蔓越莓

1、探討蔓越莓對(duì)預(yù)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(dòng)機(jī)目的EBN問(wèn)題與步驟文獻(xiàn)評(píng)讀結(jié)論討論,大綱,全院感染率1-6月份以泌尿道感染率為最高:1.68 0/00外科病房的泌尿道感染率有偏高的趨勢(shì) 95年1-6月9A病房4.1 0/00醫(yī)生常常告訴病人多喝蔓越莓汁醫(yī)院製作的衛(wèi)教單張也衛(wèi)教病人多喝蔓越莓汁但究竟應(yīng)喝多少？ 有何效果？？？？

2、院內(nèi)護(hù)理之家住民有長(zhǎng)期食用蔓越莓汁之情形，why？,動(dòng)機(jī),目的,經(jīng)由EBN之實(shí)證精神，探索神奇的蔓越莓，透過(guò)文獻(xiàn)蒐集與評(píng)讀:瞭解蔓越莓功效為何?如何實(shí)際地運(yùn)用在臨床上?,目的,Step 1: 整理出一個(gè)可以回答的問(wèn)題 Step 2: 尋找文獻(xiàn)證據(jù) Step 3: 嚴(yán)格評(píng)讀文獻(xiàn)Step 4: 應(yīng)用於病人身上 Step 5: 對(duì)過(guò)程進(jìn)行稽核,實(shí)證五步驟,,蔓越莓對(duì)預(yù)防泌尿道感染的成效?,Step 1: 整理出一個(gè)可以回答的問(wèn)題

3、,,名詞解釋,蔓越苺：又稱(chēng)小紅莓，(cranberry，學(xué)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(chǎn)地及大面積耕種的地區(qū)是北美及加拿大，主要的產(chǎn)季在九月及十月左右。,,MoweryDB ： The scientific vlidation of herbal Medicine New Canaan Conn :Keats Pub ,1986:316

4、,2. 泌尿道感染(Urinary Tract Infection) 有癥狀的泌尿道感染（Symptomatic） 無(wú)癥狀菌尿癥（Asymptomatic）,出處 ：http://www.cdc.gov.tw/file/38694_7029398148院內(nèi)感染定義.,名詞解釋,,有癥狀的泌尿道感染,癥狀：發(fā)燒、急尿、小便困難、恥骨上 壓痛☆具有尿路感染的癥狀任一項(xiàng)且尿液培養(yǎng)--菌落數(shù)每毫升大於或等於十萬(wàn)個(gè)

5、 （colony count ≧ 105ml),,☆尿液培養(yǎng)之微生物七天內(nèi)連續(xù)兩次相同方式 取得之尿液標(biāo)本，連續(xù)兩次相同，菌落數(shù)每 毫升大於或等於十萬(wàn)個(gè),,無(wú)癥狀的菌尿癥,,,Step 2: 尋找文獻(xiàn)證據(jù),Step 3: 嚴(yán)格評(píng)讀文獻(xiàn),,研究證據(jù)的價(jià)值取決於其品質(zhì)及效度評(píng)讀文獻(xiàn)的黃金標(biāo)準(zhǔn)中,以雙盲隨機(jī)對(duì)照臨床試驗(yàn)得出的結(jié)果為最佳證據(jù)等級(jí),The Evidence Pyramid臨床研究證據(jù)等級(jí),證據(jù)等級(jí),--US Ag

6、ency for Health Care Policy and Research Classification (AHCPR, 1992,文獻(xiàn)推薦等級(jí),,Develop by JBI,文獻(xiàn)評(píng)讀,,文獻(xiàn)評(píng)讀,文獻(xiàn)查證蔓越莓對(duì)預(yù)防泌尿道感染作用機(jī)轉(zhuǎn),,尿液酸化一直被認(rèn)為是蔓越莓預(yù)防尿道感染的主要作用，但是經(jīng)過(guò)許多的研究後證實(shí)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(chēng)初花

7、青素（proanthocyanidins），發(fā)現(xiàn)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(xì)胞上。,,Lowe ,F.C. (2001),每100g蔓越莓汁成分Water(%)……………………. 92.9Solid r(%) ………………….. 7.1Calories …………………........27Total carbohydrate (g)…… 6.8 Sugar (g)

8、………………….. .3.7 Dietary fiber (g)………….0.1Protein (g)…………………… ＜0.1Fat (g) ……………………….. ＜0.1Mineral Sodium(mg)…………………..3.8 potassium(mg)………………85.2 calcium(mg)………………… .6.8 iron(mg)………………………… ..0.33Vit

9、amin C(mg)……………………2PH……………………………………2.5,,,,其他的成分還包括：類(lèi)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 E

10、scherichia coli,BIOTECHNOLOGY AND BIOENGINEERING, VOL. 93, NO. 2, FEBRUARY 5, 2006,Yatao Liu, Matthew A. Black, Lizabeth Caron, Terri A. Camesano,文獻(xiàn)查證蔓越莓對(duì)預(yù)防泌尿道感染作用機(jī)轉(zhuǎn),RESULT & DISCUSSION,Exposure to cranberry juice r

11、esulted in a decrease in the equilibrium length of the p-fimbriae on the surface of E. coliCranberry juice blocks adhesive action of P-fimbriae (proanthocyanidin)Cranberry juice causes loss of expression of P-fimbriae,

12、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;2:9

13、8-102收案族群：40/21位診所小朋友，有神經(jīng)性膀胱 並需間歇性導(dǎo)尿（平均9.35歲),文獻(xiàn)評(píng)讀-1,文獻(xiàn)查證相關(guān)研究(一),實(shí)驗(yàn)設(shè)計(jì) ：?jiǎn)蚊ぃㄡt(yī)師）、交叉設(shè)計(jì) 措施：每天15ml/kg cranberry 雞尾酒汁（成分30﹪），持續(xù)6個(gè)月cranberry 雞尾酒汁，6個(gè)月水 結(jié)果：有癥狀的上泌尿道感染 -- cranberry：19/112 months（17﹪）

14、 -- Placebo：20/117 months（17.1﹪） 無(wú)癥狀的上泌尿道感染 --Cranberry：27/112 months（24.1﹪） --Placebo：34/117 months（29﹪）,AHCPR文獻(xiàn)等級(jí) ： II a,年份：1999篇名：Effect of cranberry juice on bacteriuria in chi

15、ldren 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小朋友，有神經(jīng)性膀胱並需間 歇性導(dǎo)尿（2-18歲),文獻(xiàn)查證相關(guān)研究(二),實(shí)驗(yàn)設(shè)計(jì) ：隨機(jī)/Do

16、uble blind/交叉設(shè)計(jì) 措施：每天300cc cranberry（成分30﹪），控制組：Placebo controlled（安慰劑）看起來(lái)和嚐起來(lái)相似的果汁，持續(xù)3個(gè)月cranberry juice，持續(xù)3個(gè)月安慰劑結(jié)果：有癥狀的上泌尿道感染 -- Cranberry：3 times UTI In 2 children --Placebo：3times UTI In 3 ch

17、ildren 無(wú)癥狀的上泌尿道感染 --Cranberry：120/160 months（75﹪） --Placebo：114/151months（75﹪）,AHCPR文獻(xiàn)等級(jí) ： I a,年份：2002篇名： randomized trial to evaluate effectiveness and cost effectiveness of n

18、aturopathic 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(dòng)的女性（28-44歲)收案條件： 未懷孕

19、有性交活動(dòng)的女性（18-45歲） 有過(guò)UTI病史,文獻(xiàn)查證相關(guān)研究(三),實(shí)驗(yàn)設(shè)計(jì)：Double blind/交叉設(shè)計(jì)措施：Cranberry錠劑（400mg）控制組：Placebo （安慰錠劑持續(xù)3個(gè)月cranberry 錠劑，持續(xù)3個(gè)月安慰錠劑 )結(jié)果：有癥狀的上泌尿道感染 --Cranberry：6times UTI --Placebo：15times U

20、TI,AHCPR文獻(xiàn)等級(jí) ： 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,L

21、AIN K,CROMBIE,文獻(xiàn)評(píng)讀-5,文獻(xiàn)查證相關(guān)研究(四),對(duì)象:376 在醫(yī)院的老年人方法:隨機(jī)、雙盲措施：隨機(jī)給予300ml/day cranberry juice or matching placebo beverage 結(jié)論：no significant differences were found between treatment group,AHCPR文獻(xiàn)等級(jí) ： I a,Te

22、ro 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 ofurinary tract infections in wome

23、n,文獻(xiàn)查證相關(guān)研究(五),AHCPR文獻(xiàn)等級(jí) I a,（一）,,（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. TemplerJ. L. Gaillard A P. Denys A H. Botto

24、Published online: 6 January 2006 Springer-Verlag 2006,,Reduction of Escherichia coli adherence to uroepithelial bladder cellsafter consumption of cranberry juice,文獻(xiàn)查證相關(guān)研究(六),（一）,AHCPR文獻(xiàn)等級(jí) ：1a,（二）INTRODUCTION,ZafririD

25、,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,(三)成份比較,Cranberry juice PlaceboCalories (Kcal) 41.6 42.7Total

26、carbohydrates (g) 10.4 10.7Ascorbic acid (mg) 63 63Total organic acids (g) 1.8 1.6Total phenolics (mg) 179 161Total anthocyanidins (mg) 9.3 42Proanthocyanidins (mg) 40 ND,,(四)Result Anti-adherence acti

27、vity of the cranberry juice: comparisonof the regimens, means for the 20 volunteers and 6 types of E coli strains,(四)Result,No significant differences in the pH or specific gravity between the urine samples collected af

28、ter 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 juic

29、e,Avorn,jerry Md; JAMA,271(1o).March9,1994.751-754,文獻(xiàn)查證相關(guān)研究(七),(一),AHCPR文獻(xiàn)等級(jí) ：1a,METHOD,Ocean spray cranberry Bacterial cultureAntibiotic sensitivity外觀顏色(使用糖精)瓶蓋每月收集一 次教導(dǎo)中間尿,Results,Escherichal coli was the most co

30、mmonly 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,ResultThe diffe

31、rence 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 g

32、roup (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 crede

33、nce 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

34、 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 s

35、ettings, 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 treatme

36、nt of this common disorder.,Step 4: 應(yīng)用於病人身上,現(xiàn)況：院內(nèi)護(hù)理之家住民長(zhǎng)期在食用蔓越莓汁食品處方：由營(yíng)養(yǎng)室設(shè)計(jì)安排，費(fèi)用算在伙食費(fèi)內(nèi)。使用方法：每天下午由營(yíng)養(yǎng)室配送蔓越莓原液100g（無(wú)糖），護(hù)理人員稀釋成200cc，餵食時(shí)間為11pm（原因：避免與白天藥物有交叉反應(yīng)）對(duì)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(shí)清楚，由口禁食住民多半不喝

37、， 則不強(qiáng)迫。,,為何不用錠劑： 因?yàn)樵凶∶袷秤冕嵊懈哐浨樾巍Ｃ谀虻栏腥韭剩何醋鲅芯糠治觥?經(jīng)研究證實(shí)蔓越莓可以預(yù)防泌尿道感染文獻(xiàn)上並無(wú)明確建議蔓越莓食用劑量泌尿道感染常在病人無(wú)癥狀的幾個(gè)月後才發(fā)生，有些的研究期間較短，較無(wú)法看出成果研究中退出的病人數(shù)較高(20-55﹪) 可能因病人較無(wú)法接受需長(zhǎng)期飲用蔓越莓汁， 在小孩身上這是主要原因,結(jié)論,蔓越莓汁成本高：長(zhǎng)期飲用耗費(fèi)的成本需考量 (平