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PEDIATRICS Vol. 108 No. 4 October 2001, pp. 835-844
Received Sep 25, 2000; accepted Feb 23, 2001.
,
From the Divisions of * Infectious Diseases, Objectives. The optimal
practice management of highly febrile 3- to 36-month-old children
without a focal source has been controversial. The recent release of a
conjugate pneumococcal vaccine may reduce the rate of occult bacteremia
and alter the utility of empiric testing and treatment. The objective
of this study was to determine the cost-effectiveness of 6 different
management strategies of febrile 3- to 36-month-old children at current
and declining rates of occult pneumococcal bacteremia.
Methods. A cost-effectiveness (CE) analysis was performed
to compare the strategies of "no work-up," "clinical judgment,"
"blood culture," "blood culture + treatment," "complete blood
count (CBC) + selective blood culture and treatment," and "CBC and
blood culture + selective treatment." A hypothetical cohort of
100 000 children who were 3 to 36 months of age and had a fever of
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 × 109/L prevents 48 cases of meningitis, saves 86 life-years per 100 000 patients, 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 × 109/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 cutoff of 15 × 109/L is
cost-effective at the current rate of pneumococcal bacteremia. If the
rate of occult bacteremia falls below 0.5% with widespread use of the
conjugate pneumococcal vaccine, then strategies that use empiric
testing and treatment should be eliminated.
General
Pediatrics, and § Emergency Medicine, Children's Hospital, Boston,
Massachusetts.
39°C and no source of infection was modeled for each strategy. Our
main outcome measures were cases of meningitis prevented, life-years
saved compared with "no work-up," total cost (1999 dollars), and
incremental CE ratios.
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