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Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis.

Stewart EH, Davis B, Clemans-Taylor BL, Littenberg B, Estrada CA, Centor RM - PLoS ONE (2014)

Bottom Line: Sensitivity, specificity.We could not identify sources of variability among higher quality studies.The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

View Article: PubMed Central - PubMed

Affiliation: Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America.

ABSTRACT

Background: Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach.

Objective: To examine the sensitivity and specificity, and sources of variability, of RAST for diagnosing group A streptococcal (GAS) pharyngitis.

Data sources: MEDLINE, Cochrane Reviews, Centre for Reviews and Dissemination, Scopus, SciELO, CINAHL, guidelines, 2000-2012.

Study selection: Culture as reference standard, all languages.

Data extraction and synthesis: Study characteristics, quality.

Main outcome(s) and measure(s): Sensitivity, specificity.

Results: We included 59 studies encompassing 55,766 patients. Forty three studies (18,464 patients) fulfilled the higher quality definition (at least 50 patients, prospective data collection, and no significant biases) and 16 (35,634 patients) did not. For the higher quality immunochromatographic methods in children (10,325 patients), heterogeneity was high for sensitivity (inconsistency [I(2)] 88%) and specificity (I(2) 86%). For enzyme immunoassay in children (342 patients), the pooled sensitivity was 86% (95% CI, 79-92%) and the pooled specificity was 92% (95% CI, 88-95%). For the higher quality immunochromatographic methods in the adult population (1,216 patients), the pooled sensitivity was 91% (95% CI, 87 to 94%) and the pooled specificity was 93% (95% CI, 92 to 95%); however, heterogeneity was modest for sensitivity (I(2) 61%) and specificity (I(2) 72%). For enzyme immunoassay in the adult population (333 patients), the pooled sensitivity was 86% (95% CI, 81-91%) and the pooled specificity was 97% (95% CI, 96 to 99%); however, heterogeneity was high for sensitivity and specificity (both, I(2) 88%).

Conclusions: RAST immunochromatographic methods appear to be very sensitive and highly specific to diagnose group A streptococcal pharyngitis among adults but not in children. We could not identify sources of variability among higher quality studies. The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

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Pediatric strata, forest plots for immunochromatographic methods, higher study methodological quality.
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pone-0111727-g003: Pediatric strata, forest plots for immunochromatographic methods, higher study methodological quality.

Mentions: The coupled forest plots for sensitivity and specificity shows high heterogeneity (I2 = 88% for sensitivity and I2 = 86% for specificity; Figure 3, Table 1). As mentioned in the Methods section, we explored additional variables that may explain heterogeneity. In three of the 28 strata, the testing was performed in the laboratory. None of the 28 strata reported Centor or McIssac score. Supplementary figures show HSROC subgroups, no single variable yielded homogenous groups, sponsorship (Figure S5 in File S2), location of care (Figure S6 in File S2), publication year (Figure S7 in File S2), prevalence (Figure S8 in File S2), and region (Figure S9 in File S2). The sensitivity and specificity of the studies remained heterogeneous (large prediction regions) regardless of sponsorship, studies conducted in emergency rooms, studies published more contemporarily, studies with higher GAS infection prevalence, and studies conducted in North America and Europe. Meta-regression showed that in the univariate analyses all strata mentioned above but prevalence of GAS infection by tertile were significant predictors for heterogeneity for both sensitivity and specificity. However, in the joint model, outpatient setting (p = 0.03) and prevalence of GAS infection by tertile prevalence of GAS (p = 0.05) were the only significant variables (data not shown).


Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis.

Stewart EH, Davis B, Clemans-Taylor BL, Littenberg B, Estrada CA, Centor RM - PLoS ONE (2014)

Pediatric strata, forest plots for immunochromatographic methods, higher study methodological quality.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4219770&req=5

pone-0111727-g003: Pediatric strata, forest plots for immunochromatographic methods, higher study methodological quality.
Mentions: The coupled forest plots for sensitivity and specificity shows high heterogeneity (I2 = 88% for sensitivity and I2 = 86% for specificity; Figure 3, Table 1). As mentioned in the Methods section, we explored additional variables that may explain heterogeneity. In three of the 28 strata, the testing was performed in the laboratory. None of the 28 strata reported Centor or McIssac score. Supplementary figures show HSROC subgroups, no single variable yielded homogenous groups, sponsorship (Figure S5 in File S2), location of care (Figure S6 in File S2), publication year (Figure S7 in File S2), prevalence (Figure S8 in File S2), and region (Figure S9 in File S2). The sensitivity and specificity of the studies remained heterogeneous (large prediction regions) regardless of sponsorship, studies conducted in emergency rooms, studies published more contemporarily, studies with higher GAS infection prevalence, and studies conducted in North America and Europe. Meta-regression showed that in the univariate analyses all strata mentioned above but prevalence of GAS infection by tertile were significant predictors for heterogeneity for both sensitivity and specificity. However, in the joint model, outpatient setting (p = 0.03) and prevalence of GAS infection by tertile prevalence of GAS (p = 0.05) were the only significant variables (data not shown).

Bottom Line: Sensitivity, specificity.We could not identify sources of variability among higher quality studies.The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

View Article: PubMed Central - PubMed

Affiliation: Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America.

ABSTRACT

Background: Pharyngitis management guidelines include estimates of the test characteristics of rapid antigen streptococcus tests (RAST) using a non-systematic approach.

Objective: To examine the sensitivity and specificity, and sources of variability, of RAST for diagnosing group A streptococcal (GAS) pharyngitis.

Data sources: MEDLINE, Cochrane Reviews, Centre for Reviews and Dissemination, Scopus, SciELO, CINAHL, guidelines, 2000-2012.

Study selection: Culture as reference standard, all languages.

Data extraction and synthesis: Study characteristics, quality.

Main outcome(s) and measure(s): Sensitivity, specificity.

Results: We included 59 studies encompassing 55,766 patients. Forty three studies (18,464 patients) fulfilled the higher quality definition (at least 50 patients, prospective data collection, and no significant biases) and 16 (35,634 patients) did not. For the higher quality immunochromatographic methods in children (10,325 patients), heterogeneity was high for sensitivity (inconsistency [I(2)] 88%) and specificity (I(2) 86%). For enzyme immunoassay in children (342 patients), the pooled sensitivity was 86% (95% CI, 79-92%) and the pooled specificity was 92% (95% CI, 88-95%). For the higher quality immunochromatographic methods in the adult population (1,216 patients), the pooled sensitivity was 91% (95% CI, 87 to 94%) and the pooled specificity was 93% (95% CI, 92 to 95%); however, heterogeneity was modest for sensitivity (I(2) 61%) and specificity (I(2) 72%). For enzyme immunoassay in the adult population (333 patients), the pooled sensitivity was 86% (95% CI, 81-91%) and the pooled specificity was 97% (95% CI, 96 to 99%); however, heterogeneity was high for sensitivity and specificity (both, I(2) 88%).

Conclusions: RAST immunochromatographic methods appear to be very sensitive and highly specific to diagnose group A streptococcal pharyngitis among adults but not in children. We could not identify sources of variability among higher quality studies. The present systematic review provides the best evidence for the wide range of sensitivity included in current guidelines.

Show MeSH
Related in: MedlinePlus