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Published on: September 25, 2014
Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a
Jérémie F Cohen1, Robert Cohen2, Corinne Levy2
1Obstetrical, 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 jeremie.cohen@inserm.fr.
Insights
Clinical prediction rules for diagnosing group A streptococcal infections in children with pharyngitis did not meet diagnostic accuracy targets. These rules may not be reliable for guiding rapid antigen detection testing in pediatric cases.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Diagnostics
- Epidemiology
Background:
- Group A streptococcal (GAS) pharyngitis is common in children.
- Clinical prediction rules (CPRs) exist to guide GAS testing.
- The diagnostic accuracy of CPR-based strategies needs evaluation.
Purpose of the Study:
- To compare the diagnostic accuracy of CPR-based selective testing strategies for GAS infection in children with pharyngitis.
- To validate existing CPRs in a prospective French pediatric cohort.
Main Methods:
- Systematic literature search for CPRs (MEDLINE, Embase 1975-2014).
- Prospective validation in French children with pharyngitis (2010-2011).
- GAS diagnosis via rapid antigen detection test (RADT) and throat culture (reference standard).
- Validation of three strategies: no testing (low risk), RADT (intermediate risk), empiric antibiotics (high risk).
Main Results:
- Eight CPRs identified; six prospectively validated.
- Sensitivity ranged from 66% to 94%; specificity from 40% to 88%.
- RADT use varied from 24% to 86% of patients.
- No strategy met the target accuracy of >85% sensitivity and specificity.
Conclusions:
- Rules-based selective testing strategies demonstrated insufficient diagnostic accuracy in this cohort.
- The utility of CPRs for selecting children for RADT in pharyngitis is questionable.
- Further research is needed to improve diagnostic strategies for GAS pharyngitis in children.
Background:
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.
Methods:
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.
Results:
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%).
Interpretation:
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.
