Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia

Prospective Evaluation of Indications for Testing

Shawna Bellew, Carlos G. Grijalva, Derek J. Williams, Evan J. Anderson, Richard G Wunderink, Yuwei Zhu, Grant W. Waterer, Anna M. Bramley, Seema Jain, Kathryn M. Edwards, Wesley H. Self

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. METHODS: We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. RESULTS: Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%) and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%) and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. CONCLUSIONS: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

Original languageEnglish (US)
Pages (from-to)2026-2033
Number of pages8
JournalClinical infectious diseases : an official publication of the Infectious Diseases Society of America
Volume68
Issue number12
DOIs
StatePublished - May 30 2019

Fingerprint

Legionella
Pneumonia
Legionella pneumophila
Antigens
Streptococcus pneumoniae
Communicable Diseases
Thorax
Confidence Intervals
Guidelines
Sensitivity and Specificity
Hyponatremia
Expert Testimony
Diarrhea
Fever
Logistic Models
Prospective Studies

Keywords

  • Legionella
  • pneumococcal
  • pneumonia
  • urine antigen test

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases

Cite this

Bellew, Shawna ; Grijalva, Carlos G. ; Williams, Derek J. ; Anderson, Evan J. ; Wunderink, Richard G ; Zhu, Yuwei ; Waterer, Grant W. ; Bramley, Anna M. ; Jain, Seema ; Edwards, Kathryn M. ; Self, Wesley H. / Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia : Prospective Evaluation of Indications for Testing. In: Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019 ; Vol. 68, No. 12. pp. 2026-2033.
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title = "Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia: Prospective Evaluation of Indications for Testing",
abstract = "BACKGROUND: Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. METHODS: We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. RESULTS: Among 1941 patients, UATs were positive for SP in 81 (4.2{\%}) and for LP in 32 (1.6{\%}). IDSA/ATS indications had 61{\%} sensitivity (95{\%} confidence interval [CI] 49-71{\%}) and 39{\%} specificity (95{\%} CI 37-41{\%}) for SP, and 63{\%} sensitivity (95{\%} CI 44-79{\%}) and 35{\%} specificity (95{\%} CI 33-37{\%}) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. CONCLUSIONS: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.",
keywords = "Legionella, pneumococcal, pneumonia, urine antigen test",
author = "Shawna Bellew and Grijalva, {Carlos G.} and Williams, {Derek J.} and Anderson, {Evan J.} and Wunderink, {Richard G} and Yuwei Zhu and Waterer, {Grant W.} and Bramley, {Anna M.} and Seema Jain and Edwards, {Kathryn M.} and Self, {Wesley H.}",
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Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia : Prospective Evaluation of Indications for Testing. / Bellew, Shawna; Grijalva, Carlos G.; Williams, Derek J.; Anderson, Evan J.; Wunderink, Richard G; Zhu, Yuwei; Waterer, Grant W.; Bramley, Anna M.; Jain, Seema; Edwards, Kathryn M.; Self, Wesley H.

In: Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Vol. 68, No. 12, 30.05.2019, p. 2026-2033.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia

T2 - Prospective Evaluation of Indications for Testing

AU - Bellew, Shawna

AU - Grijalva, Carlos G.

AU - Williams, Derek J.

AU - Anderson, Evan J.

AU - Wunderink, Richard G

AU - Zhu, Yuwei

AU - Waterer, Grant W.

AU - Bramley, Anna M.

AU - Jain, Seema

AU - Edwards, Kathryn M.

AU - Self, Wesley H.

PY - 2019/5/30

Y1 - 2019/5/30

N2 - BACKGROUND: Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. METHODS: We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. RESULTS: Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%) and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%) and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. CONCLUSIONS: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

AB - BACKGROUND: Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. METHODS: We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. RESULTS: Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%) and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%) and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. CONCLUSIONS: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

KW - Legionella

KW - pneumococcal

KW - pneumonia

KW - urine antigen test

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DO - 10.1093/cid/ciy826

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