所有尿道炎處理策略可能達到相同的症狀控制

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　February 24, 2010 — 根據一項發表於2月5日BMJ的隨機分派控制研究結果，所有泌尿道感染（UTI）處理策略都會達到相同的症狀控制。
　　
　　英國南安普敦大學P. Little與同事們寫到，過去研究已經證實延緩使用抗生素於呼吸道感染使症狀控制更好，降低了對抗生素療效的信任，且諮詢數量減少。我們假設，相較於立即處方抗生素，其他處理策略，症狀控制較差，特別是希望經驗性延緩使用抗生素或是那些等待中段尿液分析結果的女性。我們想要評估使用尿液試紙或是臨床流程，相較於其他處理策略（經驗性抗生素治療、延緩處方抗生素、以及根據中段尿液檢驗結果處方抗生素）的效果。
　　
　　在初級照護階段，309位被懷疑罹患UTI的18至70歲未懷孕女性，被隨機分派至1到5個不同處理方法。包括經驗性抗生素；延緩處方抗生素達48小時；或是根據症狀分數（至少要有兩個特徵：尿液味道、夜間頻尿或排尿困難）、尿液試紙結果亞硝酸鹽陽性、或尿液及血液白血球數目增加，或是中段尿液分析結果陽性。
　　
　　在這些組別中，控制了自助諮商。主要試驗終點是第2至4天症狀嚴重度、症狀時間、以及使用抗生素。
　　
　　立即使用抗生素的女性中重度症狀時間為3.5天。這5組之間的症狀時間長短與嚴重度並無顯著差異。立即使用抗生素組，症狀0至6分症狀平均頻率為2.15，中段尿液分析組為2.08，尿液試紙組為1.74，症狀分數組為1.77，而延緩處方抗生素組為2.11（這5組可能性比值檢定P值為0.177）。
　　
　　然而，不同組別之間使用抗生素的比例有差異（立即使用抗生素組為97%；中段尿液分析組為81%，尿液試紙組為80%，症狀分數組為90%，延緩使用抗生素組為77%（P=0.011），送交中段尿液樣本的比例同樣也有差異（立即抗生素組為23%，中段尿液組為89%，尿液試紙組為36%，症狀分數組為33%，延緩使用抗生素組為15%；P<0.001））。
　　
　　相較於立即使用抗生素，那些48小時後才開始使用抗生素的受試者再回來諮商的比例較低（危險比值[HR]為0.57；95%信賴區間[CI]為0.36-0.89；P=0.014），但是平均來說，症狀持續時間長了37%（發生率比值為1.37；95% CI為1.11-1.68；P=0.003）。尤其是在中段尿液檢驗組（延長了73%；95% CI為22%-140%），然而，其他組的症狀持續時間最多沒有長過22%。
　　
　　這項研究的限制包括次組分析可能的第一型誤差；試驗前各組些微但未達顯著的症狀頻率差異；以及部分組別使用尿液試紙、中段尿液分析以及延緩使用抗生素意願的差異。
　　
　　研究作者們寫到，所有處理策略都可以達到相當的症狀控制。常規地將尿液樣本送驗並沒有好處，而根據尿液試紙檢測並延緩抗生素使用、或是經驗性地延緩可以減少抗生素使用。
　　
　　這項研究由UK NHS研究發展健康科技計畫資助。其中一位作者表示受雇參加拜耳藥廠顧問工作坊，且目前未支薪與拜耳藥廠合作中。


All UTI Management Strategies May Achieve Similar Symptom Control

By Laurie Barclay, MD
Medscape Medical News

February 24, 2010 — All management strategies for urinary tract infections (UTIs) achieve similar symptom control, according to the results of a randomized controlled trial reported in the February 5 issue of the BMJ.

"Previous studies have documented that delayed antibiotic prescribing in respiratory infections results in good symptom control, reduced belief in the effectiveness of antibiotics, and fewer repeat consultations," write P. Little, from University of Southampton, United Kingdom, and colleagues. "We hypothesised that, compared with an immediate antibiotic prescription, other management strategies would result in worse symptom control, particularly in women asked to delay antibiotics empirically or while waiting for the result of midstream urine analysis. We aimed to assess the effectiveness of management using dipstick or clinical algorithms compared with the alternative management strategies (empirical antibiotic treatment, delayed prescribing, and targeted prescribing based on midstream urine results)."

In a primary care setting, 309 nonpregnant women aged 18 to 70 years seen for suspected UTI were randomly assigned to 1 of 5 different management approaches. These were empiric antibiotics; empiric antibiotics delayed by 48?hours; or targeted antibiotics based on a symptom score (at least 2 of the following features: urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result positive for nitrites or for both leukocytes and blood, or a positive result on midstream urinalysis.

For each group, self-help advice was controlled. Primary study endpoints were symptom severity on days 2 to 4, symptom duration, and antibiotic use.

Women who immediately took antibiotics had 3.5 days of moderately severe symptoms. The 5 groups did not differ significantly in duration or severity of symptoms. Mean frequency of symptoms on a scale of 0 to 6 was 2.15 for immediate antibiotics, 2.08 for midstream urinalysis, 1.74 for dipstick, 1.77 for symptom score, and 2.11 for delayed antibiotics (likelihood ratio test for the 5 groups: P = .177).

However, the percentage of patients using antibiotics differed among the groups (97% in the immediate antibiotic group, 81% in the midstream urine group, 80% in the dipstick group, 90% in the symptom score group, and 77% in the delayed antibiotics group (P = .011), as did the percentage of patients sending midstream urine samples (immediate antibiotics, 23%; midstream urine, 89%; dipstick, 36%; symptom score, 33%; and delayed antibiotics, 15%; P < .001).

Compared with patients taking immediate antibiotics, those who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.36 - 0.89; P = .014) but, on average, had symptoms for 37% longer (incidence rate ratio, 1.37; 95% CI, 1.11 - 1.68; P = .003). This was especially true for the midstream urine group (73% longer; 95% CI, 22% - 140%), whereas duration was not more than 22% longer in any of the other groups.

Limitations of this study include possible type I error for the subgroup analyses; slight but not significant difference among groups in frequency symptoms at baseline; and some group differentiation in dipstick use, midstream urinalysis, and the willingness of women to delay the use of antibiotics.

"All management strategies achieve similar symptom control," the study authors write. "There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use."

This study was funded by the Health Technology Programme of UK NHS Research and Development. One of the study authors reports having been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in an unpaid capacity.

BMJ. 2010;340:c199.