Management of febrile children in the age of the conjugate pneumococcal vaccine: A cost-effectiveness analysis

Objectives. The optimal practice management of highly febrile 3- to 36-mont h-old children without a focal source has been controversial. The recent re lease of a conjugate pneumococcal vaccine may reduce the rate of occult bac teremia and alter the utility of empiric testing and treatment. The objecti ve of this study was to determine the cost-effectiveness of 6 different man agement strategies of febrile 3- to 36-month-old children at current and de clining rates of occult pneumococcal bacteremia. Methods. A cost-effectiveness (CE) analysis was performed to compare the st rategies of "no work-up," "clinical judgment," "blood culture," "blood cult ure + treatment," "complete blood count (CBC) + selective blood culture and treatment," and "CBC and blood culture + selective treatment." A hypotheti cal cohort of 100 000 children who were 3 to 36 months of age and had a fev er of greater than or equal to 39 degreesC and no source of infection was m odeled for each strategy. Our main outcome measures were cases of meningiti s prevented, life-years saved compared with "no work-up," total cost (1999 dollars), and incremental CE ratios. Results. When compared with "no work-up," the strategy of "CBC + selective blood culture and treatment" using a white blood cell (WBC) cutoff of 15 x 10(9)/L prevents 48 cases of meningitis, saves 86 life-years per 100 000 pa tients, and is less costly at the current rate of bacteremia (1.5%). Using the strategy of "CBC + selective blood culture and treatment" with a lower WBC cutoff of 10 x 10(9)/L costs an additional $72 300 per life-year saved. If the rate of bacteremia declines to 0.5%, then the incremental CE ratio of "clinical judgment" compared with "no work-up" is $38 000 per life-year saved; however, strategies that include empiric testing or treatment result in CE ratios greater than $300 000 per life-year saved. Conclusions. "CBC + selective blood culture and treatment" using a WBC cuto ff of 15 x 10(9)/L is cost-effective at the current rate of pneumococcal ba cteremia. If the rate of occult bacteremia falls below 0.5% with widespread use of the conjugate pneumococcal vaccine, then strategies that use empiri c testing and treatment should be eliminated.