急性中耳炎：基层和指南对着干？

Primary Care Practice for Acute Otitis Media May Differ From Guidelines
急性中耳炎初级医疗实际可能与指南有异
August 10, 2007 — Primary care practice patterns for acute otitis media (AOM) differ considerably from 2004 guideline recommendations, according to the results of a study reported in the August issue of Pediatrics. Most physicians accept the concept of an option for observation but seldom use it; antibiotics prescribed for AOM vary widely from those recommended in the guidelines, and the degree of variance has increased since 2004.

2007年8月10日，根据本月出版的《儿科》的一项研究报告，急性中耳炎的初级医疗实际情况与2004年的推荐标准相差较大。多数医师认可观察理念但绝少采用；针对急性中耳炎的抗生素处方与这些推荐标准差别较大，且其程度自2004年来逐渐增大。
\"In 2004, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) released a clinical practice guideline on the management of acute otitis media that included endorsement of an observation option for selected cases and recommendations of specific antibiotics,\" write Louis Vernacchio, MD, MSc, from Boston University in Massachusetts, and colleagues. \"We sought to describe primary care physicians' current management of acute otitis media to compare it with the guideline's recommendations and describe trends since 2004.\"
“在2004年，美国儿科协会和美国家庭医师协会发布了关于控制急性中耳炎的临床实践指南，其中包括对经过挑选的病例进行观察，及推荐使用的抗生素种类”，麻州波士顿大学的路易斯教授和他的同事们写道，“我们通过探索以描述初级保健医师当前对急性中耳炎的控制方法，再将其与推荐指标相比较，并描绘其自2004年以来的趋势。”
The investigators sent a mail survey to members of the Slone Center Office-Based Research Network, a national practice-based pediatric research network, from March through June 2006. The response rate was 62.7% (299/477).
调查者自2006年3月到6月给SCOR的成员发了一封调查邮件，该组织是一个全国性的、基于实践的儿科调查网络。反馈率为62.7% (299/477)。
The option to observe AOM without immediate antibiotic treatment was considered reasonable by 88.0% of physicians in 2004 and 83.3% in 2006. However, physicians surveyed in 2006 reported using the option of observation during the previous 3 months in a median of only 15% of AOM cases. Physicians reported that the most frequent barriers to using the observation option were parental reluctance not to have antibiotics prescribed for their children (83.5%) and the cost and difficulty of following up children who fail to improve (30.9%).
对于急性中耳炎仅予观察而非立即使用抗生素这一观点，在2004年有88.0％的医师表示认可，2006年这一比率为83.3%。然而，2006年的医师调查报告中位数仅有15%的急性中耳炎病例在前三个月采用观察法。医师们报告阻碍采用观察法的最常见的原因来自父母，他们不愿看到不给他们的孩子使用抗生素(83.5%)，还有就是对那些症状没有改善的孩子进行随访的花费和困难 (30.9%)。
For each of 4 common clinical scenarios of AOM, agreement with antibiotic recommendations of the 2004 guidelines decreased from 2004 to 2006. Agreement in 2006 for each of these AOM scenarios was 57.2% for using high-dose amoxicillin for nonsevere symptoms, 12.7% for using high-dose amoxicillin-clavulanate for severe symptoms, 42.8% for using high-dose amoxicillin-clavulanate for cases refractory to amoxicillin, and 16.7% for using intramuscular ceftriaxone for cases refractory to amoxicillin-clavulanate.
自2004到2006年，4种常见急性中耳炎临床治疗中与2004年推荐抗生素一致性均有下降。在2006年，这些急性中耳炎中，对无严重症状者使用了高剂量阿莫西林有57.2%与指导一致，对有严重症状者使用高剂量阿莫西林－克拉维酸有12.7%的一致，对耐阿莫西林者使用高剂量阿莫西林－克拉维酸有42.8%的一致，而对耐阿莫西林－克拉维酸有16.7%都采用了肌内注射头孢曲松。
\"Most primary care physicians accept the concept of an observation option for acute otitis media but use it only occasionally,\" the authors write. \"Antibiotics prescribed for acute otitis media differ markedly from the guideline's recommendations, and the difference has increased since 2004.\"
”大多数初级医师认可对急性中耳炎的观察疗法，但用者瘳瘳”，作者写道。“针对急性中耳炎的抗生素处方与指南推荐用药相差明显，且这种差距自2004年开始增加。”
Limitations of the study include lack of generalizability to physicians not involved in a research network, and possible response bias or other unmeasured bias.
研究的不足主要在于缺乏对调查网络外的医师的扩大调查，以及反馈偏倚或其它未预料到的偏倚。
\"In the end, even the best evidence-based recommendations serve to improve care only if the clinicians charged with their implementation find them both scientifically convincing and clinically practical,\" the authors conclude. \"In the case of the 2004 AAP/AAFP AOM guideline, the experts still face the substantial challenge of convincing pediatric practitioners that the recommendations represent the best interpretation of the data and of assisting those practitioners in overcoming barriers to their implementation.\"
“最后，即使是最好的询证指南，也只有当负责实施的临床医师在科学验证和临床实际中得到双重肯定后，才有可能提高疗效。”
The authors have disclosed no relevant financial relationships.
作者未提及相关的财务关系。