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Performance of Stool-testing Recommendations for Acute Gastroenteritis When Used to Identify Children With 9
Gillian A M Tarr1, Linda Chui2, Bonita E Lee3
1Department of Pediatrics, University of Calgary, University of Alberta and Alberta Provincial Laboratory for Public Health, Alberta, Canada.
Insights
Current guidelines for testing bacterial enteropathogens in children with acute gastroenteritis are inconsistent and perform poorly. Evaluating these guidelines is crucial for accurate diagnosis and effective public health action.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Microbiology
- Public Health Policy
Background:
- Accurate identification of bacterial pathogens in children with acute gastroenteritis is vital for appropriate clinical management and public health interventions.
- Existing stool-testing guidelines for bacterial enteropathogens in children present inconsistent recommendations and lack defined performance characteristics.
- This study addresses the critical need to evaluate the diagnostic accuracy of current guidelines for identifying bacterial pathogens in pediatric acute gastroenteritis.
Purpose of the Study:
- To evaluate the performance characteristics (sensitivity and specificity) of six leading gastroenteritis guidelines in recommending stool testing for bacterial enteropathogens in children.
- To determine if any existing guidelines offer a balanced approach to testing for bacterial pathogens in pediatric acute gastroenteritis.
- To inform the development of improved guidelines for stool testing in children with acute gastroenteritis.
Main Methods:
- A prospective study enrolled 2447 children under 18 presenting with acute gastroenteritis (≥3 episodes of diarrhea/vomiting in 24 hours) across two emergency departments.
- All participants underwent stool testing for nine key bacterial enteropathogens, including Aeromonas, Campylobacter, and various E. coli strains.
- Sensitivity and specificity of six established gastroenteritis guidelines were calculated based on whether they would have recommended testing for identified bacterial enteropathogens.
Main Results:
- Outcome data were available for 2391 participants, with 6% testing positive for a bacterial enteropathogen.
- The sensitivity of the evaluated guidelines ranged from 25.8% to 66.9%, indicating a significant proportion of cases were missed.
- Guideline specificity varied from 63.6% to 96.5%, with the most specific guidelines failing to identify nearly 75% of infections.
Conclusions:
- No evaluated guideline demonstrated optimal balance between sensitivity and specificity for detecting bacterial enteropathogens in children with acute gastroenteritis.
- Highly sensitive guidelines risked substantially increasing testing volumes by missing one-third of actual cases.
- Highly specific guidelines compromised diagnostic accuracy by missing a large majority of infections, highlighting the need for guideline revision.
Background:
The ability to identify bacterial pathogens that necessitate specific clinical management or public health action in children with acute gastroenteritis is crucial to patient care and public health. However, existing stool-testing guidelines offer inconsistent recommendations, and their performance characteristics are unknown. We evaluated 6 leading gastroenteritis guidelines (eg, those of the Centers for Disease Control and Prevention and Infectious Disease Society of America) that recommend when to test children's stool for bacterial enteropathogens.
Methods:
Via 2 emergency departments in Alberta, Canada, we enrolled 2447 children <18 years old who presented with ≥3 episodes of diarrhea and/or vomiting in a 24-hour period. All participants were tested for 9 bacterial enteropathogens: Aeromonas, Campylobacter, Escherichia coli O157, other Shiga toxin-producing E. coli, enterotoxigenic E. coli, Salmonella, Shigella, Vibrio, and Yersinia. Patient data gathered at the index visit were used to determine whether guidelines would recommend testing. Sensitivity and specificity to recommend testing for children with bacterial enteropathogens were calculated for each guideline.
Results:
Outcome data were available for 2391 (97.7%) participants, and 6% (144/2391) of participants tested positive for a bacterial enteropathogen. Guideline sensitivity ranged from 25.8% (95% confidence interval [CI] 18.7-33.0%) to 66.9% (95% CI 59.3-74.6%), and varied for individual pathogens. Guideline specificity for all bacterial enteropathogens ranged from 63.6% (95% CI 61.6-65.6%) to 96.5% (95% CI 95.7-97.2%).
Conclusions:
No guideline provided optimally balanced performance. The most sensitive guidelines missed one-third of cases and would drastically increase testing volumes. The most specific guidelines missed almost 75% of cases.
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