《外科护理学》课程阅读资料（泌尿外科治疗指南）泌尿系感染诊断治疗指南-2011年全文版

1.一般治疗包括对症治疗、多饮水及生活方式的调整等。 2.观察一些特殊情况下的无症状菌尿患者不需要常规抗菌药物治疗，需 要密切观察病情（详见后面章节）。 3.抗菌药物治疗抗菌药物治疗是尿路感染的主要治疗方法，推荐根据药 敏试验选择用药。 常用抗菌药物的作用机制包括：①干扰细菌细胞壁合成，包括B内酰胺类的 青霉素、头孢菌素、碳青香烯类和磷毒素、万古霉素等：②损伤细菌细胞膜，有 多粘菌素B、制霉菌素等：③影响细菌蛋白质合成，有氨基糖苷类、四环素类、 红霉素、林可霉素等：④抑制细菌核酸代谢，有氟喹诺酮类、利福霉素类等：⑤ 其他，如影响叶酸合成的磺胺类药物等。 根据药效动力学特性不同将抗菌药物分为两大类5阿：①浓度依赖型药物， 这类药物在有效浓度范围内呈现浓度依赖性杀菌的特点，所用药物浓度越高，杀 菌率和杀菌范围也随之增高，如氨基糖苷类和氟喹诺酮类，这些药物的用药方案 目标是把药物浓度提高到最大限度。②时间依赖性药物，疗效主要与抗菌药物血 药浓度维持超过致病菌的最小抑菌浓度(MC)的时间有关，如B内酰胺类、部分 大环内酯类，这些药物的用药方案目标是尽可能延长接触时间，在血清浓度超过 MC期间，持续时间的长短将是这些药物效能的重要决定因素。 关于经验性抗菌药物治疗：可以对有尿路感染的患者首先施行经验性抗菌药 物治疗。但有研究显示社区性单纯尿路感染患者中，有60%患者经验用药与最 终的尿培养结果不符1。 4.手术治疗在适当时机针对感染病灶或引起感染的病因实施相应的手术 治疗。 5.中医治疗目前应用于临床治疗的中药种类很多，请参照中医或中西医 结合学会的推荐意见开展治疗。针灸治疗可以减少膀胱炎的复发57。 九、预后 1.急性单纯性膀胱炎患者经治疗和采取一定的预防措施后，总体预后较好。 未经治疗的急性膀胱炎患者进展至上尿路感染的情况较少，症状可能持续数月， 但可以逐渐自发缓解5859。 2.如果诊断和治疗及时，急性单纯性肾盂肾炎的预后较好，如果患者有肾

1. 一般治疗 包括对症治疗、多饮水及生活方式的调整等。 2. 观察 一些特殊情况下的无症状菌尿患者不需要常规抗菌药物治疗，需 要密切观察病情（详见后面章节）。 3. 抗菌药物治疗 抗菌药物治疗是尿路感染的主要治疗方法，推荐根据药 敏试验选择用药。 常用抗菌药物的作用机制包括：○1 干扰细菌细胞壁合成，包括β内酰胺类的 青霉素、头孢菌素、碳青霉烯类和磷霉素、万古霉素等；○2 损伤细菌细胞膜，有 多粘菌素 B、制霉菌素等；○3 影响细菌蛋白质合成，有氨基糖苷类、四环素类、 红霉素、林可霉素等；○4 抑制细菌核酸代谢，有氟喹诺酮类、利福霉素类等；○5 其他，如影响叶酸合成的磺胺类药物等。 根据药效动力学特性不同将抗菌药物分为两大类[55]：○1 浓度依赖型药物， 这类药物在有效浓度范围内呈现浓度依赖性杀菌的特点，所用药物浓度越高，杀 菌率和杀菌范围也随之增高，如氨基糖苷类和氟喹诺酮类，这些药物的用药方案 目标是把药物浓度提高到最大限度。○2 时间依赖性药物，疗效主要与抗菌药物血 药浓度维持超过致病菌的最小抑菌浓度(MIC)的时间有关，如β内酰胺类、部分 大环内酯类，这些药物的用药方案目标是尽可能延长接触时间，在血清浓度超过 MIC 期间，持续时间的长短将是这些药物效能的重要决定因素。 关于经验性抗菌药物治疗：可以对有尿路感染的患者首先施行经验性抗菌药 物治疗。但有研究显示社区性单纯尿路感染患者中，有 60%患者经验用药与最 终的尿培养结果不符[56]。 4. 手术治疗 在适当时机针对感染病灶或引起感染的病因实施相应的手术 治疗。 5. 中医治疗 目前应用于临床治疗的中药种类很多，请参照中医或中西医 结合学会的推荐意见开展治疗。针灸治疗可以减少膀胱炎的复发[57]。 九、预后 1. 急性单纯性膀胱炎患者经治疗和采取一定的预防措施后，总体预后较好。 未经治疗的急性膀胱炎患者进展至上尿路感染的情况较少，症状可能持续数月， 但可以逐渐自发缓解[58，59]。 2. 如果诊断和治疗及时，急性单纯性肾盂肾炎的预后较好，如果患者有肾

脏其他病变、糖尿病或应用免疫抑制等情况，血行感染和死亡的发生率升高，但 临床上缺乏此类患者的长期随访数据60。 3.如果存在严重的上尿路病变（畸形、狭窄或返流等），患者出现炎症复发 和肾功能不全的可能性明显增加

脏其他病变、糖尿病或应用免疫抑制等情况，血行感染和死亡的发生率升高，但 临床上缺乏此类患者的长期随访数据[60]。 3. 如果存在严重的上尿路病变（畸形、狭窄或返流等），患者出现炎症复发 和肾功能不全的可能性明显增加

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microbiology laboratory. Clin Microbiol Rev, 1993,6:428-442 29. Parsons CL, Stauffer C, Mulholland SF, et al. Effect of ammonium on bacterial adherence in bladder transitional epithelium. J Urol, 1984,132:365-366 30. Dumanski AJ, Hedelin H, Edin-Liljergen A, et al. Unique ability of the Proteus mirabilis capsule to enhance mineral growth in infectious urinary calculi. Infect Immun, 1994, 62:2998-3003 31. Wagenlehner FM, Weidner W, Naber KG.. Optimal management of urosepsis from the urological perspective. Int J Antimicrob Agents,2007,30:390-397 32. 魏武, 葛京平, 马宏青, 等. 经皮肾镜钬激光碎石术全身炎症反应综合征发生的相关因 素. 临床泌尿外科杂志, 2007, 22:264-267 33. FozA. Sepsis of urological origin: microbiological aspects. Antibiot Chemother, 1976,21:69-72 34. 黄锦坤, 李逊, 吴开俊, 等.复杂性肾结石合并真菌感染的防治探讨.中国医师杂 志,2006,8:747-748 35. Menninger M. Urosepsis, Klinik, diagnostik und therapie. In: Hofstetter A, editor. Urogenitale infektionen. Berlin: Heidelberg, New York: Springer, 1998. 521–528 36. 黄锦坤, 李逊, 吴开俊, 等. 复杂性肾结石感染的菌谱、耐药谱分析. 中国医药, 2006,1:110-112 37. 李光辉. 尿路感染的诊断与治疗. 中国抗感染化疗杂志, 2001, 58-60 38. Peterson J, Kaul S, Khashab M, et al. Identification and pretherapy susceptibility of pathogens in patients with complicated urinary tract infection or acute pyelonephritis enrolled in a clinical study in the United States from November 2004 through April 2006. Clin Ther, 2007, 29(10):2215-2221 39. Roghmann MC, Wallin MT, Gorman PH, et al. Prevalence and natural history of colonization with fluoroquinolone-resistant gram-negative bacilli in community-dwelling people with spinal cord dysfunction. Arch Phys Med Rehabil, 2006, 87(10):1305-1309 40. Stamm WE. Urinary tract infections and pyelonephritis. In: Harrison's Principles of Internal Medicine. 14th ed. Edited by Fauci AS Braunwald E, Isselbacher KJ, et al. New York: McGraw-Hill,. 1998. 817-823