瑞士洛桑大学医院Noémie Boillat-Blanco团队探讨了初级保健中使用降钙素原和肺超声检查是否可减少下呼吸道感染患者的抗生素处方。该项研究成果发表在2021年9月21日出版的《英国医学杂志》上。

为了评价基层护理中降钙素原和肺部超声检查是否可安全地减少下呼吸道感染患者不必要的抗生素治疗，2018年9月至2020年3月，研究组在瑞士60家基层医疗机构中进行了一项三组、务实的集群随机对照试验。每个机构包括一名全科医生。全科医生对所有急性咳嗽患者进行筛查；包括临床肺炎患者。

将患者按1：1：1的比例进行随机分组，其中152例接受序贯降钙素原和肺超声检查指导下的抗生素治疗（UltraPro组）、195例接受降钙素原指导下的抗生素治疗，122例接受常规治疗。主要结局为各组患者在28天内使用抗生素的比率。次要结局包括14天内因下呼吸道感染而限制活动的持续时间。

60名全科医生共负责469名患者，患者的中位年龄为53岁，278名（59%）为女性。降钙素原组在28天内开具抗生素处方的概率低于常规护理组，分别为0.40和0.70。UltraPro组和降钙素原组之间无显著差异，分别为0.41和0.40。降钙素原组在14天内的中位活动受限天数为4天，常规护理组为3天，未体现出非劣效性。

研究结果表明，与常规护理相比，在不影响患者安全的情况下，基层护理进行降钙素原检查可使28天抗生素处方的开具概率绝对减少26%。但肺部超声检查并未进一步减少抗生素处方使用率。

附：英文原文

Title: Procalcitonin and lung ultrasonography point-of-care testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care: pragmatic cluster randomised trial

Author: Loc Lhopitallier, Andreas Kronenberg, Jean-Yves Meuwly, Isabella Locatelli, Yolanda Mueller, Nicolas Senn, Valérie D’Acremont, Noémie Boillat-Blanco

Issue&Volume: 2021/09/21

Abstract:

Objective To assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care.

Design Three group, pragmatic cluster randomised controlled trial from September 2018 to March 2020.

Setting 60 Swiss general practices.

Participants One general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included.

Interventions Randomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122).

Main outcomes Primary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days.

Results 60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference 0.26 (95% confidence interval 0.41 to 0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, 0.03 (0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval 0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority.

Conclusions Compared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients’ safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals.

DOI: 10.1136/bmj.n2132

Source: https://www.bmj.com/content/374/bmj.n2132