Utility of shaking chills as a diagnostic sign for bacteremia in adults: a systematic review and meta-analysis

Abstract

Background: Accurate prediction of bacteremia is essential for guiding blood culture collection and optimal antibiotic treatment. Shaking chills, defined as a subjective chill sensation with objective body shivering, have been suggested as a potential predictor of bacteremia; however, conflicting findings exist. To address the evidence gap, we conducted a systematic review and meta-analysis of studies to assess the diagnostic accuracy of shaking chills for predicting bacteremia among adult patients.

Methods: We included studies reporting the diagnostic accuracy of shaking chills or chills for bacteremia. Adult patients with suspected bacteremia who underwent at least one set of blood cultures were included. Our main analysis focused on studies that assessed shaking chills. We searched these studies through CENTRAL, MEDLINE, Embase, the World Health Organization ICTRP Search Portal, and ClinicalTrials.gov. Study selection, data extraction, evaluation for risk of bias, and applicability using the QUADAS-2 tool were conducted by two independent investigators. We estimated a summary receiver operating characteristic curve and a summary point of sensitivity and specificity of the index tests, using a hierarchical model and the bivariate model, respectively.

Results: We identified 19 studies with a total of 14,641 patients in which the accuracy of shaking chills was evaluated. The pooled sensitivity and specificity of shaking chills were 0.37 (95% confidence interval [CI], 0.29 to 0.45) and 0.87 (95% CI, 0.83 to 0.90), respectively. Most studies had a low risk of bias in the index test domain and a high risk of bias and a high applicability concern in the patient-selection domain.

Conclusions: Shaking chills are a highly specific but less sensitive predictor of bacteremia. Blood cultures and early initiation of antibiotics should be considered for patients with an episode of shaking chills; however, the absence of shaking chills must not lead to exclusion of bacteremia and early antibiotic treatment.

Keywords: Bacteremia; Chills; Rigor; Sepsis; Shivering.

Fig. 1

PRISMA 2020 flow diagram. We re-searched the database, articles citing included studies, and those cited in the included research twice. In the flow of database re-search and citation search, the total number of articles based on the additional searches is described. CENTRAL, Cochrane Central Register of Controlled Trials; ICTRP, International Clinical Trials Registry Platform; RCTs, randomized controlled trials

Fig. 2

Risk-of-bias assessment of the included studies for shaking chills using the QUADAS-2 tool*. *Two cohorts are presented separately as they were included in a study conducted by Sasaki in 2021

Fig. 3

Summary of the QUADAS-2 risk-of-bias assessments in included studies for shaking chills*. *Two cohorts were included in a study conducted by Sasaki in 2021; thus, this figure includes 20 studies although 19 studies were included in the main analysis in our review

Fig. 4

Forest plot of the included studies using shaking chills as the index test. ED, emergency department; any setting: outpatient department, ward, intensive care unit, and ED

Fig. 5

HSROC analysis based on the bivariate model of the included studies for shaking chills. HSROC, hierarchical summary receiver operating characteristic