儿童病毒性脑炎药物治疗循证指南的系统评价

目的系统评价儿童病毒性脑炎的相关指南,为临床循证用药提供参考。方法计算机检索Pub Med、EMbase、CBM、万方、CNKI、维普等数据库;以及NGC、GIN、TRIP等指南数据库和各大医学行业机构网站如CDC、IDSA、AAP、WHO、中国卫生和计划生育委员会、中国临床指南文库和中国临床指南协作网。检索时限从建库或建网至2014年10月。2位研究者依纳入与排除标准独立筛选文献,采用指南研究与评价的评审工具Ⅱ(AGREEⅡ)评价指南质量,使用组内相关系数(ICC)进行一致性检验。结果最终纳入3部指南,均为近5年发布,分别来自英国、美国和欧洲。指南最终推荐均为B级,在AGREEⅡ6个领域中"范围和目的 "得分最高,平均68.54%。得分较低的是"应用性"和"编辑的独立性"。对疑似患儿应尽早经验予阿昔洛韦治疗。确诊为单纯疱疹和水痘带状疱疹病毒性脑炎,亦推荐使用阿昔洛韦。但推荐级别不同,前者为强推荐,后者推荐强度降低。此外,单纯疱疹病毒性脑炎患儿暂不推荐使用糖皮质激素;而水痘带状疱疹,可使用激素作为备选治疗,但证据尚不充分。对于巨细胞病毒脑炎推荐更昔洛韦联合膦甲酸,不建议使用西多福韦;肠病毒脑炎可以使用普拉康纳利。结论各指南推荐的治疗病毒性脑炎的药物基本一致,但制定循证指南在编辑的独立性以及应用性上要进一步加强。

A systematic review of evidence-based guidelines for drug therapies for viral encephalitis in children

Objective To systematically review the guidelines for viral encephalitis in children, and to provide a reference for evidence-based medication in clinical practice.Methods The databases including PubMed, EMbase, CBM, Wanfang Data, CNKI, and VIP were searched, as well as the guideline databases such as NGC, GIN, and TRIP, the websites of medical institutions including CDC, IDSA, AAP, WHO, and Chinese Health and Family Planning Committee, China Guideline Clearinghouse, and Clinical Practice Guideline Network. All the data were searched from the inception of the database or network to October 2014. Two investigators independently screened the literature according to inclusion and exclusion criteria and assessed the quality of guidelines with Appraisal of Guidelines for Research and Evaluation II (AGREE II). The intraclass correlation coefficient was used for conformance test.Results A total of 3 guidelines from the UK, US, and Europe were enrolled, which were released within the past 5 years. The recommendations for all three guidelines were level B. Among the 6 domains of AGREE II, the domain of "scope and purpose" had the highest score, with an average value of 68.54%, while the domains of "applicability" and "editorial independence" had lower scores. The suspected children should be given acyclovir as the empirical therapy as early as possible. Acyclovir was also recommended in patients with a confirmed diagnosis of herpes simplex virus (HSV) encephalitis or varicella zoster virus (VZV) encephalitis, but the recommendation level was different. The former had a strong recommendation level, while the latter had a decreased recommendation level. In addition, corticosteroids were not recommended in children with HSV, while it could be used as an alternative treatment of VZV, even though the evidence was not sufficient. Ganciclovir combined with foscarnet were recommended for cytomegalovirus encephalitis, while cidofovir was not recommended. Pleconaril might be a choice in patients with enterovirus encephalitis.Objective The drugs for the treatment of viral encephalitis recommended by these guidelines are basically consistent, but the development of evidence-based guidelines should be improved in the domains of "editorial independence" and "applicability" in future.