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Ann Intensive Care:重症患者抗菌药随意停用可还行?需在PCT水平的指导下

2018-01-08 石岩 环球医学资讯

对感染的及时诊断和适当的抗菌药治疗仍是重症监护环境中的主要挑战。由于感染早期缺乏特异性临床指证,可能导致诊断延误,使抗菌药治疗暂停或延缓。 另一方面,由于这种担忧,临床医生也可能在ICU中过度使用抗菌药。2017年11月,发表在《Ann Intensive Care》的一项由中国科学家进行的系统评价和meta分析,考察了重症监护患者原降钙素指导的抗菌药治疗。

感染的及时诊断和适当的抗菌药治疗仍是重症监护环境中的主要挑战。由于感染早期缺乏特异性临床指证,可能导致诊断延误,使抗菌药治疗暂停或延缓。 另一方面,由于这种担忧,临床医生也可能在ICU中过度使用抗菌药。2017年11月,发表在《Ann Intensive Care》的一项由中国科学家进行的系统评价和meta分析,考察了重症监护患者原降钙素指导的抗菌药治疗。

背景:血清原降钙素(PCT)浓度用于指导抗菌药选择、给药时机和抗感染治疗时间,从而避免过度使用抗菌药。因此,研究人员进行了一项系统评价和meta分析,旨在寻找不同PCT指导的抗菌药策略对重症患者预先设定的临床结局影响的证据。

方法:研究人员在Pubmed、Embase、知识网、Cochrane图书馆上检索了相关研究,检索截至到2017年2月25日。纳入报道PCT指导的抗菌药使用或标准治疗的成年ICU患者相关结局的随机对照试验(RCT)。结果表示为风险比(RR)或平均差(MD)及其相应95%置信区间(CI)。

数据合成:研究人员纳入了13项试验,包括5136例患者。这些研究使用了3种PCT临床策略:初始、停用或抗菌药初始和停用联合策略。汇总分析表明,PCT指导的抗菌药停用策略具有更少的抗菌药总使用天数(MD,-1.66天;95% CI,-2.36~-0.96),更长的无抗菌药天数(MD,2.26;95% CI,1.40~3.12),较低的短期死亡率(RR,0.87;95% CI ,0.76~0.98),对其他结局无不良影响。仅有很少的研究报道了其他PCT指导的抗菌药策略的数据,汇总结果表明,对结局指标无获益。

结论:Meta分析表明,所有基于PCT的策略中,仅有使用PCT指导抗菌药停用才可减少重症患者抗菌药暴露和短期死亡率。

在多项研究中考察的PCT指导策略在优化抗菌药治疗方面的结果相互矛盾。 本项meta分析证明较低水平的PCT可停止抗菌药治疗。与标准治疗相比,抗菌药治疗的持续时间可缩短约1.67天,且短期死亡率较低。由于证据不足,基线PCT值不应被用作指导初始抗菌药的标志物。

该meta分析提供了有力的证据来支持和扩大2016年SSC指南中的弱推荐,例如用低PCT水平来帮助临床医师停止经验性抗菌药的使用。至于将PCT策略与抗菌药使用的开始和终止结合在一起,研究人员未发现任何预定结局的获益,这可能是由于只有两个试验(一个正面和一个负面)考察了不同的目标和方法的组合策略。另一方面,报告的非依从率很高。

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    2018-03-24 lvliquan
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    2018-01-31 落落霞

    学习了

    0

  4. 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createdName=ms7899726347904398, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373061, encodeId=ee4413e306163, content=<a href='/topic/show?id=eb2555e176c' target=_blank style='color:#2F92EE;'>#抗菌药#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55717, encryptionId=eb2555e176c, topicName=抗菌药)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7e12358, createdName=lhlxtx, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=276656, encodeId=40812e665688, content=henhao, beContent=null, objectType=article, channel=null, level=null, likeNumber=106, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NcXNhUvfhzd2VdicMnaLeK2Im5gKx4Ucxd8Bwu6S7RG0uILBFQx5HTW2bU4VricDYlQqN20ibASSMYAeGrZrrTpy2Q/0, createdBy=b0041939716, createdName=hhh678, createdTime=Mon Jan 08 17:31:25 CST 2018, time=2018-01-08, status=1, ipAttribution=)]
    2018-01-17 张新亮1853311252142e2fm

    好东西.大家分享

    0

  5. 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href='/topic/show?id=cdb79594643' target=_blank style='color:#2F92EE;'>#重症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95946, encryptionId=cdb79594643, topicName=重症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6c3a189, createdName=longqijun248, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1330645, encodeId=acc31330645c1, content=<a href='/topic/show?id=c6b455688d1' target=_blank style='color:#2F92EE;'>#抗菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55688, encryptionId=c6b455688d1, topicName=抗菌)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/2898B09F0DA89357D0D54A725E611AC7/100, createdBy=fdd32500040, createdName=ms7899726347904398, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373061, encodeId=ee4413e306163, content=<a href='/topic/show?id=eb2555e176c' target=_blank style='color:#2F92EE;'>#抗菌药#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55717, encryptionId=eb2555e176c, topicName=抗菌药)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7e12358, createdName=lhlxtx, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=276656, encodeId=40812e665688, content=henhao, beContent=null, objectType=article, channel=null, level=null, likeNumber=106, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NcXNhUvfhzd2VdicMnaLeK2Im5gKx4Ucxd8Bwu6S7RG0uILBFQx5HTW2bU4VricDYlQqN20ibASSMYAeGrZrrTpy2Q/0, createdBy=b0041939716, createdName=hhh678, createdTime=Mon Jan 08 17:31:25 CST 2018, time=2018-01-08, status=1, ipAttribution=)]
    2018-01-14 1e0f8808m18(暂无匿称)

    学习了.谢谢分享.

    0

  6. 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href='/topic/show?id=cdb79594643' target=_blank style='color:#2F92EE;'>#重症患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95946, encryptionId=cdb79594643, topicName=重症患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6c3a189, createdName=longqijun248, createdTime=Wed Jan 10 06:22:00 CST 2018, time=2018-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1330645, encodeId=acc31330645c1, content=<a href='/topic/show?id=c6b455688d1' target=_blank style='color:#2F92EE;'>#抗菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55688, encryptionId=c6b455688d1, topicName=抗菌)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/2898B09F0DA89357D0D54A725E611AC7/100, createdBy=fdd32500040, 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createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NcXNhUvfhzd2VdicMnaLeK2Im5gKx4Ucxd8Bwu6S7RG0uILBFQx5HTW2bU4VricDYlQqN20ibASSMYAeGrZrrTpy2Q/0, createdBy=b0041939716, createdName=hhh678, createdTime=Mon Jan 08 17:31:25 CST 2018, time=2018-01-08, status=1, ipAttribution=)]
    2018-01-13 1e0f8808m18(暂无匿称)

    好文章.学习了.

    0

  7. 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  8. 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    2018-01-10 lhlxtx
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    2018-01-08 hhh678

    henhao

    0

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