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Thank you to the handful of people who have personally e-mailed me with
their opinions on this case. To answer Dr. Catibog- I didn't have a
manual diff but the computer diff was 80% polys. There is a pertinent
literature addressing the issues of  'occult bacteremia' in children
with sickle cell which nicely delineates which patients can probably be
managed as outpatients. Interestingly, one of the larger studies
eliminated patients with total WBCs greater than 30K from the study.
There has not been a documented case of deterioration in a vaccinated,
febrile  well-appearing sickler treated with ceftriaxone as an
outpatient- to my knowledge. I elected to admit this patient, but was
hassled by the hematologist and admitting pediatrician. She did well.
 
Williams J et al. A randomized study of outpatient treatment with
ceftriaxone for selected febrile children with sickle cell disease. NEJM
1993;329:472-6. ( 0/86 'low risk pts developed sepsis)
 
Rogers ZR et al. Outpatient management of febrile illness in infants and
young children sickle cell anemia. J Ped 1990;117:736-9. (Retrospective
study including 135 febrile sicklers treated as outpatients, none of
which had bacteremia and all of which did well. Also separately report
two febrile sicklers with 'occult' pneumococcal bacteremia who were
treated with ceftriaxone and were well at f/u a day later)
 
West TB et al. The presentation, frequency and outcome of bacteremia
among children with sickle cell disease and fever. Ped Emerg Care
1994;10:141-3. (Describe 517 admitted, febrile sicklers, 10 of which
were found to have positive cultures, only one of which was not less
than age 2 or had an indwelling catheter.)
 
Jay Fisher MD
Pediatric Emergency Services
UMC
Las Vegas NV
 
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