Clinical Prediction Rule to Guide Diagnostic Testing for Shigellosis and Improve Antibiotic Stewardship for Pediatric Diarrhea.
Clinical Prediction Rule to Guide Diagnostic Testing for Shigellosis and Improve Antibiotic Stewardship for Pediatric Diarrhea.
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DOI：
10.1093/ofid/ofad119
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发表时间：
2023-03
影响因子：
4.2
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中科院分区：
文献类型：
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腹泻病是5岁以下儿童死亡的主要原因。确定病因有助于指导病原体特异性治疗，但在资源匮乏的环境中，诊断检测的可用性往往有限。我们的目标是制定一个临床预测规则（CPR），以指导临床医生确定何时在急性腹泻患儿中使用志贺氏菌（POC）诊断。我们利用全球肠道多中心研究（GEMS）的临床和人口统计数据，建立了非洲和亚洲年龄≤59月龄、出现中至重度腹泻的志贺氏菌腹泻的预测模型。我们使用随机森林筛选变量，并使用随机森林回归和交叉验证的逻辑回归评估预测性能。我们使用肠道感染和营养不良的病因、危险因素和相互作用以及儿童健康和发育的后果（MAL-ED）研究来外部验证我们的gems衍生CPR。在分析的5011例病例中，1332例（27%）为志贺氏菌腹泻。我们的CPR具有较高的预测能力（受试者工作特征曲线下面积= 0.80）[95%置信区间，0.79 -。[81])使用前两个预测变量，年龄和护理人员报告的血性腹泻。我们表明，通过使用我们的CPR对接受诊断测试的患者进行分类，与目前基于症状的指南相比，可以识别出3倍多的志贺氏菌腹泻病例，只有27%的病例接受了POC诊断测试。我们演示了如何使用CPR来指导POC诊断测试对腹泻管理的使用。使用我们的CPR，可用的诊断能力可以优化，以提高适当的抗生素使用。使用外部验证的临床预测工具对接受诊断检测的患者进行分诊，与目前基于症状的指南相比，发现的志贺氏菌腹泻病例将增加3倍，只有27%的病例接受了即时诊断检测。
Diarrheal diseases are a leading cause of death for children aged <5 years. Identification of etiology helps guide pathogen-specific therapy, but availability of diagnostic testing is often limited in low-resource settings. Our goal is to develop a clinical prediction rule (CPR) to guide clinicians in identifying when to use a point-of-care (POC) diagnostic for Shigella in children presenting with acute diarrhea. We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) study to build predictive models for diarrhea of Shigella etiology in children aged ≤59 months presenting with moderate to severe diarrhea in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using cross-validation. We used the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study to externally validate our GEMS-derived CPR. Of the 5011 cases analyzed, 1332 (27%) had diarrhea of Shigella etiology. Our CPR had high predictive ability (area under the receiver operating characteristic curve = 0.80 [95% confidence interval, .79–.81]) using the top 2 predictive variables, age and caregiver-reported bloody diarrhea. We show that by using our CPR to triage who receives diagnostic testing, 3 times more Shigella diarrhea cases would have been identified compared to current symptom-based guidelines, with only 27% of cases receiving a POC diagnostic test. We demonstrate how a CPR can be used to guide use of a POC diagnostic test for diarrhea management. Using our CPR, available diagnostic capacity can be optimized to improve appropriate antibiotic use. Using an externally validated clinical prediction tool to triage who receives diagnostic testing, 3 times more Shigella diarrhea cases would have been identified compared to current symptom-based guidelines, with only 27% of cases receiving a point-of-care diagnostic test.
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