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Published on: March 14, 2017
A randomized study of outpatient treatment with ceftriaxone for selected febrile children with sickle cell disease
J A Wilimas1, P M Flynn, S Harris
1Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN 38101.
Insights
Selected children with sickle cell disease and fever can be safely treated as outpatients, reducing hospitalizations and costs. This approach offers a less expensive alternative to traditional inpatient care for febrile episodes.
Area of Science:
- Pediatric Infectious Diseases
- Hematology
- Clinical Economics
Background:
- Children with sickle cell disease (SCD) are at high risk for pneumococcal sepsis.
- Fever in SCD patients typically necessitates hospitalization for prompt antibiotic therapy.
- Outpatient management presents a potentially safe and cost-effective alternative for selected pediatric SCD patients.
Purpose of the Study:
- To evaluate the safety and cost-effectiveness of outpatient antibiotic treatment for febrile episodes in children with sickle cell disease.
- To compare outcomes of outpatient versus inpatient management for fever in pediatric SCD patients.
Main Methods:
- A randomized controlled trial was conducted involving children aged 6 months to 12 years with SCD and fever (>38.5°C).
- Patients were randomized to either inpatient or outpatient treatment after initial ceftriaxone administration.
- Exclusion criteria identified higher-risk children for sepsis or SCD complications, who were managed as inpatients.
Main Results:
- No sepsis cases occurred in the randomized groups (n=86), compared to 6 in the higher-risk excluded group (n=70).
- Outpatient treatment resulted in 22% of episodes requiring subsequent hospitalization within two weeks, versus 2% for inpatients.
- Outpatient management yielded a mean cost saving of $1,195 per febrile episode and reduced hospital stay duration.
Conclusions:
- Conservative eligibility criteria allow for safe outpatient treatment of at least half of febrile episodes in children with SCD.
- Outpatient management significantly reduces healthcare costs and resource utilization for febrile SCD patients.
- This strategy supports a shift towards more cost-effective care models in pediatric hematology.
Background:
Because of their susceptibility to pneumococcal sepsis, children with sickle cell disease and fever are usually hospitalized for antibiotic therapy. Outpatient treatment may be a safe and less expensive alternative for selected patients.
Methods:
After evaluation in the emergency room, children ranging from 6 months to 12 years of age who had sickle hemoglobinopathies and temperatures exceeding 38.5 degrees C were randomly assigned to treatment as either inpatients or outpatients. We excluded from randomization children at higher risk of sepsis (as defined by specific criteria, including temperature above 40 degrees C, white-cell count below 5000 per cubic millimeter or above 30,000 per cubic millimeter, and the presence of pulmonary infiltrates) or with complications of sickle cell disease (such as a hemoglobin level below 5 g per deciliter, dehydration, or severe pain); these children were treated as inpatients. All patients received an initial intravenous dose of ceftriaxone (50 mg per kilogram of body weight). Those treated as outpatients returned 24 hours later for a second dose of ceftriaxone, whereas the in patients were treated as directed by their physicians.
Results:
None of the 86 patients (with a total of 98 febrile episodes) in the randomized groups had sepsis, as compared with 6 of the 70 patients (7 of 86 episodes) excluded because of higher risk (P = 0.004). Among the 44 children (50 episodes) assigned to outpatient treatment, there were 11 hospitalizations (22 percent of episodes) within two weeks after treatment (95 percent confidence interval, 12 to 36 percent), whereas after inpatient care only a single patient (2 percent of episodes) was rehospitalized. When the randomized groups were compared, outpatient treatment saved a mean of $1,195 per febrile episode. The median hospital stay was 3 days (range, 1 to 6) for the children randomly assigned to inpatient care and 4 days (range, 1 to 18) for the higher-risk children treated as inpatients (P < 0.001).
Conclusions:
With the use of conservative eligibility criteria, at least half the febrile episodes in children with sickle cell disease can be treated safely on an outpatient basis, with substantial reductions in cost.
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