title: Hindsight judgement on ambiguous episodes of suspected infection in critically ill children: poor consensus amongst experts?
abstract: Few episodes of suspected infection observed in paediatric intensive care are classifiable without ambiguity by a priori defined criteria. Most require additional expert judgement. Recently, we observed a high variability in antibiotic prescription rates, not explained by the patients' clinical data or underlying diseases. We hypothesised that the disagreement of experts in adjudication of episodes of suspected infection could be one of the potential causes for this variability. During a 5-month period, we included all patients of a 19-bed multidisciplinary, tertiary, neonatal and paediatric intensive care unit, in whom infection was clinically suspected and antibiotics were prescribed ( n=183). Three experts (two senior ICU physicians and a specialist in infectious diseases) were provided with all patient data, laboratory and microbiological findings. All experts classified episodes according to a priori defined criteria into: proven sepsis, probable sepsis (negative cultures), localised infection and no infection. Episodes of proven viral infection and incomplete data sets were excluded. Of the remaining 167 episodes, 48 were classifiable by a priori criteria ( n=28 proven sepsis, n= 20 no infection). The three experts only achieved limited agreement beyond chance in the remaining 119 episodes (kappa = 0.32, and kappa = 0.19 amongst the ICU physicians). The kappa is a measure of the degree of agreement beyond what would be expected by chance alone, with 0 indicating the chance result and 1 indicating perfect agreement.
  
  
  CONCLUSIONS
  agreement of specialists in hindsight adjudication of episodes of suspected infection is of questionable reliability.
authors.affiliation: Department of Neonatology and Paediatric Intensive Care, University Children's Hospital, Steinwiesstrasse 75, 8032 Zurich, Switzerland. joachim.fischer@kispi.unizh.ch
authors.forename: Joachim E
authors.initials: JE
authors.lastname: Fischer
authors.forename: Federico G
authors.initials: FG
authors.lastname: Seifarth
authors.forename: Oskar
authors.initials: O
authors.lastname: Baenziger
authors.forename: Sergio
authors.initials: S
authors.lastname: Fanconi
authors.forename: David
authors.initials: D
authors.lastname: Nadal
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000175:diagnosis* / Q000188:drug therapy; D002648:Child; D002675:Child, Preschool; D003657:Decision Making; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D015588:Observer Variation; D015203:Reproducibility of Results; D018805:Sepsis / Q000175:diagnosis; D013557:Switzerland; D014777:Virus Diseases / Q000175:diagnosis
chemical_list: D000900:Anti-Bacterial Agents