降钙素原指导下的抗生素使用与初级保健中急性呼吸道感染的标准治疗方法对比

Procalcitonin-guided antibiotic use vs a standard approach for acute respiratory tract infections in primary care.

作者信息

Briel Matthias, Schuetz Philipp, Mueller Beat, Young Jim, Schild Ursula, Nusbaumer Charly, Périat Pierre, Bucher Heiner C, Christ-Crain Mirjam

机构信息

Department of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.

出版信息

Arch Intern Med. 2008 Oct 13;168(18):2000-7; discussion 2007-8. doi: 10.1001/archinte.168.18.2000.

DOI:10.1001/archinte.168.18.2000

PMID:18852401

Abstract

BACKGROUND

Acute respiratory tract infections are the most common reason for antibiotic therapy in primary care despite their mainly viral etiology. A laboratory test measuring procalcitonin levels in blood specimens was suggested as a tool to reduce unnecessary prescribing of antibiotics. We consider whether antibiotic therapy guided by procalcitonin reduces the use of antibiotics without increasing the restrictions experienced by patients by more than 1 day.

METHODS

Fifty-three primary care physicians recruited 458 patients, each patient with an acute respiratory tract infection and, in the physician's opinion, in need of antibiotics. Patients were centrally randomized to either a procalcitonin-guided approach to antibiotic therapy or to a standard approach. For patients randomized to procalcitonin-guided therapy, the use of antibiotics was more or less strongly discouraged (procalcitonin level, < or =0.1 or < or =0.25 microg/L, respectively) or recommended (procalcitonin level, >0.25 microg/L). Follow-up data were collected at 7 days by treating physicians and at 14 and 28 days by blinded interviewers.

RESULTS

Adjusted for baseline characteristics, the mean increase at 14 days in days in which activities were restricted was 0.14 with procalcitonin-guided therapy (95% confidence interval [CI], -0.53 to 0.81 days), which met our criterion of an increase in days in which activities were restricted by no more than 1 day. With procalcitonin-guided therapy, the antibiotic prescription rate was 72% lower (95% CI, 66%-78%) than with standard therapy. Both approaches led to a similar proportion of patients reporting symptoms of ongoing or relapsing infection at 28 days (adjusted odds ratio, 1.0 [95% CI, 0.7-1.5]).

CONCLUSIONS

As an adjunct to guidelines, procalcitonin-guided therapy markedly reduces antibiotic use for acute respiratory tract infections in primary care without compromising patient outcome. In practice, this could be achieved with 1 to 2 procalcitonin measurements in patients for whom the physician intends to prescribe antibiotics.

摘要

背景

尽管急性呼吸道感染主要由病毒引起，但它却是基层医疗中抗生素治疗最常见的原因。一项检测血液样本中降钙素原水平的实验室检查被提议作为减少不必要抗生素处方的工具。我们探讨以降钙素原指导的抗生素治疗是否能减少抗生素的使用，同时不会使患者活动受限天数增加超过1天。

方法

53名基层医疗医生招募了458例患者，每名患者均患有急性呼吸道感染，且医生认为需要使用抗生素。患者被集中随机分为降钙素原指导的抗生素治疗组或标准治疗组。对于随机分配到降钙素原指导治疗组的患者，根据降钙素原水平（分别为≤0.1或≤0.25μg/L）或多或少地不鼓励使用抗生素，或根据降钙素原水平（>0.25μg/L）推荐使用抗生素。治疗医生在7天收集随访数据，盲法访视者在14天和28天收集随访数据。

结果

校正基线特征后，降钙素原指导治疗组在14天时活动受限天数的平均增加为0.14天（95%置信区间[CI]，-0.53至0.81天），符合我们设定的活动受限天数增加不超过1天的标准。采用降钙素原指导治疗，抗生素处方率比标准治疗低72%（95%CI，66%-78%）。两种治疗方法导致在28天时报告持续或复发感染症状的患者比例相似（校正比值比，1.0[95%CI，0.7-1.5]）。