Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care
Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care
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DOI：
10.3310/hta16150
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发表时间：
2012-03-01
影响因子：
3.6
通讯作者：
Mant, D.
中科院分区：
文献类型：
--
作者：
Thompson, M.;Van den Bruel, A.;Mant, D.
背景资料：虽然绝大多数急性感染的儿童在家中接受治疗，但这是急诊科和初级保健儿童最常见的问题之一。区分严重感染的儿童与轻微或自限性感染的儿童是困难的。这可能会导致误诊的儿童严重感染，这会导致在一个较差的健康结果，或倾向于参考或接纳儿童作为预防措施，因此，不适当地利用二级保健resources.Objectives：我们系统地确定了临床特征和实验室检查，确定严重感染的儿童参加艾德和初级保健。数据来源：我们于2008年10月检索了MEDLINE、Medion、EMBASE、护理和相关健康文献累积索引和效果综述摘要数据库，并于2009年6月进行了更新，检索词包括与以下五个组成部分相关的词：严重感染、儿童、临床病史和检查、实验室检查和门诊护理环境。我们还检索了纳入研究的参考文献、临床内容专家和相关的国家卫生和临床优化研究所指南，以识别相关研究。没有语言限制。研究是有资格纳入，如果他们是基于在门诊设置在经济发达countries.Review方法：文献检索，选择和数据提取进行了两名审查员。我们使用诊断准确性研究质量评估（QUADAS）仪器评估质量，并使用光谱偏倚和参考标准的有效性作为排除标准。我们计算了每个特征的阳性似然比（LR+）和阴性似然比（LR），沿着结果的前检验和后检验概率。在适当情况下，使用双变量方法进行荟萃分析。我们外部验证的临床预测规则确定的系统评价使用现有的数据从儿童参加艾德或primary care.Results：我们确定了1939篇文章，其中35被选中纳入审查。只有一项来自初级保健的研究;所有其他研究都是在急诊室进行的。纳入的研究质量一般。我们还确定了7个数据集（11，045名儿童）用于外部验证。最有用的临床特征，在严重感染的裁决是父母或临床医生的整体关注，这种疾病是不同于以前的疾病或有什么是错误的。在低或中等流行率的环境中，发热的存在具有一定的诊断价值。其他危险信号特征包括紫绀、外周循环不良、呼吸急促、听诊时出现爆裂音、呼吸音减弱、脑膜刺激、点状皮疹、意识下降和癫痫发作。降钙素原（LR+ 1.75-2.96，LR- 0.08-0.35）和C反应蛋白（LR+ 2.53-3.79，LA- 0.25-0.61）上级白色细胞计数。表现最好的临床预测规则是五阶段决策树规则，包括医生的肠道感觉、呼吸困难、体温40 ℃、腹泻和年龄。它能够大大降低严重感染的可能性，但在验证时，它仅在低至中等流行率环境中提供了良好的排除价值（LR- 0.11-0.28）。我们还确定并验证了耶鲁观察量表和肺炎，脑膜炎和gastroenteritis.Limitations的预测规则：只有一个单一的研究被确定从初级保健设置，因此结果可能缺乏generalisability.Conclusions：几个临床特征是有用的，以增加或减少的概率，一个孩子有一个严重的感染。没有一项措施本身足以大幅提高或降低严重感染的风险。有些是高度具体的（“红旗”），因此当存在时，应提示进行更彻底或重复的评估。C-反应蛋白和降钙素原表现出相似的诊断特征，均上级白色细胞计数。然而，即使在严重感染的儿童中，红旗也很少出现，并且它们的缺失并不能降低风险。目前的诊断缺口是通过使用临床的“直觉”和诊断安全网来填补的，这两种方法仍然没有很好的定义。虽然两个严重感染的预测规则和一个脑膜炎提供了一些诊断价值，我们不建议在这个时候广泛实施。未来的研究需要确定在初级保健环境中儿童严重感染的预测因素，更广泛地验证预测规则，并确定初级保健环境中血液检测的附加值。
Background: Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources.Objectives: We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets.Data sources: We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that included terms related to five components: serious infections, children, clinical history and examination, laboratory tests and ambulatory care settings. We also searched references of included studies, clinical content experts, and relevant National Institute for Health and Clinical Excellence guidelines to identify relevant studies. There were no language restrictions. Studies were eligible for inclusion if they were based in ambulatory settings in economically developed countries.Review methods: Literature searching, selection and data extraction were carried out by two reviewers. We assessed quality using the quality assessment of diagnostic accuracy studies (QUADAS) instrument, and used spectrum bias and validity of the reference standard as exclusion criteria. We calculated the positive likelihood ratio (LR+) and negative likelihood ratio (LR) of each feature along with the pre- and post-test probabilities of the outcome. Meta-analysis was performed using the bivariate method when appropriate. We externally validated clinical prediction rules identified from the systematic review using existing data from children attending ED or primary care.Results: We identified 1939 articles, of which 35 were selected for inclusion in the review. There was only a single study from primary care; all others were performed in the ED. The quality of the included studies was modest. We also identified seven data sets (11,045 children) to use for external validation. The most useful clinical features for ruling in serious infection was parental or clinician overall concern that the illness was different from previous illnesses or that something was wrong. In low- or intermediate-prevalence settings, the presence of fever had some diagnostic value. Additional red flag features included cyanosis, poor peripheral circulation, rapid breathing, crackles on auscultation, diminished breath sounds, meningeal irritation, petechial rash, decreased consciousness and seizures. Procalcitonin (LR+ 1.75-2.96, LR- 0.08-0.35) and C-reactive protein (LR+ 2.53-3.79, LA- 0.25-0.61) were superior to white cell counts. The best performing clinical prediction rule was a five-stage decision tree rule, consisting of the physician's gut feeling, dyspnoea, temperature 40 C, diarrhoea and age. It was able to decrease the likelihood of serious infections substantially, but on validation it provided good ruling out value only in low-to-intermediate-prevalence settings (LR- 0.11-0.28). We also identified and validated the Yale Observation Scale and prediction rules for pneumonia, meningitis and gastroenteritis.Limitations: Only a single study was identified from primary-care settings, therefore results may lack generalisability.Conclusions: Several clinical features are useful to increase or decrease the probability that a child has a serious infection. None is sufficient on its own to substantially raise or lower the risk of serious infection. Some are highly specific ('red flags'), so when present should prompt a more thorough or repeated assessment. C-reactive protein and procalcitonin demonstrate similar diagnostic characteristics and are both superior to white cell counts. However, even in children with a serious infection, red flags will occur infrequently, and their absence does not lower the risk. The diagnostic gap is currently filled by using clinical 'gut feeling' and diagnostic safety-netting, which are still not well defined. Although two prediction rules for serious infection and one for meningitis provided some diagnostic value, we do not recommend widespread implementation at this time. Future research is needed to identify predictors of serious infection in children in primary-care settings, to validate prediction rules more widely, and determine the added fvalue of blood tests in primar-care settings.Funding: The National Institute for Health Research Health Technology Assessment programme.