孩子上医院，先查个血，然后说白细胞高，是细菌感染，要吃抗生素，这应该是很多家长的经历。
我在之前的文章里写过，血常规不是完全没有任何临床价值，但对于判断是否是细菌感染的价值很有限。
但因为血常规简便快捷，很容易开展，中国医生们又建立了白细胞高=细菌感染的思维定式，所以就把这项检查当成了判断用不用抗生素的工具。
血常规或许筛查出了一些需要治疗的病，但本不需要开抗生素只因白细胞高而开的情况肯定更多，所以在实际应用中，血常规这项检查，已经是弊远大于利了。
很多人可能会问，既然血常规价值有限，那怎么判断孩子是不是细菌感染要不要吃抗生素呢？
这个问题回答起来就没那么简单，这是因为“细菌感染”是一大类疾病的总称，细菌性鼻窦炎、中耳炎、细菌性肠炎、泌尿系感染等，都属于“细菌感染”，但它们的诊断方法却各有不同，我们来看看这些相对常见的细菌感染性疾病是怎么诊断的。
儿童细菌性鼻窦炎：主要依据临床表现，比如流涕和日间咳嗽持续超过10天没有改善。
儿童肺炎：主要根据发热、咳嗽、呼吸快、窘迫、肺部听诊、胸片、CT来诊断。
细菌性脑膜炎：主要依据发热、脑膜刺激征，以及意识改变、抽搐等神经系统症状来诊断，确诊主要靠脑脊液化验及培养。
泌尿系感染：主要依据发热、尿频、尿急、排尿困难、腹痛等症状，确诊要靠尿常规、尿培养。
细菌性肠炎：主要依据高热、腹痛、腹胀、大便带血以及大便培养。
急性阑尾炎：主要依据转移性右下腹痛，发烧、腹膜刺激征以及超声及CT等影响检查。
看了这些，大家应该能看出，这些“细菌感染”性疾病，主要靠临床表现、体格检查或者影像检查或病原学检查。而且，同样的症状，在不同年龄段的孩子需要考虑的病也会不同。
血常规对于一些疾病的判断有参考意义，比如诊断肺炎后，如果白细胞大于1.5万/ul，则要考虑细菌性肺炎可能性大；对于一个腹痛孩子，白细胞高时，医生也要多警惕阑尾炎。但总的来说，没有任何一种细菌感染性疾病，可以单纯根据白细胞高而诊断。细菌感染也不是导致白细胞高的唯一原因，病毒感染、免疫性疾病、创伤、运动也都可以导致白细胞高。
所以，白细胞高≠细菌感染。
哪怕是同一种病，如果病原体不同，表现也可能会有差异，治疗也可能会不同。比如大肠杆菌导致的急性细菌性肠炎，就不应该常规使用抗生素，而志贺菌导致的细菌性肠炎，则需要用抗生素。
哪怕是同一种细菌感染引起的同一种病，病情的轻重不同，导致的治疗方案也可能不同，比如儿童细菌性鼻窦炎，症状重的需要马上用抗生素，症状不严重的，可以再多观察3天再决定是否用药。
所以，细菌感染≠要用抗生素。
而在现实里，有的医院在孩子还没见到医生之前，就先由护士开血常规验好血再去见医生，有的医院还在用大人的标准来判断孩子的血常规是否异常，本来在正常范围的白细胞数值，也成了吃抗生素的依据。
看病先查血常规之所以成为比较普遍做法，还是和我们的医疗环境有关，公立医院医生一天要看几十上百个病人，医生需要在几分钟内完成一个病人的诊断和治疗，而且要让病人尽量满意，就需要用一些简单快捷的的手段。
血常规因为简单快捷，医生们对它的临床价值理解也有偏差，所以就成了医生分拣和筛选有危险因素病人的这个快捷工具。
一旦白细胞高，医生就指着化验单上向上的箭头对病人说：看，这有炎症了啊，要吃消炎药了啊。然后开上抗生素，或者还搭上几盒声称有“抗菌消炎”的中成药；如果白细胞不高，就说：这是病毒感染，然后开几盒清热解毒的中成药。
儿童的常见病，绝大部分还是病毒引起的，不管吃不吃药，吃什么药，过几天大部分都能好，好了后病人就很容易认为是医生的检查和用药对路，认为医生很高明，慢慢地也觉得验血、吃抗生素是合理做法。至于以后抗生素耐药什么的，也搞不清到底是什么时候吃药导致的了。
如果吃几天药没好，要是有了不好的结果去找医生，验过血开过药的医生也可以说，我给你血也验了，药也开了，我已经尽力了，这远比那些没验血也没开药的医生更容易得到病人谅解。
白细胞高—细菌感染—吃抗生素 这种思维方式，本质上和 长痘了—上火了—喝点凉茶 的思维方式一样的，用一种简单的因果关系，给一个直接的解释，然后做出“积极”干预，就有了一个粗暴而“有效”的处理病人路径了。有了这种“有效”的路径，也就可以不去做那些耗时耗力还需要承担风险的精准诊断和治疗了。
但事实上，在很多国家，对于3个月以上的孩子，尤其是门诊病人，不会常规做血常规，抗生素的使用也是需要在有比较具体而明确的诊断下才能用，比如考虑的是哪一种细菌感染性疾病，有的甚至是确定哪种病原体导致的感染，再开相应的敏感药物来治疗，而不是简单来个考虑“细菌感染”所以要吃抗生素。
做更精准的诊断和治疗，需要更详细地问病史，做体格检查，根据初步的怀疑有选择地做一些需要做的检验或者影像检查，有的时候还需要动态观察病情变化，完成整个诊疗过程需要比较多的时间和精力去做沟通和观察，还需要医生有足够的专业判断能力。做出不验血、不开没有指征的抗生素，需要更多的担当，也需要承受更大的压力，这在十几块钱挂号费的服务价格下是很难实现的。
所以要想从根本上改变这种验血开抗生素的模式，还有很长的路要走。而对家长来说，要减少孩子被开滥开抗生素的机会，可以多问医生一句话：是考虑哪种病才开这个药呢？
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