, nothing gives an answer to the question "who is to blame?". The question "what to do?" - is always up to date. But, all the time:

“I had to give injections!”;

“Don’t you know any other medicine besides penicillin?”;

“What does expensive mean, we don’t feel sorry for Masha”;

"And you, doctor , guarantee what will it help?";

“The third time you change the antibiotic, but you still can’t cure an ordinary sore throat!”

- The boy Sasha has bronchitis. The doctor prescribed ampicillin, 5 days passed and it became much better. After 2 months, another illness, all the symptoms are exactly the same - again bronchitis. There is personal experience: ampicillin helps with this disease. Let's not disturb the pediatrician. We will swallow the proven and effective ampicillin. The described situation is very typical. But its consequences are unpredictable. The fact is that any antibiotic is able to combine with blood serum proteins and, under certain circumstances, becomes an antigen, that is, cause the production of antibodies. After taking ampicillin (or any other drug), there may be antibodies to ampicillin in the blood. In this case, there is a high probability of developing allergic reactions, sometimes very (!) Severe. In this case, an allergy is possible not only to ampicillin, but also to any other antibiotic that is similar in its chemical structure (oxacillin, penicillin, cephalosporin). Any repeated use of an antibiotic greatly increases the risk of allergic reactions.. There is another important aspect. If the same disease recurs after a short time, then it is quite logical to assume that when it reappears, it (the disease) is already associated with those microbes that “survived” after the first course of antibiotic therapy, and, therefore, the antibiotic used will not be effective.

- Corollary of the previous point. The doctor cannot choose the right antibiotic if he does not have information about when, about what, what drugs and in what doses your child received. Parents must know this information! Write down! Pay special attention to any manifestations of allergies.

- Do not try to adjust the dose of the drug . Antibiotics in small doses are very dangerous because resistant bacteria are likely to develop. And if it seems to you that “2 tablets 4 times a day” is a lot, and “1 tablet 3 times a day” is just right, then it is quite possible that 1 injection 4 times a day will soon be needed.

– Do not part with your doctor until you understand exactly the rules for taking a particular drug. Erythromycin, oxacillin, chloramphenicol - before meals, taking ampicillin and cephalexin - at any time, tetracycline cannot be taken with milk ... Doxycycline - 1 time per day, biseptol - 2 times a day, tetracycline - 3 times a day, cephalexin - 4 times a day day...

Once again about the most important thing.

Antibiotics- substances that are products of the vital activity of microorganisms that inhibit the growth and development of certain groups of other microorganisms.

The main groups of antibiotics:

1. Penicillins:

benzylpenicillin (natural antibiotic);

semi-synthetic penicillins: penicillase-resistant - oxacillin, methicillin, ampicillin, amoxicillin;

combined: ampioks, augmentin, unazine.

2. Cephalosporins: cefazolin, cefamandol, cefaclor, kefzol, cefuroxime, ceftriaxone, cefpirome.

3. Aminoglycosides: streptomycin, gentamicin, kanamycin, tobramycin, sisomycin, amikacin, netromycin.

4. Tetracyclines: tetracycline, metacycline, doxycycline.

5. Macrolides: erythromycin, oleandomycin, roxithromycin, azithromycin, clarithromycin.

7. Linkosamides: levomecithin.

8. Rifampicins: rifampicin.

9. Antifungal antibiotics : levorin, nystatin.

10. Polymyxin c.

11. Lincosamines: lincomycin, clindamycin.

12. Fluoroquinolones: ofloxacin, ciprofloxacin, etc.

13. Carbapenems: impenem, meropenem.

14. Glycopeptides: vancomycin, eremomycin, teicoplanin

15. Monbactams: aztrenoam, carumonam.

16. Chloramphenicols : levomecithin.

17 . Streptogramins: synercid

18 . Oxazolidinones: linezolid

Basic principles of antibiotic therapy

The use of antibiotics only under strict indications.

Prescribe the maximum therapeutic or, in severe forms of infection, subtoxic doses of antibiotics.

Observe the frequency of administration during the day to maintain a constant bactericidal concentration of the drug in the blood plasma.

If long-term treatment with antibiotics is necessary, they should be changed every 5-7 days, in order to avoid adaptation of the microflora to antibiotics.

Produces a change of antibiotic if it is ineffective.

When choosing an antibiotic, be based on the results of a microflora sensitivity study.

Take into account synergism and antagonism when prescribing a combination of antibiotics, as well as antibiotics and other antibacterial drugs.

When prescribing antibiotics, pay attention to the possibility of side effects and toxicity of drugs.

To prevent complications of the allergic series, carefully collect an allergic history, in some cases it is mandatory to conduct an allergic skin test (penicillins), and prescribe antihistamines.

With long courses of antibiotic therapy, prescribe antifungal drugs to prevent dysbacteriosis, as well as vitamins.

Use the optimal route of administration of antibiotics.

Routes of administration of antibiotics:

filling the wound with antibiotic powder;

the introduction of tampons with antibiotic solutions;

introduction through drainages (for irrigation of cavities);

the introduction of antibiotics through an injection needle after a puncture and the extraction of pus from the cavities.

endotracheal and endobronchial administration through a catheter inserted into the nose and trachea, through a bronchoscope or by puncture of the trachea;

chipping with an antibiotic solution of inflammatory infiltrates (introduction under the infiltrate);

intraosseous injection (for osteomyelitis).

endolumbar injection (purulent meningitis);

intravenous administration;

intramuscular administration;

intra-arterial administration is used for severe purulent limbs and some internal organs - antibiotics are injected into the artery by puncture, and if necessary, long-term intra-arterial infusion through a catheter inserted into the corresponding arterial branch;

taking antibiotics per os;

endolymphatic administration of antibiotics allows you to create a high concentration of them in organs and tissues, with an inflammatory purulent process.

Methods are applied:

a) direct injection, when the lumen of the isolated lymphatic vessel is filled through a needle or a permanent catheter;

b) by injection into large lymph nodes;

c) subcutaneously in the projection of the lymphatic collectors.

Endolymphatic administration of antibiotics creates a 10 times greater concentration in the focus of infection compared to traditional routes of administration, which ensures faster relief of the inflammatory process.

Antibiotics are a huge group of bactericidal drugs, each of which is characterized by its spectrum of action, indications for use and the presence of certain consequences.

Antibiotics are substances that can inhibit the growth of microorganisms or destroy them. According to the definition of GOST, antibiotics include substances of plant, animal or microbial origin. At present, this definition is somewhat outdated, since a huge number of synthetic drugs have been created, but it was natural antibiotics that served as the prototype for their creation.

The history of antimicrobial drugs begins in 1928, when A. Fleming was first discovered penicillin. This substance was just discovered, and not created, since it has always existed in nature. In wildlife, it is produced by microscopic fungi of the genus Penicillium, protecting themselves from other microorganisms.

In less than 100 years, more than a hundred different antibacterial drugs have been created. Some of them are already outdated and are not used in treatment, and some are only being introduced into clinical practice.

How antibiotics work

We recommend reading:

All antibacterial drugs according to the effect on microorganisms can be divided into two large groups:

• bactericidal- directly cause the death of microbes;
• bacteriostatic- prevent the growth of microorganisms. Unable to grow and multiply, the bacteria are destroyed by the sick person's immune system.

Antibiotics realize their effects in many ways: some of them interfere with the synthesis of microbial nucleic acids; others interfere with the synthesis of the bacterial cell wall, others disrupt the synthesis of proteins, and others block the functions of respiratory enzymes.

Groups of antibiotics

Despite the diversity of this group of drugs, all of them can be attributed to several main types. This classification is based on the chemical structure - drugs from the same group have a similar chemical formula, differing from each other in the presence or absence of certain molecular fragments.

The classification of antibiotics implies the presence of groups:

1. Derivatives of penicillin. This includes all drugs created on the basis of the very first antibiotic. In this group, the following subgroups or generations of penicillin preparations are distinguished:

• Natural benzylpenicillin, which is synthesized by fungi, and semi-synthetic drugs: methicillin, nafcillin.
• Synthetic drugs: carbpenicillin and ticarcillin, which have a wider range of effects.
• Mecillam and azlocillin, which have an even wider spectrum of action.

1. Cephalosporins are close relatives of penicillins. The very first antibiotic of this group, cefazolin C, is produced by fungi of the genus Cephalosporium. Most of the drugs in this group have a bactericidal effect, that is, they kill microorganisms. There are several generations of cephalosporins:

• I generation: cefazolin, cephalexin, cefradin, etc.
• II generation: cefsulodin, cefamandol, cefuroxime.
• III generation: cefotaxime, ceftazidime, cefodizime.
• IV generation: cefpir.
• V generation: ceftolosan, ceftopibrol.

The differences between different groups are mainly in their effectiveness - later generations have a greater spectrum of action and are more effective. Cephalosporins of the 1st and 2nd generations are now used extremely rarely in clinical practice, most of them are not even produced.

1. - drugs with a complex chemical structure that have a bacteriostatic effect on a wide range of microbes. Representatives: azithromycin, rovamycin, josamycin, leukomycin and a number of others. Macrolides are considered one of the safest antibacterial drugs - they can be used even by pregnant women. Azalides and ketolides are varieties of macrolides that differ in the structure of active molecules.

Another advantage of this group of drugs is that they are able to penetrate the cells of the human body, which makes them effective in the treatment of intracellular infections:,.

1. Aminoglycosides. Representatives: gentamicin, amikacin, kanamycin. Effective against a large number of aerobic gram-negative microorganisms. These drugs are considered the most toxic, can lead to quite serious complications. Used to treat urinary tract infections,.
2. Tetracyclines. Basically, this semi-synthetic and synthetic drugs, which include: tetracycline, doxycycline, minocycline. Effective against many bacteria. The disadvantage of these drugs is cross-resistance, that is, microorganisms that have developed resistance to one drug will be insensitive to others from this group.
3. Fluoroquinolones. These are completely synthetic drugs that do not have their natural counterpart. All drugs in this group are divided into the first generation (pefloxacin, ciprofloxacin, norfloxacin) and the second (levofloxacin, moxifloxacin). They are most often used to treat infections of the upper respiratory tract (,) and respiratory tract (,).
4. Lincosamides. This group includes the natural antibiotic lincomycin and its derivative clindamycin. They have both bacteriostatic and bactericidal effects, the effect depends on the concentration.
5. Carbapenems. These are one of the most modern antibiotics, acting on a large number of microorganisms. The drugs of this group belong to the reserve antibiotics, that is, they are used in the most difficult cases when other drugs are ineffective. Representatives: imipenem, meropenem, ertapenem.
6. Polymyxins. These are highly specialized drugs used to treat infections caused by. Polymyxins include polymyxin M and B. The disadvantage of these drugs is toxic effects on the nervous system and kidneys.
7. Anti-tuberculosis drugs. This is a separate group of drugs that have a pronounced effect on. These include rifampicin, isoniazid, and PAS. Other antibiotics are also used to treat tuberculosis, but only if resistance has developed to the mentioned drugs.
8. Antifungals. This group includes drugs used to treat mycoses - fungal infections: amphotyrecin B, nystatin, fluconazole.

Ways to use antibiotics

Antibacterial drugs are available in different forms: tablets, powder, from which a solution for injection is prepared, ointments, drops, spray, syrup, suppositories. The main ways to use antibiotics:

1. Oral- intake by mouth. You can take the medicine in the form of a tablet, capsule, syrup or powder. The frequency of administration depends on the type of antibiotics, for example, azithromycin is taken once a day, and tetracycline - 4 times a day. For each type of antibiotic, there are recommendations that indicate when it should be taken - before meals, during or after. The effectiveness of treatment and the severity of side effects depend on this. For young children, antibiotics are sometimes prescribed in the form of syrup - it is easier for children to drink a liquid than to swallow a tablet or capsule. In addition, the syrup can be sweetened to get rid of the unpleasant or bitter taste of the medicine itself.
2. Injectable- In the form of intramuscular or intravenous injections. With this method, the drug enters the focus of infection faster and acts more actively. The disadvantage of this method of administration is pain when injected. Injections are used for moderate and severe diseases.

Important:injections should only be given by a nurse in a clinic or hospital! Doing antibiotics at home is strongly discouraged.

1. Local- applying ointments or creams directly to the site of infection. This method of drug delivery is mainly used for skin infections - erysipelas, as well as in ophthalmology - for infectious eye damage, for example, tetracycline ointment for conjunctivitis.

The route of administration is determined only by the doctor. This takes into account many factors: the absorption of the drug in the gastrointestinal tract, the state of the digestive system as a whole (in some diseases, the absorption rate decreases, and the effectiveness of treatment decreases). Some drugs can only be administered one way.

When injecting, you need to know how you can dissolve the powder. For example, Abaktal can only be diluted with glucose, since when sodium chloride is used, it is destroyed, which means that the treatment will be ineffective.

Sensitivity to antibiotics

Any organism sooner or later gets used to the most severe conditions. This statement is also true in relation to microorganisms - in response to prolonged exposure to antibiotics, microbes develop resistance to them. The concept of sensitivity to antibiotics was introduced into medical practice - with what efficiency this or that drug affects the pathogen.

Any prescription of antibiotics should be based on knowledge of the susceptibility of the pathogen. Ideally, before prescribing the drug, the doctor should conduct a sensitivity test and prescribe the most effective drug. But the time for such an analysis in the best case is a few days, and during this time the infection can lead to the saddest result.

Therefore, in case of an infection with an unknown pathogen, doctors prescribe drugs empirically - taking into account the most likely pathogen, with knowledge of the epidemiological situation in a particular region and medical institution. For this, broad-spectrum antibiotics are used.

After performing a sensitivity test, the doctor has the opportunity to change the drug to a more effective one. Replacement of the drug can be made in the absence of the effect of treatment for 3-5 days.

Etiotropic (targeted) prescription of antibiotics is more effective. At the same time, it turns out what caused the disease - with the help of bacteriological research, the type of pathogen is established. Then the doctor selects a specific drug to which the microbe has no resistance (resistance).

Are antibiotics always effective?

Antibiotics only work on bacteria and fungi! Bacteria are unicellular microorganisms. There are several thousand species of bacteria, some of which coexist quite normally with humans - more than 20 species of bacteria live in the large intestine. Some bacteria are conditionally pathogenic - they become the cause of the disease only under certain conditions, for example, when they enter an atypical habitat for them. For example, very often prostatitis is caused by Escherichia coli, which enters from the rectum in an ascending way.

Note: antibiotics are completely ineffective in viral diseases. Viruses are many times smaller than bacteria, and antibiotics simply do not have a point of application of their ability. Therefore, antibiotics for colds do not have an effect, since colds in 99% of cases are caused by viruses.

Antibiotics for coughs and bronchitis may be effective if these symptoms are caused by bacteria. Only a doctor can figure out what caused the disease - for this he prescribes blood tests, if necessary - a sputum examination if it departs.

Important:Do not prescribe antibiotics to yourself! This will only lead to the fact that some of the pathogens will develop resistance, and the next time the disease will be much more difficult to cure.

Of course, antibiotics are effective for - this disease is exclusively bacterial in nature, it is caused by streptococci or staphylococci. For the treatment of angina, the simplest antibiotics are used - penicillin, erythromycin. The most important thing in the treatment of angina is compliance with the frequency of taking drugs and the duration of treatment - at least 7 days. You can not stop taking the medicine immediately after the onset of the condition, which is usually noted for 3-4 days. True tonsillitis should not be confused with tonsillitis, which may be of viral origin.

Note: untreated angina can cause acute rheumatic fever or!

Inflammation of the lungs () can be of both bacterial and viral origin. Bacteria cause pneumonia in 80% of cases, so even with empirical prescription, antibiotics for pneumonia have a good effect. In viral pneumonia, antibiotics do not have a therapeutic effect, although they prevent the bacterial flora from joining the inflammatory process.

Antibiotics and alcohol

The simultaneous use of alcohol and antibiotics in a short period of time does not lead to anything good. Some drugs are broken down in the liver, like alcohol. The presence of an antibiotic and alcohol in the blood gives a strong load on the liver - it simply does not have time to neutralize ethyl alcohol. As a result of this, the likelihood of developing unpleasant symptoms increases: nausea, vomiting, intestinal disorders.

Important: a number of drugs interact with alcohol at the chemical level, as a result of which the therapeutic effect is directly reduced. These drugs include metronidazole, chloramphenicol, cefoperazone and a number of others. The simultaneous use of alcohol and these drugs can not only reduce the therapeutic effect, but also lead to shortness of breath, convulsions and death.

Of course, some antibiotics can be taken while drinking alcohol, but why risk your health? It is better to abstain from alcohol for a short time - the course of antibiotic therapy rarely exceeds 1.5-2 weeks.

Antibiotics during pregnancy

Pregnant women suffer from infectious diseases no less than everyone else. But the treatment of pregnant women with antibiotics is very difficult. In the body of a pregnant woman, a fetus grows and develops - an unborn child, very sensitive to many chemicals. The ingress of antibiotics into the developing organism can provoke the development of fetal malformations, toxic damage to the central nervous system of the fetus.

In the first trimester, it is advisable to avoid the use of antibiotics altogether. In the second and third trimesters, their appointment is safer, but also, if possible, should be limited.

It is impossible to refuse the prescription of antibiotics to a pregnant woman with the following diseases:

• Pneumonia;
• angina;
• infected wounds;
• specific infections: brucellosis, borreliosis;
• genital infections:,.

What antibiotics can be prescribed to a pregnant woman?

Penicillin, cephalosporin preparations, erythromycin, josamycin have almost no effect on the fetus. Penicillin, although it passes through the placenta, does not adversely affect the fetus. Cephalosporin and other named drugs cross the placenta in extremely low concentrations and are not capable of harming the unborn child.

Conditionally safe drugs include metronidazole, gentamicin and azithromycin. They are prescribed only for health reasons, when the benefit to the woman outweighs the risk to the child. Such situations include severe pneumonia, sepsis, and other severe infections in which a woman can simply die without antibiotics.

Which of the drugs should not be prescribed during pregnancy

The following drugs should not be used in pregnant women:

• aminoglycosides- can lead to congenital deafness (with the exception of gentamicin);
• clarithromycin, roxithromycin– in experiments they had a toxic effect on animal embryos;
• fluoroquinolones;
• tetracycline- violates the formation of the skeletal system and teeth;
• chloramphenicol- dangerous in late pregnancy due to inhibition of bone marrow function in a child.

For some antibacterial drugs, there is no evidence of a negative effect on the fetus. This is explained simply - on pregnant women, they do not conduct experiments to determine the toxicity of drugs. Experiments on animals do not allow with 100% certainty to exclude all negative effects, since the metabolism of drugs in humans and animals can differ significantly.

It should be noted that before you should also stop taking antibiotics or change plans for conception. Some drugs have a cumulative effect - they are able to accumulate in a woman's body, and for some time after the end of the course of treatment they are gradually metabolized and excreted. Pregnancy is recommended no earlier than 2-3 weeks after the end of antibiotics.

Consequences of taking antibiotics

The ingress of antibiotics into the human body leads not only to the destruction of pathogenic bacteria. Like all foreign chemicals, antibiotics have a systemic effect - in one way or another they affect all body systems.

There are several groups of side effects of antibiotics:

allergic reactions

Almost any antibiotic can cause allergies. The severity of the reaction is different: a rash on the body, Quincke's edema (angioneurotic edema), anaphylactic shock. If an allergic rash is practically not dangerous, then anaphylactic shock can be fatal. The risk of shock is much higher with antibiotic injections, which is why injections should only be given in medical facilities - emergency care can be provided there.

Antibiotics and other antimicrobial drugs that cause cross-allergic reactions:

Toxic reactions

Antibiotics can damage many organs, but the liver is most susceptible to their effects - against the background of antibiotic therapy, toxic hepatitis can occur. Some drugs have a selective toxic effect on other organs: aminoglycosides - on the hearing aid (cause deafness); tetracyclines inhibit bone growth in children.

note: the toxicity of the drug usually depends on its dose, but with individual intolerance, sometimes smaller doses are enough to show the effect.

Impact on the gastrointestinal tract

When taking certain antibiotics, patients often complain of stomach pain, nausea, vomiting, stool disorders (diarrhea). These reactions are most often due to the local irritating effect of drugs. The specific effect of antibiotics on the intestinal flora leads to functional disorders of its activity, which is most often accompanied by diarrhea. This condition is called antibiotic-associated diarrhea, which is popularly known as dysbacteriosis after antibiotics.

Other side effects

Other side effects include:

• suppression of immunity;
• the emergence of antibiotic-resistant strains of microorganisms;
• superinfection - a condition in which microbes resistant to a given antibiotic are activated, leading to the emergence of a new disease;
• violation of vitamin metabolism - due to the inhibition of the natural flora of the colon, which synthesizes some B vitamins;
• Jarisch-Herxheimer bacteriolysis is a reaction that occurs when bactericidal drugs are used, when, as a result of the simultaneous death of a large number of bacteria, a large amount of toxins are released into the blood. The reaction is clinically similar to shock.

Can antibiotics be used prophylactically?

Self-education in the field of treatment has led to the fact that many patients, especially young mothers, try to prescribe themselves (or their child) an antibiotic at the slightest sign of a cold. Antibiotics do not have a preventive effect - they treat the cause of the disease, that is, they eliminate microorganisms, and in the absence, only side effects of the drugs appear.

There are a limited number of situations where antibiotics are administered before the clinical manifestations of infection, in order to prevent it:

• surgery- in this case, the antibiotic in the blood and tissues prevents the development of infection. As a rule, a single dose of the drug administered 30-40 minutes before the intervention is sufficient. Sometimes, even after an appendectomy, antibiotics are not injected in the postoperative period. After "clean" surgical operations, antibiotics are not prescribed at all.
• major injuries or wounds(open fractures, soil contamination of the wound). In this case, it is absolutely obvious that an infection has entered the wound and it should be “crushed” before it manifests itself;
• emergency prevention of syphilis carried out with unprotected sexual contact with a potentially sick person, as well as with health workers who have got the blood of an infected person or other biological fluid on the mucous membrane;
• penicillin can be given to children for the prevention of rheumatic fever, which is a complication of tonsillitis.

Antibiotics for children

The use of antibiotics in children in general does not differ from their use in other groups of people. Pediatricians most often prescribe antibiotics in syrup for young children. This dosage form is more convenient to take, unlike injections, it is completely painless. Older children may be prescribed antibiotics in tablets and capsules. In severe infections, they switch to the parenteral route of administration - injections.

Important: the main feature in the use of antibiotics in pediatrics lies in dosages - children are prescribed smaller doses, since the drug is calculated in terms of a kilogram of body weight.

Antibiotics are very effective drugs that have at the same time a large number of side effects. In order to be cured with their help and not harm your body, you should take them only as directed by your doctor.

What are antibiotics? When are antibiotics needed and when are they dangerous? The main rules of antibiotic treatment are told by the pediatrician, Dr. Komarovsky:

Gudkov Roman, resuscitator