Lieu T A, Baskin M N, Schwartz J S, Fleisher G R
Robert Wood Johnson Clinical Scholars Program, University of California, San Francisco.
Pediatrics. 1992 Jun;89(6 Pt 2):1135-44.
Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory criteria received antibiotic treatment were less effective but incurred lower rates of antibiotic complications. Clinical judgment alone was the least clinically effective and the second least cost-effective strategy.(ABSTRACT TRUNCATED AT 400 WORDS)
发热的小婴儿有发生严重细菌感染的风险，但在诊断和治疗的最佳方法上尚未达成共识。尽管传统建议总是进行所有败血症检查，包括腰椎穿刺，并给予静脉注射（IV）抗生素，直到培养结果为阴性，但最近的研究表明，可给予肌肉注射（IM）头孢曲松并进行门诊随访，或使用实验室和临床数据将低风险患者排除在住院、进一步检查和抗生素治疗之外。使用决策分析模型来评估六种针对体温大于或等于38.0摄氏度的28至90天龄婴儿的诊断和治疗策略。来自文献的数据、1991年对503名发热婴儿的研究数据以及费城儿童医院的直接短期成本被用作模型输入。该模型针对100,000名不需要因局灶性感染或其他明确需要住院的原因而住院的发热婴儿的假设队列运行。该模型包括六种策略：（1）不干预；（2）所有败血症检查（腰椎穿刺、血培养、尿培养、白细胞计数和尿液分析），然后所有婴儿住院并接受静脉抗生素治疗；（3）所有败血症检查，然后对大多数婴儿给予肌肉注射头孢曲松并进行门诊管理；（4）进行血培养和尿培养以及白细胞计数和尿液分析，然后对高风险婴儿进行腰椎穿刺和静脉抗生素治疗，或对低风险婴儿进行无抗生素的门诊管理；（5）进行白细胞计数和尿液分析，然后对高风险婴儿进行腰椎穿刺、血培养和尿培养以及静脉抗生素治疗，或对低风险婴儿进行无抗生素的门诊管理；（6）临床判断，然后对高风险婴儿进行所有败血症检查和静脉抗生素治疗，或对低风险婴儿进行无抗生素的门诊管理。两种“所有败血症检查”策略预防的死亡或神经功能损害病例最多，占所有潜在病例的78%（使用静脉抗生素时）和76%（使用肌肉注射头孢曲松时）。最具成本效益的策略是对所有无脑膜炎的患者进行所有败血症检查，然后给予肌肉注射头孢曲松，相对于不干预，每预防一例后遗症的增量成本仅为3900美元。仅根据实验室标准被选为高风险的患者接受抗生素治疗的策略效果较差，但抗生素并发症发生率较低。仅靠临床判断是临床效果最差且成本效益第二低的策略。
