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Availability of a pneumococcal vaccine may change the way physicians manage young children who have high fevers

Doctors typically order blood tests to rule out serious bacterial infections in children 3 years of age and younger who have a high fever with no obvious source of infection (occult infection), even though most of these children have viral or minor bacterial infections and make an uneventful recovery. This is because a small proportion of children are found to harbor occult bacteremia and subsequently develop serious illnesses (e.g., meningitis) despite a benign clinical appearance when first seen in the doctor's office.

Current guidelines recommend that doctors obtain complete blood counts (CBC) and blood cultures and treat children with antibiotics if their white blood cell count (WBC) is equal to or greater than 15x109/L. This is still the most cost-effective approach, despite the recent release of a conjugate pneumococcal vaccine, according to a recent study that was supported by the Agency for Healthcare Research and Quality (National Research Service Award T32 HS00063).

However, if widespread use of the vaccine brings the current rate of occult bacterial infections from 1.5 percent to 0.5 percent, then strategies that use empiric testing and antibiotic treatment should be eliminated, conclude the researchers who are from Children's Hospital in Boston. They performed a cost-effective analysis of six different management strategies for a hypothetical group of 100,000 3- to 36-month-old children, who had a fever of 39 degrees C or higher and no obvious source of infection, at both current and declining rates of occult pneumococcal bacteremia.

They concluded that compared with no work-up, the current recommended strategy prevents 48 cases of meningitis, saves 86 life-years per 100,000 patients, and is less costly at the current rate of bacteremia. Using the strategy of CBC plus selective blood culture (done if WBC count is greater than the cutoff) and treatment with a lower WBC cutoff of 10x109/L costs an additional $72,300 per life-year saved. If the rate of bacteremia declines to 0.5 percent, then the incremental cost-effectiveness (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 are not cost effective, resulting in CE ratios greater than $300,000 per life-year saved.

For details, see "Management of febrile children in the age of conjugate pneumococcal vaccine: A cost effectiveness analysis," by Grace M. Lee, M.D., Gary R. Fleisher, M.D., and Marvin B. Harper, M.D., in the October 2001 Pediatrics 108(4), pp. 835-844.

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