title: Clinical presentation and microbiological diagnosis in paediatric respiratory tract infection: a systematic review.
abstract: BACKGROUND
  Antibiotic prescribing decisions for respiratory tract infection (RTI) in primary care could be improved if clinicians could target bacterial infections. However, there are currently no evidence-based diagnostic rules to identify microbial aetiology in children presenting with acute RTIs.
  
  
  OBJECTIVE
  To analyse evidence of associations between clinical symptoms or signs and detection of microbes from the upper respiratory tract (URT) of children with acute cough.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  A literature search identified articles reporting relationships between individual symptoms and/or signs, and microbes detected from URT samples. Associations between pathogens and symptoms or signs were summarised, and meta-analysis conducted where possible.
  
  
  RESULTS
  There were 9984 articles identified, of which 28 met inclusion criteria. Studies identified 30 symptoms and 41 signs for 23 microbes, yielding 1704 potential associations, of which only 226 (13%) have presently been investigated. Of these, relevant statistical analyses were presented for 175 associations, of which 25% were significant. Meta-analysis demonstrated significant relationships between respiratory syncytial virus (RSV) detection and chest retractions (pooled odds ratio [OR] 1.9, 95% confidence interval [CI] = 1.6 to 2.3), wheeze (pooled OR 1.7, 95% CI = 1.5 to 2.0), and crepitations/crackles (pooled OR 1.7, 95% CI = 1.3 to 2.2).
  
  
  CONCLUSIONS
  There was an absence of evidence for URT pathogens other than RSV. The meta-analysis identified clinical signs associated with RSV detection, suggesting clinical presentation may offer some, albeit poor, diagnostic value. Further research is urgently needed to establish the value of symptoms and signs in determining microbiological aetiology and improve targeting of antibiotics in primary care.
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, NIHR School of Primary Care Research, University of Bristol, Bristol.
authors.forename: Hannah V
authors.initials: HV
authors.lastname: Thornton
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, NIHR School of Primary Care Research, University of Bristol, Bristol.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Blair
authors.affiliation: Bristol Centre for Antimicrobial Research and Evaluation (BCARE), North Bristol NHS Trust, Southmead Hospital, Bristol, Bristol.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Lovering
authors.affiliation: Specialist Virology Centre, Public Health Laboratory Bristol, Public Health England, Bristol, Bristol.
authors.forename: Peter
authors.initials: P
authors.lastname: Muir
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, NIHR School of Primary Care Research, University of Bristol, Bristol.
authors.forename: Alastair D
authors.initials: AD
authors.lastname: Hay
mesh_terms: D001419:Bacteria / Q000302:isolation & purification*; D002648:Child; D006801:Humans; D020545:Respiratory Mucosa / Q000382:microbiology*; D012141:Respiratory Tract Infections / Q000175:diagnosis* / Q000382:microbiology*
keywords: child; diagnosis; microbiology; point-of-care systems; primary health care; respiratory tract infections