Diagnostic accuracy of rapid antigen detection tests for group A Streptococcus in children with extrapharyngeal infections: systematic review and meta-analysis
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Benoît Batallan1, Alix Flamant1, Philippe Bidet2
1Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants malades Hospital, Université Paris Cité, Paris, France.
Insights
Rapid antigen detection tests (RADTs) show high sensitivity and specificity for Group A Streptococcus (GAS) in children with extrapharyngeal infections. These findings support their use beyond pharyngitis, aiding clinical decisions.
Area of Science:
- Pediatric Infectious Diseases
- Diagnostic Accuracy Studies
- Microbiology
Background:
- Group A Streptococcus (GAS) causes significant morbidity and mortality from invasive infections.
- Rapid antigen detection tests (RADTs) are validated for pediatric pharyngitis but not extrapharyngeal infections.
Purpose of the Study:
- To systematically evaluate the diagnostic accuracy of RADTs for GAS in children with extrapharyngeal infections.
Main Methods:
- Systematic review and bivariate random-effects meta-analysis of diagnostic test accuracy studies.
- Searched PubMed and Web of Science (inception to November 2025).
- Assessed risk of bias using QUADAS-2.
Main Results:
- Included 16 studies (1,737 patients).
- RADTs demonstrated a summary sensitivity of 92% and specificity of 99%.
- Specificity varied by infection type, invasiveness, and reference standard.
Conclusions:
- RADTs exhibit high sensitivity and very high, albeit variable, specificity for GAS in pediatric extrapharyngeal infections.
- Findings suggest RADTs can aid clinical management in scenarios beyond pharyngitis.
- Further high-quality research is needed to define RADTs' role in specific infection types.
Background:
Group A Streptococcus (GAS) causes a wide range of infections, with substantial morbidity and mortality associated with invasive infections and suppurative complications. The diagnostic accuracy of rapid antigen detection tests (RADTs) is well established in children with pharyngitis, but not in extrapharyngeal infections.
Objectives:
To evaluate the diagnostic accuracy of RADTs for identifying GAS in children with extrapharyngeal infections.
Methods:
Systematic review of diagnostic test accuracy.
Protocol:
CRD420251108689 (PROSPERO).
Data Sources:
PubMed and Web of Science (inception to November 2025).
Study Eligibility Criteria:
Studies evaluating RADTs in children with suspected extrapharyngeal infections caused by GAS.
Participants:
Children (0-18 years). TEST: RADTs for GAS.
Reference Standard:
Bacterial culture and PCR.
Assessment Of Risk Of Bias:
Quality Assessment of Diagnostic Accuracy Studies-2.
Methods Of Data Synthesis:
Bivariate random-effects meta-analysis of sensitivity and specificity. Heterogeneity was evaluated through prespecified subgroup analyses and meta-regression. Robustness of the results was assessed through sensitivity analyses.
Results:
We included 16 studies (23 RADT evaluations; 1737 unique patients; 2610 test results). Methodological quality varied across studies, with only four studies judged to have an overall low risk of bias. RADTs had a summary sensitivity of 92% (95% CI: 89-94) and a summary specificity of 99% (95% CI: 96-100). Sensitivity was similar across studies, whereas specificity varied according to infection type (p = 0.043), infection invasiveness (p <0.001), and the reference standard used (p <0.001). Sensitivity analyses restricted to various study subsets yielded consistent results.
Discussion:
This systematic review found high sensitivity and very high, but variable, specificity of RADTs for identifying GAS in children with extrapharyngeal infections, particularly in those with pleural empyema. These findings suggest that RADTs may have a role in various clinical scenarios beyond pharyngitis, particularly when rapid results directly influence clinical management, but further high-quality studies are needed to define their precise role in diagnostic pathways for each infection type.
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