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CMAJ. 2015 Jan 6;187(1):23-32. doi: 10.1503/cmaj.140772. Epub 2014 Dec 8.

Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study.

Author information

1
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 jeremie.cohen@inserm.fr.
2
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.

Abstract

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.

PMID:
25487666
PMCID:
PMC4284164
DOI:
10.1503/cmaj.140772
[Indexed for MEDLINE]
Free PMC Article

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