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[JAMA最新论文]:广谱抗生素不能改善急性呼吸道感染患儿的临床预后
2017年12月27日 时讯速递, 进展交流 暂无评论

Original Investigation

December 19, 2017

Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections

Jeffrey S. Gerber, Rachael K. Ross, Matthew Bryan, et al

JAMA. 2017;318(23):2325-2336. doi:10.1001/jama.2017.18715

Abstract

Importance 背景

Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment.

急性呼吸道感染是儿童使用抗生素的主要原因,广谱抗生素越来越多地用于治疗急性呼吸道感染。与窄谱抗生素相比,尚不明确广谱抗生素的使用是否伴随预后改善。

Objective 目的

To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children.

比较广谱与窄谱抗生素治疗儿童急性呼吸道感染的疗效。

Design, Setting, and Participants 设计,场景和研究对象

A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score–matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts.

对于诊断为急性呼吸道感染并口服抗生素的6个月至12岁患儿进行回顾性队列研究评价临床预后,2015年1月至2016年4月间,宾夕法尼亚州及新泽西州的31个儿科初级保健机构组成的研究网络进行前瞻性队列研究,评价患者为中心的预后。两个队列研究分别进行分层及倾向性评分匹配分析,以校正医生及患者特征。

Exposures 暴露因素

Broad-spectrum antibiotics vs narrow-spectrum antibiotics.

广谱及窄谱抗生素。

Main Outcomes and Measures 主要预后指标

In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events.

在回顾性队列研究中,主要预后指标为诊断后14天治疗失败率及不良事件发生率。在前瞻性队列研究中,主要预后指标为生活质量,其他患者预后指标及患者报告的不良事件。

Results 结果

Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, −0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, −1.4% [95% CI, −2.4% to −0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]).

回顾性队列研究总共30159名患儿(19 179名急性中耳炎; 6746名,甲型链球菌咽炎;4234名,急性鼻窦炎)中,4307名 (14%) 使用广谱抗生素,包括阿莫西林-克拉维酸,头孢菌素及大环内酯。广谱抗生素治疗并不伴随治疗失败率的显著降低(广谱抗生素3.4% vs 窄谱抗生素3.1%;完全匹配分析风险差异,0.3% [95% CI, −0.4% to 0.9%])。前瞻性队列研究共纳入2472名患儿(1100名急性中耳炎;705名,甲型链球菌咽炎;667名,急性鼻窦炎),868名 (35%) 使用广谱抗生素。广谱抗生素伴随患儿生活质量轻度恶化(广谱抗生素评分 90.2 vs 窄谱抗生素 91.5 ;完全匹配分析分差,−1.4% [95% CI, −2.4% to −0.4%]),但其他预后指标无差异。使用广谱抗生素者医生(广谱抗生素3.7%  vs 窄谱抗生素 2.7% ;完全匹配分析风险差异,1.1% [95% CI, 0.4% to 1.8%])和患者(广谱抗生素 35.6% vs 窄谱抗生素 25.1%;完全匹配分析的风险差异,12.2% [95% CI, 7.3% to 17.2%])记录的不良事件风险增加。

Conclusions and Relevance 结论与意义

Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.

对于急性呼吸道感染患儿,与窄谱抗生素相比,使用广谱抗生素并不伴随临床或患者预后改善,而且不良事件发生率升高。这些数据支持多数急性呼吸道感染患儿使用窄谱抗生素。

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