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Research Critique

Group 2
Roll Number: 23-44
Title

A comparative study of Widal Test with blood


culture in the diagnosis of typhoid fever in
febrile patient
Relevance
• The objective of the paper which is to access the
sensitivity, specificity, predictive values and
agreement of Widal test as a gold standard for
diagnosis of typhoid among typhoid suspected
patients with similar symptoms to typhoid fever
which is relevant on clinical question which is to
determine if we can rely on widal test for diagnosis
of typhoid.
Validity
1. Was there an independent comparison with a
reference standard?
No, there is no independent comparison with the
reference standard because this study was carried
out to evaluate the value of a single acute-phase
Widal test result by blood culture for the diagnosis of
typhoid fever in febrile patients in St. Paul’s General
Specialized Hospital, Addis Ababyta, Ethiopia.
2. Did the patient sample include an appropriate spectrum of
patients to whom the test will be used?
No, the patient sample did not included an appropriate
spectrum of patients to whom the test will be done because,
however, those febrile patients who had received antibiotic
treatment for their symptom within two weeks before coming
to the hospital and those who diagnosed for other known
febrile illness were not included in this study. By using these
inclusion and exclusion criteria about 277 suspected febrile
patients were recruited for this study, then data and blood
sample were collected from these 277 patients.
3. Was the reference standard done regardless of the
result of the diagnostic test being evaluated?
Yes, the reference standard was done regardless of the
result of diagnostic test been evaluated because the
sensitivity and specificity of Widal titer of anti TO 1:80 and
higher in this study were about 71.4% and 74.1%
respectively.
4. Were the methods for performing and interpreting the result of
the test described in sufficient details to permit replication
Yes, the methods for performing and interpreting the result of the
test described are in sufficient details to permit replication because
in addition to S.typhi and S.paratyphi, other bacteria were identified
from blood culture of the febrile patients who had positive or
negative Widal titer. In the current study seven (2.6%) cases of non
typhoidal salmonella and 51 (18.8%) cases of other bacteria were
identified from blood culture. The result of non typhoidal
salmonella (2.6%) was similar to a study done in Tanzania; the study
identified 2.9% of non typhoidal salmonella from blood culture
[9,20]. Positive Widal titers were also seen in cases of non typhoidal
salmonella and in blood culture positive cases for other bacteria.
Three out of 7 (42.9%) of non typhoidal salmonella cases and 17 of
the 51 (33.3%) other bacteria positive cultures res had a positive
titer of anti TO.
Specificity & Sensitivity
PPV
blood culture is regarded as the gold standard for determining
the patients who are febrile as a typhoid positive or
negative.
out of n= 270 only, 7 had a positive blood culture for
salmonella typhi.
out of those positive blood culture for s.typhi only 5 shown
positive for widal o antigen test and 2 shown positive for
widal h antigen test. And the positive predictive vale for o
and h antigen of widal test has a value of 6.8 and 5.2
respectively.
In this study only 7 had culture proven febrile typhoid fever.so,
a negative widal test is good predictive value for the
absence of disease which is 98.8 for o antigen and 97.8 for
h antigen, but a positive result would have a low predictive
value which is mentioned above.
NPV
• It is the percentage of the patients with a negative test
who donot have the disease
• NPV =d/d+c
• =d (true negative)/ c+d (false negative + true negative)
For blood culture NPV = d(201)/d+c(201+0)*100
=100%
For widal test o antigen NPV=d(205)/d+c(205+2)*100
=99%
For widal test H antigen NPV= d(227)/d+c(227+5)*100
=97.84%
LR for Positive
• LR- = SENSITIVITY / ( 1- SPECIFICITY )

LR = 0.714 / ( 1- 0.6844 )
= 0.714/ 0.3156
LR =2.66
RESULT : Increase the likelihood of the disease.
LR for Negative
• LR- = (1- SENSITIVITY) / SPECIFICITY

LR- = (1- 0.714) /0.6844


=0.286/0.6844
LR- =0.417
RESULT : Decrease the likelihood of the disease.
OR
Odds ratio = a/b * c/d = ad/bc
where
a = number of persons exposed and with disease
b = number of persons exposed but without disease
c = number of persons unexposed but with disease
d = number of persons unexposed and without disease
a + c = total number of persons with disease (case - patients)
b + d = total number of persons without disease (controls)
In the given case:
a = 11 patients (Salmonella typhi & Salmonella
Paratyphi)
b = 7 patients (Non typhoidal salmonella)
c = 51 patients (Pathogenic Bacteria)
d = 201 patients (Negative results)

OR = a/b * c/d = (11/ 51) * (201/7) = 2211/357 = 6.19%

OR = 6.19%
Therefore, there is an increased odds of exposure
among patients who are ill
Incidence & Prevalence

• Incidence: Mid December 2010 to March 2011

• Prevalence: 4.07%
Post-test Probability (-)
Likelihood ratio(-ve).
=(1-sensitivity )/specificity
=(1-0.714)/0.6844
=0.286/0.6844
=0.41
LR(-)=0.41.
Pretest probability=population prevalence
Pretest probability=4.07%
Post test probability:
Pretest odd=p/(1-p)
=0.047/(1-0.047)
Pretest odd=0.0424267
Post test odd=pretest odd*LR(-)
=0.0424267*0.41
Post test odd=0.0173949755. Post test prob(-
)=post test odd/(post test odd+1)
=0.0173949755/1.01739
=0.017097.
Post test probability=1.7%.
Post-test Probablity (+)
Likelihood ratio (+) = Sensitivity/(1-Specifictiy)
= 71.4%/(1-68.44%)
=0.714/ (1-0.6844)
= 0.714/ 0.3156
= 2.26

Pre-test probability  Population prevalence


Pre-test odds = Pre-test odds * LR(+)
= Pre-test odds * 2.26
= _____ (insufficient data provided)
LR(+) * Pre-test odds = Post-test odds
= _____ (insufficient data provided)
Post-test probability = Post-test odds/ (Post-test odds + 1)
= _____ (insufficient data provided)
Manual Computation
1. Convert the pre test probability to pre test odds (p/1-p)
Pre test odds:0.041/(1-0.041)=0.04
2. Multiply pre test odds by the LR to get the post test
odds
a. If widal test positive:0.0.04x2.3=0.09
b. If widal test negative:0.04x0.4==0.16
3. Convert the post test odds to post test
probability(o/o+1)
a. If widal test positive:0.09/0.09+1=0.1 or 10%
b. if widal test negative:0.16/0.16+1=0.14 or 14%
Applicability
The results derived from this journal can be applied to
practical use; As seen from the results discussed in the
journal, widal test had a sensitivity of 71.4%, specificity
of 68.44%, positive predictive value of 5.7% and a
negative predictive value of 98.9%. It can be
understood from the results that even though the
widal test got lower values in sensitivity, specificity and
positive predictive value, it has a relatively high
negative predictive value, which basically means that if
a patient is negative with widal test, we can pretty
much rule out typhoid fever from the differential
diagnosis.
Thank You!