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. 2023 Jul 26:32:100682.
doi: 10.1016/j.lanepe.2023.100682. eCollection 2023 Sep.

Relationship between molecular pathogen detection and clinical disease in febrile children across Europe: a multicentre, prospective observational study

Priyen Shah  1 , Marie Voice  2 , Leonides Calvo-Bado  2 , Irene Rivero-Calle  3   4 , Sophie Morris  2 , Ruud Nijman  1 , Claire Broderick  1 , Tisham De  1 , Irini Eleftheriou  5 , Rachel Galassini  1 , Aakash Khanijau  6 , Laura Kolberg  7 , Mojca Kolnik  8 , Aleksandra Rudzate  9 , Manfred G Sagmeister  10 , Nina A Schweintzger  10 , Fatou Secka  11 , Clare Thakker  1 , Fabian van der Velden  12 , Clementien Vermont  13 , Katarina Vincek  8 , Philipp K A Agyeman  14 , Aubrey J Cunnington  1 , Ronald De Groot  15 , Marieke Emonts  12   16 , Katy Fidler  17 , Taco W Kuijpers  18   19 , Marine Mommert-Tripon  20 , Karen Brengel-Pesce  20 , Francois Mallet  20 , Henriette Moll  21 , Stéphane Paulus  22 , Marko Pokorn  8   23 , Andrew Pollard  22 , Luregn J Schlapbach  24 , Ching-Fen Shen  25   26 , Maria Tsolia  5 , Effua Usuf  11 , Michiel van der Flier  15   27 , Ulrich von Both  7   28 , Shunmay Yeung  29 , Dace Zavadska  9   30 , Werner Zenz  10 , Victoria Wright  1 , Enitan D Carrol  6   31 , Myrsini Kaforou  1 , Federico Martinon-Torres  3   4   32 , Colin Fink  2 , Michael Levin  1 , Jethro Herberg  1 ; PERFORM consortium
Collaborators, Affiliations

Relationship between molecular pathogen detection and clinical disease in febrile children across Europe: a multicentre, prospective observational study

Priyen Shah et al. Lancet Reg Health Eur. .

Abstract

Background: The PERFORM study aimed to understand causes of febrile childhood illness by comparing molecular pathogen detection with current clinical practice.

Methods: Febrile children and controls were recruited on presentation to hospital in 9 European countries 2016-2020. Each child was assigned a standardized diagnostic category based on retrospective review of local clinical and microbiological data. Subsequently, centralised molecular tests (CMTs) for 19 respiratory and 27 blood pathogens were performed.

Findings: Of 4611 febrile children, 643 (14%) were classified as definite bacterial infection (DB), 491 (11%) as definite viral infection (DV), and 3477 (75%) had uncertain aetiology. 1061 controls without infection were recruited. CMTs detected blood bacteria more frequently in DB than DV cases for N. meningitidis (OR: 3.37, 95% CI: 1.92-5.99), S. pneumoniae (OR: 3.89, 95% CI: 2.07-7.59), Group A streptococcus (OR 2.73, 95% CI 1.13-6.09) and E. coli (OR 2.7, 95% CI 1.02-6.71). Respiratory viruses were more common in febrile children than controls, but only influenza A (OR 0.24, 95% CI 0.11-0.46), influenza B (OR 0.12, 95% CI 0.02-0.37) and RSV (OR 0.16, 95% CI: 0.06-0.36) were less common in DB than DV cases. Of 16 blood viruses, enterovirus (OR 0.43, 95% CI 0.23-0.72) and EBV (OR 0.71, 95% CI 0.56-0.90) were detected less often in DB than DV cases. Combined local diagnostics and CMTs respectively detected blood viruses and respiratory viruses in 360 (56%) and 161 (25%) of DB cases, and virus detection ruled-out bacterial infection poorly, with predictive values of 0.64 and 0.68 respectively.

Interpretation: Most febrile children cannot be conclusively defined as having bacterial or viral infection when molecular tests supplement conventional approaches. Viruses are detected in most patients with bacterial infections, and the clinical value of individual pathogen detection in determining treatment is low. New approaches are needed to help determine which febrile children require antibiotics.

Funding: EU Horizon 2020 grant 668303.

Keywords: Bacterial; Diagnostic; Febrile illness; Infectious disease; Molecular diagnostics; Respiratory infection; Viral.

PubMed Disclaimer

Conflict of interest statement

AC received research funding from UK-NIHR and EPSRC. He has unpaid roles at ESPID, and the Excellence in Paediatrics Institute. He filed a patent for a new diagnostic method in children. AP received grant funding from Gates Foundation, Wellcome Trust, Cepi, UK-MRC and NIHR. He received consulting fees from Shionogi. He leads the UK Joint Committee on Vaccination and Immunisation, and was a memeber of WHO-SAGE until 2022. Oxford University has entered into a partnership with AZ for development of COVID19 vaccines. CB received UK-NIHR research funding. FMT received funding from Consorcio Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Grupos de Referencia Competitiva, and Instituto de Salud Carlos III. MT has unpaid role at the National Committee on Immunization Practices, and at the Scientific Advisory Group of Experts for COVID-19. TK has unpaid roles at the National Working Party on Immunodeficiencies, and the National Advisory Committee on SARS-CoV-2 vaccination. UVB received funding from TeleKasper—Innovationsfonds, German G-BA, and has received funds for lectures at MSD—Workshop Pädiatrie. The other authors have no conflict of interests.

Figures

Fig. 1
Fig. 1
(A) Clinical investigative process to assign patients to individual diagnostic categories. ∗Denotes diagnostic categories in which viral co-infection may or may not be present. §Pathogens normally only detected on mucosal surfaces or diagnosed serologically (M. tuberculosis, B. pertussis, M. pneumoniae, Borrelia species, Campylobacter and Salmonella) were included in the Definite Bacterial category if the clinical presentation was consistent with the pathogen detected, but were analyzed separately for some analyses. (B) Patient flow and numbers from recruitment to final diagnostic categories. Children with fever, history of recent fever or suspicion of infection of sufficient severity to warrant blood tests were assigned to a presumptive diagnostic group based on clinical findings on presentation. After results of all microbiological investigations, biochemical and hematological investigations and imaging were available, patients were assigned to final diagnostic categories using the definitions in Table 1. (C) Frequency of detection of pathogen DNA or RNA by research molecular tests in cases and controls. Donut plots show the breakdown of the total number of patients with one or more positive molecular pathogen detection from the research study in cases and controls for respiratory pathogens found in throat swabs, viruses detected in blood, and bacteria detected in blood.
Fig. 1
Fig. 1
(A) Clinical investigative process to assign patients to individual diagnostic categories. ∗Denotes diagnostic categories in which viral co-infection may or may not be present. §Pathogens normally only detected on mucosal surfaces or diagnosed serologically (M. tuberculosis, B. pertussis, M. pneumoniae, Borrelia species, Campylobacter and Salmonella) were included in the Definite Bacterial category if the clinical presentation was consistent with the pathogen detected, but were analyzed separately for some analyses. (B) Patient flow and numbers from recruitment to final diagnostic categories. Children with fever, history of recent fever or suspicion of infection of sufficient severity to warrant blood tests were assigned to a presumptive diagnostic group based on clinical findings on presentation. After results of all microbiological investigations, biochemical and hematological investigations and imaging were available, patients were assigned to final diagnostic categories using the definitions in Table 1. (C) Frequency of detection of pathogen DNA or RNA by research molecular tests in cases and controls. Donut plots show the breakdown of the total number of patients with one or more positive molecular pathogen detection from the research study in cases and controls for respiratory pathogens found in throat swabs, viruses detected in blood, and bacteria detected in blood.
Fig. 1
Fig. 1
(A) Clinical investigative process to assign patients to individual diagnostic categories. ∗Denotes diagnostic categories in which viral co-infection may or may not be present. §Pathogens normally only detected on mucosal surfaces or diagnosed serologically (M. tuberculosis, B. pertussis, M. pneumoniae, Borrelia species, Campylobacter and Salmonella) were included in the Definite Bacterial category if the clinical presentation was consistent with the pathogen detected, but were analyzed separately for some analyses. (B) Patient flow and numbers from recruitment to final diagnostic categories. Children with fever, history of recent fever or suspicion of infection of sufficient severity to warrant blood tests were assigned to a presumptive diagnostic group based on clinical findings on presentation. After results of all microbiological investigations, biochemical and hematological investigations and imaging were available, patients were assigned to final diagnostic categories using the definitions in Table 1. (C) Frequency of detection of pathogen DNA or RNA by research molecular tests in cases and controls. Donut plots show the breakdown of the total number of patients with one or more positive molecular pathogen detection from the research study in cases and controls for respiratory pathogens found in throat swabs, viruses detected in blood, and bacteria detected in blood.
Fig. 2
Fig. 2
(A) Odds ratios for molecular pathogen identifications comparing febrile children and non-febrile controls. Square symbols show the mean and bars and whiskers the 95% confidence intervals. Odds Ratio's above 1 (to right of the dotted line; blue arrow) indicate increased detection of pathogen in cases. OR less than 1 (left of dotted line; red arrow) indicate increased pathogen detection in controls. (B) Odds ratios for molecular pathogen identifications comparing definite bacterial and definite viral groups. Square symbols show the mean and bars and whiskers the 95% confidence intervals. Odds Ratio's above 1 (to right of the dotted line; blue arrow) indicate increased detection of pathogen in DB; OR less than 1 (left of dotted line; red arrow) indicate increased pathogen detection in the viral group.
Fig. 2
Fig. 2
(A) Odds ratios for molecular pathogen identifications comparing febrile children and non-febrile controls. Square symbols show the mean and bars and whiskers the 95% confidence intervals. Odds Ratio's above 1 (to right of the dotted line; blue arrow) indicate increased detection of pathogen in cases. OR less than 1 (left of dotted line; red arrow) indicate increased pathogen detection in controls. (B) Odds ratios for molecular pathogen identifications comparing definite bacterial and definite viral groups. Square symbols show the mean and bars and whiskers the 95% confidence intervals. Odds Ratio's above 1 (to right of the dotted line; blue arrow) indicate increased detection of pathogen in DB; OR less than 1 (left of dotted line; red arrow) indicate increased pathogen detection in the viral group.
Fig. 3
Fig. 3
(A) Proportion of patients in each diagnostic category with pathogen detected. Blue bars show pathogens detected by local investigations; green bars show detection by both local and centralized molecular tests (CMT); orange bars show pathogen detection only by CMT. Purple bar shows patients classified as DB on the basis of mucosal detection of specific pathogens (see definitions Table 1). Combined colored bar height indicates proportion of all patients in each diagnostic category with pathogens detected. Individual panels show detection of respiratory viruses (left), blood viruses (middle) and bacterial and fungal pathogens (right). (B) Sankey diagram showing patient reassignment from final diagnostic category based on local investigations alone, to a final diagnostic group based on addition of CMT. The height of each colored bar represents number of patients in each group, and the curves crossing groups indicate patients reassigned based on CMT results. Addition of CMT resulted in an addition of 87 (2%) of patients to the definite bacterial group and 53 (1%) of patients to the definite viral group.
Fig. 3
Fig. 3
(A) Proportion of patients in each diagnostic category with pathogen detected. Blue bars show pathogens detected by local investigations; green bars show detection by both local and centralized molecular tests (CMT); orange bars show pathogen detection only by CMT. Purple bar shows patients classified as DB on the basis of mucosal detection of specific pathogens (see definitions Table 1). Combined colored bar height indicates proportion of all patients in each diagnostic category with pathogens detected. Individual panels show detection of respiratory viruses (left), blood viruses (middle) and bacterial and fungal pathogens (right). (B) Sankey diagram showing patient reassignment from final diagnostic category based on local investigations alone, to a final diagnostic group based on addition of CMT. The height of each colored bar represents number of patients in each group, and the curves crossing groups indicate patients reassigned based on CMT results. Addition of CMT resulted in an addition of 87 (2%) of patients to the definite bacterial group and 53 (1%) of patients to the definite viral group.
See this image and copyright information in PMC

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