Use of antibiotics in suspected haemolytic-uraemic syndrome
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《英国医生杂志》
1 Paediatric Intensive Care Unit, St James's Hospital, Leeds LS9 7TF
Correspondence to: B Phillips bob.phillips@doctors.org.uk
Introduction
Ideally this question would be answered by large randomised controlled trials. If trials were absent or inadequate, cohort studies or well conducted case-control reports would be helpful. As systematic reviews are increasingly used in all areas of research (not just randomised controlled trials) we looked first for such reports. Not expecting to find randomised controlled trials, we looked for studies using the PubMed clinical queries systematic review filter rather than the Cochrane Library. The search terms "hemolytic uremic syndrome AND antibiotics" returned three citations. Only one of these was a relevant systematic review of trials and observational studies.1 As this was published in 2002, we searched for more recent relevant individual studies and found none.
Appraise the evidence
The combination of uncertainties in this case is important. Our patient was not in the typical age range, she did not have the typical haematological picture for E coli haemolytic uraemic syndrome, and she was critically ill. Various other organisms can produce haemolytic uraemic syndrome as part of a septic illness.4 The clinical balance was between leaving untreated (for example) pneumococcal sepsis and worsening an E coli 0157:H7 enteritis by giving antibiotics. The evidence we found highlighted the paucity of clinical evidence indicating harm from treating children with E coli enteritis compared with the overwhelming clinical experience regarding the use of antibiotics in sepsis.5 We concluded that the perceived benefit of treating sepsis in this complex atypical patient outweighed the potential harm if E coli 0157:H7 enteritis was the underlying problem. If the child had presented with the typical picture of haemolytic uraemic syndrome the lack of benefits of antibiotics would have swayed us against using them
Assess the outcome
Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis. JAMA 2002;288: 996-1001.
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group. JAMA 2000;283: 2008-12.
GRADE Working Group. www.gradeworkinggroup.org
Meyers K, Kaplan BS. Haemolytic-uraemic syndrome. In: Barrett TM, Avnar ED, Harmon WE, eds. Paediatric nephrology. Baltimore: Lippincott, Williams, and Wilkins, 1999.
Florey HW, Abraham EP. The work on penicillin at Oxford. J Hist Med Allied Sci 1951;6: 302-17.(Bob Phillips, specialist registrar in pa)
Correspondence to: B Phillips bob.phillips@doctors.org.uk
Introduction
Ideally this question would be answered by large randomised controlled trials. If trials were absent or inadequate, cohort studies or well conducted case-control reports would be helpful. As systematic reviews are increasingly used in all areas of research (not just randomised controlled trials) we looked first for such reports. Not expecting to find randomised controlled trials, we looked for studies using the PubMed clinical queries systematic review filter rather than the Cochrane Library. The search terms "hemolytic uremic syndrome AND antibiotics" returned three citations. Only one of these was a relevant systematic review of trials and observational studies.1 As this was published in 2002, we searched for more recent relevant individual studies and found none.
Appraise the evidence
The combination of uncertainties in this case is important. Our patient was not in the typical age range, she did not have the typical haematological picture for E coli haemolytic uraemic syndrome, and she was critically ill. Various other organisms can produce haemolytic uraemic syndrome as part of a septic illness.4 The clinical balance was between leaving untreated (for example) pneumococcal sepsis and worsening an E coli 0157:H7 enteritis by giving antibiotics. The evidence we found highlighted the paucity of clinical evidence indicating harm from treating children with E coli enteritis compared with the overwhelming clinical experience regarding the use of antibiotics in sepsis.5 We concluded that the perceived benefit of treating sepsis in this complex atypical patient outweighed the potential harm if E coli 0157:H7 enteritis was the underlying problem. If the child had presented with the typical picture of haemolytic uraemic syndrome the lack of benefits of antibiotics would have swayed us against using them
Assess the outcome
Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis. JAMA 2002;288: 996-1001.
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group. JAMA 2000;283: 2008-12.
GRADE Working Group. www.gradeworkinggroup.org
Meyers K, Kaplan BS. Haemolytic-uraemic syndrome. In: Barrett TM, Avnar ED, Harmon WE, eds. Paediatric nephrology. Baltimore: Lippincott, Williams, and Wilkins, 1999.
Florey HW, Abraham EP. The work on penicillin at Oxford. J Hist Med Allied Sci 1951;6: 302-17.(Bob Phillips, specialist registrar in pa)