Chest
Volume 152, Issue 2, August 2017, Pages 353-367
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Original Research: Signs and Symptoms of Chest Diseases
Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.chest.2017.04.186Get rights and content

Background

Pertussis (whooping cough) is a highly infective cause of cough that causes significant morbidity and mortality. Existing case definitions include paroxysmal cough, whooping, and posttussive vomiting, but diagnosis can be difficult. We determined the diagnostic accuracy of clinical characteristics of pertussis-associated cough.

Methods

We systematically searched CINAHL, Embase, Medline, and SCI-EXPANDED/CPCI-S up to June 2016. Eligible studies compared clinical characteristics in those positive and negative for Bordetella pertussis infection, confirmed by laboratory investigations. Two authors independently completed screening, data extraction, and quality and bias assessments. For each characteristic, RevMan was used to produce descriptive forest plots. The bivariate meta-analysis method was used to generate pooled estimates of sensitivity and specificity.

Results

Of 1,969 identified papers, 53 were included. Forty-one clinical characteristics were assessed for diagnostic accuracy. In adult patients, paroxysmal cough and absence of fever have a high sensitivity (93.2% [CI, 83.2-97.4] and 81.8% [CI, 72.2-88.7], respectively) and low specificity (20.6% [CI, 14.7-28.1] and 18.8% [CI, 8.1-37.9]), whereas posttussive vomiting and whooping have low sensitivity (32.5% [CI, 24.5-41.6] and 29.8% [CI, 8.0-45.2]) and high specificity (77.7% [CI, 73.1-81.7] and 79.5% [CI, 69.4-86.9]). Posttussive vomiting in children is moderately sensitive (60.0% [CI, 40.3-77.0]) and specific (66.0% [CI, 52.5-77.3]).

Conclusions

In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, posttussive vomiting is much less helpful as a clinical diagnostic test.

Section snippets

Study Selection and Data Extraction

A diagnostic test accuracy protocol was developed by using the relevant Cochrane handbook16 but not formally registered (available on request). We considered as eligible studies those that included patients of any age attending any health-care setting, including pertussis outbreaks, with any clinical characteristic (index test) that might be associated with pertussis, compared with laboratory confirmation of B pertussis (reference standard). All studies with sufficient published or unpublished

Results

Figure 1 shows the flowchart of study selection. A total of 1,969 unique papers were identified; 422 of these had a full-text review. Forty-seven studies met inclusion criteria for this review and contained sufficient data in the published article for complete data extraction. Fourteen additional articles were identified with potential unpublished data. The authors of these articles were contacted, six of whom provided the necessary information. Overall, 53 articles were included in descriptive

Summary of Evidence

Our meta-analysis demonstrates four key characteristics that are important in ruling in or ruling out a clinical diagnosis of pertussis in adults: paroxysmal cough, posttussive vomiting, inspiratory whoop, and absence of fever.

We found that paroxysmal cough and absence of fever in adults have high sensitivity and low specificity. The clinical implication is that if an adult patient does not have paroxysmal cough or does have a fever, they are very unlikely to have pertussis, good “rule out”

Conclusions

There is substantial statistical heterogeneity between all included studies, which reflects heterogeneity in study designs used. As a result, meta-analysis was only possible of a limited number of clinical characteristics, predominantly in adult patients. The results of the meta-analysis showed that recognizing the classical triad of symptoms in adults remains helpful for clinicians. In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of

Acknowledgments

Author contributions: A. M. takes responsibility for the content of the manuscript, including the data and analysis. N. W. R. designed the search strategy and ran and updated the searches. A. M. and H. F. A. screened the abstracts and completed full-text reviews, data extraction, and assessments of quality and bias. A. H. acted as an independent adjudicator for any discrepancies in this process. B. S. completed the statistical analysis. All authors contributed substantially to the study design,

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      The systematic review followed all the standards of the National Academy of Medicine (previously referred to as the Institute of Medicine).13 After generating the key clinical question for the systematic review, population, index test, reference test, and target condition elements were derived to inform the literature review (Table 3).10 The authors of the review systematically searched the following databases: CINAHL (EBSCHost from 1982 to 2016), Embase (OvidSP from 1974 to 2016), Medline & Medline In-Process (OvidSP from 1946 to 2016), and SCI-EXPANDED/CPCI-S (Web of Science Core Collection from 1945 to 2016).

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    FUNDING/SUPPORT: B. S. is funded by the National Institute for Health Research Leeds Diagnostic Evidence Co-operative. D. S. L. is funded by the National Institute for Health Research Oxford Biomedical Research Centre.

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