Previous studies have indicated that febrile children with sickle cell disease (SCD) had a 3% to 5% risk of being bacteremic due to compromised immune function. The introduction of routine penicillin prophylaxis and conjugate vaccines may have lowered the risk of bacteremia. Our goals were to determine the rate of bacteremia among children with SCD per febrile episode and to estimate the safety of outpatient management among these febrile SCD patients.
This 18-year retrospective cohort study included febrile SCD patients who presented to Boston Children’s Hospital between 1993 and 2010.
A total of 1118 febrile episodes were evaluated. Nine blood specimens had growth of a pathogen in culture (0.8%; 95% confidence interval: 0.3%–1.3%). Of the 466 febrile patients initially managed as outpatients, 3 were bacteremic (0.6%). All 3 received intravenous ceftriaxone at the initial outpatient visit and returned when contacted after growth of bacteria was detected in the blood culture. Upon return to the hospital, none were “ill appearing,” required supportive care, or were admitted to an ICU.
Our rate of bacteremia among febrile children with SCD is much lower than previous estimates, and there was no associated morbidity or mortality among the patients managed as outpatients. A well-appearing febrile child with SCD may be managed as an outpatient after blood is obtained for bacterial culture and parenteral antibiotics are administered, provided there are no other reasons for admission and the patient is able to return promptly for worsening condition or for growth of a pathogen from their blood culture.
Comments
Rare but potentially fatal: ceftriaxone associated adverse drug reactions in children with sickle cell disease
We read with interest the article by Baskin et al addressing outpatient management of febrile patients with sickle cell disease. In this study, ceftriaxone was used in the majority of cases (87%) accounting for 958 administered antibiotics. The authors briefly mention that no patient had allergic reactions requiring ICU admission and there were no cases of ceftriaxone-induced hemolysis; however no further data were offered concerning unexpected adverse drug reactions (ADRs).
Practitioners should be aware though that ceftriaxone is one of the most common drugs associated with autoimmune hemolysis.1 Although rare, ADRs such as autoimmune hemolytic anemia have been associated with ceftriaxone use in those with sickle cell disease, particularly those with prior exposure.2-4 These reactions can occur rapidly and result in death. Thus obtaining a history of prior ceftriaxone exposure as well as having a discussion with the patient and family including symptomatology associated with intravascular hemolysis (i.e. pallor, jaundice and hemoglobinuria) should be a part of routine outpatient management.
Although outpatient management has obvious benefits when appropriate for the patient (i.e. convenience, cost, and appropriate usage of resources), an evident disadvantage is the inability to monitor for unpredictable adverse drug effects. Thus, education concerning these unanticipated reactions must be performed in the setting of outpatient usage, particularly when a rare and potentially catastrophic ADR has been observed in a specific population.
1. Garratty G. Immune hemolytic anemia associated with drug therapy. Blood reviews. 2010; 24(4-5):143-50 2. Bernini JC, Mustafa MM, Sutor LJ, Buchanan GR. Fatal hemolysis induced by ceftriaxone in a child with sickle cell anemia. J Pediatr. 1995; 126(5 Pt 1):813-5 3. Schuettpelz LG, Behrens D, Goldsmith MI, Druley TE. Severe ceftriaxone -induced hemolysis complicated by diffuse cerebral ischemia in a child with sickle cell disease. Journal of pediatric hematology/oncology. 2009; 31(11):870-2 4. Viner Y, Hashkes PJ, Yakubova R, Segal-Kupershmit D, Luder AS. Severe hemolysis induced by ceftriaxone in a child with sickle-cell anemia. Pediatr Infect Dis J. 2000; 19(1):83-5
Conflict of Interest:
None declared