4. 抗生素在预防感染诱发的早产中的作用

Andrews等[ 4 ]的研究中,对照组与干预组平均孕周无明显差异,关于细菌性阴道炎、滴虫性阴道炎的随机临床试验也有相似发现[ 3 ]。为什么?医学的基本原则是只给予能受益者治疗措施,如对抗射线肿瘤患者不能进行放疗、对疾病机制与感染无关的病人不能抗炎。抗菌素药效强劲足以改变人体正常菌群,如消炎可改变阴道菌群而易罹患阴道念珠菌病,而且可能影响肠道及牙周菌群。杀菌性抗生素可导致细菌性产物释放,可能引发对宿主(母亲和胎儿)有害的炎症反应。亚临床细菌性阴道炎和念珠菌性阴道炎是自发早产的一般风险因素,许多参与研究的病人并不会发生早产,因此,抗菌治疗对其无效。我们从有价值的研究中认识到:阴道分泌物的革兰氏染色及从下生殖道培养微生物的检测手段对鉴定病人是否会从抗菌素治疗中获益是不足够的。理解宿主反应看来可以提高风险评估、确定可以从治疗中获益的病人,从而避免病人受损。相关研究的数据资源将使未来的研究集中于子宫内膜、下生殖道的细菌—宿主相互作用的生物学、及其与早产的关系。对高风险群的介入有可能使临床受益。其挑战是要确定这一群体并设计出合适的干预方案,包括抗菌素与生物学反应修饰。如同感染性休克时单用抗生素并不足以避免死亡一样,虽然感染是早产的原因之一,但抗生素干预并不能预防早产,微生物只是问题的一部分,问题的另一方面是炎症反应与抗炎症反应的调节。简而言之,在产科,有研究者建议通过改变炎症[ 18 ]、生成凝血酶[ 19 ]预防早产。

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