急诊科老年人急性细菌感染现行诊断标准的准确性
Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department.
作者信息
Caterino Jeffrey M, Leininger Robert, Kline David M, Southerland Lauren T, Khaliqdina Salman, Baugh Christopher W, Pallin Daniel J, Stevenson Kurt B
机构信息
Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio.
Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, OH, The Ohio State University, Columbus, Ohio.
出版信息
J Am Geriatr Soc. 2017 Aug;65(8):1802-1809. doi: 10.1111/jgs.14912. Epub 2017 Apr 25.
OBJECTIVES
To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review.
DESIGN
Prospective, observational study.
SETTING
Urban, tertiary-care ED.
PARTICIPANTS
Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent.
MEASUREMENTS
Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines.
RESULTS
Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-).
CONCLUSION
Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.
目的
通过标准专家评审，比较勒布标准、急诊科（ED）医生诊断以及美国疾病控制与预防中心（CDC）指南对老年急性细菌感染诊断的准确性。
设计
前瞻性观察性研究。
地点
城市三级护理急诊科。
参与者
急诊科65岁及以上个体，排除被监禁者、受过创伤者、不会说英语者或无法签署知情同意书者。
测量
两名医生专家通过临床判断、参与者调查和病历确定细菌感染；如有分歧则由第三名专家进行裁决。对急诊科医生诊断、勒布标准和CDC监测指南的一致性及检验特征进行测量。
结果
标准评审确定424名参与者中有77人（18%）感染细菌（18人（4.2%）为下呼吸道感染，19人（4.5%）为尿路感染（UTI），22人（5.2%）为胃肠道感染，15人（3.5%）为皮肤和软组织感染）。急诊科医生诊断出71人（17%）感染，但有33人诊断不足，27人诊断过度。医生对总体感染及每种感染类型与标准的一致性为中度（κ = 0.48 - 0.59），但敏感性较低（<67%），所有感染的阴性似然比（LR(-)）均大于0.30。勒布标准对下呼吸道感染（50%，κ = 0.55；0.51）和尿路感染（26%，κ = 0.34；0.74）的敏感性、一致性及LR(-)较差，但对皮肤和软组织感染的敏感性为87%（κ = 0.78；LR(-) 0.14）。CDC指南一致性为中度，但敏感性和LR(-)较差。
结论
急诊科医生对老年人感染的诊断常常存在不足和过度诊断。勒布标准仅对诊断皮肤和软组织感染有用。CDC指南在急诊科并不适用。需要新的标准来帮助急诊科医生准确诊断老年人的感染。
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