探讨蔓越莓对预防泌尿道感染之成效.pptx

,按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,#,探讨蔓越莓对预防泌尿道感染之成效,探讨蔓越莓对预防泌尿道感染之成效,第1页,動機,目标,EBN,問題與步驟,文獻評讀,結論,討論,大綱,探讨蔓越莓对预防泌尿道感染之成效,第2页,全院感染率,1-6,月份以泌尿道感染率為最高,:1.68,0/00,外科病房泌尿道感染率有偏高趨勢,95,年,1-6,月,9A,病房,4.1 0/00,醫生经常告訴病人多喝蔓越莓汁醫院製作衛教單張也衛教病人多喝蔓越莓汁但终究應,喝多少？有何效果？,院內護理之家住民有長期食用蔓越莓汁之情形，,why,？,動機,探讨蔓越莓对预防泌尿道感染之成效,第3页,目标,經由,EBN,之實證精神,，,探索神奇,蔓越莓,，,透過,文獻蒐集與評讀,:,瞭解,蔓越莓功效,為何,?,怎样實際地運用在臨床上,?,目标,探讨蔓越莓对预防泌尿道感染之成效,第4页,Step 1:,整理出一個能够回答問題,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,探讨蔓越莓对预防泌尿道感染之成效,第5页,蔓越莓對預防泌尿道感染成效,?,Step 1:,整理出一個能够回答問題,探讨蔓越莓对预防泌尿道感染之成效,第6页,名詞解釋,蔓越苺：,又稱小紅莓，,(cranberry,，學名,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地區是北美及加拿大，主要產季在九月及十月左右。,MoweryDB,：,The scientific vlidation of herbal Medicine New Canaan Conn:Keats Pub,1986:316,探讨蔓越莓对预防泌尿道感染之成效,第7页,2.,泌尿道感染,(Urinary Tract Infection,),有症狀泌尿道感染,（,Symptomatic,）,無症狀菌尿症,（,Asymptomatic,）,出處,：,www.cdc.gov.tw/file/38694_7029398148,院內感染定義,.,名詞解釋,探讨蔓越莓对预防泌尿道感染之成效,第8页,有症狀泌尿道感染,症狀：發燒,、,急尿,、,小便困難,、,恥骨上 壓痛,含有尿路感染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,10,5,ml),探讨蔓越莓对预防泌尿道感染之成效,第9页,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,無症狀菌尿症,探讨蔓越莓对预防泌尿道感染之成效,第10页,Step 2:,尋找文獻證據,EBMSEARCH FRAMEWORK,搜尋實證文獻之架構,Evidence-based,Medicine Review,NGC,PubMed,Systematic Review,(National Guide Clearinghouse),MEDLINE,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,Cochrane,Library,探讨蔓越莓对预防泌尿道感染之成效,第11页,Step 3:,嚴格評讀文獻,研究證據價值取決於其品質及效度,評讀文獻黃金標準中,以,雙盲隨機對照臨床試驗,得出結果為最正确證據等級,The Evidence Pyramid,臨床研究證據等級,探讨蔓越莓对预防泌尿道感染之成效,第12页,等級,實證類別,I a,具規模含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,最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,最少有類似或靠近完整之實驗方法,(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,探讨蔓越莓对预防泌尿道感染之成效,第13页,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 D,Effectiveness established to a limited degree,Grade E,Effectiveness not established,文獻推薦等級,Develop by JBI,探讨蔓越莓对预防泌尿道感染之成效,第14页,文獻評讀,文獻評讀,探讨蔓越莓对预防泌尿道感染之成效,第15页,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主要作用，不过經過許多研究後證實這只是蔓越莓作用之一。,蔓越莓汁中分離而得濃縮單寧酸,（,condensed tannins,）,，或稱初花青素,（,proanthocyanidins,）,，發現其含有特殊,抗黏附活性,成份，能抑制大腸桿菌,E.coli,P,型纖毛黏附於尿道細胞上。,Lowe,F.C.(),探讨蔓越莓对预防泌尿道感染之成效,第16页,每,100g,蔓越莓汁成份,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,PH,2.5,其它成份還包含,：,類黃酮,(flavonoids),、,前花青素,(proanthocyanidins),、兒茶素,(catechin),Lowe,F.C.(),探讨蔓越莓对预防泌尿道感染之成效,第17页,Role of Cranberry Juice on Molecular-Scale,Surface,Characteristics and Adhesion Behavior of Escherichia coli,BIOTECHNOLOGY AND BIOENGINEERING,VOL.93,NO.2,FEBRUARY 5,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,探讨蔓越莓对预防泌尿道感染之成效,第18页,RESULT,&DISCUSSION,Exposure to cranberry juice resulted in a decrease in the equilibrium,length,of the p-fimbriae on the surface of E.coli,Cranberry juice,blocks adhesive action,of P-fimbriae(proanthocyanidin),Cranberry juice causes loss of expression of P-fimbriae,探讨蔓越莓对预防泌尿道感染之成效,第19页,年份,:1995,篇名：,Efficacy of cranberry in prevention of urinary tract infection in a susceptible pediatric population.,作者,：,Foda MM,Middlebrook PF,Gatfield CT,Potvin G,Wells G,Schillinger JF,.,Can J Urol;2:98-102,收案族群：,40/21,位診所儿童，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,),探讨蔓越莓对预防泌尿道感染之成效,第20页,實驗設計,：單盲（醫師）,、,交叉設計,办法：,天天,15ml/kg cranberry,雞尾酒汁（成份,30,），持續,6,個月,cranberry,雞尾酒汁，,6,個月水,結果：,有症狀上泌尿道感染,-c,ranberry,：,19/112 months,（,17,）,-Placebo,：,20/117 months,（,17.1,）,無症狀上泌尿道感染,-Cranberry,：,27/112 months,（,24.1,）,-Placebo,：,34/117 months,（,29,）,AHCPR,文獻等級：,II a,探讨蔓越莓对预防泌尿道感染之成效,第21页,年份：,1999,篇名：,Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization.J Pediatr 1999;135:698-702.,作者,：,Schlager TA,Anderson S,Trudell J,Hendley JO.,收案族群：,15/15,儿童，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,),探讨蔓越莓对预防泌尿道感染之成效,第22页,實驗設計,：隨機,/,Double blind,/,交叉設計,办法：,天天,300cc cranberry,（,成份,30,）,，,控制組：,Placebo controlled,（抚慰劑）看起來和嚐起來相同果汁，持續,3,個月,cranberry juice,，持續,3,個月抚慰劑,結果：,有症狀上泌尿道感染,-Cranberry,：,3 times UTI In 2 children,-Placebo,：,3times UTI In 3 children,無症狀上泌尿道感染,-Cranberry,：,120/160 months,（,75,）,-Placebo,：,114/151months,（,75,）,AHCPR,文獻等級：,I a,探讨蔓越莓对预防泌尿道感染之成效,第23页,年份：,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;9:1558-62,.,作者,：,Walker EB,Barney DP,Mickelsen JN,Walton RJ,Mickelsen RA Jr.,收案族群：,19/10,有性交活動女性（,28-44,歲,),收案條件：,未懷孕有性交活動女性（,18-45,歲）,有過,UTI,病史,文獻查證,相關研究,(,三,),探讨蔓越莓对预防泌尿道感染之成效,第24页,實驗設計,：,Double blind/,交叉設計,办法：,Cranberry,錠劑（,400mg,）控制組：,Placebo,（抚慰錠劑持續,3,個月,cranberry,錠劑，持續,3,個月抚慰錠劑,),結果：,有症狀上泌尿道感染,-Cranberry,：,6times UTI,-Placebo,：,15times UTI,AHCPR,文獻等級：,II a,探讨蔓越莓对预防泌尿道感染之成效,第25页,年份,：,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,),探讨蔓越莓对预防泌尿道感染之成效,第26页,對象,:,376,在醫院老年人,方法,:,隨機、雙盲,办法：,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,探讨蔓越莓对预防泌尿道感染之成效,第27页,Tero Kontiokari,Kaj Sundqvist,M Nuutinen,T Pokka,M Koskela and M Uhari,BMJ,;322;1571,Randomized trial of cranberry-lingo berry juice,and,lactobacillus,G,G 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,探讨蔓越莓对预防泌尿道感染之成效,第28页,（一）,Objective,To determine whether,recurrences of urinary tract infection can be prevented,with cranberry,lingonberry 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.,Intervention,50 ml of cranberry,lingonberry 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.,探讨蔓越莓对预防泌尿道感染之成效,第29页,（二）,This is a 20%reduction in absolute risk in the cranberry group compared with the control group,探讨蔓越莓对预防泌尿道感染之成效,第30页,P.Di Martino A R.Agniel A K.David A C.TemplerJ.L.Gaillard A P.Denys A H.BottoPublished online:6 January Springer-Verlag,Reduction of Escherichia coli adherence to uroepithelial bladder cellsafter consumption of cranberry juice,文獻查證,相關研究,(,六,),探讨蔓越莓对预防泌尿道感染之成效,第31页,（一）,Abstract,To,determine the efficacy of the consumption of cranberry juice versus placebo,with regard to,the presence of in vitro bacterial,anti-adherence activity,in the urine of healthy volunteers,Participants,Twenty healthy volunteers,10 men and 10 women,were included,Design,The study was a double-blind,randomized,placebo-controlled,and cross-over study.,with a washout period of at least 6 days between every change in regimen,AHCPR,文獻等級：,1a,探讨蔓越莓对预防泌尿道感染之成效,第32页,（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,探讨蔓越莓对预防泌尿道感染之成效,第33页,(,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,探讨蔓越莓对预防泌尿道感染之成效,第34页,(,四,)Result,Anti-adherence activity of the cranberry juice,:comparisonof the regimens,means for the 20 volunteers and 6 types of E coli strains,Regimens,Decrease in bacterial adherence(%),250 ml placebo+500 ml mineral water,-,750 ml placebo,12,250 ml cranberry+500 ml mineral water,45,750 ml cranberry,65,探讨蔓越莓对预防泌尿道感染之成效,第35页,(,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.,探讨蔓越莓对预防泌尿道感染之成效,第36页,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,),探讨蔓越莓对预防泌尿道感染之成效,第37页,(,一,),Objectives,To determine the effect of,regular intake,of cranberry juice beverage on bacteriuria and pyuria,in elderly women,Intervention,Subjects were randomly to consume,300 mL,per day of a commercially available,standard cranberry beverage,or a,specially prepared synthetic placebo cranberry drink-,6MONTHSurine samples were collected at approximately 1-month intervals and tests quantitatively for,bacteriuria and the presence of white blood cells.,Design,Randomized,double-blind,placebo-controlled trial.,Participants,109:LONG-TERM COMMUNITY DWELLING.,44:LONG TERM CARE FACILITY,AHCPR,文獻等級：,1a,探讨蔓越莓对预防泌尿道感染之成效,第38页,METHOD,Ocean spray cranberry,Bacterial culture,Antibiotic sensitivity,外觀顏色,(,使用糖精,),瓶蓋每个月搜集一 次,教導中間尿,探讨蔓越莓对预防泌尿道感染之成效,第39页,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.,探讨蔓越莓对预防泌尿道感染之成效,第40页,Placebo group,Cranberry group,Result,The difference was not present in the first month,INFECTED URINE SAMPLES%,探讨蔓越莓对预防泌尿道感染之成效,第41页,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,探讨蔓越莓对预防泌尿道感染之成效,第42页,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.,探讨蔓越莓对预防泌尿道感染之成效,第43页,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,探讨蔓越莓对预防泌尿道感染之成效,第44页,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.,探讨蔓越莓对预防泌尿道感染之成效,第45页,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：天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：防止與白天藥物有交叉反應）,對象：泌尿道感染住民一定使用，除糖尿病、腸胃出血、高血鉀、洗腎病人不給，其它住民也一律給。但意識清楚，由口禁食住民多半不喝，,則不強迫。,探讨蔓越莓对预防泌尿道感染之成效,第46页,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。,探讨蔓越莓对预防泌尿道感染之成效,第47页,經研究證實蔓越莓能够預防泌尿道感染,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幾個月後才發生，有些研究期間較短，較無法看出结果,研究中退出病人數較高,(20-55),可能因病人較無法接收需長期飲用蔓越莓汁，,在小孩身上這是主要原因,結論,探讨蔓越莓对预防泌尿道感染之成效,第48页,蔓越莓汁成本高：長期飲用耗費成本需考量,(,平均每年約需,625-1400,元美金,),，蔓越莓濃 縮物或錠劑也許能够克服。,但當病人每年有經歷,2,次有症狀泌尿道感染，和抗生素成本比較起來則有大大節省。,結論,探讨蔓越莓对预防泌尿道感染之成效,第49页,錠劑好,?,果汁好,?,蔓越莓汁到底要喝多少,?,日後能够努力方向,1.,要長時間追蹤,2.,衛教單宜增加使用劑量說明,3.,需註明服用,蔓越莓禁忌,討論,探讨蔓越莓对预防泌尿道感染之成效,第50页,