Sickle cell disease and fever, strong considerations for hospital admission for children and adults

Consider admission if one or more of the following are present
Clinical findings	Temperature >40°C (>104°F)
	Persistent tachycardia, hypotension, increased respiratory rate for age*, SaO₂ <3% below baseline, hypoperfusion
	Indwelling central venous catheter, port, or PICC
	Suspected or confirmed acute chest syndrome
	Suspected meningitis
	Additional acute complications of SCD such as Stroke Pain Aplastic crisis Splenic sequestration
	Dehydration that cannot be corrected by oral intake
	Concern about length/duration of empiric antibiotic coverage (antibiotics other than ceftriaxone)^¶
Laboratory findings	WBC count >30,000/microL If not taking hydroxyurea: WBC <5000/microL If taking hydroxyurea: ANC <500/microL (ANC <1000/microL if ill-appearing)
	Hemoglobin <5 g/dL Decreased by ≥2 g/dL from the individual's baseline
	Platelet count^Δ <100,000/microL (if baseline is normal) Decreased by ≥20,000/microL (if baseline is <100,000/microL)
History and social considerations	Prior history of sepsis or bacteremia, particularly with Strep. pneumoniae
	Immunizations not up to date
	Nonadherence to prophylactic penicillin, if prescribed
	Concern about parent/family/caregiver ability to identify changes should the patient's clinical status deteriorate
	Concern about ability to return to the emergency department if needed
	Inability to reliably contact the patient/family/caregiver if blood cultures turn positive (lack of telephone, lack of transportation)

Any individual with SCD and a temperature above a predetermined cutoff (refer to UpToDate text) should be seen in person. Presence of one of more of the findings listed in the table suggests the need for hospital admission; other features may also indicate the need for admission based on the judgment of the individual's primary clinician or the clinician performing the in-person evaluation. There is no consensus regarding an age at which all infants or toddlers with SCD and fever should be admitted; many factors must be considered.

SCD: sickle cell disease; SaO₂: oxygen saturation by pulse oximetry; PICC: peripherally inserted central catheter; WBC: white blood cell; ANC: absolute neutrophil count.
* Increased respiratory rate is defined as:^[1,2]

Ages 2 to 12 months – ≥50 breaths/min
Ages 12 months to 5 years – ≥40 breaths/min
Adults – >20 breaths/min

¶ Consider admission if not treated empirically with ceftriaxone, because shorter-acting antibiotics do not provide 24 hours of coverage.
Δ Individuals with thrombocytopenia or a decline in platelet count should be assessed for hypersplenism.

References:

Mulholland EK, Simoes EA, Costales MO, et al. Standardized diagnosis of pneumonia in developing countries. Pediatr Infect Dis J 1992; 11:77.
Strauß R, Ewig S, Richter K, et al. The prognostic significance of respiratory rate in patients with pneumonia: a retrospective analysis of data from 705,928 hospitalized patients in Germany from 2010-2012. Dtsch Arztebl Int 2014; 111:503.

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Sickle cell disease and fever, strong considerations for hospital admission for children and adults