Department of General Practice, Katholieke Universiteit Leuven, Leuven, Belgium.
Lancet. 2010 Mar 6;375(9717):834-45. doi: 10.1016/S0140-6736(09)62000-6. Epub 2010 Feb 2.
Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries.
In this systematic review, we searched electronic databases (Medline, Embase, DARE, CINAHL), reference lists of relevant studies, and contacted experts to identify articles assessing clinical features of serious infection in children. 1939 potentially relevant studies were identified. Studies were selected on the basis of six criteria: design (studies of diagnostic accuracy or prediction rules), participants (otherwise healthy children aged 1 month to 18 years), setting (ambulatory care), outcome (serious infection), features assessed (assessable in ambulatory care setting), and sufficient data reported. Quality assessment was based on the Quality Assessment of Diagnostic Accuracy Studies criteria. We calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of each clinical feature and pre-test and post-test probabilities of the outcome. Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection); features with a negative likelihood ratio of less than 0.2 were deemed rule-out signs.
30 studies were included in the analysis. Cyanosis (positive likelihood ratio range 2.66-52.20), rapid breathing (1.26-9.78), poor peripheral perfusion (2.39-38.80), and petechial rash (6.18-83.70) were identified as red flags in several studies. Parental concern (positive likelihood ratio 14.40, 95% CI 9.30-22.10) and clinician instinct (positive likelihood ratio 23.50, 95 % CI 16.80-32.70) were identified as strong red flags in one primary care study. Temperature of 40 degrees C or more has value as a red flag in settings with a low prevalence of serious infection. No single clinical feature has rule-out value but some combinations can be used to exclude the possibility of serious infection-for example, pneumonia is very unlikely (negative likelihood ratio 0.07, 95% CI 0.01-0.46) if the child is not short of breath and there is no parental concern. The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10-6.70) or excluding (negative likelihood ratio range 0.16-0.97) the possibility of serious infection.
The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken.
Health Technology Assessment and National Institute for Health Research National School for Primary Care Research.
我们的目的是确定在发达国家的门诊环境中，哪些临床特征对于确认或排除儿童严重感染的可能性具有价值。
在这项系统评价中，我们检索了电子数据库（Medline、Embase、DARE、CINAHL）、相关研究的参考文献列表，并联系了专家，以确定评估儿童严重感染临床特征的文章。确定了 1939 篇潜在相关的研究。研究是根据以下六个标准选择的：设计（诊断准确性或预测规则的研究）、参与者（年龄在 1 个月至 18 岁的健康儿童）、环境（门诊）、结果（严重感染）、评估的特征（可在门诊环境中评估）以及报告的充分数据。质量评估基于诊断准确性研究标准的质量评估。我们计算了每个临床特征的存在（阳性似然比）或不存在（阴性似然比）的比值以及试验前和试验后的结果概率。阳性似然比大于 5.0 的临床特征被视为危险信号（即严重感染的警告信号）；阴性似然比小于 0.2 的特征被视为排除标志。
30 项研究纳入了分析。在几项研究中，发绀（阳性似然比范围 2.66-52.20）、呼吸急促（1.26-9.78）、外周灌注不良（2.39-38.80）和瘀点皮疹（6.18-83.70）被确定为危险信号。父母的担忧（阳性似然比 14.40，95%CI 9.30-22.10）和医生的直觉（阳性似然比 23.50，95%CI 16.80-32.70）在一项初级保健研究中被确定为强烈的危险信号。体温达到 40 度或更高具有作为危险信号的价值，前提是严重感染的患病率较低。没有单一的临床特征具有排除价值，但一些组合可以用于排除严重感染的可能性，例如，如果孩子不呼吸急促且父母不担心，肺炎发生的可能性非常低（阴性似然比 0.07，95%CI 0.01-0.46）。耶鲁观察量表在确认（阳性似然比范围 1.10-6.70）或排除（阴性似然比范围 0.16-0.97）严重感染的可能性方面几乎没有价值。
我们确定的严重感染危险信号应常规使用，但如果不有效使用预防措施，仍会漏诊严重疾病。我们现在需要确定应采取临床行动的风险水平。
卫生技术评估和英国国民健康保险制度国家初级保健研究学院。
