Cohen Jérémie F, Cohen Robert, Levy Corinne, Thollot Franck, Benani Mohamed, Bidet Philippe, Chalumeau Martin
Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
CMAJ. 2015 Jan 6;187(1):23-32. doi: 10.1503/cmaj.140772. Epub 2014 Dec 8.
Several clinical prediction rules for diagnosing group A streptococcal infection in children with pharyngitis are available. We aimed to compare the diagnostic accuracy of rules-based selective testing strategies in a prospective cohort of children with pharyngitis.
We identified clinical prediction rules through a systematic search of MEDLINE and Embase (1975-2014), which we then validated in a prospective cohort involving French children who presented with pharyngitis during a 1-year period (2010-2011). We diagnosed infection with group A streptococcus using two throat swabs: one obtained for a rapid antigen detection test (StreptAtest, Dectrapharm) and one obtained for culture (reference standard). We validated rules-based selective testing strategies as follows: low risk of group A streptococcal infection, no further testing or antibiotic therapy needed; intermediate risk of infection, rapid antigen detection for all patients and antibiotic therapy for those with a positive test result; and high risk of infection, empiric antibiotic treatment.
We identified 8 clinical prediction rules, 6 of which could be prospectively validated. Sensitivity and specificity of rules-based selective testing strategies ranged from 66% (95% confidence interval [CI] 61-72) to 94% (95% CI 92-97) and from 40% (95% CI 35-45) to 88% (95% CI 85-91), respectively. Use of rapid antigen detection testing following the clinical prediction rule ranged from 24% (95% CI 21-27) to 86% (95% CI 84-89). None of the rules-based selective testing strategies achieved our diagnostic accuracy target (sensitivity and specificity>85%).
Rules-based selective testing strategies did not show sufficient diagnostic accuracy in this study population. The relevance of clinical prediction rules for determining which children with pharyngitis should undergo a rapid antigen detection test remains questionable.
目前有几种用于诊断咽炎患儿A组链球菌感染的临床预测规则。我们旨在比较基于规则的选择性检测策略在咽炎患儿前瞻性队列中的诊断准确性。
我们通过系统检索MEDLINE和Embase（1975 - 2014年）确定了临床预测规则，然后在一个前瞻性队列中对其进行验证，该队列涉及在1年期间（2010 - 2011年）出现咽炎的法国儿童。我们使用两根咽拭子诊断A组链球菌感染：一根用于快速抗原检测试验（StreptAtest，Dectrapharm），另一根用于培养（参考标准）。我们验证了基于规则的选择性检测策略如下：A组链球菌感染风险低，无需进一步检测或抗生素治疗；感染风险中等，对所有患者进行快速抗原检测，检测结果阳性者给予抗生素治疗；感染风险高，给予经验性抗生素治疗。
我们确定了8条临床预测规则，其中6条可进行前瞻性验证。基于规则的选择性检测策略的敏感性和特异性分别为66%（95%置信区间[CI]61 - 72）至94%（95%CI 92 - 97）和40%（95%CI 35 - 45）至88%（95%CI 85 - 91）。根据临床预测规则使用快速抗原检测试验的比例为24%（95%CI 21 - 27）至86%（95%CI 84 - 8９）。没有一种基于规则的选择性检测策略达到我们的诊断准确性目标（敏感性和特异性>85%）。
在本研究人群中，基于规则的选择性检测策略未显示出足够的诊断准确性。临床预测规则对于确定哪些咽炎患儿应进行快速抗原检测的相关性仍值得怀疑。
