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我们在治疗小儿社区获得性肺炎(CAP)的Lorgelly读得津津有味成本最小化分析et al。1在的当前问题188bet体育备用网址欧洲呼吸杂志.该分析是基于随机对照非盲多中心等效性试验(PIVOT研究),其中口服阿莫西林和静脉基青霉素在246个治疗小儿CAP的有相当于功效入院2.The median time for temperature to be <38°C for 24 h was 1.23 days in the intravenous penicillin group and 1.30 days in the oral amoxicillin group2.口服阿莫西林组的中位住院时间明显短于静脉注射青霉素组(1.77与分别为2.10天)。PIVOT研究没有考虑CAP的病因、严重程度以及患者的年龄。非特异性炎症标志物的高水平提示大多数患者存在细菌或混合病毒-细菌CAP。合并肺炎的儿童,如氧饱和度<85%、休克需要液体复苏或胸膜液需要引流的儿童被排除在外2.
将成本降至最低的分析包括了232名具有充分经济数据的儿童,并考虑了在儿童完全康复之前的保健服务、家庭和社会(社会角度)的成本。与口服阿莫西林相比,静脉注射青霉素治疗更贵,平均住院时间更长(3.12与分别为1.93天;p < 0.001)1.从统计学角度来看,口服阿莫西林的差异(以平均值(1.19天)计算)大于原始分析(以中位数(0.33天)计算)。2.平均而言,口服阿莫西林治疗组的总费用是静脉注射青霉素治疗组的61.2% (95% CI 40.3-81.4)。
我们最近发表了关于病因学的研究结果3.,严重程度4和临床图片5在为住院患者或门诊治疗的101名儿童放射学诊断CAP。我们进行二次分析,以评估患者的改善。体温测量每天在医院和在家出院后每天两次四次。If primarily treated at home, the parents were contacted by phone 48–72 h after starting antibiotics. The treatment was selected on clinical grounds by the doctors on duty, and the recommended drugs were oral amoxicillin in mild-to-moderate cases and intravenous ampicillin in severe cases. Cephalosporins or macrolides were recommended for children with penicillin allergy. Body temperature data were available in 94 children, and among them: 59 received amoxicillin orally as the first-line drug, 21 received ampicillin intravenously, and 14 received other antibiotics (including cephalosporins in eight cases and macrolides in four cases). The mean (range) hospitalisation time was 5 (3–13) days in the 25 subjects treated as in-patients.
开始抗生素后,平均±sdduration of fever was 23.0±19.2 h, being 15.6±13.4 h in children <2 yrs of age, 18.9±14.9 h in children aged 2–4 yrs and 31.2±23.1 h in children aged >5 yrs (p = 0.003). Fever decreased in 44 (47%) children within 12 h, in 25 (27%) between 13–24 h, in 21 (22%) between 25–48 h and in only four (4%) children after 48 h. Clinical signs5或血清学调查结果3.与发热持续时间无关唯一的例外是,高呼吸频率与持续时间短的发烧有关。与PIVOT研究一样,哮喘患儿也被排除在外2.非特异性炎症标记物研究承认有一个逆与发热持续时间的年龄调整线性回归:红细胞沉降率(β= -0.204,p < 0.001),原降钙素(β= -0.261,p = 0.031),白细胞(β= -0.000,p = 0.053)和c反应蛋白(β= -0.038,p = 0.050)。静脉注射氨苄西林组发热持续时间(13.4±11.3 h)短于口服阿莫西林组(25.2±18.6 h, p = 0.012,年龄调整后p = 0.002)。排除两个脓胸患儿后,氨苄青霉素静脉给药的平均持续时间为3.3(1-7)天,高于英国研究的平均持续时间1.5天2.
这种务实的二次分析的结果给了证据表明,治疗方式为静脉注射抗生素开始,并继续口服可能比单独口服治疗住院患儿大概是细菌性肺炎更有效的CAP。这项研究的目的不是比较的治疗方式,如抗生素是由医生值班其临床考虑选择。因此,结果表明,这些患者中,有更严重的疾病,谁也从静脉滴注治疗中获益,被分配到正确的组。治疗方式之间的成功和理性选择(静脉注射抗生素严重的细菌感染和口服抗生素轻度到中度细菌感染)也是最划算。To increase cost-effectiveness, the times for intravenous treatment (on average, 3.3 days与1。5 days in the PIVOT study) and the hospital stay (on average 5 days与2–3 days in the PIVOT study) should be shortened. We appreciate the cost-minimising analysis1,这使从PIVOT研究中获得的信息大大多样化。未来关于儿童CAP治疗的研究应尽可能多地以成本效益分析作为补充,但应考虑病因、CAP严重程度和儿童年龄。
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