Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study

SPS commentary:

All eight guidelines reviewed had a sensitivity of 1.0 for identifying meningococcal disease.  The specificity of NICE CG102 (Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management ) was 0.01 and the specificity of NICE NG51 (Sepsis: recognition, diagnosis and early management) was 0.00.

 

A related commentary discusses this research, and concludes that it shows some important points. First, the proportion of participants who had invasive meningococcal disease was low (1%, however, Neisseria meningitidis infection is still one of the leading causes of morbidity and mortality among febrile children). Second, all eight clinical practice guidelines included in the study  had high sensitivities but very different specificities, and finally, individual clinician decision making was associated with the lowest number of interventions, but at the cost of a higher number of missed invasive meningococcal disease cases when compared with the clinical practice guidelines.

 

It suggests guidelines could be updated with improved diagnostics for early detection of serious illness and invasive meningococcal disease to improve their specificity without compromising sensitivity. However, the low number of cases of invasive meningococcal disease identified in the study highlights the difficulty of identifying predictors of the disease in future studies. These low numbers of cases could hinder the identification of new biomarkers. Furthermore, patients and doctors value false-positive classifications (resulting in overtreatment) differently to false-negative classifications (resulting in missed cases of invasive meningococcal disease). The relative weight of harms versus benefits might differ from patient to patient and from doctor to doctor.

 

It notes that less conservative clinical practice guidelines require parents to be more empowered to recognise serious infections in, or unexpected deterioration of, their child and to know how to act on this knowledge. Therefore, at the same time as clinical practice guidelines are revised and potential new biomarkers are implemented, appropriate tools will need to be developed to inform parents about serious illnesses and how to seek help. It adds that the art of evidence-based medicine is the individual trade-off between the risk of missing invasive disease and the benefits of a more efficient clinical practice guideline. This approach cannot exist without adequate contingency measures (i.e. the so-called safety net), which should be tailored to each individual case and its setting, and to the possibility of a rapidly deteriorating disease course.