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通过检测C反应蛋白指导COPD加重患者的抗生素处方
C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations


Christopher C. Butler ... 呼吸系统疾病 • 2019.07.11
相关阅读
• 降钙素原指导下使用抗生素治疗下呼吸道感染 • 降钙素原指导COPD急性加重的治疗

摘要


背景

C反应蛋白(CRP)即时检测可能能够减少慢性阻塞性肺疾病(COPD)急性加重患者不必要的抗生素治疗,而不会给患者造成伤害。

 

方法

我们开展了一项多中心、开放标签、随机、对照试验,纳入了初级保健病历中诊断为COPD,且因COPD急性加重而在英格兰和威尔士86家全科诊所之一就诊的患者。患者被分配接受CRP即时检测指导下的常规治疗(CRP指导组),或者单独常规治疗(常规治疗组)。主要结局是随机分组后4周内患者报告因COPD急性加重使用抗生素(以证明优效性),以及随机分组后2周时使用临床COPD问卷(包含10个项目的量表,评分范围为0[非常好的COPD健康状况]~6分[极差的COPD健康状况])测定的COPD相关健康状况(以证明非劣效性)。

 

结果

共有653例患者被随机分组。CRP指导组报告使用抗生素的患者比常规治疗组少(57.0% vs. 77.4%;校正比值比,0.31;95%置信区间[CI],0.20~0.47)。2周时临床COPD问卷总分的校正平均差为-0.19分(双侧90% CI,-0.33~-0.05),CRP指导组的结果较好。本试验确认了除1例患者外所有患者初次就诊时临床医师开出的抗生素处方,并确认了前4周随访期间96.9%患者的抗生素处方。初次就诊时(47.7% vs. 69.7%,差异为22.0个百分点;校正比值比,0.31;95% CI,0.21~0.45)和前4周随访期间(59.1% vs. 79.7%,差异为20.6个百分点;校正比值比,0.30;95% CI,0.20~0.46),CRP指导组收到抗生素处方的患者百分比低于常规治疗组。在随机分组后4周内,常规治疗组2例患者死于研究者认为与参与试验无关的原因。

 

结论

在初级保健诊所,在CRP指导下为COPD加重患者开具抗生素处方与由临床医师开具抗生素处方相比,前一种方案报告使用抗生素的患者比例较低,且无造成伤害的证据(由英国国家卫生研究院医疗技术评估计划[National Institute for Health Research Health Technology Assessment Program]资助;PACE在Current Controlled Trials注册号为ISRCTN24346473)。





作者信息

Christopher C. Butler, F.Med.Sci., David Gillespie, Ph.D., Patrick White, M.D., Janine Bates, M.Phil., Rachel Lowe, Ph.D., Emma Thomas-Jones, Ph.D., Mandy Wootton, Ph.D., Kerenza Hood, Ph.D., Rhiannon Phillips, Ph.D., Hasse Melbye, Ph.D., Carl Llor, Ph.D., Jochen W.L. Cals, M.D., Ph.D., Gurudutt Naik, M.B., M.S., M.P.H., Nigel Kirby, M.A., Micaela Gal, D.Phil., Evgenia Riga, M.Sc., and Nick A. Francis, Ph.D.
From the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford (C.C.B., E.R.), the Centre for Trials Research (D.G., J.B., R.L., E.T.-J., K.H., N.K.), the Division of Population Medicine (R.P., G.N., N.A.F.), and Wales Centre for Primary and Emergency Research, School of Medicine (M.G.), Cardiff University, the Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales (M.W.), Cardiff, and the School of Population Health and Environment Science, King’s College, London (P.W.) — all in the United Kingdom; the General Practice Research Unit, Department of Community Medicine, University of Tromsø–the Arctic University of Norway, Tromsø, Norway (H.M.); the University Institute in Primary Care Research Jordi Gol, Via Roma Health Center, Barcelona (C.L.); and the Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands (J.W.L.C.). Address reprint requests to Dr. Butler at the Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Bldg., Radcliffe Observatory Quarter, Woodstock Rd., Oxford OX2 6GG, United Kingdom, or at christopher.butler@phc.ox.ac.uk.

 

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