Wilimas J A, Flynn P M, Harris S, Day S W, Smith R, Chesney P J, Rodman J H, Eguiguren J M, Fairclough D L, Wang W C
Department of Hematology-Oncology, St. Jude Children's Research Hospital, Memphis, TN 38101.
N Engl J Med. 1993 Aug 12;329(7):472-6. doi: 10.1056/NEJM199308123290705.
Because of their susceptibility to pneumococcal sepsis, children with sickle cell disease and fever are usually hospitalized for antibiotic therapy. Outpatient treatment may be a safe and less expensive alternative for selected patients.
After evaluation in the emergency room, children ranging from 6 months to 12 years of age who had sickle hemoglobinopathies and temperatures exceeding 38.5 degrees C were randomly assigned to treatment as either inpatients or outpatients. We excluded from randomization children at higher risk of sepsis (as defined by specific criteria, including temperature above 40 degrees C, white-cell count below 5000 per cubic millimeter or above 30,000 per cubic millimeter, and the presence of pulmonary infiltrates) or with complications of sickle cell disease (such as a hemoglobin level below 5 g per deciliter, dehydration, or severe pain); these children were treated as inpatients. All patients received an initial intravenous dose of ceftriaxone (50 mg per kilogram of body weight). Those treated as outpatients returned 24 hours later for a second dose of ceftriaxone, whereas the in patients were treated as directed by their physicians.
None of the 86 patients (with a total of 98 febrile episodes) in the randomized groups had sepsis, as compared with 6 of the 70 patients (7 of 86 episodes) excluded because of higher risk (P = 0.004). Among the 44 children (50 episodes) assigned to outpatient treatment, there were 11 hospitalizations (22 percent of episodes) within two weeks after treatment (95 percent confidence interval, 12 to 36 percent), whereas after inpatient care only a single patient (2 percent of episodes) was rehospitalized. When the randomized groups were compared, 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 the higher-risk children treated as inpatients (P < 0.001).
With the use of conservative eligibility criteria, at least half the febrile episodes in children with sickle cell disease can be treated safely on an outpatient basis, with substantial reductions in cost.
由于镰状细胞病患儿易患肺炎球菌败血症，患有镰状细胞病且发热的儿童通常需住院接受抗生素治疗。对于部分选定的患者，门诊治疗可能是一种安全且成本较低的替代方案。
在急诊室进行评估后，将年龄在6个月至12岁之间、患有镰状血红蛋白病且体温超过38.5摄氏度的儿童随机分为住院治疗组或门诊治疗组。我们将败血症风险较高的儿童（根据特定标准定义，包括体温高于40摄氏度、白细胞计数低于每立方毫米5000或高于每立方毫米30000，以及存在肺部浸润）或患有镰状细胞病并发症（如血红蛋白水平低于每分升5克、脱水或严重疼痛）的儿童排除在随机分组之外；这些儿童接受住院治疗。所有患者均接受初始静脉注射头孢曲松（每公斤体重50毫克）。门诊治疗的患者在24小时后返回接受第二剂头孢曲松，而住院患者则按照医生的指示进行治疗。
随机分组的86例患者（共98次发热发作）均未发生败血症，而因风险较高被排除的70例患者中有6例（86次发作中的7次）发生败血症（P = 0.004）。在分配至门诊治疗的44例儿童（50次发作）中，治疗后两周内有11例住院（占发作次数的22%，95%置信区间为12%至36%），而住院治疗后只有1例患者（占发作次数的2%）再次住院。比较随机分组时，门诊治疗每次发热发作平均节省1195美元。随机分配至住院治疗的儿童中位住院时间为3天（范围为1至6天），而作为住院患者治疗的高风险儿童中位住院时间为4天（范围为1至18天）（P < 0.001）。
采用保守的入选标准，至少一半的镰状细胞病患儿发热发作可在门诊安全治疗，且成本大幅降低。
