VANCOUVER, B.C. – Immunosuppressed children with fever who are otherwise well can be managed as outpatients pending culture results, and don’t need to be routinely admitted to the hospital, according to a retrospective review from the Children’s Hospital of Michigan, Detroit.
Among 103 admissions involving 60 immunosuppressed children with fever above 38.3º C, 79 (76.6%) admissions were of children who were okay outside of the fever, and 24 (23.4%) were of children who presented with low blood pressure, tachycardia, abnormal cardiac/chest auscultation, abdominal tenderness, or abnormal lab results.
Dr. Tej Mattoo
The children who were doing well didn’t really need to go into the hospital, according to Dr. Tej K. Mattoo, the study’s senior investigator. Five admissions were of children ultimately diagnosed with strep pharyngitis, two with otitis media, and two with urinary tract infections. There were just two positive cultures in the group, both urine, and no positive chest x-rays. Outpatient management would have been fine, Dr. Mattoo said at the annual meeting of the Pediatric Academic Societies.
Admission turned out to be the wise choice, however, in 20 of 24 (83.3%) cases with significant presentations. Among them were eight cases of pneumonia, five abscesses, and one case each of peritonitis, sepsis, and acute gastritis. There were two positive blood cultures, four positive urine cultures, three positive wound cultures, one positive peritoneal culture, and a positive Clostridium difficile test.
The research team concluded that "immunosuppressed renal patients with high fever and insignificant clinical findings do not need routine hospitalization; they could be sent home with appropriate counseling/follow-up after culture specimens are collected."
The findings help define who can be safely sent home, and who needs to go upstairs, said Dr. Mattoo, chief of pediatric nephrology and hypertension at Children’s.
"The way it works now is that we routinely admit children on immunosuppression who have high fever. Once they are in, they stay in hospital at least for 3 days as you wait for the culture results. It turns out that about 75% of the patients in our study could have been managed as outpatients. A lot of it depends on a good history and physical. When things other than the fever are normal, that gives you a high comfort level to tell parents ‘I can send your child home’ " with appropriate outpatient care and pledges to bring the child back if things get worse and to check up on culture results in a few days, he said.
The average age at admission was 9 years, and about 60% of the admissions were boys. The children had nephrotic syndrome, systemic lupus erythematosus, or kidney transplants. Most were on two or three immunosuppressives, generally some combination of prednisone, mycophenolate mofetil, and tacrolimus/sirolimus. Patients with diabetes, cardiorespiratory disease, or lupus flares were excluded from the investigation.
Dr. Mattoo has no disclosures relevant to the study, and the work had no outside funding.