Doing the right thing for asymptomatic bacteriuria: knowing less leads to doing less.
Doing the right thing for asymptomatic bacteriuria: knowing less leads to doing less.
复制标题
针对无症状菌尿症采取正确的做法：了解越少，行动就越少。
DOI：
10.1093/cid/ciu011
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发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Trautner,BarbaraW
中科院分区：
文献类型：
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作者：
Naik,AanandD;Trautner,BarbaraW
临床实践指南是专业协会定义安全有效医疗保健的首选方法。尽管专业协会广泛传播，但指南对常规临床实践的影响仍不理想[1]。美国传染病学会无症状菌尿（ASB）指南是一个特别突出的例子[2]，三分之一到三分之二的ASB患者不适当地接受抗菌药物治疗[3，4]。当患者入院或长期护理状态发生任何变化时，无论是否存在泌尿系统症状，通常都会反射性地进行尿培养[3-5]。临床医生对这些培养的阳性结果作出反应，处方不必要的抗菌药物，经常受到关于老年和虚弱、尿分析脓尿以及尿培养结果中特定类型细菌微生物（例如革兰氏阴性杆菌）的指南不一致认知偏见的影响[3，5]。在这种情况下，Leis等人[6]发表在本版《临床传染病》上的非常简单的干预措施特别优雅。作者探讨了未插管患者在订购时抑制报告尿培养结果的有效性。临床医生收到的标准化声明不是接受尿培养结果作为默认选项，而是声明：“来自未留置导尿管的住院患者的大多数阳性尿培养物代表无症状菌尿”[6]。如果他们“强烈怀疑”尿路感染，他们被鼓励打电话给微生物实验室。这项研究的积极结果在许多层面上都具有挑衅性。首先，他们证实了在74例无导尿管患者的培养物中，ASB（86%）的患病率显著高于尿路感染（14%）。其次，在尿培养公开报告的患者中，根据标准方法，近一半确诊ASB的患者接受了抗生素治疗。第三，干预设计对临床医生的行为有很强的影响。当报告培养结果的默认值被删除时，ASB的指南不一致治疗率从48%下降到12%，临床医生仅为14%（37例中的5例）的抑制培养结果致电微生物实验室。只有4例尿路感染发生在未插管的患者中，在这些病例中，临床医生都根据经验开始治疗，并假设存在临床显著的尿路感染症状。此外，在收集尿培养物后72小时，未接受治疗的患者均未出现具有临床意义的脓毒症或尿路感染体征。这项研究有局限性，在进行大规模评价之前应加以解决。研究人员承认，他们只在一家机构研究了一小部分患者和临床医生。使用导尿管患者作为对照组与未插入导尿管患者的干预样本的原理尚不清楚。这些群体之间的治疗决策可能存在差异，这些差异可以通过临床因素而不是习惯和默认决策错误来更好地解释。最后，任何大规模的干预
Clinical practice guidelines are the preferred method among professional societies for defining safe and effective healthcare. Despite widespread dissemination by professional societies, the impact of guidelines on routine clinical practice remains suboptimal [1]. The Infectious Diseases Society of America guidelines for asymptomatic bacteriuria (ASB) are a particularly salient example [2], with one-third to two-thirds of patients with ASB inappropriately receiving treatment with antimicrobial agents [3, 4]. Urine cultures are often ordered reflexively when patients are admitted to the hospital or have any change in status in long-term care, regardless of the absence of urinary symptoms [3–5]. Clinicians react to positive results on these cultures by prescribing unnecessary antimicrobial agents, frequently swayed by guidelinesdiscordant cognitive biases regarding older age and frailty, pyuria on urinalysis, and the particular types of bacterial organisms (eg, gram-negative rods) on urine culture results [3, 5]. In this context, the very simple intervention by Leis et al [6] published in this edition of Clinical Infectious Diseases is particularly elegant. The authors explored the effectiveness of suppressing reporting of urine culture results when ordered for noncatheterized patients. Instead of receiving urine culture results as the default option, clinicians received a standardized statement declaring,“The majority of positive urine cultures from inpatients without an indwelling urinary catheter represent asymptomatic bacteriuria”[6]. They were encouraged to call the microbiology laboratory if they “strongly suspected” a urinary tract infection. The positive results of this study are provocative on many levels. First, they confirm the significantly higher prevalence of ASB (86%) vs urinary tract infections (14%) among the 74 cultures from patients without urinary catheters. Second, in patients whose urine cultures were reported openly, as per the standard approach, nearly half of all patients with confirmed ASB received antibiotics. Third, the intervention design had a strong effect on clinician behavior. When the default of reporting culture results was removed, the rate of guidelinesdiscordant treatment for ASB dropped from 48% to 12%, and clinicians called the microbiology laboratory for only 14%(5 of 37) of suppressed culture results. Only 4 urinary tract infections occurred in noncatheterized patients, and in each of these cases clinicians had empirically started therapy, with the presumption that clinically significant symptoms of urinary tract infection were present. Furthermore, no untreated patients had clinically significant signs of sepsis or urinary tract infection 72 hours after urine culture collection. The study has limitations that should be addressed prior to conducting a large-scale evaluation. The investigators acknowledge that they studied a small sample of patients and clinicians at only one institution. The rationale for using patients with urinary catheters as the comparison group to the intervention sample of noncatheterized patients is not clear. Treatment decisions may differ between these groups in ways that are better explained by clinical factors rather than customary and default decision errors. Finally, any large-scale intervention