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Three Part Question

In [a patient with sickle cell disease presenting with an increased temperature]does [giving empirical antibiotics compared to waiting for the blood cultures] decrease [the length of stay in hospital]?

Clinical Scenario

A 30 year old man with sickle cell disease presents with a 3 day history of pain in his arms and legs. His pain is consistent with his usual painful crisis. He is febrile but has normal vital signs and no acute findings on physical examination. You promptly treat his pain. As you order blood cultures and other tests to find if there is any cause for infection you wonder would starting empirical antibiotics be of any benefit to the patient.

Search Strategy

MEDLINE (1966 to present)
EMBASE (1988 to present)
OVID: [sickl$.mp.] AND [exp Anemia/ or anaemia$.mp] OR [exp Anemia, Sickle Cell/ or sickle cell crisis.mp.] AND [painful.mp. and crisis.mp.] AND [exp Fever/ or empirical antibiotics.mp.] OR [antibiotics] limited to English language and humans.

Search Outcome

This search yielded 91 articles. Bibliographic references found in these articles were also examined to identify related literature. Only original research articles were included. Three articles directly addressed the question. The Cochrane library was also searched but no relevant results were found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hsu, L 2001 USA	Patients with sickle cell anaemia presenting with fever	Guidelines	management	In children with fever prompt administration of intravenous antibiotics active against S.pneumoniae (for example Ceftriaxone) is indicated after always obtaining a blood culture. In adults with fever the clinical presentation, results of sputum and urine analysis and x-rays can frequently guide empiric antibiotics therapy until cultures and sensitivities are available.	No data was provided
Wong YW 2001 USA	Children with sickle cell anaemia	Review	Management	The immediate administration of intravenous antibacterials, after appropriate blood and urine cultures, is of great importance in the treatment of the febrile child with SCA.	No data available
Charache, S 1979 USA	28 patients between 25 to 34 years old with sickle cell anaemia	Decision rule	management	Antibiotics were used in 38 out of the 47 episodes that could be analyzed. The duration of fever did not differ between patients who did or did not received antibiotics (5.2 vs 4.3 days)	Small study size Study was not blinded.

Comment(s)

No trials on empiric antibiotics in sickle cell crisis presenting with fever have been carried out. This is an area for possible future research. However most clinicians and guidelines on sickle cell disease would recommend that if there is a high risk of bacterial infection in patients with sickle cell disease, that broad-spectrum antibiotics be used in the presence of fever. Empiric treatment with antibiotics should be started after the appropriate cultures have been obtained. Third generation cephalosporins with activity against S.pneumonia and H.influenzae sensitivity are recommended as initial choices. A macrolide has also been recommended if Chlamydia and Mycoplasma infections are thought to be present. Antibiotics should then be changed based on response to the therapy and results of the cultures and sensitivities taken.[2,3]

Clinical Bottom Line

There is no empirical evidence to guide whether antibiotics should or should not be given. Most guidelines say they should be given. Local guidance should be followed.

References

1. Hsu, L The sickle cell information centre protocols 2000
2. Wong YW Prevention and Management of Infection in Children with Sickle Cell Anaemia Pediatric Drugs 2001;793-801
3. Charache, S et al Acute chest syndrome in adults with sickle cell anemia: Microbiology, treatment and prevention Archives of internal medicine 1979
4. Vijay, V The anaesthetist's role in acute sickle cell crisis British Journal of Anaesthesia 1998;820-828