Correspondence

Outpatient Treatment of Febrile Children with Sickle Cell Disease

N Engl J Med 1994; 330:219-220January 20, 1994

Article

To the Editor:

The study by Wilimas et al. (Aug. 12 issue)1 was well designed and addressed an important clinical problem. I cannot, however, agree with the authors' conclusion that intravenous ceftriaxone has been proved to be an appropriate treatment for selected febrile children with sickle cell disease. Since none of the randomized patients had sepsis, the investigators proved that outpatient ceftriaxone is an effective treatment for children without sepsis. In view of the apparent ability of the selection criteria to distinguish children with sepsis from other patients, it may be concluded that the optimal outpatient treatment for children at low risk of bacterial infection should not include antibiotics.

Simon P. Ros, M.D.
Loyola University Medical Center, Maywood, IL 60153

1 References

1. 1

   Wilimas JA, Flynn PM, Harris S, et al. A randomized study of outpatient treatment with ceftriaxone for selected febrile children with sickle cell disease. N Engl J Med 1993;329:472-476
   Full Text | Web of Science | Medline

To the Editor:

Wilimas et al. performed their study with care. It is certainly encouraging for clinicians to be able to consider a safe alternative to hospitalization for a carefully screened febrile child.

Of the 197 patients evaluated for the study, 117 were eligible for randomization (70 high-risk patients and 10 pilot-study patients were excluded). Of the 117 eligible children, 31 did not participate, resulting in a rather high attrition rate (26 percent). The authors do not mention how many of these children were not included because they were unable to return for the important visit the next day. In our experience, the lack of a household telephone and the lack of reliable transportation are major impediments in making this protocol safe. The clinician must establish with certainty the ability of the caretaker to assume the responsibility for taking care of a febrile child with sickle cell disease at home.

Sharada A. Sarnaik, M.D.
Wayne State University School of Medicine, Detroit, MI 48201

Author/Editor Response

The authors reply:

To the Editor: We certainly agree with Dr. Sarnaik's observations regarding the importance of a reliable caretaker with available transportation, and we stressed this point in explaining the study to the parents. Exclusion of the 31 otherwise eligible patients (39 febrile episodes) was due to transportation problems in 6 instances, refusal to participate in 12, and a history of parental noncompliance in 2. Nineteen episodes were not identified at the time of the visit to the emergency room. Of the 44 outpatients who underwent randomization (50 episodes), only 2 did not return for the second visit. We are currently assessing the feasibility of omitting the second hospital visit, although the ability to return to the hospital in an emergency remains critical.

We strongly disagree with Dr. Ros's interpretation of our findings. We were pleased that none of the patients who met our selection criteria had sepsis. However, no criteria are universally effective. In a nonrandomized study of outpatient ceftriaxone therapy, pneumococcal bacteremia was subsequently detected in two patients who met selection criteria similar to ours.1 Both these children did well, whereas sepsis is almost always fatal in the absence of antibiotic treatment. Given the risks associated with unrecognized and untreated sepsis in febrile patients with sickle cell disease, antibiotic therapy is essential.

Judith Wilimas, M.D.
Winfred Wang, M.D.
St. Jude Children's Research Hospital, Memphis, TN 38101

1 References

1. 1

   Rogers ZR, Morrison RA, Vedro DA, Buchanan GR. Outpatient management of febrile illness in infants and young children with sickle cell anemia. J Pediatr 1990;117:736-739
   CrossRef | Web of Science | Medline