A RANDOMIZED STUDY OF OUTPATIENT TREATMENT WITH CEFTRIAXONE FOR SELECTED FEBRILE CHILDREN WITH SICKLE-CELL DISEASE

Background. Because of their susceptibility to pneumococcal sepsis, ch ildren with sickle cell disease and fever are usually hospitalized for antibiotic therapy. Outpatient treatment may be a safe and less expen sive alternative for selected patients. Methods. After evaluation in t he emergency room, children ranging from 6 months to 12 years of age w ho had sickle hemoglobinopathies and temperatures exceeding 38.5-degre es-C were randomly assigned to treatment as either inpatients or outpa tients. We excluded from randomization children at higher risk of seps is (as defined by specific criteria, including temperature above 40-de grees-C, white-cell count below 5000 per cubic millimeter or above 30, 000 per cubic millimeter, and the presence of pulmonary infiltrates) o r with complications of sickle cell disease (such as a hemoglobin leve l below 5 g per deciliter, dehydration, or severe pain); these childre n were treated as inpatients. All patients received an initial intrave nous dose of ceftriaxone (50 mg per kilogram of body weight). Those tr eated as outpatients returned 24 hours later for a second dose of ceft riaxone, whereas the inpatients were treated as directed by their phys icians. Results. None of the 86 patients (with a total of 98 febrile e pisodes) in the randomized groups had sepsis, as compared with 6 of th e 70 patients (7 of 86 episodes) excluded because of higher risk (P = 0.004). Among the 44 children (50 episodes) assigned to outpatient tre atment, there were 11 hospitalizations (22 percent of episodes) within two weeks after treatment (95 percent confidence interval, 12 to 36 p ercent), whereas after inpatient care only a single patient (2 percent of episodes) was rehospitalized. When the randomized groups were comp ared, 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 th e higher-risk children treated as inpatients (P<0.001). Conclusions. W ith the use of conservative eligibility criteria, at least half the fe brile episodes in children with sickle cell disease can be treated saf ely on an outpatient basis, with substantial reductions in cost.