精品探讨蔓越莓对预防泌尿道感染课件

探討蔓越莓對預防泌尿道感染 之成效 外科組:趙美珍.陳麗麗.江雪黛. 陳秀鉛.郁文棋.林步鴻 動機 目的 EBN問題與步驟 文獻評讀 結論 討論 大綱 1. 全院感染率1-6月份以泌尿道感染率為最高: 1.68 0/00 2. 外科病房的泌尿道感染率有偏高的趨勢 95年1-6月9A病房4.1 0/00 3. 醫生常常告訴病人多喝蔓越莓汁 醫院製作的衛教單張也衛教病人多喝蔓越莓汁 但究竟應喝多少？ 有何效果？ 4. 院內護理之家住民有長期食用蔓越莓汁之情形，why ？ 動機 目的 經由EBN之實證精神，探索神奇的蔓 越莓，透過文獻蒐集與評讀: 瞭解蔓越莓功效為何? 如何實際地運用在臨床上? 目的 Step 1: 整理出一個可以回答的問題 Step 2: 尋找文獻證據 Step 3: 嚴格評讀文獻 Step 4: 應用於病人身上 Step 5: 對過程進行稽核 實證五步驟 蔓越莓對預防泌尿道感染的成蔓越莓對預防泌尿道感染的成 效效? ? Step 1: 整理出一個可以回答的問題 名詞解釋 1. 蔓越苺：又稱小紅莓，又稱小紅莓，(cranberry(cranberry，學名，學名 Vaccinium macrocarpon)Vaccinium macrocarpon) 蔓生植物漿果，正圓球體約1公分大小，呈紅、 暗紅色，表面平滑富光澤。 原產地及大面積耕種的地區是北美及加拿大， 主要的產季在九月及十月左右。 MoweryDB ： The scientific vlidation of herbal Medicine New Canaan Conn :Keats Pub ,1986:316 2. 泌尿道感染(Urinary Tract Infection) 有症狀的泌尿道感染（Symptomatic） 無症狀菌尿症（Asymptomatic） 出處 ： .tw/file/38694_7029398148院內 感染定義. 名詞解釋 有症狀的泌尿道感染 症狀：發燒、急尿、小便困難、恥 骨上 壓痛 具有尿路感染的症狀任一項且尿 液培養-菌落數每毫升大於或等於 十萬個 （colony count 105ml) 尿液培養之微生物七天內連續兩次相同 方式 取得之尿液標本，連續兩次相同，菌落 數每 毫升大於或等於十萬個 無症狀的菌尿症 Step 2: 尋找文獻證據 EBMEBM SEARCH SEARCH FRAMEWORKFRAMEWORK 搜尋實證文獻之架構 Evidence-based Medicine Review NGCNGC PubMedPubMed Systematic Review (National Guide Clearinghouse) MEDLINEMEDLINE 全文電子期刊 政府研究資料 全國碩博士論文 館際合作 搜尋策略 CochraneCochrane Library Step 3: 嚴格評讀文獻 研究證據的價值取決於其品質及效度 評讀文獻的黃金標準中,以雙盲隨機對照臨床雙盲隨機對照臨床 試驗試驗得出的結果為最佳證據等級 The Evidence Pyramid 臨床研究證據等級 等級 實證類別 I a 具規模具有隨機取樣及控制組(randomized controlled trials, RCT)對照所作之實證研究(Mata-analysis) I b 至少由一組有良好之隨機化及控制組(RCT)之實驗研究 II a 有控制組, 但不屬於隨機化 II b 至少有類似或接近完整之實驗方法(quasi-experimental study) 之實證研究 III 由描述性之實證研究,如:比較方法, 相關問題之探討, 或個案 報告 IV 由專家會議所發表之報告或專家之意見 證據等級 -US Agency for Health Care Policy and Research Classification (AHCPR, 1992 Grade A Effectiveness established to a degree that merits application Grade B Effectiveness established to a degree that suggests application Grade C Effectiveness established to a degree that warrants consideration of applying the finding Grade DEffectiveness established to a limited degree Grade EEffectiveness not established 文獻推薦等級 Develop by JBI 文獻評讀 文獻評讀 文獻查證 蔓越莓對預防泌尿道感染作用機轉 尿液酸化一直被認為是蔓越莓預防尿道感 染的主要作用，但是經過許多的研究後證實 這只是蔓越莓的作用之一。 蔓越莓汁中分離而得的濃縮單寧酸（ condensed tannins） ，或稱初花青素（ proanthocyanidins），發現其具有特殊的抗黏 附活性成份，能抑制大腸桿菌E.coli 的P型纖 毛黏附於尿道細胞上。Lowe ,F.C. (2001) 每100g蔓越莓汁成分 Water(%). 92.9 Solid r(%) 7.1 Calories 27 Total carbohydrate (g) 6.8 Sugar (g) .3.7 Dietary fiber (g).0.1 Protein (g) 0.1 Fat (g) 0.1 Mineral Sodium(mg)3.8 potassium(mg)85.2 calcium(mg) .6.8 iron(mg) 0.33 Vitamin C(mg)2 PH2.5 其他的成分還包括： 類黃酮(flavonoids) 、 前花青素 (proanthocyanidins)、 兒茶素(catechin) Lowe ,F.C. (2001) Role of Cranberry Juice on Molecular- Scale Surface Characteristics and Adhesion Behavior of Escherichia coli BIOTECHNOLOGY AND BIOENGINEERING, VOL. 93, NO. 2, FEBRUARY 5, 2006 Yatao Liu, Matthew A. Black, Lizabeth Caron, Terri A. Camesano 文獻查證 蔓越莓對預防泌尿道感染作用機轉 RESULT 2:98102 收案族群：40/21位診所小朋友，有神經性膀胱 並需間歇性導尿（平均9.35歲) 文獻評讀-1 文獻查證 相關研究(一) 實驗設計 ：單盲（醫師）、交叉設計 措施：每天15ml/kg cranberry 雞尾酒汁（成分 30），持續6個月cranberry 雞尾酒汁，6 個月水 結果：有症狀的上泌尿道感染 cranberry：19/112 months（17 ） Placebo：20/117 months（17.1 ） 無症狀的上泌尿道感染 Cranberry：27/112 months（24.1 ） Placebo：34/117 months（29 ） AHCPR文獻等級 ： II a 年份：1999 篇名：Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization. J Pediatr 1999;135:698702. 作者：Schlager TA, Anderson S, Trudell J, Hendley JO. 收案族群：15/15小朋友，有神經性膀胱並需間 歇性導尿（2-18歲) 文獻查證 相關研究(二) 實驗設計 ：隨機/Double blind/交叉設計 措施：每天300cc cranberry（成分30 ），控制組： Placebo controlled（安慰劑）看起來和嚐起來 相似的果汁，持續3個月cranberry juice，持續 3個月安慰劑 結果：有症狀的上泌尿道感染 Cranberry：3 times UTI In 2 children Placebo：3times UTI In 3 children 無症狀的上泌尿道感染 Cranberry：120/160 months（75 ） Placebo：114/151months（75） AHCPR文獻等級 ： I a 年份：2002 篇名： randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women. Can J Urol 2002;9:1558 62. 作者：Walker EB, Barney DP, Mickelsen JN, Walton RJ, Mickelsen RA Jr. 收案族群：19/10有性交活動的女性（28-44歲) 收案條件： 未懷孕有性交活動的女性（18-45歲） 有過UTI病史 文獻查證 相關研究(三) 實驗設計：Double blind/交叉設計 措施：Cranberry錠劑（400mg）控制組：Placebo （安慰錠劑持續3個月cranberry 錠劑，持 續3個月安慰錠劑 ) 結果：有症狀的上泌尿道感染 Cranberry：6times UTI Placebo：15times UTI AHCPR文獻等級 ： II a 年份： 2005 題目： Dose ingestion of cranberry juice reduce symptomatic urinary tract infection In older people in hospital ? 作者： MarionE.T.Mcmurdo, LINDA Y.BISSETT,ROSEMARY J.G.PRICE,GABBY PHILLIPS,LAIN K,CROMBIE 文獻評讀-5文獻查證 相關研究(四) 對象:376 在醫院的老年人 方法:隨機、雙盲 措施：隨機給予300ml/day cranberry juice or matching placebo beverage 結論：no significant differences were found between treatment group AHCPR文獻等級 ： I a Tero Kontiokari, Kaj Sundqvist, M Nuutinen, T Pokka, M Koskela and M Uhari BMJ2001;322;1571 Randomized trial of cranberry-lingo berry juice and lactobacillus GG drink for the prevention of urinary tract infections in women 文獻查證 相關研究(五) AHCPR文獻等級 I a （一） Objective To determine whether recurrences of urinary tract infection can be prevented with cranberrylingonberry juice or with Lactobacillus GG drink. Design Open, randomized controlled 12 month follow up trial. Setting Health centers for university students and staff of university hospital. Participants 150 women with urinary tract infection caused by Escherichia coli randomly allocated into three groups. Intervention50 ml of cranberrylingonberry juice concentrate daily for six months or 100 ml of lactobacillus GG drink five days a week for one year,and the third group served as an open control group. （二） This is a 20% reduction in absolute risk in the cranberry group compared with the control group P. Di Martino A R. Agniel A K. David A C. Templer J. L. Gaillard A P. Denys A H. BottoPublished online: 6 January 2006 Springer-Verlag 2006 Reduction of Escherichia coli adherence to uroepithelial bladder cells after consumption of cranberry juice 文獻查證 相關研究(六) （一） Abstract To determine the efficacy of the consumption of cranberry juice versus placebo with regard to the presence of in vitro bacterial antiadherence activity in the urine of healthy volunteers Participants Twenty healthy volunteers, 10 men and 10 women, were included Design The study was a doubleblind, randomized, placebocontrolled, and crossover study. with a washout period of at least 6 days between every change in regimen AHCPR文獻等級 ：1a （二） INTRODUCTION ZafririD,ofek I,Pocino M,Sharon N(1989) inhibitory activity of cranberry juice on adherence of type 1and type p fimbriated E coli to eukaryotic cells E Coli adherence : type 1 and type p fimbriae cranberry juice constituents proanthocyanidins(cranberry juice )type p fructose(many fruit juice ) type 1 (三) 成份比較 Cranberry juice Placebo Calories (Kcal) 41.6 42.7 Total carbohydrates (g) 10.4 10.7 Ascorbic acid (mg) 63 63 Total organic acids (g) 1.8 1.6 Total phenolics (mg) 179 161 Total anthocyanidins (mg) 9.3 42 Proanthocyanidins (mg) 40 ND (四)Result Anti-adherence activity of the cranberry juice: comparison of the regimens, means for the 20 volunteers and 6 types of E coli strains RegimensDecrease in bacterial adherence(%) 250 ml placebo + 500 ml mineral water 750 ml placebo12 250 ml cranberry + 500 ml mineral water 45 750 ml cranberry65 (四)Result No significant differences in the pH or specific gravity between the urine samples collected after cranberry or placebo consumption. We observed a dose dependent significant decrease in bacterial adherence associated with cranberry consumption. Reduction of bacteriuria and pyuria after ingestion of Cranberry juice Avorn,jerry Md; JAMA,271(1o).March9,1994.751-754 文獻查證 相關研究(七) (一) ObjectivesTo determine the effect of regular intake of cranberry juice beverage on bacteriuria and pyuria in elderly women InterventionSubjects were randomly to consume 300 mL per day of a commercially available standard cranberry beverage or a specially prepared synthetic placebo cranberry drink 6MONTHS urine samples were collected at approximately 1month intervals and tests quantitatively for bacteriuria and the presence of white blood cells. DesignRandomized ,doubleblind,placebocontrolled trial. Participants109: LONGTERM COMMUNITY DWELLING . 44:LONG TERM CARE FACILITY AHCPR文獻等級 ：1a METHOD Ocean spray cranberry Bacterial culture Antibiotic sensitivity 外觀顏色(使用糖精) 瓶蓋每月收集一 次 教導中間尿 Results Escherichal coli was the most commonly identified organism (43% of isolates), with Klebsiella the second most common single organism (7%); mixed flora accounted for 22% of bacteriuric -pyuric urine samples. Placebo group Cranberry group Result The difference was not present in the first month INFECTED URINE SAMPLES% Result We did not find evidence that urinary acidification was responsible for the observed effect, since the median pH of urine samples in the cranberry group (6.0) was actually higher than that in the experimental group (5.5) 8 Result Demonstration of the capacity of cranberry beverage to reduce the occurrence of bacteriuria with pyuria in elderly women dose lend credence to the belief that it contains a substance with biologic activity in relation to the urinary tract. Conclusions These findings suggest that use of a cranberry beverage reduces the frequency of bacteriuria with pyuria in older women. Prevalent beliefs about the effects of cranberry juice on the urinary tract may have microbiologic justification. Jama.1994;271;751-754 COMMENT These finding, if replicated in other settings, would suggest evidence for the bacteriostatic property of cranberry beverage in the bladder. Further studies are needed on the biochemical properties of this substance As an adjunct to antibiotic，in the treatment of this common disorder. Step 4: 應用於病人身上 現況：院內護理之家住民長期在食用蔓越莓汁 食品處方：由營養室設計安排，費用算在伙食費 內。 使用方法：每天下午由營養室配送蔓越莓原液 100g（無糖），護理人員稀釋成200cc，餵食時 間為11pm（原因：避免與白天藥物有交叉反應 ） 對象：泌尿道感染的住民一定使用，除糖尿病、 腸胃出血、高血鉀、洗腎病人不給，其他住民 也一律給。但意識清楚，由口禁食住民多半不 喝， 則不強迫。 為何不用錠劑： 因為曾有住民食用後有高血鉀情形。 泌尿道感染率：未做研究分析。 經研究證實蔓越莓可以預防泌尿道感染 文獻上並無明確建議蔓越莓食用劑量 泌尿道感染常在病人無症狀的幾個月後才發生，有些 的研究期間較短，較無法看出成果 研究中退出的病人數較高(20-55) 可能因病人較無法接受需長期飲用蔓越莓汁， 在小孩身上這是主要原因 結論 蔓越莓汁成本高：長期飲用耗費的成本需考量 (平均每年約需6251400元美金)，蔓越莓的濃 縮物或錠劑也許可以克服。 但當病人每年有經歷2次的有症狀泌尿道感染， 和抗生素的成本比較起來則有大大的節省。 結論 錠劑好?果汁好? 蔓越莓汁到底要喝多少? 日後可以努力的方向 1.要長時間追蹤 2.衛教單宜增加使用劑量的說明 3.需註明服用蔓越莓的禁忌 討論 報告完畢 敬請指教 QfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1zw&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2Ax*u$qZnWkShPdMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2Ax*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1Ax*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1Aw*t!qYnVjSgPdLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1zw&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2Ax*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1Ax*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1Aw*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1zw&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8H5D2Ax*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1Ax*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1Aw*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1A w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1zw&t!qYmVjSgOdL9I6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1zw&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2Ax*u$qZnWkShPeMaJ7F4C1z)s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1zw&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2Ax*t$qZnVkShPdMaI7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1Aw*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1zw&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2Ax*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjbK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1Ax*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1Aw*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1zw*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1zw&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOdL9I6E3B0y(v%s#kThPeMbJ7G4D1z w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1zw&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2Ax*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2Ax*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1Aw*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1Aw*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkTLaI6F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMbJ7G4C1zw&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2Ax*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1Ax*t$qYnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1zw*t!qYnVjSgOdLaI6F3C0y)v%s#pXlQeNbJ8G4D1Aw*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1zw*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4D1zw&t!qY