RESUMO
In response to the COVID-19 pandemic, the Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) began developing "practice points" to provide clinical advice based on the best available evidence for the public, patients, clinicians, and public health professionals. As one of the first organizations in the United States to develop evidence-based clinical guidelines, ACP continues to lead and advance the science of evidence-based medicine by implementing new methods to rapidly publish practice points and maintain them as living advice that regularly assesses and incorporates new evidence. The overarching aim of practice points is to answer targeted key questions for which there is a timely need to synthesize evidence for decision making. The SMPC believes these methods can potentially be adapted to address various clinical and public health topics beyond the COVID-19 pandemic. This article presents an overview of the SMPC's living, rapid practice points development process, which includes a rapid systematic review, use of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, use of stringent policies on the disclosure of interests and management of conflicts of interest, incorporating a public (nonclinician) perspective, and maintenance of the documents as living through ongoing surveillance and synthesis of new evidence as it emerges.
Assuntos
COVID-19/diagnóstico , COVID-19/terapia , Medicina Baseada em Evidências/métodos , Guias de Prática Clínica como Assunto , Teste para COVID-19 , Tomada de Decisão Clínica , Conflito de Interesses , Humanos , Pandemias , Revisões Sistemáticas como Assunto/métodos , Estados UnidosRESUMO
DESCRIPTION: Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections. METHODS: The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence. BEST PRACTICE ADVICE 1: Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). BEST PRACTICE ADVICE 2: Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. BEST PRACTICE ADVICE 3: In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility. BEST PRACTICE ADVICE 4: In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.
Assuntos
Antibacterianos/administração & dosagem , Infecções Bacterianas/tratamento farmacológico , Uso Excessivo de Medicamentos Prescritos/prevenção & controle , Bronquite/tratamento farmacológico , Celulite (Flegmão)/tratamento farmacológico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Cistite/tratamento farmacológico , Esquema de Medicação , Feminino , Humanos , Masculino , Pneumonia Bacteriana/tratamento farmacológico , Atenção Primária à Saúde , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Pielonefrite/tratamento farmacológicoRESUMO
DESCRIPTION: The widespread availability of SARS-CoV-2 antibody tests raises important questions for clinicians, patients, and public health professionals related to the appropriate use and interpretation of these tests. The Scientific Medical Policy Committee (SMPC) of the American College of Physicians developed these rapid, living practice points to summarize the current and best available evidence on the antibody response to SARS-CoV-2 infection, antibody durability after initial infection with SARS-CoV-2, and antibody protection against reinfection with SARS-CoV-2. METHODS: The SMPC developed these rapid, living practice points based on a rapid and living systematic evidence review done by the Portland VA Research Foundation and funded by the Agency for Healthcare Research and Quality. Ongoing literature surveillance is planned through December 2021. When new studies are identified and a full update of the evidence review is published, the SMPC will assess the new evidence and any effect on the practice points. PRACTICE POINT 1: Do not use SARS-CoV-2 antibody tests for the diagnosis of SARS-CoV-2 infection. PRACTICE POINT 2: Antibody tests can be useful for the purpose of estimating community prevalence of SARS-CoV-2 infection. PRACTICE POINT 3: Current evidence is uncertain to predict presence, level, or durability of natural immunity conferred by SARS-CoV-2 antibodies against reinfection (after SARS-CoV-2 infection).
Assuntos
Anticorpos Antivirais/imunologia , Formação de Anticorpos , Teste para COVID-19/normas , COVID-19/imunologia , Imunidade Inata/imunologia , SARS-CoV-2/imunologia , HumanosRESUMO
Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.
Assuntos
Ética Médica , Manuais como Assunto , Humanos , Relações Interprofissionais , Papel do Médico , Relações Médico-Paciente , Administração da Prática Médica/ética , Profissionalismo , Responsabilidade Social , Assistência Terminal/éticaAssuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Guias como Assunto , Máscaras/estatística & dados numéricos , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , COVID-19 , Infecções por Coronavirus/transmissão , Humanos , Pneumonia Viral/transmissão , SARS-CoV-2 , Estados Unidos/epidemiologiaAssuntos
Azitromicina/uso terapêutico , Cloroquina/uso terapêutico , Hidroxicloroquina/uso terapêutico , Azitromicina/efeitos adversos , Betacoronavirus , Cloroquina/efeitos adversos , Infecções por Coronavirus/tratamento farmacológico , Humanos , Hidroxicloroquina/efeitos adversos , SARS-CoV-2 , Estados Unidos , Tratamento Farmacológico da COVID-19RESUMO
[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].
Assuntos
Antibacterianos/uso terapêutico , Infecções por Clostridium/diagnóstico , Infecções por Escherichia coli/diagnóstico , Doença Iatrogênica , Infecções Urinárias/diagnóstico , Administração Intravenosa , Administração Oral , Idoso de 80 Anos ou mais , Infecções por Clostridium/tratamento farmacológico , Infecções por Clostridium/fisiopatologia , Infecções por Escherichia coli/tratamento farmacológico , Infecções por Escherichia coli/fisiopatologia , Feminino , Febre , Humanos , Resultado do Tratamento , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/fisiopatologiaRESUMO
[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].
Assuntos
Estágio Clínico/ética , Ética Médica/educação , Estudantes de Medicina , Estágio Clínico/métodos , Humanos , Rhode IslandRESUMO
[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].