http://bmj.com/cgi/content/full/325/7364/587
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Des Spence
Maryhill Health Centre, Glasgow G20 9DR
Evidence based medicine is the holy grail of medical practice
well,
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
| 1. | ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58 050 patients with suspected acute myocardial infarction. Lancet 1995; 345: 669-685[Medline]. |
| 2. | Evans AT, Husain S, Durairaj L, Sadowski LS, Charles-Damte M, Wang Y. Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial. Lancet 2002; 359: 1648[Medline]. |
| 3. | Horton R, Smith R. Time to register randomised trials. BMJ 1999; 319: 865-866[Full Text]. |
| 4. | Hilton E, Isenberg HD, Alperstein P, France K, Borenstein MT. Ingestion of yogurt containing Lactobacillus acidophilus as prophylaxis for candidal vaginitis. Annals Int Med 1992; 116: 353-357[Medline]. |
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