Abstract：
BACKGROUND: Shigella is a leading cause of childhood diarrhea mortality in sub-Saharan Africa. Current World Health Organization guidelines recommend antibiotics for children in non cholera-endemic areas only in the presence of dysentery, a proxy for suspected Shigella infection.
METHODS: To assess the sensitivity and specificity of the syndromic diagnosis of Shigella-associated diarrhea, we enrolled children aged 6 months to 5 years presenting to 1 of 3 Western Kenya hospitals between November 2011 and July 2014 with acute diarrhea. Stool samples were tested using standard methods for bacterial culture and multiplex polymerase chain reaction for pathogenic Escherichia coli. Stepwise multivariable logit models identified factors to increase the sensitivity of syndromic diagnosis.
RESULTS: Among 1360 enrolled children, median age was 21 months (interquartile range, 11-37), 3.4% were infected with human immunodeficiency virus, and 16.5% were stunted (height-for-age z-score less than -2). Shigella was identified in 63 children (4.6%), with the most common species being Shigella sonnei (53.8%) and Shigella flexneri (40.4%). Dysentery correctly classified 7 of 63 Shigella cases (sensitivity, 11.1%). Seventy-eight of 1297 children without Shigella had dysentery (specificity, 94.0%). The combination of fecal mucous, age over 23 months, and absence of excessive vomiting identified more children with Shigella-infection (sensitivity, 39.7%) but also indicated antibiotics in more children without microbiologically confirmed Shigella (specificity, 82.7%).
CONCLUSIONS: Reliance on dysentery as a proxy for Shigella results in the majority of Shigella-infected children not being identified for antibiotics. Field-ready rapid diagnostics or updated evidence-based algorithms are urgently needed to identify children with diarrhea most likely to benefit from antibiotic therapy.
METHODS: To assess the sensitivity and specificity of the syndromic diagnosis of Shigella-associated diarrhea, we enrolled children aged 6 months to 5 years presenting to 1 of 3 Western Kenya hospitals between November 2011 and July 2014 with acute diarrhea. Stool samples were tested using standard methods for bacterial culture and multiplex polymerase chain reaction for pathogenic Escherichia coli. Stepwise multivariable logit models identified factors to increase the sensitivity of syndromic diagnosis.
RESULTS: Among 1360 enrolled children, median age was 21 months (interquartile range, 11-37), 3.4% were infected with human immunodeficiency virus, and 16.5% were stunted (height-for-age z-score less than -2). Shigella was identified in 63 children (4.6%), with the most common species being Shigella sonnei (53.8%) and Shigella flexneri (40.4%). Dysentery correctly classified 7 of 63 Shigella cases (sensitivity, 11.1%). Seventy-eight of 1297 children without Shigella had dysentery (specificity, 94.0%). The combination of fecal mucous, age over 23 months, and absence of excessive vomiting identified more children with Shigella-infection (sensitivity, 39.7%) but also indicated antibiotics in more children without microbiologically confirmed Shigella (specificity, 82.7%).
CONCLUSIONS: Reliance on dysentery as a proxy for Shigella results in the majority of Shigella-infected children not being identified for antibiotics. Field-ready rapid diagnostics or updated evidence-based algorithms are urgently needed to identify children with diarrhea most likely to benefit from antibiotic therapy.
摘要：
背景：志贺氏菌是撒哈拉以南非洲儿童腹泻死亡率的主要原因。目前的世界卫生组织指南建议仅在出现痢疾的非霍乱流行地区的儿童使用抗生素，疑似志贺氏菌感染的代理人。
方法：为了评估志贺氏菌相关性腹泻综合征诊断的敏感性和特异性，我们纳入了2011年11月至2014年7月期间在肯尼亚西部3家医院中有1家急性腹泻的6个月至5岁儿童.粪便样品使用标准的细菌培养方法和致病性大肠杆菌的多重聚合酶链反应进行测试。逐步多变量logit模型确定了增加综合征诊断敏感性的因素。
结果：在1360名注册儿童中，中位年龄为21个月(四分位距，11-37),3.4%的人感染了人类免疫缺陷病毒，16.5%发育迟缓(身高年龄z评分小于-2)。在63名儿童中发现了志贺氏菌（4.6％），最常见的物种是宋内志贺氏菌（53.8％）和福氏志贺氏菌（40.4％）。痢疾正确分类了63例志贺氏菌病例中的7例(敏感性，11.1%）。1297名无志贺氏菌的儿童中有78名患有痢疾(特异性，94.0%）。粪便粘液的组合，年龄超过23个月，并且没有过度呕吐可以确定更多患有志贺氏菌感染的儿童（敏感性，39.7%)，但也表明更多儿童没有微生物证实的志贺氏菌(特异性，82.7%）。
结论：依赖痢疾作为志贺氏菌的代表，导致大多数志贺氏菌感染的儿童未被确定为抗生素。迫切需要现场快速诊断或更新的循证算法，以确定最有可能从抗生素治疗中受益的腹泻儿童。
方法：为了评估志贺氏菌相关性腹泻综合征诊断的敏感性和特异性，我们纳入了2011年11月至2014年7月期间在肯尼亚西部3家医院中有1家急性腹泻的6个月至5岁儿童.粪便样品使用标准的细菌培养方法和致病性大肠杆菌的多重聚合酶链反应进行测试。逐步多变量logit模型确定了增加综合征诊断敏感性的因素。
结果：在1360名注册儿童中，中位年龄为21个月(四分位距，11-37),3.4%的人感染了人类免疫缺陷病毒，16.5%发育迟缓(身高年龄z评分小于-2)。在63名儿童中发现了志贺氏菌（4.6％），最常见的物种是宋内志贺氏菌（53.8％）和福氏志贺氏菌（40.4％）。痢疾正确分类了63例志贺氏菌病例中的7例(敏感性，11.1%）。1297名无志贺氏菌的儿童中有78名患有痢疾(特异性，94.0%）。粪便粘液的组合，年龄超过23个月，并且没有过度呕吐可以确定更多患有志贺氏菌感染的儿童（敏感性，39.7%)，但也表明更多儿童没有微生物证实的志贺氏菌(特异性，82.7%）。
结论：依赖痢疾作为志贺氏菌的代表，导致大多数志贺氏菌感染的儿童未被确定为抗生素。迫切需要现场快速诊断或更新的循证算法，以确定最有可能从抗生素治疗中受益的腹泻儿童。
