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降钙素原指导下使用抗生素治疗下呼吸道感染
Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection


David T. Huang ... 呼吸系统疾病 • 2018.07.19
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测降钙素原是否能降低抗生素滥用

 

David T. Huang*†‡§

*CRISMA Center; †Department of Critical Care Medicine; ‡Department of Emergency Medicine; §MACRO, University of Pittsburgh, Pittsburgh, PA, USA

 

此前有欧洲试验报告,遵循降钙素原指导抗生素用药指南,可减少LRTI中的抗生素用药。然而,这些数据是否适用于日常临床实践尚不明确。在既往最大型的试验中,医师只有在咨询协调中心、确定危重病或军团菌感染后才能否决降钙素原指南中的建议,而且各国官方和专业学会对降钙素原指导的抗生素处方得出的结论各不相同。值得注意的是,只有极少数研究在美国进行,而美国的处方模式可能与别处不同。

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摘要


背景

降钙素原指导下使用抗生素治疗疑似下呼吸道感染的效果尚不清楚。

 

方法

在14家严格遵循肺炎治疗质量措施的美国医院,我们为临床医师提供了有关下呼吸道感染治疗和降钙素原测定解读的国家临床实践建议。随后我们将到急诊就诊,治疗医师不确定是否有抗生素治疗指征的疑似下呼吸道感染患者随机分为以下两组:降钙素原组(向治疗医师提供实时初始和连续[如果患者住院]降钙素原测定结果,以及抗生素使用指南和基于4个层级降钙素原水平的分级建议)或常规治疗组。我们假设,在纳入研究后30天内,降钙素原组的抗生素用药总天数低于常规治疗组,并且有不良结局的患者百分比高出常规治疗组不超过4.5个百分点。

 

结果

总共1,656例患者被纳入最终分析队列(826例被随机分配至降钙素原组,830例被分配至常规治疗组),在30天内,其中782例(47.2%)住院治疗,984例(59.4%)接受了抗生素治疗。治疗医师收到了降钙素原组826例患者中792例(95.9%)(从采样至获得测定结果的中位时间,77分钟)和常规治疗组830例患者中18例(2.2%)的降钙素原测定结果。在两组中,降钙素原水平层级与急诊科开具抗生素处方的决定相关。在降钙素原组和常规治疗组之间,30天内的抗生素用药天数(平均值,分别为4.2天和4.3天;差异,-0.05天;95%置信区间[CI],-0.6~0.5;P=0.87)或有不良结局的患者比例(11.7% [96例患者]和13.1% [109例患者];差异,-1.5个百分点;95% CI,-4.6~1.7;对于非劣效性,P<0.001)无显著差异。

 

结论

在疑似下呼吸道感染患者中,与常规治疗相比,向急诊科和医院医师提供降钙素原测定结果及其解读方法说明并未减少抗生素用药(由美国国立综合医学研究所[National Institute of General Medical Sciences]资助;ProACT在ClinicalTrials.gov注册号为NCT02130986)。





作者信息

David T. Huang, M.D., M.P.H., Donald M. Yealy, M.D., Michael R. Filbin, M.D., Aaron M. Brown, M.D., Chung-Chou H. Chang, Ph.D., Yohei Doi, M.D., Ph.D., Michael W. Donnino, M.D., Jonathan Fine, M.D., Michael J. Fine, M.D., Michelle A. Fischer, M.D., M.P.H., John M. Holst, D.O., Peter C. Hou, M.D., John A. Kellum, M.D., Feras Khan, M.D., Michael C. Kurz, M.D., Shahram Lotfipour, M.D., M.P.H., Frank LoVecchio, D.O., M.P.H., Octavia M. Peck-Palmer, Ph.D., Francis Pike, Ph.D., Heather Prunty, M.D., Robert L. Sherwin, M.D., Lauren Southerland, M.D., Thomas Terndrup, M.D., Lisa A. Weissfeld, Ph.D., Jonathan Yabes, Ph.D., and Derek C. Angus, M.D., M.P.H. for the ProACT Investigators*
From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.). Address reprint requests to Dr. Huang at Scaife Hall, Rm. 606B, University of Pittsburgh, 3550 Terrace St., Pittsburgh, PA 15261, or at huangdt@upmc.edu *The complete list of the ProACT Investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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