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Purpose  The study’s aim is to analyse the diagnostic performance of chest radiography (CXR) in patients with suspected coronavirus disease 19 (COVID-19).    Methods  We retrospectively considered 826 consecutive patients with suspected COVID-19 presenting to our emergency department (ED) from February 21 to March 31, 2020, in a high disease prevalence setting. We enrolled patients who underwent CXR and rhino-oropharyngeal swab for real-time reverse transcription-polymerase chain reaction (rRT-PCR). CXRs were evaluated by an expert radiologist; a second independent analysis was performed by two residents in consensus. All readers, blinded to rRT-PCR results, classified CXRs positive/negative depending on presence/absence of typical findings of COVID-19, using rRT-PCR as reference standard.    Results  We finally analysed 680 patients (median age 58); 547 (80%) tested positive for COVID-19. The diagnostic performance of CXR, interpreted by the expert reader, was as follows: sensitivity (79.0%; 95% CI: 75.3–82.3), specificity (81.2%; 95% CI: 73.5–87.5), PPV (94.5%;95% CI: 92.0–96.4), NPV (48.4%; 95% CI: 41.7–55.2), and accuracy (79.3%; 95% CI: 76.0–82.2). For the residents: sensitivity (75.1%; 95% CI: 71.2–78.7), specificity (57.9%; 95% CI: 49.9–66.4), PPV (88.0%; 95% CI: 84.7–90.8), NPV (36.2%; 95% CI: 29.7–43.0), and accuracy (71.6%; 95% CI: 68.1–75.0). We found a significant difference between the reporting sensitivity ( p  = 0.013) and specificity ( p  < 0.0001) of expert radiologist vs residents. CXR sensitivity was higher in patients with symptom onset > 5 days before ED presentation compared to ≤ 5 days (84.4% vs 70.7%).    Conclusions  CXR showed a sensitivity of 79% and a specificity of 81% in diagnosing viral pneumonia in symptomatic patients with clinical suspicion of COVID-19. Further studies in lower prevalence settings are needed.    Supplementary Information  The online version contains supplementary material available at 10.1007/s10140-021-01946-x.

Diagnostic performance of chest radiography in high COVID-19 prevalence setting: experience from a European reference hospital