A Cost-Effectiveness Analysis of Bacterial Endocarditis Prophylaxis for Febrile Children Who Have Cardiac Lesions and Undergo Urinary Catheterization in the Emergency Department

Abstract

Objective. To prevent bacterial endocarditis (BE) in those at risk, the American Heart Association recommends antibiotics for patients who have a known urinary tract infection and are about to undergo urinary catheterization (UC). In young children who have cardiac lesions and undergo UC for fever without a source, the problem with prophylaxis only in the presence of infected urine is that the presence of urinary tract infection is unknown before testing. This study was conducted to determine the cost-effectiveness of BE prophylaxis before UC in febrile children aged 0–24 months with moderate-risk cardiac lesions. Methods. We evaluated the cost-effectiveness of BE prophylaxis compared with no prophylaxis from the societal perspective. Clinical outcomes were based on BE incidence and quality-adjusted life years (QALYs). Probabilities were derived from the medical literature. Costs were derived from national and local sources in US dollars for the reference year 2000, using a discount rate of 3%. Results. On the basis of the analysis, prophylaxis prevents 7 BE cases per 1 million children treated. When antibiotic-associated deaths were included, the no-prophylaxis strategy was more effective and less costly than the prophylaxis strategy. When antibiotic-associated deaths were excluded, amoxicillin cost $10 million per QALY gained and $70 million per case prevented. For vancomycin, it was $13 million per QALY gained and $95 million per case prevented. The results were robust to variations in the prophylactic efficacy of antibiotics, incidence of bacteremia after UC, incidence of BE after bacteremia, and costs associated with BE prophylaxis and treatment. Conclusion. In the emergency department, BE prophylaxis before UC in febrile children who are aged 0 to 24 months and have moderate-risk cardiac lesions is not a cost-effective use of health care resources.