Benjamin Littenberg and colleagues conducted a meta-analysis of 59 studies involving nearly 56,000 patients to analyze the accuracy and inconsistencies of rapid strep tests. They found that while the tests are generally excellent at correctly diagnosing patients, their ability to accurately return negative results varied between 70-95%. Key factors influencing a test's accuracy included the patient's age, testing location, and whether the study was sponsored by a manufacturer. The analysis revealed inconsistencies in test performance but not the underlying reasons. Littenberg concludes more research is needed to address sources of variability and improve data on rapid strep test accuracy.

1. Benjamin Littenberg, M.D., Henry and Carleen Tufo Professor of
Medicine at the University of Vermont College of Medicine.
University Communications
Littenberg Studies Accuracy of Rapid Strep Tests
11-21-2014 By Meredith Woodward King
When a patient suffers from a lingering sore throat, many healthcare
practitioners turn to rapid antigen streptococcus tests (RAST),
commonly known as rapid strep tests, to help determine the presence of
group A Streptococcus bacteria. Given the 13 million office visits
annually in the United States for these sore throats – called pharyngitis
– clinicians’ reliance on these tests is significant, but despite their
popularity, researchers found the accuracy is inconsistent.
To get a clearer picture of the tests’ accuracy, researchers including
Benjamin Littenberg, M.D., University of Vermont Henry and Carleen
Tufo Professor of Medicine and professor of nursing, and colleagues
analyzed and summarized the variances in 59 studies of rapid strep
tests encompassing nearly 56,000 patients, mostly in North America
and Europe. This systematic analysis was published in the November
4, 2014 PLoS ONE.
Current guidelines from the Infectious Diseases Society of America
(IDSA) for treating strep are not based on a meta-analysis that could
shed light on why test performance varies, note researchers. The
IDSA’s non-systematic review shows that tests produce excellent specificity, correctly diagnosing 95 percent or more of sick people, but
have variable sensitivity, accurately returning negative results for 70 to 95 percent of healthy people. The IDSA recommends
prescribing antibiotics for patients who test positive.
Littenberg and colleagues’ meta-analysis reveals where studies vary, but not why. They examined possible sources of heterogeneity,
including funding sponsors, settings – such as emergency rooms, outpatient clinics or student health centers – as well as number of
swabs, methodology (immunochromatographic, enzyme immunoassay or optical immune-assay), age groups, study design and more.
“What we discovered was there weren’t a lot of really good studies,” Littenberg says. “In some cases, there is publication bias. But there
are other cases where there is something else going on that we don’t understand. It’s not clear why the test is more accurate in
one situation versus another. That inconsistency is a real problem."
The analysis, he says, “will not resolve the issue of whether or not to get rapid strep tests.” But it does make clear that “the sources of
heterogeneity need to be addressed in future tests, and we need to get better data.”
Among the team’s finding regarding the most widely used and most studied tests (those that employ lateral flow
immunochromatographic methods) are:
· The tests can more accurately identify strep in adults versus children
· Inconsistencies were higher for children than for adults.
· Test results for children are more consistently accurate when used in outpatient clinics versus emergency rooms.
· The tests are shown to be more accurate in evaluations sponsored by manufacturers.
The group’s analysis employed a statistical technique, which uses a graphical curve to compare data points, that Littenberg published in
1993 to compare diagnostic tests with the “gold standard” test. Since then, it has been used hundreds of times to compare positive-
negative tests for a wide variety of medical conditions.
Two professors of medicine at the University of Alabama at Birmingham – Robert M. Centor, M.D., regional dean for the Huntsville
Regional Medical Campus and the foremost expert on management of adult strep throat, and Carlos A. Estrada, M.D. – called on
Littenberg’s expertise for the PLoS ONE study.
Lead authors on the article are Emily Stewart, M.D., of Walter Reed National Military Medical Center, Bethesda, Md., and Brian Davis,
M.D., of University of Texas Southwestern Medical Center, Dallas. B. Lee Clemans-Taylor, M.L.S., director of the medical library at
University of Alabama at Birmingham-Huntsville, is a co-author.
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