P0292 - Management and outcome of the sickle cell patients with febrile illness: Adherence to the evidence-based guidelines.

Background:
Children with sickle cell disease are at increased risk of serious bacterial infection from loss of splenic function, genetic polymorphism, leukocyte adhesion, microvascular occlusion and leaky gut (1, 2) During the last 20 years, the use of penicillin prophylaxis and pneumococcal vaccination has decreased invasive pneumococcal disease. Many citations in the literature show a low incidence of bacteremia ranging from 1.3-16%. (2, 3, 4, 5, 6, 7) There seems to be a variation between clinicians with the NHLBI recommendation. (8,9,10) Recently there is an emphasis on the healthy microbiome and adverse effects of antibiotics on the micro biome. (11,12). The link between use of antibiotics and asthma, a comorbid condition in SCD is noted. (14, 15)

Methods:
A single center retrospective electronic chart review of febrile patients with SCD seen in the Pediatric emergency room from May 2010 to May 2019.

Objective:
To look into rate of adherence to the guidelines by ED physicians and its impact. To find the rate of serious bacterial infections among febrile sickle cell patients, the differences among the patients with and without bacteremia, hospitalized vs discharged patients and the effect of initial management on the patient 72-hour returns.

Results:
Between May 2010 and May 2019, we reviewed 229 visits of which 222 (96%) had blood cultures, 49 (21.4%) had urine cultures with four (1.8%) bacteremia (3 female, one male) and nine (22.5%) UTI (all female), 23 (10%) were required hospitalizations, of which twelve (52.1%) had respiratory symptoms. Prophylactic antibiotics were received by 210 (95%). Children with bacteremia were younger (median age 1.21 y), lower median temperature, and higher median heart (163) and respiratory rates (33) when compared to patients without bacteremia. However, patients without bacteremia had increased rates of respiratory symptoms like cough and congestion (34.4%), admitted more often for the respiratory symptoms (9.47%), had more returns (24-48 hour) to the emergency department, likely had a documented viral infection. None of the bacteremia patients were returned 24-48 hours after being treated and released from the emergency department. One patient was called back to the clinic and was admitted to the inpatient unit had both bacteremia and UTI. Hospitalized patients were older with median age of 7 years, more likely have respiratory symptoms with median length of stay of two days and had increased 24-48-hour returns.

Conclusion:
Our rate of adherence to the guidelines of obtaining blood cultures and the use of empiric antibiotics was 95%, rate of bacteremia at 1.8%. Empiric treatment for UTI should be instituted early and all are female. Multicenter studies are needed to gather large data set to decrease the use of prophylactic antibiotic for every febrile illness for children with SCD with such a low incidence of bacteremia.