Tu J V, Biem H J, Detsky A S
Department of Medicine, University of Toronto, Ontario, Canada.
Am Rev Respir Dis. 1993 Aug;148(2):370-7. doi: 10.1164/ajrccm/148.2.370.
The outcomes of alternative strategies for the management of pulmonary complications in patients infected with the human immunodeficiency virus (HIV) and with suspected Pneumocystis carinii pneumonia were compared using a decision analysis model. A decision tree was constructed using baseline probabilities derived from published data and expert opinion. The case scenario analyzed was that of a patient not currently receiving anti-Pneumocystis prophylaxis who presents with moderate pulmonary symptoms and fulfills the Centers for Disease Control (CDC) criteria for presumptive P. carinii pneumonia. Two strategies were compared: (1) early bronchoscopy with appropriate therapy based on the results, and (2) empiric treatment for P. carinii (trimethoprim/sulfamethoxazole or pentamidine, and steroids) with delayed bronchoscopy in those not responding to 5 days of empiric therapy. The expected 1-month survival rate (with and without quality of life adjustment) was found to be essentially the same for the two strategies using the baseline probabilities, and the decision remained a toss-up within the clinically relevant range of published probabilities for P. carinii pneumonia in patients fulfilling the CDC criteria. Because early bronchoscopy does not offer any additional survival benefits and is associated with greater costs and disutility, empiric therapy would appear to be the superior management strategy in this scenario.
运用决策分析模型比较了人类免疫缺陷病毒（HIV）感染者疑似卡氏肺孢子虫肺炎时肺部并发症的不同管理策略的结果。使用从已发表数据和专家意见得出的基线概率构建了决策树。分析的病例场景是一名目前未接受抗肺孢子虫预防治疗的患者，出现中度肺部症状且符合疾病控制中心（CDC）推定卡氏肺孢子虫肺炎的标准。比较了两种策略：（1）早期进行支气管镜检查，并根据结果进行适当治疗；（2）对卡氏肺孢子虫进行经验性治疗（甲氧苄啶/磺胺甲恶唑或喷他脒，以及类固醇），对5天经验性治疗无反应者延迟进行支气管镜检查。使用基线概率发现，两种策略的预期1个月生存率（有和没有生活质量调整）基本相同，在符合CDC标准的患者中，对于已发表的卡氏肺孢子虫肺炎概率的临床相关范围内，决策仍然难以确定。由于早期支气管镜检查没有提供任何额外的生存益处，且与更高的成本和负效用相关，因此在这种情况下，经验性治疗似乎是更优的管理策略。
