Background: The ability to identify bacterial pathogens that necessitate specific clinical management or public health action in children with acute gastroenteritis is crucial to patient care and public health. However, existing stool-testing guidelines offer inconsistent recommendations, and their performance characteristics are unknown. We evaluated 6 leading gastroenteritis guidelines (eg, those of the Centers for Disease Control and Prevention and Infectious Disease Society of America) that recommend when to test children's stool for bacterial enteropathogens. Methods: Via 2 emergency departments in Alberta, Canada, we enrolled 2447 children <18 years old who presented with ≥3 episodes of diarrhea and/or vomiting in a 24-hour period. All participants were tested for 9 bacterial enteropathogens: Aeromonas, Campylobacter, Escherichia coli O157, other Shiga toxin-producing E. coli, enterotoxigenic E. coli, Salmonella, Shigella, Vibrio, and Yersinia. Patient data gathered at the index visit were used to determine whether guidelines would recommend testing. Sensitivity and specificity to recommend testing for children with bacterial enteropathogens were calculated for each guideline. Results: Outcome data were available for 2391 (97.7%) participants, and 6% (144/2391) of participants tested positive for a bacterial enteropathogen. Guideline sensitivity ranged from 25.8% (95% confidence interval [CI] 18.7-33.0%) to 66.9% (95% CI 59.3-74.6%), and varied for individual pathogens. Guideline specificity for all bacterial enteropathogens ranged from 63.6% (95% CI 61.6-65.6%) to 96.5% (95% CI 95.7-97.2%). Conclusions: No guideline provided optimally balanced performance. The most sensitive guidelines missed one-third of cases and would drastically increase testing volumes. The most specific guidelines missed almost 75% of cases.
Bibliographical noteFunding Information:
The authors thank the patients and their families for cooperating with their study and the APPETITE for their contributions. Tey also thank the Department of Laboratory Medicine and Pathology, University of Alberta, DynaLIFE Diagnostic Laboratory Services, community laboratories, and the Provincial Laboratory for Public Health (ProvLab), and especially the bacteriology state, for their assistance with receiving, handling, and processing specimens. Te authors thank the emergency department research nurses and Pediatric Emergency Medicine Research Associate Program at the Alberta Children's Hospital for recruiting study participants; the emergency department bedside nurses for assisting with rectal swab performance, and the research assistants, research nurses, and the Little Bit of Help research volunteer program for their assistance with participant recruitment at the Stollery Children's Hospital.
- acute gastroenteritis
- culture-independent diagnostic testing
- enteric bacteria
- laboratory utilization
- stool culture