ARTICLE IN PRESS

Current Paediatrics (2004) 14, 482–488

www.elsevier.com/locate/cupe

How to perform a literature search

Leanne V. Jonesa,, Rosalind L. Smythb

a
Evidence-Based Child Health Unit
b
Department of Child Health, Institute of Child Health, University of Liverpool, Royal Liverpool Children’s
NHS Trust, Eaton Road, Liverpool LI2 2AP, UK

KEYWORDS Summary The first and most crucial stage in performing a comprehensive search
Clear question; of the literature is to formulate a clearly defined question which can easily be
Search strategy; translated into an effective search strategy. The next stage is to choose the most
Clinical appropriate information resource. There are many resources available, some of
effectiveness which provide access to summaries of pre-appraised high-quality information. These
resource; resources should be searched initially and can be interrogated simply by using one or
MEDLINE two key terms taken from the search strategy developed. If this approach fails to
retrieve any relevant material then more general medical databases should be
sought. General medical databases such as MEDLINE provide access to primary
research articles. These require more complex interrogation, using many terms from
the devised search strategy to maximize the number of relevant hits.
r 2004 Elsevier Ltd. All rights reserved.

Practice points
 Clearly define the question in order to
devise an effective search strategy
 Start with resources that have already
summarized the literature on clinical effec-
tiveness, e.g. The Cochrane Library, Clinical
Evidence
 Use a more complex search strategy to
interrogate general medical databases,
e.g. MEDLINE
Corresponding author. Tel.: +44-151-252-5693.
E-mail address: l.v.jones@liverpool.ac.uk (L.V. Jones).
Introduction
There is an ever-increasing amount of research
information available electronically either over the
Internet, on CD-Rom, online, or on computer
networks.1 In order for busy clinicians to access
the literature quickly and effectively, key skills are
needed. The first stage before searching the
literature is to translate the clinical problem into
a clearly focused question. The next stage is to
decide which resources to search and in which
order. Wherever possible help from information
specialists/librarians should be sought. They can
identify resources available locally and can provide
assistance in carrying out the actual search if
necessary. There are many resources that provide
access to high-quality research information, which

0957-5839/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cupe.2004.07.007
 ARTICLE IN PRESS
How to perform a literature search 483

has already been evaluated, synthesized and
summarized in easy-to-use formats,2 e.g. the
Cochrane Library, Clinical Evidence, the TRIP
database. These resources should be searched
initially. A good literature search will involve
searching several of these resources, usually in
order of usefulness. A simple one- or two-word
search can be used. If these resources are not
accessible or do not provide answers to the clinical
problem initially posed, then databases of primary
research should be searched; for example, PubMed,
the Internet version of MEDLINE provided by the
National Library of Medicine in the USA, provides
access to a wealth of research evidence. A more
complex search strategy would need to be designed
in order to search PubMed effectively. This article
aims to guide the busy clinician to those resources
having a high yield of information relating to
clinical effectiveness, which can be searched easily
and quickly. Guidance is also given on how to
interrogate a more general medical database if
required. The sort of complex search strategy
required for a secondary research project such as
a systematic review of the literature has been
written about extensively elsewhere.3,4
Formulating a clearly focused question
The most fundamental stage in performing an
effective search of the literature is to formulate a
clearly focused question from the clinical problem.
This question is then used to guide each step of the
search, be it a simple one-or two-step search
formulation or a more complex search strategy.
There are four components to a clearly focused
question. Each clinical problem posed should be
translated into the ‘Patient or Problem’ compo-
nent; ‘Intervention or Exposure’ component; ‘Com-
parison Intervention or Comparison Exposure’
component; and the ‘Outcome(s)’ of interest
component. This four-part question is often re-
ferred to as ‘PICO’.5 Using this formula to translate
the question into its four components ensures that
the question is both directly relevant to the
patient’s problem and phrased in a way that directs
the search to relevant and precise information.
Table 1 summarizes the steps involved in translat-
ing the following clinical problem into a four-part
question: ‘In children with acute urinary tract
infections, is a short course of antibiotic therapy
as effective as standard duration therapy in
clearing the infection?’
Constructing the search strategy
The four-part question can then be taken and used
to construct the search strategy. Each component
should be taken in isolation and word lists compiled
for each. Using the clinical problem given in
Table 1, words, synonyms or related terms for the
Patient or Problem component should be drawn up.
This process should be repeated for each compo-
nent, resulting in a comprehensive word list for
each as in Table 2.
Once word lists have been compiled for each
component, searching can begin. Initially, the Help
section of the resource in question should be
checked to see which search tools are available.
Boolean logic, truncation, wild card and controlled
vocabulary are all tools, which may be available.
Boolean logic
Search terms can be combined using Boolean logic,
i.e. the terms AND, OR and NOT (this section will
cover AND and OR). If the term ‘urinary tract
infection’ is typed in, several thousand records will
be retrieved. In order to retrieve a more relevant
and manageable set of records it is best to combine
terms using Boolean operators. In this instance the
term ‘urinary tract infection’ would be combined
with the term ‘child’ using the Boolean operator
AND. This will retrieve articles which talk about
urinary tract infection in children (see Fig. 1).

Table 1 Clearly focused questions contain four components.

Patient or problem Intervention or Comparison Outcomes

exposure intervention or
exposure

Four-part question Child with urinary Long course of Short course of Resolution of
tract infection antibiotics (7–10 antibiotics (o5 dysuria frequency
days) standard days) and fever. Urine
culture negative
 ARTICLE IN PRESS
484 L.V. Jones, R.L. Smyth

Table 2 Word lists for each component of the four–part question.

Patient or problem Intervention or exposure Comparison Intervention or exposure Outcomes

Urinary tract infection Antibiotic(s) Antibiotic(s) Dysuria

UTI Long course Short course Frequency
Infant (s) Standard Fever
Preschool child (ren) Urine culture
child(ren)
Adolesence/adolescent

Figure 2 Or identifies articles containing both words/

Figure 1 And identifies articles containing both words/ phrases.
phrases.

If ‘urinary tract infection’ had been combined
with ‘child’ using the operator OR, only articles
which were about either children or urinary tract
infection would be retrieved, but not necessarily
articles about both topics. However, synonyms or
related terms should always be combined using the
OR operator, e.g. ‘child’ OR ‘infant’ (see Fig. 2).
Truncation
Truncation allows searching of terms that all begin
with the same search string. Truncation symbols
vary between databases. The asterisk is the symbol
used within most databases. If an asterisk is placed
at the end of the text string child*, then all terms
beginning with the string child will be retrieved,
e.g. child, children, childhood, etc.
Wildcard
In order to search for variations in spelling, some
databases allow wildcard characters. The wildcard
character may be denoted by a question mark ‘?’ in
some databases. The wild card is inserted in the
word to denote a possible variation in spelling, e.g.
an additional or alternative letter. For example,
p?ediatric would pick up both the terms paediatric
and pediatric.
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How to perform a literature search
Controlled vocabulary
So far we have compiled word lists within each
component of the question in Table 2, e.g. urinary
traction, uti, child, infant, preschool child, ado-
lescent. These terms are referred to as ‘text
words’. These are terms we would expect the
author of an article to have used in the title (TI)
and abstract (AB) fields of an article. Some
database producers also add indexing terms to
articles within their databases. The indexing terms
usually refer to the main subject topic of the
article. For example, the indexing term diabetes
mellitus may be assigned to every article whose
main focus is about the disease diabetes mellitus. A
search using indexing terms can sometimes be more
efficient, because it picks up articles that are
specifically about the topic of interest, instead of
picking up irrelevant articles which may have only
mentioned the topic of interest in passing. Each
article is usually assigned several indexing terms.
For example, an article, which refers to a study of
diabetes mellitus in preschool children, might be
assigned the indexing terms ‘diabetes mellitus’ and
‘child preschool’. A search using just indexing
terms is referred to as a search on ‘controlled
vocabulary’.1
The MEDLINE database produced by the National
Library of Medicine in the USA uses indexing terms
known as MeSHTM (Medical Subject Headings).
Within the MEDLINE database, indexing terms can
be identified by looking in the Thesaurus section.
The Thesaurus contains carefully constructed sets
of terms. These terms or subject headings are
arranged in both an alphabetical and a hierarchical
tree structure. At the most general level of the
hierarchical structure are very broad headings such
as ‘Child’, ‘Neoplasms’, and ‘Antibiotics’. At more
narrow levels are found more specific headings such
as ‘Child, Abandoned’, ‘Nose Neoplasms’, and
‘Azithromycin’. There are more than 22 000 main
headings in MeSHTM. Ideally, when searching both
text words and indexing terms should be used in
combination. This improves the sensitivity of a
search and ensures that as many relevant articles
as possible are retrieved.
Note: MeSH is a registered trademark of the
United States National Library of Medicine.
Clinical effectiveness resources
It has been suggested that many clinical questions
can be answered by using a limited range of
extracting, evaluating databases, which can be
485
interrogated using simple two- or three-step search
formulations.6 These databases, known as clinical
effectiveness resources, are much smaller than
large general medical databases such as MEDLINE
and therefore allow quick and easy access to
relevant information. The databases are generally
smaller because the information therein has been
extracted from many other sources and evaluated
and summarized in easy to use formats.
The question, ‘In children with acute urinary
tract infections is a short course of antibiotic
therapy as effective as standard duration therapy
in clearing the infection?’ suggests the search terms
‘child’ and ‘urinary tract infection’.
The following four resources are, in our experi-
ence, useful starting points for any literature
search.
The Cochrance Library7
What is it?
This is the first place to search in terms of
identifying any literature on the effects of treat-
ments or other healthcare interventions, e.g. what
is the effectiveness of taking vitamin C for pre-
venting colds? It is not suitable for the following
questions: general healthcare queries, e.g. causal,
prognosis, epidemiology; statistical queries on
prevalence or incidence; primary research other
than randomized controlled trials; guidelines; or
current research. It contains high-quality informa-
tion which is produced by two organizations: the
Cochrane Collaboration8 and the NHS Centre for
Reviews and Dissemination (NHS CRD).9 The infor-
mation is organized within several databases. The
main databases include: the Cochrane Database of
Systematic Reviews (CDSR), containing a collection
of full-text systematic reviews and protocols for
ongoing reviews done by the Cochrane Collabora-
tion; the Database of Abstracts of Reviews of
Effects (DARE) containing detailed abstracts asses-
sing reviews published elsewhere in the medical
literature; and the Cochrane Central Register of
Controlled Trials (CENTRAL) containing the largest
collection of references to randomized controlled
trials identified in the medical literature. When
trying to look for information regarding treat-
ments, if a relevant Cochrane review on CDSR is
not located, then DARE and CENTRAL may yield
relevant results. The library is updated quarterly.
How to search
The library allows searching of all databases at
once from one search interface, which makes for
quick and efficient searching. It is suggested that
 ARTICLE IN PRESS
486
two or at most three relevant and discriminating
terms are selected for a simple search. The
following search could then be conducted in order
to carry out a complete interrogation of the
Cochrane Library it would be necessary to search
using a combination of text words and indexing
terms. This is because some records within the
Cochrane Library are not indexed. The Cochrane
Library uses indexing terms drawn from the MeSHTM
Thesaurus and offers the facility to look up MeSHTM
terms. If time is a limiting factor, the search should
be conducted just using text words. If relevant
information is retrieved taking this approach, then
all well and good. However, if as much relevant
information as possible on a topic needs to be
identified, then the search will need to be
conducted using text words combined with indexing
terms.
The following search would be used to retrieve
all relevant information within the Cochrane
Library (from the History display and MeSH search
facility):
#I child*
#2 infant’*
#3 CHILD-PRESCHOOL single term (MeSH)
#4 INFANT (MeSH)
#5 #I OR #2 OR #3 OR #4
#6 urinary tract infection
#7 URINARY-TRACT-INFECTIONS (MeSH)
#8 #6 OR #7
#9 #5 AND #8
(MeSH) denotes a MeSHTM term search. These
terms are first identified within the MeSHTM
browser. The appropriate term is then chosen and
searched upon.
How to access
The Cochrane Library is freely available to NHS
staff, patients and the public in England via the
National Electronic Library for Health10 (NeLH).
The Database of Abstracts of Reviews of Effects
(DARE) is also freely available on the NHS CRD
website.9 Alternatively the Cochrane Library can be
subscribed to via John Wiley & Sons, Ltd.7
Clinical evidence
What is it?
‘‘Clinical Evidence’’ is a regularly updated guide to
evidence about the effectiveness of care. It high-
lights areas where evidence is lacking as well as
indicating both the benefits and harms of preven-
tative and therapeutic interventions. It describes
the best available evidence from systematic
L.V. Jones, R.L. Smyth
reviews and RCTs, based on thorough searches and
appraisal of the literature. ‘‘Clinical Evidence’’ is
divided into various clinical areas including one on
‘‘child health’’.
How to search
The quickest and easiest way to identify informa-
tion relating to child health (in an electronic
version of Clinical Evidence) is to scroll through
the topics currently reviewed within the child
health section. There is the facility to search, but
until the publication is much larger, it is just as
quick to scroll through the appropriate sections
under the topic of interest.
How to access
Clinical Evidence is available as hard copy, CD-ROM
as well as electronically via the Internet and is
produced by the British Medical Journal Publishing
Group. Clinical Evidence is currently freely avail-
able to NHS staff, patients and the public in
England via NeLH10. Once within NeLH, Clinical
Evidence is listed under the ‘Knowledge’ section.
This link should be taken and the option to ‘Search
Clinical Evidence’ chosen. Once logged in, the
contents listed for the current issue can be viewed.
Further details regarding Clinical Evidence can be
found on their web site.11
Turning research into practice database
(TRIP)12
What is it?
The TRIP database12 is a meta-search engine that
searches across high-quality medical information on
the Internet. (Meta-searching just means that
searches are carried out across multiple sites.)
The TRIP database provides access to the largest
collection of ‘evidence -based’ material on the
web, such as Cochrane reviews, the DARE database,
National Institute of Clinical Excellence (NICE)
guidance and articles from premier on-line journals.
How to search
The TRIP database allows quick and simple search-
ing from one search interface. Key terms, usually
no more than two, are typed into the search box.
The results of the search are displayed in sections
according to the source of information retrieved
e.g.evidence based or guidelines. The title and / or
text of any article within the database is searched.
There is also a link to the Clinical Queries section of
PubMed, which allows the search to be repeated
focusing on therapeutic, diagnostic, aetiological,
or prognostic articles. TRIPwire, a powerful search
 ARTICLE IN PRESS
How to perform a literature search
refinement tool, allows researchers to re-focus the
query if the initial search retrieves too many hits.
To search for articles of relevance to the clinical
question, using a simple two-word search formula-
tion, the following search could be used:
child AND urinary tract infection
How to access
The TRIP database12 is freely available over the
Internet or via a link from the NeLH,10 within the
section entitled ‘Editorial Resources’ under the
‘Dictionaries and Searching’ heading. Access to the
TRIPdatabase12 is by suscription, although currently
non-subscribers are able to conduct five free
searches per week.
SUMSearch13
What is it?
The SUMSearch13 service based at the University of
Texas in the United States allows a number of key
Internet databases and resources to be queried
such as PubMed, the DARE database, American
Practice Guidelines and key journals from one
search interface. It aims to select the most
appropriate source, format the search query,
modify this query if too few or too many hits are
found, and return a single document to the
clinician.
How to search
The two most important key terms from the search
strategy should be taken. SUMSearch allows the use
of controlled vocabulary (MeSHTM) by looking up
terms within the MeSH browser. It also allows the
search to focus on a particular type of research
study such as intervention, prognosis or diagnosis.
Finally, it allows the search to focus on a particular
age group.
The MeSH browser identifies ‘urinary tract infec-
tions’ as the appropriate indexing term to use. The
search can be limited to treatment studies, with
the population being child (o18 years). The
following search terms could be used:
child AND urinary tract infections
The search results are presented in a useful
hierarchy, including reviews, practice guidelines,
systematic reviews and original research.
How to access
SUMSearch is freely available over the Internet13 or
via a link from the NeLH,10 within the section
entitled ‘Editorial Resources’ under the ‘Diction-
aries and Searching’ heading.
487
Bibliographic databases
It may well be that the clinical effectiveness
resources already described are not available to
search or do not yield any material of relevance. At
this point it is worth thinking about searching other
databases of primary research such as MEDLINE,
EMBASE or CINAHL,1 or specialist databases such as
AIDSLINE, CANCERLIT or AMED.1 These databases
contain a wealth of research information, which has
not been appraised. It will be up to the individual to
obtain and appraise the full text of the records
retrieved. These databases are generally larger,
containing several million as opposed to several
thousand records. More complex searches are
usually required. Many of these databases are
available to NHS clinicians as part of the NHS Core
Content databases and can be accessed via the
NeLH10. The following section details how to search
PubMed, an Internet version of MEDLINE.
PubMed14
What is it?
PubMed14 is an Internet version of MEDLINE,
provided by the National Library of Medicine in
the United States. It provides access to over 14
million MEDLINE citations, some dating back to the
mid-1950s. PubMed includes links to full text
articles where available.
How to search
In order to search PubMed efficiently and effec-
tively, a more complex search strategy is required.
This is because the database is so vast. At this
point, it is best to refer back to the table of word
lists originally complied and to search using each
word or phrase within each component.
Within the History section of PubMed, each word
or phrase can be typed in separately and then
combined at a later stage.
An example of a full search strategy, within
PubMed would be:
#1 urinary tract infection OR UTI
# 2 child OR infant OR preschool OR adolescent
#3 #1 AND #2
#4 antibiotic
#5 long course OR standard OR short course
#6 #4 AND #5
#7 dysuria
#8 frequency
#9 fever
#10 urine culture
#11 #7 0R #8 0R #90 R#10
#12 #3 AND #6 AND #II
 ARTICLE IN PRESS
488
Within PubMed text words are automatically
mapped to the appropriate MeSHTM term.
How to access
PubMed is freely available over the Internet14 and
on the NeLH.10 The main advantage of PubMed over
commercially provided MEDLINE is that it is more
up-to-date and provides access to some full text
articles. PubMed also has a Clinical Queries
feature, which allows the search to be focused on
therapy, prognosis, diagnosis or aetiology studies by
applying built-in search filters.15 These can be used
to narrow the search down further.
References
1. Beaven O. Searching the literature. In: Craig JV, Smyth RL
(editors). The evidence based manual for nurses. London:
Harcourt Health Sciences, 2002, in press (Chapter 2).
2. Glanville J, Lefebvre C. Accessing the evidence on clinical
effectiveness. Effectiveness Matters 2001;5:Issue(1).
3. State II, Phase 3. Undertaking Systematic Reviews of
Research on Effectiveness: CRD’s Guidance for Carrying
Out or Commissioning Reviews. CRD Report 4, 2nd March
2001.
4. Clarke M, Oxman AD, editors. Locating and selecting studies.
Cochrane Reviewers Handbook 4.1.3 [updated June 2001];
Section 5. In: The Cochrane Library, Issue 3, 2001. Oxford:
Update Software. Updated quarterly.
5. Focusing clinical questions [online]. Oxford: Centre for
Evidence Based Medicine, 2000. http://cebm.jr2.ox.ac.uk/
docs/focusquest.html
6. Clarke J. Wentz Reinhard Pragmatic approach is effective in
evidence based health care. Br Med J 2000;321:566–7.
L.V. Jones, R.L. Smyth
7. The Cochrane Library [quarterly CD-Rom and database
online]. John Wiley & Sons Ltd. http://www.wileyeurope.
com/go/cochrane
8. Cochrane Collaboration. http://www.cochrane.org/index0.
htm
9. NHS Centre for Reviews and Dissemination (NHS CRD).
http://www.york.ac.uk/inst/crd.
10. National Electronic Library for Health (NeLH). http://
www.nelh.nhs.uk/
11. Clinical Evidence. BMA House, Tavistock Square, London:
BMJ Publishing, http://www.clinicalevidence.org
12. TRIP database http://www.tripdatabase.com
13. SUMSearch http://sumsearch.uthscsa.edu/
14. PubMed http://www.ncbi.nlm.nih.gov/entrez/quety.fcgi
15. Haynes RB, Wilczynski N, McKibbon KA, Walker CJ, Sinclair
JC. Developing optimal search strategies for detecting
clinically sound studies in MEDLINE. J Am Med Inform Assoc
1994;1(6):447–58.
Further reading
1. Glanville J, Lefebvre C. Accessing the evidence on clinical
effectiveness. Effectiveness Matters 2001;5(1).
2. Beaven O. Searching the literature. In: Craig JV, Smyth RL,
editors. The evidence based manual for nurses. London:
Harcourt Health Sciences, 2002, in press (Chapter 2).
3. Cochrane Library Materials: 2001; Issue 3: http://www.york.
ac.uk/inst;/crd/cochlib.htm.
4. Rosenberg WMC, Deeks J, Lusher A, Snowball R, Dooley G,
Sackett D. Improving searching skills and evidence retrieval.
J R Coll Phys London 1998;32(6):557–63.
5. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The
well-built clinical question: a key to evidence-based deci-
sions. ACP J Club 1995;123:A12–3.
6. Booth A, O’Rourke A. Searching for evidence: principles and
practice. Evidence-Based Med 1999;4(5):133–6.