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Antibiotic Optimization: Concepts and Strategies In Clinical Practice
http://www.100md.com 《新英格兰医药杂志》
     During the past decade, there has been a substantial rise in the number of antibiotic-resistant infectious organisms. Antimicrobial resistance is important because of its effect on the success and cost of antimicrobial treatment and on the treatment of patients in both the hospital and the community. There are few new antimicrobial compounds on the horizon, because many major pharmaceutical companies are no longer involved in the discovery of antimicrobial drugs. To that end, the principles of and programs for reducing the spread of resistant pathogens and of optimizing the efficacy of currently available antimicrobial agents are of interest to many clinicians.

    "Antimicrobial stewardship," a term coined by Dr. Dale Gerding, applies to the selection of an antimicrobial agent and its appropriate dosage and duration of therapy. In principle, this results in the best clinical outcome in the treatment or prevention of infection, with the least toxicity and, most important, a minimal effect on the development of resistance in the patient and in larger populations, whether in the hospital or the community. The goal of Antibiotic Optimization is to provide the practicing clinician and the interested administrator with the background, scientific foundation, and practical knowledge required to develop institutional programs that foster good antimicrobial stewardship.

    The book draws on many recommendations by professional societies and national and international organizations that have recognized the importance of antimicrobial stewardship as a mechanism to prevent antimicrobial resistance. The editors are to be congratulated for assembling an expert group of authors to write the 19 chapters that make up this treatise.

    The book has two main parts. The initial chapters provide an overview of topics that serve as the foundation of a successful program of antimicrobial stewardship, such as the importance of a pharmacy and therapeutics committee, a program for infection control and hospital epidemiology, and a basic understanding of pharmacoeconomics, pharmacokinetics, and pharmacodynamics. The remainder of the book deals with examples of the application of antimicrobial stewardship. These chapters provide insight into the importance of pharmacodynamic principles, transitional-therapy programs, and the development and implementation of an antimicrobial formulary.

    The chapters are very well referenced and understandable for readers without expert knowledge of the subject. In general, the references are to articles published up to 2003, with a few from 2004. The chapters that focus on the optimization of antibacterial therapy to maximize patient safety, the application of pharmacodynamics, and the importance of an antimicrobial formulary are especially well written. The examples of successfully implemented programs — for example, the use of continuous infusions of antimicrobial agents or the transition of antimicrobial therapy from a parenteral to an oral form — provide "real-life" methods of optimizing antimicrobial therapy.

    One criticism is the absence of a chapter on the role of the microbiology laboratory in the optimization of antibiotics. Appropriate testing and reporting are critical factors in the choice of an antimicrobial agent. In addition, some figures in the book are unreadable, and in the chapter on antimicrobial cycling, there is probably too much of the primary data without a countervailing discussion of the inconsistencies of the data in terms of efficacy. This subject is still being debated among most authorities.

    Despite these few deficiencies, this book is a good resource by which to ensure the appropriate use of antimicrobial therapy. Physicians already involved in antimicrobial-stewardship programs will not find much new information here, although the book will serve as a useful reference for them. It is written in a way that will appeal to a broad group of clinicians, pharmacists, nurses, researchers, hospital administrators, and policymakers.

    David R. Snydman, M.D.

    Kenneth R. Lawrence, Pharm.D.

    Tufts–New England Medical Center

    Boston, MA 02111

    dsnydman@tufts-nemc.org(Robert C. Owens, Jr., Pau)