Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis.
OBJECTIVE
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 >/=39 degrees 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.


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 x 10(9)/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 x 10(9)/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 x 10(9)/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.
Lee
G M
GM
Division of Infectious Diseases, Children's Hospital, Boston, Massachusetts, 02115, USA. grace.lee@tch.harvard.edu
Fleisher
G R
GR
Harper
M B
MB
D016470:Bacteremia / Q000175:diagnosis / Q000191:economics / Q000517:prevention & control; D001769:Blood / Q000382:microbiology; D001772:Blood Cell Count / Q000191:economics; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005334:Fever / Q000175:diagnosis* / Q000191:economics / Q000628:therapy*; D006801:Humans; D007223:Infant; D010372:Pediatrics / Q000191:economics / Q000379:methods; D022242:Pneumococcal Vaccines / Q000191:economics / Q000627:therapeutic use*; D010818:Practice Patterns, Physicians' / Q000191:economics
D022242:Pneumococcal Vaccines