McIsaac Warren J, Moineddin Rahim, Gágyor Ildikó, Mazzulli Tony
Granovsky-Gluskin Family Medicine Centre, Ray D. Wolfe Department of Family Medicine, Sinai Health System, Mount Sinai Hospital, 60 Murray Street, Toronto, M5T 3L9, Canada.
Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
BMC Fam Pract. 2017 Oct 2;18(1):89. doi: 10.1186/s12875-017-0660-y.
Empirical prescribing of antibiotics to women with symptoms of acute cystitis prior to culture results is common, but subsequent culture results are often negative. A clinical decision aid for prescribing decisions in acute cystitis was previously developed that could reduce these unnecessary antibiotic prescriptions but has not been validated. This study sought to validate this decision aid for empirical antibiotic prescribing decisions in a new cohort of women with suspected acute cystitis.
External validation study of a clinical decision aid in 397 women with symptoms of acute cystitis, involving 230 Canadian family practitioners across Canada between 2009 and 2011. The sensitivity and specificity of the decision aid compared to a gold standard positive urine culture (defined as ≥10 cfu/ml (≥10 CFU/L)) was determined, and compared with physician management, and the earlier development cohort study estimates. Other outcomes assessed were total antibiotic prescriptions, unnecessary antibiotics for negative urine cultures, and recommendations for urine culture testing. Chi-square tests were used for unpaired comparisons, adjusted for physician clustering. McNemar's test was used for paired comparisons.
There were 245/397 (61.7%) positive urine cultures. The cystitis aid sensitivity was 202/245 (82.5%, 95% Confidence Interval (CI)) = 77.1%, 86.8%), compared to 167/208 (80.3%) in the previous development cohort (p = 0.54), and 239/245 (97.6%) by family physicians in the current study (p < 0.001). Specificity was low for physicians (10/152, 6.6%) compared to the decision aid (54/152, 35.5%; p < 0.001, resulting in more antibiotic prescriptions by physicians (381/397, 96.0%) than would occur with decision aid recommendations (300/397, 75.6%, p < 0.001). Unnecessary antibiotic prescriptions where urine cultures were negative would be reduced an absolute 11.1% with cystitis aid recommendations (98/397, 24.7%) compared to usual physician care (142/397, 35.8%; p = 0.001). Urine cultures would also be reduced (97/397, 24.4% decision aid vs 351/397, 88.4% physicians; p < 0.001).
A 3-item clinical decision aid demonstrated reproducible accuracy in two cohorts of women with acute cystitis symptoms. Clinically important reductions in total and unnecessary antibiotic use, as well as urine culture testing, could result with routine clinical use compared to current empirical physician management practices.
在获得培养结果之前，对有急性膀胱炎症状的女性进行经验性抗生素处方是常见做法，但随后的培养结果往往为阴性。先前已开发出一种用于急性膀胱炎处方决策的临床决策辅助工具，它可以减少这些不必要的抗生素处方，但尚未得到验证。本研究旨在在一组新的疑似急性膀胱炎女性中验证这种用于经验性抗生素处方决策的决策辅助工具。
对397名有急性膀胱炎症状的女性进行临床决策辅助工具的外部验证研究，研究对象包括2009年至2011年间加拿大各地的230名家庭医生。确定该决策辅助工具与金标准阳性尿培养（定义为≥10 cfu/ml（≥10 CFU/L））相比的敏感性和特异性，并与医生的管理方式以及早期开发队列研究的估计值进行比较。评估的其他结果包括抗生素总处方量、尿培养阴性时的不必要抗生素使用以及尿培养检测建议。采用卡方检验进行非配对比较，并对医生聚类进行校正。采用麦克尼马尔检验进行配对比较。
397例中有245例（61.7%）尿培养阳性。膀胱炎辅助工具的敏感性为202/245（82.5%，95%置信区间（CI）=77.1%，86.8%），而先前开发队列中的敏感性为167/208（80.3%）（p = 0.54），本研究中家庭医生的敏感性为239/245（97.6%）（p < 0.001）。与决策辅助工具相比，医生的特异性较低（10/152，6.6%）（54/152，35.5%；p < 0.001），导致医生开具的抗生素处方（381/397，96.0%）比决策辅助工具建议的更多（300/397，75.6%，p < 0.001）。与常规医生护理（142/397，35.8%）相比，膀胱炎辅助工具建议可使尿培养阴性时的不必要抗生素处方绝对减少11.1%（98/397，24.7%）（p = 0.001）。尿培养检测也会减少（决策辅助工具为97/397，24.4%，医生为351/397，88.4%；p < 0.001）。
一个包含三项内容的临床决策辅助工具在两组有急性膀胱炎症状的女性中显示出可重复的准确性。与当前经验性医生管理实践相比，常规临床使用该工具可使抗生素总使用量和不必要使用量以及尿培养检测在临床上得到显著减少。
