目的:感染的即时检测(POCT)可提供准确的快速诊断,但不能持续改善疑似呼吸机相关性肺炎的抗生素管理(ASP)。我们旨在测量阴性PCR-POCT结果对重症监护病房(ICU)临床医生抗生素决定的影响,以及患者轨迹和认知行为因素的额外影响(临床医生直觉,DIS/对POCT的兴趣,风险避免)。
方法:观察性队列模拟研究。
方法:ICU。
方法:在英国教学医院工作的70名ICU顾问/学员。
方法:临床医生观察了4个案例,描述了已经完成一个疗程的抗生素治疗呼吸道感染的患者。小插图包括临床和生物学数据(即,白细胞计数,C反应蛋白),变化以创建四个轨迹:临床生物学改善(“改善”案例),临床生物学恶化(\'恶化\'),临床改善/生物学恶化(“不一致临床更好”),临床恶化/生物学改善(“不一致的临床恶化”)。基于此,临床医生做出了抗生素治疗的初步决定(停止/继续)和置信水平(6分Likert量表).然后提供了基于PCR的POCT,临床医生可以接受或拒绝。向所有临床医生(包括拒绝的医生)显示结果,这是负面的。临床医生更新了他们的抗生素决定和信心。
方法:比较POCT前和POCT后的抗生素决策和信心,每个小插图。
结果:POCT阴性结果增加了停止决策的比例(POCT前54%vsPOCT后70%,χ2(1)=25.82,p<0.001,w=0.32),除了改善(已经很高),最明显的是不和谐的CLIN恶化(POCT前49%对POCT后74%)。在线性回归中,显著降低临床医生停止抗生素倾向的因素是恶化的轨迹(b=-0.73(-1.33,-0.14),p=0.015),持续的初始信心(b=0.66(0.56,0.76),p<0.001)和非自愿收到POCT结果(接受POCT的临床医生比拒绝POCT的临床医生更倾向于停止,b=1.30(0.58,2.02),p<0.001)。没有发现临床医生的风险平均度会影响抗生素的决定(b=-0.01(-0.12,0.10),p=0.872)。
结论:PCR-POCT结果阴性可促使ICU停用抗生素,特别是在临床恶化的情况下(否则可能会继续)。这种影响可能会减少高临床医生的信心继续和/或不感兴趣的POCT,也许是由于低信任/感知效用。这种认知行为和轨迹因素在未来的ASP研究设计中值得更多考虑。
Point-of-care tests (POCTs) for infection offer accurate rapid diagnostics but do not consistently improve antibiotic stewardship (ASP) of suspected ventilator-associated pneumonia. We aimed to measure the effect of a negative PCR-POCT result on intensive care unit (ICU) clinicians\' antibiotic decisions and the additional effects of patient trajectory and cognitive-behavioural factors (clinician intuition, dis/interest in POCT, risk averseness).
Observational cohort simulation study.
ICU.
70 ICU consultants/trainees working in UK-based teaching hospitals.
Clinicians saw four case vignettes describing patients who had completed a course of antibiotics for respiratory infection. Vignettes comprised clinical and biological data (ie, white cell count, C reactive protein), varied to create four trajectories: clinico-biological improvement (the \'improvement\' case), clinico-biological worsening (\'worsening\'), clinical improvement/biological worsening (\'discordant clin better\'), clinical worsening/biological improvement (\'discordant clin worse\'). Based on this, clinicians made an initial antibiotics decision (stop/continue) and rated confidence (6-point Likert scale). A PCR-based POCT was then offered, which clinicians could accept or decline. All clinicians (including those who declined) were shown the result, which was negative. Clinicians updated their antibiotics decision and confidence.
Antibiotics decisions and confidence were compared pre-POCT versus post-POCT, per vignette.
A negative POCT result increased the proportion of stop decisions (54% pre-POCT vs 70% post-POCT, χ2(1)=25.82, p<0.001, w=0.32) in all vignettes except improvement (already high), most notably in discordant clin worse (49% pre-POCT vs 74% post-POCT). In a linear regression, factors that significantly reduced clinicians\' inclination to stop antibiotics were a worsening trajectory (b=-0.73 (-1.33, -0.14), p=0.015), initial confidence in continuing (b=0.66 (0.56, 0.76), p<0.001) and involuntary receipt of POCT results (clinicians who accepted the POCT were more inclined to stop than clinicians who declined it, b=1.30 (0.58, 2.02), p<0.001). Clinician risk averseness was not found to influence antibiotic decisions (b=-0.01 (-0.12, 0.10), p=0.872).
A negative PCR-POCT result can encourage antibiotic cessation in ICU, notably in cases of clinical worsening (where the inclination might otherwise be to continue). This effect may be reduced by high clinician confidence to continue and/or disinterest in POCT, perhaps due to low trust/perceived utility. Such cognitive-behavioural and trajectorial factors warrant greater consideration in future ASP study design.