Lau Timothy, Nurek Martine, Singhal Archit, Moore Luke, Mughal Nabeela, Singh Suveer
Imperial College London, London, UK.
Faculty of Medicine, Imperial College London, London, UK.
BMJ Open. 2024 Dec 20;14(12):e084872. doi: 10.1136/bmjopen-2024-084872.
Intensive care unit (ICU) clinicians stop antibiotics more often, with a negative infection: point-of-care test (PCR-POCT). Simulated cases of diagnostic uncertainty regarding infection resolution led clinicians to choose options such as procalcitonin (PCT) and/or PCR-POCTs +/- de-escalation to aid stop decisions. We hypothesised that a direct infection indicator, PCR-POCT, would influence stop judgements more than indirect PCT. Accordingly, we tested antibiotic-stop decisions when presented with a negative PCR-POCT despite borderline-positive PCT.
Observational prospective study.
ICU.
66 ICU clinicians from University hospitals.
Clinicians saw four scenarios of different clinico-biological trajectories: (1) clear improvement, (2) clear worsening, (3) discordant-clinically better/biologically worse and (4) discordant-clinically worse/biologically better. Participants gave an initial decision (stop/continue/continue-escalate/continue-de-escalate). Then PCR-POCT and/or PCT was offered (accept/decline). After a negative PCR-POCT and borderline-positive PCT result, a final antibiotic decision was taken.
Proportion of stop decisions before versus after test results per scenario. The association of the final decision with the clinician's change in confidence, willingness to request the biomarker(s) and the case trajectory was determined.
Fewer clinicians than expected stopped antibiotics versus baseline (36%, 94/264 vs 42%, 110/264, p=0.045). This was so in three of four scenarios, significantly less in the improvement (p<0.001) and the discordant clinically better scenario (p=0.024). PCT was requested more frequently than PCR-POCT (61% vs 53%, p<0.001). PCT requesters (vs declining) were significantly less inclined to stop antibiotics (p<0.001), while PCR-POCT requesting led to more stopping (p<0.001), before knowing the test results.
A negative PCR-POCT result did not increase clinicians' inclination to stop antibiotics when alongside a borderline-positive PCT. This reflects clinicians' natural risk aversion. PCT was more popular than PCR-POCT, but PCR-POCT was more likely to aid stop decisions.Their comparison, role, utility and selective deployment for influencing antibiotic-stop decisions more effectively require a large randomised controlled trial.
重症监护病房（ICU）的临床医生更频繁地停用抗生素，采用即时检测（PCR-POCT）以排除感染。关于感染是否已消除的诊断存在不确定性的模拟病例，促使临床医生选择降钙素原（PCT）和/或PCR-POCT等选项，并酌情进行降阶梯治疗，以辅助做出停药决定。我们假设，作为直接感染指标的PCR-POCT比间接指标PCT对停药判断的影响更大。因此，我们在PCT临界阳性但PCR-POCT为阴性的情况下，测试了抗生素停药决策。
前瞻性观察研究。
ICU。
来自大学医院的66名ICU临床医生。
临床医生查看了四种不同临床生物学轨迹的场景：（1）明显改善，（2）明显恶化，（3）临床改善但生物学指标恶化，（4）临床恶化但生物学指标改善。参与者给出初步决定（停药/继续用药/继续加量/继续减量）。然后提供PCR-POCT和/或PCT检测（接受/拒绝）。在PCR-POCT为阴性且PCT临界阳性的结果出来后，做出最终的抗生素决策。
每个场景中检测结果前后停药决策的比例。确定最终决策与临床医生信心变化、要求进行生物标志物检测的意愿以及病例轨迹之间的关联。
与基线相比（42%，110/264），实际停用抗生素的临床医生少于预期（36%，94/264，p=0.045）。在四种场景中的三种都是如此，在病情改善场景（p<0.001）和临床改善但生物学指标恶化场景（p=0.024）中显著减少。要求检测PCT的频率高于PCR-POCT（61%对53%，p<0.001）。在得知检测结果之前，要求检测PCT的人（与拒绝检测的人相比）明显不太倾向于停用抗生素（p<0.001），而要求进行PCR-POCT检测则导致更多人停药（p<0.001）。
当PCT临界阳性而PCR-POCT为阴性时，PCR-POCT阴性结果并未增加临床医生停用抗生素的倾向。这反映了临床医生天生的风险规避心理。PCT比PCR-POCT更受欢迎，但PCR-POCT更有可能辅助停药决策。为了更有效地影响抗生素停药决策，对它们进行比较、明确其作用、效用和选择性应用，需要进行一项大型随机对照试验。
