TOPLINE:
A risk stratification approach based on factors such as a history of central line placement or previous bacteremia infection could help identify the right children with sickle cell disease (SCD) for bacteremia treatment and help avoid excessive use of emergency department (ED) resources.
METHODOLOGY:
- Despite a decrease in incidences of bacteremia owing to advanced vaccines and penicillin prophylaxis, bacteremia and invasive infections cause mortality in children and young adults with SCD.
- The US guidelines recommend prompt ED evaluation for fever >38.5 °C and standardized care, such as collecting laboratory studies, performing blood cultures, and administrating antibiotics, for this high-risk population.
- This retrospective study identified 35,548 ED encounters among 11,181 children and adults aged <22 years with SCD presenting with fever or undergoing diagnostic testing and treatment for fever.
- Primary outcome was diagnosis of bacteremia from presentation to 3 days after an ED discharge, and secondary outcome was using ED resource at the index visit and clinical outcomes.
- Bacteremia within 3 days of index visit was diagnosed in 1.1% of encounters, representing 371 unique children and young adults.
- History of bacteremia (odds ratio [OR], 1.36; 95% CI, 1.01-1.83), central line–associated bloodstream infection (OR, 6.39; 3.02-13.52), and apheresis (OR, 1.77; 1.22-2.55) were significantly associated with the diagnosis of bacteremia.
- Individuals with bacteremia were more likely to be admitted (P <.001) and be admitted to the intensive care unit (P =. 01) than those without.
- Complete blood cell and reticulocyte counts were performed in ˃ 95% of the encounters and chest roentgenography, blood cultures, and urine studies in 68.5%, 87.6%, and 29.1% of encounters, respectively.
The authors write, “The last major shift in care for febrile children with SCD occurred more than 30 years ago with the introduction of outpatient management if children were deemed low risk.” They further add, “Risk stratification may be possible and even a larger proportion of children with SCD and fever could have their care managed as outpatients after clinical and laboratory assessment in the ED.”
In an invited commentary, John J. Strouse, MD, PhD, Division of Hematology, Department of Medicine, Duke University, Durham, and colleagues say, “Perhaps, it is time to critically reexamine our approach to fever in children with SCD with a more comprehensive analysis of contemporary risks and benefits.”
SOURCE:
This study was led by Stephen Rinner and published online June 20, 2023, in the JAMA Network Open, with an accompanying invited commentary.
LIMITATIONS:
This study procured data from an administrative database and may have misclassification bias for disease code. Moreover, blood culture was not obtained in 0.8% of children and young adults diagnosed with bacteremia within first 48 hours.
DISCLOSURES:
- This study did not report any funding source.
- The study authors declared no conflict of interest.
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