A cost-effectiveness analysis of bacterial endocarditis prophylaxis for febrile children who have cardiac lesions and undergo urinary catheterization in the emergency department.
OBJECTIVE
To prevent bacterial endocarditis (BE) in those at risk, the American Heart Association recommends antibiotics for patients who have a known urinary tract infection and are about to undergo urinary catheterization (UC). In young children who have cardiac lesions and undergo UC for fever without a source, the problem with prophylaxis only in the presence of infected urine is that the presence of urinary tract infection is unknown before testing. This study was conducted to determine the cost-effectiveness of BE prophylaxis before UC in febrile children aged 0-24 months with moderate-risk cardiac lesions.


METHODS
We evaluated the cost-effectiveness of BE prophylaxis compared with no prophylaxis from the societal perspective. Clinical outcomes were based on BE incidence and quality-adjusted life years (QALYs). Probabilities were derived from the medical literature. Costs were derived from national and local sources in US dollars for the reference year 2000, using a discount rate of 3%.


RESULTS
On the basis of the analysis, prophylaxis prevents 7 BE cases per 1 million children treated. When antibiotic-associated deaths were included, the no-prophylaxis strategy was more effective and less costly than the prophylaxis strategy. When antibiotic-associated deaths were excluded, amoxicillin cost 10 million dollars per QALY gained and 70 million dollars per case prevented. For vancomycin, it was 13 million dollars per QALY gained and 95 million dollars per case prevented. The results were robust to variations in the prophylactic efficacy of antibiotics, incidence of bacteremia after UC, incidence of BE after bacteremia, and costs associated with BE prophylaxis and treatment.


CONCLUSIONS
In the emergency department, BE prophylaxis before UC in febrile children who are aged 0 to 24 months and have moderate-risk cardiac lesions is not a cost-effective use of health care resources.
Caviness
A Chantal
AC
Section of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA. accavine@texaschildrenshospital.org
Cantor
Scott B
SB
Allen
Coburn H
CH
Ward
Mark A
MA
D019072:Antibiotic Prophylaxis / Q000191:economics*; D016470:Bacteremia / Q000209:etiology / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004632:Emergency Medical Services / Q000191:economics; D004697:Endocarditis, Bacterial / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D005334:Fever / Q000150:complications*; D006331:Heart Diseases / Q000150:complications*; D006801:Humans; D007223:Infant; D011336:Probability; D019057:Quality-Adjusted Life Years; D012306:Risk; D014546:Urinary Catheterization / Q000009:adverse effects; D014552:Urinary Tract Infections / Q000150:complications / Q000175:diagnosis