IMMEDIATE OUTCOMES OF CHILDREN WITH SICKLE CELL ANEMIA AND FEVER MANAGED AS OUT PATIENTS AT MULAGO HOSPITAL SICKLE CELL CLINIC

Abstract

Background: Fever is a common presentation of children with sickle cell anaemia (SCA). Outpatient management of selected patients with SCA and fever is safe, effective and reduces hospital admissions in high income countries. The effectiveness of this approach, however, is heavily reliant on stringent guidelines and rigorous follow up procedures. At the Mulago hospital sickle cell clinic (MHSCC), a select group of patients with SCA and fever are managed on outpatient basis, as guided by the clinic’s fever protocol. Challenges with follow up and limited laboratory capacity to investigate for the causes of fever may contribute to poor outcomes in our setting. Presently, the outcomes of this management are unknown. Objectives: To determine the immediate outcomes and factors associated with poor outcomes in children with sickle cell anemia and fever managed as outpatients at the MHSCC Methods: Children aged 0-12 years with confirmed SCA, presenting to the MHSCC from October 2018 to February 2019, with documented axillary temperature of 37.5 °C or more, were prospectively enrolled and followed up for seven days to assess fever resolution, hospitalization or death. Children were recruited after a decision to treat as an outpatient had been made by a non study clinician after obtaining written informed consent and assent. Guided by a standardized questionnaire, a detailed history and physical exam, review of the laboratory tests done, as well as treatment prescribed and received by the enrolled patients was carried out. On day 7, a final interview, guided by a (second) standardized questionnaire, was carried out to assess for the study outcomes of fever resolution, return to the sickle cell clinic, hospitalization and death in the first 7 days following outpatient management for fever, as well as factors associated with hospitalization. Statistical analyses were performed using the Chi-squared distribution and Fisher’s exact test for measures < 0.2. A p-value of <0.05 was considered to be significant. Results Data from a total of 220 children were analyzed. By day 7, 200/220 (90.9%) enrolled participants had fever resolution, with the majority 108/200 (54.0%), reporting fever resolution by day 2 following treatment at the clinic. Hospitalization in the first 7 days following treatment at the clinic occurred in 23/220 (10.5%) study participants. Most of the hospitalized patients 14/23 (60.9%), were 60 months of age or older. The most common reasons for admission were vasoocclusive crises and acute chest syndrome/severe pneumonia, each accounting for 12/23 (52.2%). At xiii multivariate analysis, axillary temperature of 38.0℃ or more (AOR 7.36 95% CI 1.09-49.81, P= 0.041), not being on malaria chemoprophylaxis ( AOR 21.84 95% CI 2.97-160.85, P=0.002), chest pain at enrolment ( AOR 7.91 95% CI 1.32-47.28, P=0.023), pain in the extremities at enrolment (AOR 39.40 95% CI 4.13-375.5, P=0.001) and the caregiver not having attained secondary level education ( AOR 0.09 95% CI 0.02-0.61, P=0.013) were associated with hospitalization. There was no death among the enrolled participants in the first 7 days following outpatient treatment at the clinic for fever. Conclusions and Recommendations Ninety percent of children with SCA treated for fever had it resolved by day 7. However, 1 in every 10 children with a febrile episode needed hospitalization, with children aged 60 months and above being at the highest risk. In order to reduce hospitalization rates in children with SCA presenting with fever, we recommend careful follow up for children older than 60 months of age, with axillary temperature of 38.0℃ and above, pain in the extremities and chest, and those children not on malaria prophylaxis. Future research is needed to study children with SCA aged 60 months and above since they have the highest risk for hospitalization.