CRP检测可用于呼吸道感染的抗生素处方指引


  【24drs.com】March 23, 2010 — 根据发表于3/4月家庭医学志(Annals of Family Medicine)的新研究,于诊间进行C反应蛋白(CRP)检测以辨识身体的发炎或感染,可帮助医师确认哪里些呼吸道感染病患可以获益于抗生素治疗,因而减少不必要的抗生素使用。
  
  荷兰马斯垂克大学的Jochen W. L. Cals博士等人写道,在全科医疗中,抗生素是急性下呼吸道感染(lower respiratory tract infections,LRTI)与鼻窦炎病患的唯一有用方式,但是经常被过度处方,根据征兆与症状对于确认这些病患是否需使用抗生素的帮助有限。
  
  研究作者写道,不确定诊断、病患的期待与压力等因素往往会促使家庭医师处方不合理使用的抗生素。
  
  研究目标为探讨于诊间进行CRP检测是否有助于医师将病患区分为无需处方、之后再处方、立即需要处方,且不会有害于结果。
  
  因此,研究者于2007年11月至2008年4月间随机指派107名LRTI病患以及151名鼻窦感染病患,接受CRP检测或不予检测,病患来自荷兰东南部11 个全科医疗中心的33个家庭医师。
  
  研究者使用QuikRead CRP分析器(芬兰艾斯博(Espoo)、Orion Diagnostica公司制造)进行CRP分析,在3分钟之内可以获得结果。
  
  若CRP检测结果为小于20 mg/L,则建议医师不要开立抗生素,若结果为大于100 mg/L,则建议立即开立抗生素,若CRP检测结果介于20-99 mg/L,则建议延后开立抗生素,不过,他们随时可以决定跳脱此建议处方计划 。
  
  初级结果是指标谘商后的抗生素使用情况,次级结果包括追踪28天期间的抗生素使用情形、病患满意度以及临床恢复程度。
  
  研究者发现,在指标谘商之后,CRP组的病患(43.4%)比对照组病患(56.6%)使用较少抗生素(相对风险[RR]为0.77;95%信心区间[CI]为0.56 -0.98)。
  
  此一差异在追踪期间依旧显著(52.7% vs 65.1%;RR,0.81;95% CI,0.62 - 0.99)。
  
  再者,延后开立处方或者开立症状持续时方可使用之处方方面,相较于对照组(72%),CRP组较少人(23%)实际领用药品(P < 0.001)。
  
  研究者也发现,当有在诊间进行CRP检测时,病患对于照护的满意度也较高 (P = .03)。
  
  两组的恢复率相当。
  
  研究限制是,强度不足以侦测出呼吸道感染与鼻窦炎病患之间的差异,另外,医师无法对研究过程不知情,因为他们必须知道病患的CRP结果,以决定合适的临床处置。
  
  研究作者结论表示,定点照护检测CRP可以帮助医师决定处方或延迟处方抗生素,他们写道,重要的是,这类检查可以帮助减少不适当的抗生素使用,也可在不影响恢复下增加病患满意度。
  
  宾州匹兹堡大学医学中心肺部、过敏与重症照护医疗小组主任Mark T. Gladwin医师受邀对此研究发表评论时向Medscape Family Medicine表示,在其它许多研究中,使用另一种称为「前降钙素(procalcitonin) 」的标记,以类似的方法来辨识那些细菌感染风险较高或严重细菌感染的病患。
  
  他表示,使用这些标记与决策模式,研究者可以减少使用抗生素的病患比率,虽然未使用抗生素的病患比率只有适度降低,这些策略有助于减少目前美国病毒性上呼吸道感染的抗生素使用情况。仍需更大型的研究来确认这些方法的一般性,探讨这些方法是否可以降低抗生素抗药性的发生。
  
  制造QuikRead定点照护CRP检测装置的Orion Diagnostica公司(芬兰)资助该研究。
  
  Cals医师接受荷兰健康研究与发展组织之资助,研究作者之一(Rogier M. Hopstaken, MD, PhD) 宣告与Axis-Shield (挪威)和Orion Diagnostica (芬兰)有财务关系。

CRP Test Guides Antibiotic Prescribing for Respiratory Tract Infections

By Fran Lowry
Medscape Medical News

March 23, 2010 — C-reactive protein (CRP) testing done in the office to identify inflammation or infection in the body may help physicians determine which patients with respiratory tract infection will benefit from antibiotic treatment, and so reduce unnecessary antibiotic use, according to a new study published in the March/April issue of the Annals of Family Medicine.

"Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common," write Jochen W. L. Cals, MD, PhD, from Maastricht University, Maastricht, the Netherlands, and colleagues. "Signs and symptoms are of limited value in identifying those patients in need of antibiotic treatment for these conditions."

Uncertainty about the diagnosis and patient expectations and pressure can often prompt family physicians to prescribe antibiotics that are not justified, the study authors write.

The goal of this study was to see whether CRP testing at the time of the office visit would help the physician triage patients into no prescription, delayed prescription, or immediate prescription categories, without compromising their outcomes.

To do so, the investigators randomly assigned 107 patients with LRTI and 151 patients with sinus infections to testing with CRP vs no testing. The patients were recruited from 33 family physicians working in 11 family practice centers in the southeastern part of the Netherlands from November 2007 until April 2008.

The researchers carried out the CRP analysis using QuikRead CRP analyzers (Orion Diagnostica, Espoo, Finland), and results from the test were available within 3 minutes.

The physicians were advised not to prescribe antibiotics when the CRP test results were less than 20 mg/L, to give immediate antibiotics when the results were greater than 100 mg/L, and to consider writing a prescription for delayed antibiotics when the CRP levels were between 20 and 99 mg/L. However, they were free to deviate from this proposed prescribing plan at any time.

The primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery.

The investigators found that patients in the CRP group used fewer antibiotics (43.4%) than patients in the control group (56.6%) after the index consultation (relative risk [RR], 0.77; 95% confidence interval [CI], 0.56 - 0.98).

This difference remained significant during the follow-up period (52.7% vs 65.1%; RR, 0.81; 95% CI, 0.62 - 0.99).

Moreover, in the CRP group, delayed prescriptions, or prescriptions written under the condition that they were not to be used immediately but only if symptoms persisted, were filled only in a minority of patients (23%) vs 72% in the control group (P < 0.001).

The researchers also found that patient satisfaction with care was higher when CRP testing was used during the office visit (P = .03).

Both groups had similar recovery rates.

A limitation of the study is that it was not powered to detect differences between patients with respiratory tract infections and rhinosinusitis. Another is that physicians were not blinded because they needed to know patients' CRP results to decide on appropriate clinical management.

The study authors conclude that point-of-care CRP testing can assist clinicians in making decisions about prescribing, or delaying prescribing, antibiotics. Importantly, they write, such testing may help decrease inappropriate antibiotic use and also increase patient satisfaction without compromising recovery.

Asked to comment on this study by Medscape Family Medicine, Mark T. Gladwin, MD, chief of the Division of Pulmonary, Allergy and Critical Care Medicine at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, said that a similar approach to identifying patients at higher risk of having a bacterial infection or a more severe bacterial infection has been used in many studies using another marker called procalcitonin.

"Using these markers and decision protocols, the investigators were able to reduce the percentage of people who received antibiotics. While the percentage of patients that do not receive antibiotics is only modestly reduced, these strategies may help reduce our current high use of antibiotics for viral upper respiratory illnesses in the US," he said. "Larger studies will be needed to confirm the generalizability of these approaches and to show that these approaches reduce the development of antibiotic resistance."

This study was funded by Orion Diagnostica (Finland), which is the maker of the QuikRead point-of-care CRP testing device.

Dr. Cals is supported by a grant of the Netherlands Organization for Health Research and Development. One of the study authors (Rogier M. Hopstaken, MD, PhD) has disclosed financial relationships with Axis-Shield (Norway) and Orion Diagnostica (Finland).

Ann Fam Med. 2010;8:124-133.

    
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