【Cochrane简语概要】在初级保健机构接受治疗的患者中，提供书面信息是否能够减少上呼吸道感染的抗生素使用?

本综述的研究问题 

我们想弄清楚书面信息是否会减少急性上呼吸道感染（感冒、喉咙痛、咳嗽或耳痛）的抗生素使用量。

研究背景 

大多数感冒、喉咙痛、咳嗽和耳朵痛都是由病毒引起的。虽然抗生素对病毒无效，但有时医生会开处抗生素。我们想确定，与医生的常规做法相比，额外在医生就诊前或就诊期间提供关于抗生素使用的书面信息，是否会改变抗生素的使用情况。我们还想了解是否：病人更有可能回到他们的医生那里；症状会很快改善；患者对抗生素的认识将会提高；病人对医生的医疗感到满意；会出现并发症。

（图片来源于网络）

检索日期 

我们检索了截至2016年7月的文献。

研究特征 

我们发现了两项研究纳入了上呼吸道感染儿童：一项涉及558名儿童，他们来自英格兰和威尔士的61个普通诊所；还有269名医生提供了美国肯塔基州33,792名患者-医生诊疗的数据。受试者为一名成年人陪同的儿童。一项研究为经过培训的全科医生与家长讨论书面信息，另一项研究中，医生向家长分发政府资助的小册子。

研究经费来源 

这两项研究都是由政府机构资助的，其中一项研究还受辉瑞制药公司资助。

主要结果 

由一位受过专门培训的医生提供一本小册子并进行解释，可将儿童抗生素使用量减少20%（从42%降至22%），而不会影响家长对咨询的满意度或因相同疾病的复诊次数。两项研究表明，与医生的常规做法相比，提供一本小册子能使儿童处方抗生素的比例减少9%至21%。当医生在给家长提供小册子的同时，也得到了关于他们开抗生素处方的反馈时，开抗生素处方的儿童比例增加了6%（从44%增加到50%）。没有一项纳入的研究评估患者是否收到了通知信息，症状持续了多长时间，或者患者是否有并发症。

证据质量 

证据质量为中低等。医生和家长知道什么时候使用书面信息。一项研究存在很高的偏倚风险，因为试验组间基线没有可比性，所以我们对结果保持怀疑。

研究地点为英国和美国，所以结果并不适用于低收入国家，也不适用于不同的初级医疗服务，包括不需要处方来获得抗生素的地区。

结论: 

与常规医疗相比，一项研究提供的中等质量证据表明，受过培训的全科医生在初级医疗阶段，向患有急性URTIs的患儿父母提供书面信息，可以减少患者使用抗生素的数量，而不会对复诊率或父母对咨询满意度产生任何负面影响。两项研究提供的低等质量证据表明，与常规医疗相比，全科医生给急性URTIs患者开出更少的抗生素，但与仅提供处方反馈相比，当提供书面信息的同时进行处方反馈时，全科医生会开出更多的抗生素。没有研究提供解决患者症状，患者对急性URTIs使用抗生素的认知，或并发症发生频率的相关证据。

为了填补证据上的空白，未来的研究应该考虑在没有培训临床医生的情况下，以不同的形式（如电子形式），在高收入和低收入的环境下，向急性URTIs成人患者提供关于使用抗生素的书面信息，来确定书面信息是否会造成影响。未来的研究设计应尽力针对结果评价者实施盲法。研究目的应包括调查书面信息对患者使用抗生素数量和临床医生处方的影响、患者满意度、复诊率、患者对抗生素的认知程度、症状的缓解程度和并发症情况。

译者：关英杰；审校：张英英、鲁春丽；编辑排版：张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】Does written information reduce antibiotic use for upper airway infections among people treated in primary care settings?

Review question 

We wanted to find out if written information reduces antibiotic use for acute upper airway infections (colds, sore throats, cough, or earaches).

Background 

Most colds, sore throats, coughs and earaches are caused by viruses. Although antibiotics do not work against viruses, they are sometimes prescribed. We wanted to find out if giving written information about antibiotics immediately before or during doctor visits, together with usual care, changed antibiotic use compared with the doctor's usual practice or something else. We also wanted to know if: patients would be more likely to return to their doctor; symptoms would improve sooner; patients' knowledge about antibiotics would improve; patients were satisfied with their doctor's care; and if complications occurred.

Search date 

We searched the literature up to July 2016.

Study characteristics 

We found two studies that included children with upper airway infections: one involved 558 children who were recruited from 61 general practices in England and Wales; and another of 269 doctors who provided data on 33,792 patient-doctor consultations in Kentucky, USA. Participants were children accompanied by an adult. One study trained general practitioners (GPs) to discuss written information with parents, and in the other, doctors distributed copies of government-sponsored pamphlets to parents.

Study funding sources 

Both studies were funded by government bodies and one was also funded by Pfizer (a pharmaceutical company).

Key results 

Providing a booklet and explanation by a specially-trained doctor reduced the number of antibiotics children consumed by 20% (from 42% to 22%) without affecting parent satisfaction with consultation or numbers of return visits for the same illness. Compared to the doctor’s usual practice, two studies showed that providing a booklet reduced the proportion of children prescribed an antibiotic by 9% to 21%. When doctors were also given feedback on their antibiotic prescribing along with providing a booklet to parents, the proportion of children prescribed an antibiotic increased by 6% (from 44% to 50%). None of the included studies assessed if people were better informed, how long symptoms lasted, or if people had complications.

Quality of evidence 

Evidence quality was moderate to low. Doctors and parents knew when written information had been used. One study had a high risk of bias because study groups were not comparable at baseline, so we can be less confident of its findings.

Studies were set in the UK and USA, so results are not applicable to lower-income countries, nor for different primary healthcare services, including settings where prescriptions are unnecessary to obtain antibiotics.

Authors' conclusions: 

Compared to usual care, moderate quality evidence from one study showed that trained GPs providing written information to parents of children with acute URTIs in primary care can reduce the number of antibiotics used by patients without any negative impact on reconsultation rates or parental satisfaction with consultation. Low quality evidence from two studies shows that, compared to usual care, GPs prescribe fewer antibiotics for acute URTIs but prescribe more antibiotics when written information is provided alongside prescribing feedback (compared to prescribing feedback alone). There was no evidence addressing resolution of patients' symptoms, patient knowledge about antibiotics for acute URTIs, or frequency of complications. 

To fill evidence gaps, future studies should consider testing written information on antibiotic use for adults with acute URTIs in high- and low-income settings provided without clinician training and presented in different formats (such as electronic). Future study designs should endeavour to ensure blinded outcome assessors. Study aims should include measurement of the effect of written information on the number of antibiotics used by patients and prescribed by clinicians, patient satisfaction, reconsultation, patients' knowledge about antibiotics, resolution of symptoms, and complications.

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