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BMJ 2002;325:587 ( 14 September )

Clinical review

Interpreting the evidence

Des Spence, general practitioner. 

Maryhill Health Centre, Glasgow G20 9DR

Evidence based medicine is the holy grail of medical practicewell, that is what some of us think. Remember, however, the dangers of meta-analysis,¹ and even "quality sources" must be treated with some suspicion. Dark forces such as publication bias, pharmaceutical vested interest, incomplete search databases, and publication fraud are at work. Remember the first rule of medicine: "Do no harm."²

Although the quality of the data in this review is good, it is important to be conscious of the limitations of the data available. Many of the data are from the early 1980s, before the rigour of evidence based medicine and peer review that is now in place in medical journals. This is reflected in the randomisation and blinding that is inconsistent across the studies reviewed leading to potential bias. The trials are also small which has lead to pooled analysis, which obviously introduces uncertainty over the final conclusions. The setting of these trials is important and many of the data are drawn from hospital practice. This may not be applicable to primary care and more specifically to direct pharmacy sales, which is the common setting in the United Kingdom. Whether there was pharmaceutical sponsorship of the research papers is unclear. Much of this work predates trial registration, which seeks to address the issue of positive publication bias.³

Though the data may be doubtful, it would be fair to say that the numbers needed to treat are low and confidence intervals given in the main Clinical Evidence text narrow, suggesting that most of the conclusions are fair, given the data available. They are also relevant to daily practice. In acute symptomatic vulvovaginitis, all imidazoles seem to be equally effective, so using the most cost effective would make sense. Duration of treatment makes little difference to outcome, so using a one-dose preparation would seem the most acceptable to patients. An oral preparation of fluconazole is an effective alternative to intravaginal treatment. And we should no longer treat the male partner.

In recurrent vulvovaginitis the quality and amount of research was poor. The widespread practice of imidazole prophylaxis in recurrent vulvovaginitis is not supported by evidence and should be questioned.

Important issues remain unanswered, particularly in the clinical course of candidiasis, incidental asymptomatic infection being present on swabs, delaying treatment, and dietary modifications (such as yogurt containing Lactobacillus acidophilus⁴).

Footnotes

Competing interests: DS is a peer reviewer for Clinical Evidence.

References
 

© BMJ 2002
 

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Other related articles in BMJ:

CLINICAL REVIEW
Extracts from "Concise Clinical Evidence": Vulvovaginal candidiasis.

Jeanne Marrazzo
BMJ 2002 325: 586. [Full text]  

 

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