Reply to Musher et al.
Reply to Musher et al.
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回复 Musher 等人。
DOI：
10.1093/infdis/jit580
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发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Walsh,EdwardE
中科院分区：
文献类型：
--
作者：
Falsey,AnnR;Walsh,EdwardE
致编辑-我们感谢Musher等人[1]对我们的文章[2]的评论，以及他们对最近发表的与我们相似的研究[3]的全面审查。我们同意，医学实践仍然是一门艺术，严格遵守治疗算法和过度依赖任何单一的测试结果，而没有在适当的临床背景下进行深思熟虑的解释，这并不能很好地服务。然而，我们也认为医学也应该以有效的科学数据为指导，现在有大量的证据表明，血清生物标志物虽然不完美，但对患者管理有用[4]。我们希望再次强调，我们研究的目的是确定使病毒性呼吸道感染复杂化的细菌感染的发生率，这是一个非常有争议的问题，数据很少。为此，我们使用标准检测来确定细菌感染，但也包括降钙素原水平升高，以提供最保守的估计。我们并没有试图验证血清降钙素原水平作为细菌感染的标志物，我们也没有声明或暗示该测试应该是停用抗生素算法的起点。大多数专家都同意，使用传统的微生物技术诊断细菌性呼吸道感染非常困难，而且获得高质量的痰液标本仍然存在很大问题。尽管我们付出了巨大的努力，但我们仅在51%的受试者中在抗生素给药后6小时内成功采集了足够的样本，而Musher等人仅在31%的受试者中在抗生素给药后18小时内采集了足够的样本。目前，还没有敏感和特异性的细菌性呼吸道感染的诊断测试。那么，我们如何尝试回答这个重要的问题呢？Musher et al承认血清降钙素原水平升高通常与细菌感染一致，因此我们不确定他们为什么会担心我们使用传统微生物学数据和降钙素原水平升高来定义病毒感染的细菌并发症。大多数人会同意，单独使用特定的微生物测试会大大低估这个问题。我们的研究与Musher et al的研究之间的一个重要差异是，我们没有将入选限于因肺炎住院的患者。由于美国传染病学会和美国胸科学会都建议对肺炎患者进行早期经验性抗生素治疗，因此细菌并发症的发生率和血清生物标志物在病毒感染患者中的有用性可能不太相关。然而，许多因呼吸道病毒感染住院的患者并没有肺炎;相反，他们患有其他疾病，如慢性阻塞性肺疾病（COPD）急性加重、哮喘急性加重、急性支气管炎和失代偿性慢性疾病，如充血性心力衰竭。这些综合征的抗生素使用没有明确的定义，但它几乎是普遍的住院患者。在Musher等人先前的COPD研究中，我们发现，
TO THE EDITOR—We thank Musher et al [1] for their comments about our article [2] and their thorough review of their recently published study [3] that was similar to ours. We concur that the practice of medicine remains an art that is not well served by strict adherence to treatment algorithms and overreliance on any single test result without thoughtful interpretation in the proper clinical context. However, we also believe that medicine should also be guided by valid scientific data, and there is now a large body of evidence that indicates that serum biomarkers, although not perfect, are useful for patient management [4]. We wish to reemphasize that the goal of our study was to determine the incidence of bacterial infections that complicate viral respiratory infections, a highly debated issue for which there are very few data. To this end, we used standard assays to identify bacterial infection but also included elevated procalcitonin level to provide the most conservative estimate. We were not attempting to validate the serum procalcitonin level as a marker of bacterial infection, nor did we state or imply that this test should be the starting point in algorithms to withhold antibiotics. Most experts would agree that the diagnosis of bacterial respiratory infection by use of traditional microbiologic techniques is remarkably difficult and that the acquisition of good-quality sputum specimens remains very problematic. Despite Herculean efforts to do so, we successfully obtained adequate samples within 6 hours of antibiotic administration in only 51% of subjects, whereas Musher et al collected adequate samples within 18 hours of antibiotic administration from only 31%. At present, there are no sensitive and specific diagnostic tests for bacterial respiratory infection. So how do we attempt to answer this important question? Musher et al acknowledge that an elevated serum procalcitonin level is generally consistent with a bacterial infection, so we are uncertain as to why they would have concerns that we used both traditional microbiologic data and elevated procalcitonin levels for the most inclusive definition for bacterial complications of viral infection. Most would agree that the use of specific microbiologic testing alone would have significantly underestimated the problem. An important difference between our study and the study by Musher et al is that we did not limit inclusion to patients hospitalized with pneumonia. Since both the Infectious Diseases Society of America and the American Thoracic Society recommend early empirical antibiotic therapy for patients with pneumonia, the question of the incidence of bacterial complications and the usefulness of serum biomarkers in this group with viral infection may be less relevant. However, many patients hospitalized with respiratory virus infection do not have pneumonia; rather, they have other conditions, such as acute exacerbation of chronic obstructive pulmonary disease (COPD), acute exacerbation of asthma, acutebronchitis, anddecompensatedchronic medical conditions, such as congestive heart failure. The use of antibiotics for these syndromes is not clearly defined, yet it is nearly universal among hospitalized patients. In our previous study of COPD to which Musher et al refer, we found that the serum procalcitonin level was significantly higher in
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