The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses
The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses
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DOI：
10.1136/bmj.c1594
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发表时间：
2010-04-20
影响因子：
105.7
通讯作者：
McCaskill, Mary
中科院分区：
文献类型：
--
作者：
Craig, Jonathan C.;Williams, Gabrielle J.;McCaskill, Mary
目的评价目前以发热性疾病为表现但怀疑有严重细菌感染的幼儿的诊断和治疗过程，并建立和检验一个多变量模型来区分严重细菌感染和自限性非细菌疾病。设计2年前瞻性队列研究。澳大利亚韦斯特米德儿童医院急诊科。参与者2004年7月1日至2006年6月30日期间出现发热性疾病的5岁以下儿童。干预措施由医生进行标准化临床评估，包括强制将40项临床特征输入医院的电子记录保存系统。通过标准放射学和微生物学检查和随访，确认或排除严重的细菌感染。主要观察指标：三种关键类型严重细菌感染（尿路感染、肺炎和菌血症）中的一种的诊断，以及我们的临床决策模型和临床医生在做出这些诊断时判断的准确性。结果在研究期间记录的15781例发热性疾病病例中，我们有93%的随访数据。三种感染（尿路感染、肺炎或菌血症）的总患病率为7.2%(1120/15 781,95%可信区间（CI） 6.7%至7.5%)，其中尿路感染诊断为543例（3.4%）发热性疾病（95% CI 3.2%至3.7%），肺炎诊断为533例（3.4%）（95% CI 3.1%至3.7%），菌血症诊断为64例（0.4%）（95% CI 0.3%至0.5%）。几乎所有严重细菌感染的儿童（bbbb94%）都进行了适当的检查（尿培养、胸片或血培养）。尿路感染患儿中66%（359/543）、肺炎患儿中69%（366/533）、菌血症患儿中81%（52/64）急性使用抗生素。然而，20%（2686/13 557）无细菌感染的儿童也开了抗生素。根据临床评价和确诊数据，采用多项logistic回归方法建立诊断模型。医生对细菌感染的诊断具有低敏感性（10-50%）和高特异性（90-100%），而临床诊断模型提供了广泛的敏感性和特异性值。结论急诊科医生往往低估发热幼儿发生严重细菌感染的可能性，导致抗生素治疗不足。临床诊断模型可以通过提高检测严重细菌感染的敏感性来改善决策，从而改善早期治疗。
Objectives To evaluate current processes by which young children presenting with a febrile illness but suspected of having serious bacterial infection are diagnosed and treated, and to develop and test a multivariable model to distinguish serious bacterial infections from self limiting non-bacterial illnesses.Design Two year prospective cohort study.Setting The emergency department of The Children's Hospital at Westmead, Westmead, Australia.Participants Children aged less than 5 years presenting with a febrile illness between 1 July 2004 and 30 June 2006.Intervention A standardised clinical evaluation that included mandatory entry of 40 clinical features into the hospital's electronic record keeping system was performed by physicians. Serious bacterial infections were confirmed or excluded using standard radiological and microbiological tests and follow-up.Main outcome measures Diagnosis of one of three key types of serious bacterial infection (urinary tract infection, pneumonia, and bacteraemia), and the accuracy of both our clinical decision making model and clinician judgment in making these diagnoses.Results We had follow-up data for 93% of the 15781 instances of febrile illnesses recorded during the study period. The combined prevalence of any of the three infections of interest (urinary tract infection, pneumonia, or bacteraemia) was 7.2% (1120/15 781, 95% confidence interval (CI) 6.7% to 7.5%), with urinary tract infection the diagnosis in 543 (3.4%) cases of febrile illness (95% CI 3.2% to 3.7%), pneumonia in 533 (3.4%) cases (95% CI 3.1% to 3.7%), and bacteraemia in 64 (0.4%) cases (95% CI 0.3% to 0.5%). Almost all (>94%) of the children with serious bacterial infections had the appropriate test (urine culture, chest radiograph, or blood culture). Antibiotics were prescribed acutely in 66% (359/543) of children with urinary tract infection, 69% (366/533) with pneumonia, and 81% (52/64) with bacteraemia. However, 20% (2686/13 557) of children without bacterial infection were also prescribed antibiotics. On the basis of the data from the clinical evaluations and the confirmed diagnosis, a diagnostic model was developed using multinomial logistic regression methods. Physicians' diagnoses of bacterial infection had low sensitivity (10-50%) and high specificity (90-100%), whereas the clinical diagnostic model provided a broad range of values for sensitivity and specificity.Conclusions Emergency department physicians tend to underestimate the likelihood of serious bacterial infection in young children with fever, leading to undertreatment with antibiotics. A clinical diagnostic model could improve decision making by increasing sensitivity for detecting serious bacterial infection, thereby improving early treatment.