Outpatient therapy with ceftriaxone and oral cefixime for selected febrile children with sickle cell disease

Causes and Recommendations for Fever in Sickle Cell Pediatric Patients in the Emergency Department: A Single-Center Study

Background Children with sickle cell disease (SCD) are prone to bacterial infections, culminating in life-threatening incidences. Early evaluation of children with SCD helps in effective management and support. Methodology A retrospective study was conducted using medical records for febrile episodes in SCD children ≤14 years of age who presented to the Emergency Department of King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia from 2015 to 2018. A total of 304 episodes were encountered in the Emergency Department during this period. Results The clinical diagnosis included confirmed bacterial infection (4.5%), presumed bacterial infection (24.6%), and those without bacterial infection (57.5%). The incidence of bacteremia was found in 3.0% of the episodes and urinary tract infection in 1.5%. The most common isolates were Staphylococcus aureus, Streptococcus viridians, Salmonella species, and Escherichia coli. Overall, 52% of the febrile episodes resulted in hospitalization, of which 74% had at least one prior hospitalization. The hospitalization probability across the two sexes was statistically insignificant (p = 0.029). The likelihood of admission increased with age (p < 0.001) and temperature (p < 0.001). The study included 140 children with SCD who had at least one abdominal sonogram performed at our hospital between 2015 and 2018. There were changes in the radiographic appearance of the spleen in patients with SCD who were expected to undergo autosplenectomy between the ages of five and 17 years. Conclusions The study envisages the risk associated with febrile episodes and the prompt recovery of such patients through clinical confirmations. Parents should be aware and observant of the complications of infectious illnesses for speedy medical assistance.

Early oral switch to combined cefixime therapy for management of osteoarticular infections in pediatric sickle cell disease patients: A descriptive analysis

BACKGROUND

The treatment of osteoarticular infections in pediatric patients with sickle cell disease (SCD) is a challenging task for the practitioner. The aim of this study is to evaluate cefixime for the treatment of osteoarticular infections in pediatric SCD patients by retrospective design.

METHODS

This study was done in the pediatric hospital of King Saud Medical City, Riyadh, Saudi Arabia. The data was obtained from medical records of patients aged 1-16 years admitted between January 2019 to December 2020, diagnosed with SCD and received cefixime for the treatment of OI. A descriptive study for pediatric patients admitted between January 2019 to December 2020 diagnosed with sickle cell disease and diagnosed with osteoarticular infection. All patients were treated with cefixime. Medians and interquartile ranges (IQRs) were used for the descriptive analysis.

RESULTS

A total of 260 patients were screened, and 51 cases [osteomyelitis (OM), n = 43, and septic arthritis (SA), n = 8] met the inclusion criteria. The median age of OM patients was 7 years, with males making up 67.4% of the cohort. The median length of IV antibiotics and hospital stays were 10 days and 11 days, respectively. The median total duration of antibiotic use was 37 and 25 days for OM and SA, respectively. The treatment success rate was 88% in OM cases and 100% in SA patients. Readmission was noted in 39.5% of the OM patients, while only 25% of the SA patients were recorded for reinfection.

CONCLUSION

The study's findings revealed that Cefixime is a viable oral alternative for treating osteoarticular infection in pediatric SCD patients. Nonetheless, a prospective investigation is required to corroborate the findings of this study.

Prevalence of Serious Bacterial Infections in Children with Sickle Cell Disease at King Abdulaziz Hospital, Al Ahsa

Objective

The main aim was to report the prevalence and severity of serious bacterial infections (SBI) in children with sickle cell disease at King Abdulaziz Hospital (KAH), Al Ahsa, Saudi Arabia, to aid in determining whether outpatient management of such cases is appropriate.

Methods

We conducted a retrospective chart review of febrile children less than 14 years of age admitted with sickle cell disease 2005 through 2015.

Results

During 320 admissions, 25 children had SBIs (8%) including pneumonia (n=11), osteomyelitis (n=8), bacteremia (n=3, all with Salmonella species) and UTI (n=3). All recovered uneventfully.

Conclusion

It appears that in the current era, less than 10% of febrile children with sickle cell disease in our center are diagnosed with an SBI. Over 11 years, there were no sequelae or deaths from SBI. Given these excellent outcomes, outpatient ceftriaxone should be considered for febrile well-appearing children with sickle cell disease if they have no apparent source and parents are judged to be reliable.

Outcomes of febrile events in pediatric patients with sickle cell anemia

BACKGROUND

Limited evidence exists to create institutional admission criteria guidelines for febrile sickle cell patients. In addition, evidence is lacking to understand readmission rates for febrile sickle cell patients discharged from the emergency department (ED) or hospital.

PROCEDURES

We conducted a 16-year retrospective study of bacteremia outcomes for febrile sickle cell patients. Risk variables analyzed included fever (either ≥ 39.5°C or ≥40°C), abnormal white blood cell (WBC) (>30,000 or <5,000/mcL), tachycardia and hypotension, or "ill appearing." Fourteen-day readmission rates were analyzed to determine outcomes for febrile sickle cell patients discharged from the ED or discharged within 72 h.

RESULTS

Bacteremia was identified in 17 (2.6%) of 653 febrile events that are presented to the ED. "Ill-appearing" patients had an 8.5-fold increased odds of being diagnosed with bacteremia. Models using WBC count, "ill appearing," and hypotension have the highest sensitivity and specificity (AUC > 0.75). Among 427 patients discharged from the ED or within 72 h of hospitalization, only 10 (2.3%) were readmitted for a new sickle cell complication.

CONCLUSIONS

Institutions can develop admission criteria based on WBC count, hypotension, and "ill appearance." Persistently febrile, well-appearing patient can be discharged at 48 h with minimal risk for new complications.

Systematic and Meta-Analytic Review: Medication Adherence Among Pediatric Patients With Sickle Cell Disease

OBJECTIVE

To provide a comprehensive summary (systematic review) of medication adherence rates by assessment method and medication type for pediatric patients with sickle cell disease (SCD), as well as identify important correlates for future research.

METHODS

Articles assessing medication adherence and published between 1982 and February 2015 (n = 49) were identified using electronic databases. A meta-analysis of 14 studies examining demographic, medical, and psychosocial factors and medication adherence was conducted.

RESULTS

Adherence rates ranged from 12% to 100% across all medications. Approximately 30% of studies reported associations between adherence and key demographic, medical, and psychosocial correlates. Mean effect sizes were small to moderate (r = .02-.53).

CONCLUSIONS

The wide range of adherence rates reported in the literature may be because of, in part, the use of variable assessment strategies. Future studies examining pediatric SCD adherence should incorporate key correlates with the goal of replication.

Prevalence of pneumococcal bacteremia in children with sickle cell disease

We performed a retrospective chart review of children with sickle cell disease hospitalized for fever at our local institution. We reviewed 456 hospitalizations in 133 patients between January 2006 and June 2012. The prevalence of true bacteremia was 4%. The mean C-reactive protein values and temperatures were nonsignificantly higher in patients with positive blood cultures. The mean time to detection was 22.5 hours in bacteremia compared to 32.6 hours in blood cultures that grew contaminants (p = .034). Only two (0.4%) cases of pneumococcal bacteremia were reported and both occurred before May 2010, which marks the introduction of 13-valent pneumococcal vaccine (PCV13). Both patients with pneumococcal bacteremia had discontinued penicillin prophylaxis after the age of 5 years. The first patient was immunized but contracted a nonvaccine serotype (23B). The second patient was partially vaccinated and acquired a vaccine-preventable serotype (23F). Both serotypes were sensitive to ceftriaxone and vancomycin; one was resistant to penicillin. This is the first study reporting the prevalence of pneumococcal bacteremia since the introduction of PCV13.

Bacteremia in children with sickle hemoglobinopathies

BACKGROUND

Bacteremia is one of the most feared infectious complications of sickle cell disease, and it is associated with a high mortality rate in children. The objective of our study was to investigate the proportion of bacteremia among febrile children with sickle hemoglobinopathies and the clinical factors associated with bacteremia.

METHODS

Clinical and microbiological data from children with sickle hemoglobinopathies being followed up at the Pediatric Hematology Clinic at the University of Rochester Medical Center in Rochester, New York, were retrospectively analyzed. The data were collected from medical records covering the time period of June 1997 to December 2006, which included the periods before and after the introduction of routine heptavalent pneumococcal conjugate vaccine usage. Proportions of positive blood cultures among febrile children, the types of organisms causing bacteremia, and clinical and sociodemographic factors were analyzed by χ and t tests as appropriate.

RESULTS

The overall proportion of positive blood cultures was 3.8%; 1% was considered to yield true pathogens. Pneumococcal bacteremia decreased from 0.7% in the pre-pneumococcal conjugate vaccine-7 era to 0.2% in the post-pneumococcal conjugate vaccine-7 era; however, the difference was not statistically significant. Pathogens other than pneumococcus were responsible for most bacteremic episodes. No clinical or social factors were found to have statistically significant associations with positive blood cultures.

CONCLUSIONS

Approximately 1% of children with sickle hemoglobinopathies with fever have bacteremia despite current penicillin prophylaxis and pneumococcal immunization, although most episodes are due to nonpneumococcal pathogens. Prompt evaluation of such febrile children with sickle hemoglobinopathies remains warranted.

Sickle cell disease

Sickle cell disease is a serious and life threatening disease that affects approximately 1 in 600 African-Americans. Since its first description in 1910 by Herrick, our understanding and treatment of this disease has grown tremendously. Most pediatricians will encounter one or more children with sickle cell disease and should have a thorough understanding of the disease, its complications, and treatment. This article summarizes present day knowledge about the complications and potential treatments for patients with sickle cell disease.

Ceftriaxone: an update of its use in the management of community-acquired and nosocomial infections

Ceftriaxone is a parenteral third-generation cephalosporin with a long elimination half-life which permits once-daily administration. It has good activity against Streptococcus pneumoniae, methicillin-susceptible staphylococci, Haemophilus influenzae, Moraxella catarrhalis and Neisseria spp. Although active against Enterobacteriaceae, the recent spread of derepressed mutants which hyperproduce chromosomal beta-lactamases and extended-spectrum beta-lactamases has diminished the activity of all third-generation cephalosporins against these pathogens necessitating careful attention to sensitivity studies. Extensive data from randomised clinical trials confirm the efficacy of ceftriaxone in serious and difficult-to-treat community-acquired infections including meningitis, pneumonia and nonresponsive acute otitis media. Ceftriaxone also has efficacy in other community-acquired infections including uncomplicated gonorrhoea, acute pyelonephritis and various infections in children. In the nosocomial setting, extensive data also confirm the efficacy of ceftriaxone with or without an aminoglycoside in serious Gram-negative infections, pneumonia, spontaneous bacterial peritonitis and as surgical prophylaxis. Outpatient use of ceftriaxone, either as part of a step-down regimen or parenterally, is a distinguishing feature of the data gathered on the agent over the last decade. The review focuses on new applications of the drug and its use in infections in which the causative pathogens or their resistance patterns have changed over the past decade. Ceftriaxone has a good tolerability profile, the most common events being diarrhoea, nausea, vomiting, candidiasis and rash. Ceftriaxone may cause reversible biliary pseudolithiasis, notably at higher dosages of the drug (>/=2 g/day); however, the incidence of true lithiasis is <0.1%. Injection site discomfort or phlebitis can occur after intramuscular or intravenous administration.

CONCLUSIONS

As a result of its strong activity against S. pneumoniae, ceftriaxone holds an important place, either alone or as part of a combination regimen, in the treatment of invasive pneumococcal infections, including those with reduced beta-lactam susceptibility. Its once-daily administration schedule allows simplification of otherwise complex regimens in a hospital setting and has also contributed to its popularity as a parenteral agent in an ambulatory setting. These properties, together with a well characterised tolerability profile, mean that ceftriaxone is likely to retain its place as an important third-generation cephalosporin in the treatment of serious community-acquired and nosocomial infections.