Management of Febrile Children in the Age of the Conjugate Pneumococcal Vaccine: A Cost-Effectiveness Analysis

OBJECTIVES: 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.