Важны ли клинические рекомендации в практике педиатра?
Важны ли клинические рекомендации в практике педиатра?
Бехтерева М.К., Комарова А.М. Важны ли клинические рекомендации в практике педиатра? Педиатрия. Consilium Medicum. 2022;1:98–104. DOI: 10.26442/26586630.2022.1.201534
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Bekhtereva MK, Komarova AM. Are clinical guidelines important in pediatric practice? Pediatrics. Consilium Medicum. 2022;1:98–104. DOI: 10.26442/26586630.2022.1.201534
Важны ли клинические рекомендации в практике педиатра?
Бехтерева М.К., Комарова А.М. Важны ли клинические рекомендации в практике педиатра? Педиатрия. Consilium Medicum. 2022;1:98–104. DOI: 10.26442/26586630.2022.1.201534
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Bekhtereva MK, Komarova AM. Are clinical guidelines important in pediatric practice? Pediatrics. Consilium Medicum. 2022;1:98–104. DOI: 10.26442/26586630.2022.1.201534
В связи с мерами по оптимизации системы здравоохранения роль специалиста первичного звена постоянно возрастает. В профессиональном стандарте врача-педиатра первичного звена четко определены его трудовые функции, однако значительное число педиатров не всегда следуют регламентирующим документам по оказанию медицинской помощи пациентам. Тем не менее в случае каких-либо конфликтных ситуаций, проведения оценки качества оказания медицинской помощи в рамках различных видов экспертиз в первую очередь оценивается соответствие оказанной медицинской помощи действующим регламентирующим документам. Стандарт оказания медицинской помощи не предназначен для принятия каких-либо решений по лечению конкретного пациента, он является экономическим инструментом. Поправки к закону №323-ФЗ «Об основах охраны здоровья граждан в РФ», принятые в 2018 г., наделили клинические рекомендации статусом обязательных для исполнения наряду со стандартами, положением и порядками оказания медпомощи. Таким образом, клинические рекомендации в нашей стране являются основой оказания медицинской помощи, подготовлены профессиональными медицинскими сообществами с учетом отечественных и зарубежных метаанализов и рандомизированных клинических исследований и направлены на защиту прав пациентов и медицинских работников. В статье на примере клинической рекомендации по сальмонеллезу у детей разобрана опция терапии в виде применения пробиотиков, обоснованность их использования в различных клинических ситуациях.
Due to measures to optimize the healthcare system, the role of the primary care specialist is constantly increasing. The professional standard of a primary care pediatrician clearly defines his/her job functions, but a significant number of pediatricians do not always follow the regulatory documents on the provision of medical care to patients. Nevertheless, in case of any conflicts and in case of assessing the quality of medical care within the framework of various types of examinations, first of all, the compliance of the provided medical care with the current regulatory documents is assessed. The standard of medical care is not intended to make any decisions on the treatment of a particular patient, it is an economic tool. Amendments to the law №323-FZ "On the Fundamentals of Healthcare in the Russian Federation", adopted in 2018, gave clinical guidelines the status of mandatory for implementation along with standards, regulations, and procedures for providing medical care. Thus, clinical guidelines in our country are the basis for medical care, prepared by professional medical communities taking into account domestic and foreign meta-analyses and randomized clinical trials, and are aimed at protecting the rights of patients and medical workers. In the article on the example of clinical guidelines for salmonellosis in children the therapy option in the form of probiotics, the validity of their use in various clinical situations is analyzed.
1. Федеральный закон от 21.11.2011 №323-ФЗ (ред. от 02.07.2021) «Об основах охраны здоровья граждан в Российской Федерации» (с изм. и доп., вступ. в силу с 01.10.2021). Режим доступа: https://minzdrav.gov.ru/documents. Ссылка активна на 16.03.2022 [Federal Law №323-FZ of November 21, 2011 (as amended on July 2, 2021) “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (as amended and supplemented, effective from October 1, 2021). Available at: https://minzdrav.gov.ru/documents. Accessed: 16.03.2022 (in Russian)].
2. Приказ Минздрава России от 10.05.2017 №203н «Об утверждении критериев оценки качества медицинской помощи». Режим доступа: https://minzdrav.gov.ru/poleznye-resursy. Ссылка активна на 16.03.2022 [Order of the Ministry of Health of the Russian Federation of May 10, 2017 № 203-n “On approval of criteria for assessing the quality of medical care”. Available at: https://minzdrav.gov.ru/poleznye-resursy. Accessed: 16.03.2022 (in Russian)].
3. Сальмонеллез у детей. Клиническая рекомендация. М., 2021 [Sal'monellez u detei. Klinicheskaia rekomendatsiia. Moscow, 2021 (in Russian)].
4. Горелов А.В., Милютина Л.Н., Усенко Д.В. Клинические рекомендации по диагностике и лечению острых кишечных инфекций у детей. Пособие для врачей. М., 2006 [Gorelov AV, Miliutina LN, Usenko DV. Klinicheskie rekomendatsii po diagnostike i lecheniiu ostrykh kishechnykh infektsii u detei. Posobie dlia vrachei. Moscow, 2006 (in Russian)].
5. Guarino A, Albano F, Ashkenazi S, et al. European Society for Paediatric Infectious Diseases Evidence-based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. J Pediat Gastroenterol Nutr. 2008;46(2):81-122.
6. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organisation Global Guidelines. February 2012.
7. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59(1):132-52.
8. Распоряжение Правительства РФ от 12.10.2019 №2406-р «Об утверждении перечня жизненно необходимых и важнейших лекарственных препаратов на 2020 год» с изм., внесенными распоряжением Правительства РФ от 23.12.2021 №3781-р, вступ. в силу с 1 января 2022 г. Режим доступа: https://www.mgfoms.ru/documents/16321. Ссылка активна на 16.03.2022 [Decree of the Government of the Russian Federation of October 12, 2019 № 2406-r “On approval of the list of vital and essential drugs for 2020” as amended by the Decree of the Government of the Russian Federation of December 23, 2021 №3781-r, entry effective from January 1, 2022. Available at: https: https://www.mgfoms.ru/documents/16321. Accessed: 16.03.2022 (in Russian)].
9. World Gastroenterology Organization. Probiotics and prebiotics: Practice Guideline 2011. Available at: http://www.worldgastroenterology.org/probiotics-prebiotics.html. Accessed: 16.03.2022
10. Canani RB, Cirillo P, Terrin GA, et al. Probiotics for treatment of acute diarrhea in children: randomised clinical trial of five different preparations. BMJ. 2007;335:340-7.
11. de Vrese M, Marteau PR. Probiotics and prebiotics: effects on diarrhea. J Nutr. 2007;137(Suppl. 2):803S-11S.
12. Gaon D, Garcia H, Winter L, et al. Effect of Lactobacillus strains and Saccharomyces boulardii on persistent diarrhea in children. Medicina. 2003;63:293-8.
13. Vandenplas Y, Brunser O, Szajewska H. Saccharomyces boulardii in childhood. Eur J Pediatr. 2009;168(3):253-65.
14. Корниенко Е.А. Механизмы воздействия антибиотиков на кишечник, роль Энтерола в профилактике и лечении антибиотик-ассоциированной диареи у детей. Фарматека. 2010;2:33-7 [Kornienko EA. Mekhanizmy vozdeistviia antibiotikov na kishechnik, rol' Enterola v profilaktike i lechenii antibiotik-assotsiirovannoi diarei u detei. Farmateka. 2010;2 (in Russian)].
15. Buts JP. Twenty-five years of research on Saccharomyces boulardii trophic effects: updates and perspectives. Dig Dis Sci. 2009;54:15-8.
16. Blobaut H, Massot J, Elmer GW, et al. Disposition kinetics of Saccharomyces boulardii in man and rat. Biopharm Drug Dispos. 1989;10:353-64.
17. Elmer GW, Moyer KA, Vega R, et al. Evaluation of Saccharomyces boulardii forpatients with HIV-related chronic diarrhoea and in healthy volunteers receiving antifungals. Microecol and Ther. 1995;25:23-31.
18. Castaneda C, Garcia E, Santa Cruz M, et al. Effects of Saccharomyces boulardii in children with chronic diarrhea, especially cases due to giardiasis. Rev Mex Pueric Pediatr. 1995;2:12‑6.
19. Jabn HU, Ullrich R, Schneider T, et al. Immunological and trophical effects of Saccharomyces boulardii on the small intestine in healthy human volunteers. Digestion. 1996;57:95-104.
20. Castagliuolo I, Riegler MF, Valenick L, et al. Saccharomyces boulardii protease mediates Clostridium difficile toxin A and B effects in human colonic mucosa. Infect Immun. 1999;67:302-7.
21. Girard P, Pansart Y, Lorette I, et al. Dose-response relationship and mechanism of action of Saccharomyces boulardii in castor oilinduced diarrhea in rats. Dig Dis Sci. 2003;48:770-4.
22. Szajewska H, Mrukowicz J. Meta-analysis: non-pathogenic yeast S. boulardii in the prevention of antibiotic-associated diarrhea. Aliment Pharmacol Ther. 2005;22(5):365-72.
23. Buts JP, De Keyser N, De Raedemaeker L. Saccharomyces boulardii enhances rat intestinal enzyme expression by endoluminal release of polyamines. Pediatr Res. 1994;36:522-7.
24. Turck D, Bernet JP, Marx J, et al. Incidence and risk factors of oral antibioticassociated diarrhea in an outpatient pediatric population. J Pediatr Gastroenterol Nutr. 2003;37:22-6.
25. Grandy G, Medina M, Soria R, et al. Probiotics in the treatment of acute rotavirus diarrhea. BMC Infect Dis. 2010;10:253.
26. McFarland LV. Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;5:97-105.
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1. Federal Law №323-FZ of November 21, 2011 (as amended on July 2, 2021) “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (as amended and supplemented, effective from October 1, 2021). Available at: https://minzdrav.gov.ru/documents. Accessed: 16.03.2022 (in Russian).
2. Order of the Ministry of Health of the Russian Federation of May 10, 2017 № 203-n “On approval of criteria for assessing the quality of medical care”. Available at: https://minzdrav.gov.ru/poleznye-resursy. Accessed: 16.03.2022 (in Russian).
3. Sal'monellez u detei. Klinicheskaia rekomendatsiia. Moscow, 2021 (in Russian).
4. Gorelov AV, Miliutina LN, Usenko DV. Klinicheskie rekomendatsii po diagnostike i lecheniiu ostrykh kishechnykh infektsii u detei. Posobie dlia vrachei. Moscow, 2006 (in Russian).
5. Guarino A, Albano F, Ashkenazi S, et al. European Society for Paediatric Infectious Diseases Evidence-based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. J Pediat Gastroenterol Nutr. 2008;46(2):81-122.
6. Acute diarrhea in adults and children: a global perspective. World Gastroenterology Organisation Global Guidelines. February 2012.
7. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59(1):132-52.
8. Decree of the Government of the Russian Federation of October 12, 2019 № 2406-r “On approval of the list of vital and essential drugs for 2020” as amended by the Decree of the Government of the Russian Federation of December 23, 2021 №3781-r, entry effective from January 1, 2022. Available at: https: https://www.mgfoms.ru/documents/16321. Accessed: 16.03.2022 (in Russian).
9. World Gastroenterology Organization. Probiotics and prebiotics: Practice Guideline 2011. Available at: http://www.worldgastroenterology.org/probiotics-prebiotics.html. Accessed: 16.03.2022
10. Canani RB, Cirillo P, Terrin GA, et al. Probiotics for treatment of acute diarrhea in children: randomised clinical trial of five different preparations. BMJ. 2007;335:340-7.
11. de Vrese M, Marteau PR. Probiotics and prebiotics: effects on diarrhea. J Nutr. 2007;137(Suppl. 2):803S-11S.
12. Gaon D, Garcia H, Winter L, et al. Effect of Lactobacillus strains and Saccharomyces boulardii on persistent diarrhea in children. Medicina. 2003;63:293-8.
13. Vandenplas Y, Brunser O, Szajewska H. Saccharomyces boulardii in childhood. Eur J Pediatr. 2009;168(3):253-65.
14. Kornienko EA. Mekhanizmy vozdeistviia antibiotikov na kishechnik, rol' Enterola v profilaktike i lechenii antibiotik-assotsiirovannoi diarei u detei. Farmateka. 2010;2 (in Russian).
15. Buts JP. Twenty-five years of research on Saccharomyces boulardii trophic effects: updates and perspectives. Dig Dis Sci. 2009;54:15-8.
16. Blobaut H, Massot J, Elmer GW, et al. Disposition kinetics of Saccharomyces boulardii in man and rat. Biopharm Drug Dispos. 1989;10:353-64.
17. Elmer GW, Moyer KA, Vega R, et al. Evaluation of Saccharomyces boulardii forpatients with HIV-related chronic diarrhoea and in healthy volunteers receiving antifungals. Microecol and Ther. 1995;25:23-31.
18. Castaneda C, Garcia E, Santa Cruz M, et al. Effects of Saccharomyces boulardii in children with chronic diarrhea, especially cases due to giardiasis. Rev Mex Pueric Pediatr. 1995;2:12‑6.
19. Jabn HU, Ullrich R, Schneider T, et al. Immunological and trophical effects of Saccharomyces boulardii on the small intestine in healthy human volunteers. Digestion. 1996;57:95-104.
20. Castagliuolo I, Riegler MF, Valenick L, et al. Saccharomyces boulardii protease mediates Clostridium difficile toxin A and B effects in human colonic mucosa. Infect Immun. 1999;67:302-7.
21. Girard P, Pansart Y, Lorette I, et al. Dose-response relationship and mechanism of action of Saccharomyces boulardii in castor oilinduced diarrhea in rats. Dig Dis Sci. 2003;48:770-4.
22. Szajewska H, Mrukowicz J. Meta-analysis: non-pathogenic yeast S. boulardii in the prevention of antibiotic-associated diarrhea. Aliment Pharmacol Ther. 2005;22(5):365-72.
23. Buts JP, De Keyser N, De Raedemaeker L. Saccharomyces boulardii enhances rat intestinal enzyme expression by endoluminal release of polyamines. Pediatr Res. 1994;36:522-7.
24. Turck D, Bernet JP, Marx J, et al. Incidence and risk factors of oral antibioticassociated diarrhea in an outpatient pediatric population. J Pediatr Gastroenterol Nutr. 2003;37:22-6.
25. Grandy G, Medina M, Soria R, et al. Probiotics in the treatment of acute rotavirus diarrhea. BMC Infect Dis. 2010;10:253.
26. McFarland LV. Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;5:97-105.
Авторы
М.К. Бехтерева*, А.М. Комарова
ФГБУ «Детский научно-клинический центр инфекционных болезней» ФМБА России, Санкт-Петербург, Россия;
ФГБОУ ВО «Санкт-Петербургский государственный педиатрический медицинский университет» Минздрава России, Санкт-Петербург, Россия
*mkbechtereva@mail.ru
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Maria K. Bekhtereva*, Anna M. Komarova
Children's Scientific and Clinical Center for Infectious Diseases, Saint Petersburg, Russia;
Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
*mkbechtereva@mail.ru