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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 洪健華 | 重新評估成年女性急性單純性膀胱炎抗生素治療的療程：61篇隨機對照臨床試驗的系統性回顧和網絡統合分析 | 2020/8/31 下午 04:20:42 | 0 |
| 原 文 | 題 目 | Reappraisal of the treatment duration of antibiotic regimens for acute uncomplicated cystitis in adult women: a systematic review and network meta-analysis of 61 randomised clinical trials |
| 作 者 | Do Kyung Kim, Jae Heon Kim, Joo Yong Lee, Nam Su Ku, Hye Sun Lee, Ju-Young Park, Jong Won Kim, Kwang Joon Kim, Kang Su Cho | |
| 出 處 | Lancet Infect Dis . 2020 May 21;S1473-3099(20)30121-3. | |
| 出版日期 | 2020-5-21 | |
| 評 論 |
「非複雜性膀胱炎」定義為急性、偶發性或復發性膀胱炎，限於非妊娠，沒有已知相關的尿路解剖或功能異常或共病。不同指引之治療建議各有不同。此篇研究提供一個系統性的回顧與建議。 背景 有眾多隨機臨床試驗的證據顯示，對於治療急性單純性膀胱炎，短期抗生素治療與長期抗微生物治療在根治症狀一樣有效。然而，並非所有短期治療都在臨床指引中被採用。這項研究是在目前的急性單純性膀胱炎指引中，利用特別的統計分析方式（網絡統合分析）重新評估了每種抗生素的治療時間，以進一步研究是否可以減少抗生素的療程長短。 方法 此研究透過系統性在PubMed，Embase和Cochrane圖書館數據庫中，從數據庫建立開始到2019年12月31日間，搜索了所有相關出版報告。其中僅針對急性單純性女性的隨機臨床試驗，包括評估抗生素治療並有報告臨床或微生物反應結果值的膀胱炎，進行了網絡統合分析。並評估了所有納入研究的證據質量。主要結果是看臨床反應，定義為在回診評估是否痊癒測試中(test-of-cure)，所有初始症狀完全消失。對於二元結果變項，則透過Bayesian hierarchical random-effects 模型，直接和間接地比較每種藥物的療效。 結果 整體而言，此統合分析評估了61項隨機臨床試驗，共包括20,780例患者。對於第三代和第四代氟喹諾酮類(fluoroquinolones)藥物，為期3天的治療療程與 單次劑量之臨床反應相近（風險比0.994 [95％信賴區間0.939-1•052]與1.024[0.974–1.083]，且證據質量中等。對於pivmecillinam，5天和7天的療程則類似於3天之療程，證據質量中等（5天療程風險比 1.041 [0.910-1.193]和7天療程的1.095 [0.999-1.203]。同時，對於第三代頭孢菌素和阿莫西林(amoxicillin)，clavulanate，單次劑量和3天療程間沒有差異，但是相關支持之證據等級很低。對於第二代喹諾酮和co-trimoxazole，單次劑量在臨床反應比3天療程相比，療效較差，證據質量中等。 詮釋 第三代和第四代喹諾酮類藥物和pivmecillinam的治療療程比目前建議的急性單純性膀胱炎治療療程要短。對於其他抗生素，可以考慮較短期療程，但是由於支持質量低，因此需要進一步研究證據。 本統合分析研究的主要價值在避免過度濫用抗生素，接受適度的療程治療一方面可減少抗藥性，一方面也減少藥物的費用以及相關副作用。然而在解讀上要特別注意幾點—涵蓋在統合分析中的文獻，即便相同抗生素的使用劑量並不一致，且各研究病人收錄的條件也不盡相同；此外，以臨床症狀作為評估標準較不客觀，容易受病人原有某些下泌尿道症狀干擾，值得一提的是，收錄的研究從1980到2019年，不同時間，不同地區細菌的抗藥性變化也可能影響，因此抗生素的治療選擇以及療程，還是要根據臨床的表現和檢驗結果而調整，台灣泌尿科醫學會的診療指引針對非複雜性膀胱炎也有提供相關治療建議，建議還是與您的治療醫師多加討論。 |
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| abstract |
Background Evidence from numerous randomised clinical trials suggest that shorter-term antimicrobial therapy is as effective as—and has other advantages over—longer-term antimicrobial regimens at achieving symptomatic cure for acute uncomplicated cystitis. Nevertheless, not all shorter regimens are adopted in clinical guidelines. This study was done to reappraise the treatment duration of each antibiotic in current guidelines for acute uncomplicated cystitis to investigate whether the regimen lengths of guideline approved antibiotics could be reduced. Methods We systematically searched the PubMed, Embase, and Cochrane Library databases for relevant publications from inception of the databases until Dec 31, 2019. Only randomised clinical trials of women with acute uncomplicated cystitis that assessed antibiotic therapy and reported clinical or microbial response outcome values were included. A network meta-analysis was done and the quality of evidence of all of the included studies was rated. Clinical response was the primary outcome, defined as the complete disappearance of all baseline symptoms at the test-of-cure visit. Bayesian hierarchical random-effects model for dichotomous outcomes was used to compare the efficacy of each antibiotic treatment regimen directly and indirectly. This systematic review is registered in PROSPERO, CRD42018093529. Findings Overall, 61 randomised clinical trials—which included 20,780 patients—were assessed in our systematic review. For the third-generation and fourth-generation fluoroquinolones, a 3-day regimen had similar effect to a single-dose regimen for clinical response (risk ratio [RR] 0•994 [95% credible interval 0•939–1•052] vs 1•024 [0•974–1•083]), with moderate quality of evidence. For pivmecillinam, 5-day and 7-day regimens were similar to a 3-day regimen for clinical response, with moderate quality of evidence (RR 1•041 [0•910–1•193] for the 5-day regimen and 1•095 [0•999–1•203] for the 7-day regimen). Meanwhile, for third-generation cephalosporins and amoxicillin and clavulanate, there was no difference between single-dose and 3-day regimens, but quality of evidence supporting this conclusion was low. For second-generation quinolones and co-trimoxazole, single-dose regimen was less effective than 3-day regimen in clinical response, with moderate quality of evidence. Interpretation Treatment duration of the third-generation and fourth-generation quinolones and pivmecillinam could be shorter than the currently recommended regimens for acute uncomplicated cystitis. For other antibiotics, shorter duration of regimens could be considered, but further research is needed because of the low quality of supporting evidence |
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