Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With ß-Lactam Allergies.

BACKGROUND: ß-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the ß-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of ß-lactams that are structurally dissimilar. METHODS: An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented ß-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS: A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a ß-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS: Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of ß-lactam antibiotics for surgical prophylaxis.

Antimicrobial Stewardship by Transitions of Care Pharmacists at Hospital Discharge.

Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.

Therapeutic drug monitoring and use of an adjusted body weight strategy for high-dose voriconazole therapy.

Objectives: A high-dose 12 mg/kg/day (6 mg/kg twice daily) voriconazole regimen was recommended by the CDC to treat patients injected with contaminated methylprednisolone acetate that caused a multi-state fungal outbreak in 2012-13. Therapeutic drug monitoring results of this unique regimen are unknown, as is the most appropriate dosing weight for obese patients. We evaluated voriconazole trough measurements for this dosing scheme, as well as the use of adjusted body weight dosing for obese patients. Methods: Voriconazole trough levels were analysed in obese (BMI ≥35 kg/m 2 ) and non-obese (BMI <35 kg/m 2 ) patients who were given initial therapy with 12 mg/kg/day. Results: Of 138 patients, the first steady-state voriconazole troughs were supratherapeutic (>5 mg/L) in 65 (47%) patients, therapeutic (2-5 mg/L) in 57 (41%) patients and subtherapeutic (<2 mg/L) in 16 (12%) patients. Twenty-three patients had pre-steady-state dose decreases due to supratherapeutic levels, with subsequent first steady-state troughs in the therapeutic ( n = 17) and subtherapeutic ( n = 6) categories. Voriconazole doses >11 and >8 mg/kg/day produced mainly first steady-state supratherapeutic troughs in 44 obese and 94 non-obese patients, respectively. An initial 12 mg/kg/day was progressively lowered to a median maintenance dose of 8.5 mg/kg/day in the obese and 8.6 mg/kg/day in the non-obese. Conclusions: A high-dose voriconazole regimen produced initial supratherapeutic troughs that required dose adjustment downward by nearly 30%. Adjusted body weight dosing in obese patients resulted in a similar maintenance dose to total body weight dosing in the non-obese, and appears to be a sensible dosing strategy for these patients.

Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection.

OBJECTIVES: The study objective was to determine whether there was an improvement in compliance with recommended Clostridium difficile infection (CDI) treatment after introduction of an institutional CDI bundle with daily antimicrobial stewardship assessment. PATIENTS AND METHODS: This was a single-centre, quasi-experimental study evaluating compliance with an antimicrobial stewardship team-implemented care bundle in patients with CDI compared with historical controls. The primary outcome, compliance with overall bundle elements, was achieved when the following measures were accomplished: (i) appropriate CDI antimicrobial therapy based on the institutional treatment algorithm; (ii) discontinuation of acid-suppressant therapy in the absence of a pre-specified indication; and (iii) discontinuation of unnecessary antimicrobials. Secondary objectives were to evaluate the extent to which antimicrobial stewardship involvement affected treatment compliance and to assess trends in CDI clinical outcomes, such as mortality and readmission. RESULTS: One-hundred-and-sixty-nine patients were evaluated; 83 after implementation of the care bundle (bundle group) and 89 prior to bundle implementation (historical control group). Compliance with overall bundle endpoints was significantly higher in the bundle group versus the control group (81% versus 45%, P < 0.001). Individual bundle components that were significantly improved in the bundle group were discontinuation of non-essential acid suppressants (90% versus 18%, P < 0.001) and administration of appropriate CDI therapy (82% versus 64%, P < 0.009). No significant differences were observed in overall or CDI-related mortality or readmissions, durations of therapy or reduction of non-essential concomitant antimicrobials. CONCLUSIONS: Introduction of an antimicrobial stewardship bundle for CDI significantly improved adherence to institutional treatment recommendations and overall management of patients with CDI.

Linezolid Versus Vancomycin in the Empiric Treatment of Nosocomial Pneumonia: A Cost-Utility Analysis Incorporating Results from the ZEPHyR Trial.

OBJECTIVE: To examine the cost-effectiveness of vancomycin versus linezolid in the empiric treatment of nosocomial pneumonias incorporating results from a recent prospective, double-blind, multicenter, controlled trial in adults with suspected methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia. METHODS: A decision-analytic model examining the cost-effectiveness of linezolid versus vancomycin for the empiric treatment of nosocomial pneumonia was created. Publicly available cost, efficacy, and utility data populated relevant model variables. A probabilistic sensitivity analysis varied parameters in 10,000 Monte-Carlo simulations, and univariate sensitivity analyses assessed the impact of model uncertainties and the robustness of our conclusions. RESULTS: Results indicated that the cost per quality-adjusted life-year (QALY) increased 6% ($22,594 vs. $23,860) by using linezolid versus vancomycin for nosocomial pneumonia. The incremental cost per QALY gained by using linezolid over vancomycin was $6,089, and the incremental cost per life saved was $68,615 with the use of linezolid. Vancomycin dominated linezolid in the subset of patients with documented MRSA. The incremental cost per QALY gained using linezolid if no mortality benefit exists between agents or a 60-day time horizon was analyzed was $19,608,688 and $443,662, respectively. CONCLUSIONS: Linezolid may be a cost-effective alternative to vancomycin in the empiric treatment of patients with suspected MRSA nosocomial pneumonia; however, results of our model were highly variable on a number of important variables and assumptions including mortality differences and time frame analyzed.

Impact of infectious diseases consultation for hospitalized patients with Clostridioides difficile infection.

Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality. This study described outcomes associated with mandatory infectious diseases (ID) consultation in hospitalized patients with CDI. ID consultation was associated with increased appropriate concomitant antibiotic use, however longer courses of concomitant antibiotics were administered.

Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia.

BACKGROUND: Integration of rapid diagnostic testing via matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) with antimicrobial stewardship team (AST) intervention has the potential for early organism identification, customization of antibiotic therapy, and improvement in patient outcomes. The objective of this study was to assess the impact of this combined approach on clinical and antimicrobial therapy-related outcomes in patients with bloodstream infections. METHODS: A pre-post quasi-experimental study was conducted to analyze the impact of MALDI-TOF with AST intervention in patients with bloodstream infections. The AST provided evidence-based antibiotic recommendations after receiving real-time notification following blood culture Gram stain, organism identification, and antimicrobial susceptibilities. Outcomes were compared to a historic control group. RESULTS: A total of 501 patients with bacteremia or candidemia were included in the final analysis: 245 patients in the intervention group and 256 patients in the preintervention group. MALDI-TOF with AST intervention decreased time to organism identification (84.0 vs 55.9 hours, P < .001), and improved time to effective antibiotic therapy (30.1 vs 20.4 hours, P = .021) and optimal antibiotic therapy (90.3 vs 47.3 hours, P < .001). Mortality (20.3% vs 14.5%), length of intensive care unit stay (14.9 vs 8.3 days) and recurrent bacteremia (5.9% vs 2.0%) were lower in the intervention group on univariate analysis, and acceptance of an AST intervention was associated with a trend toward reduced mortality on multivariable analysis (odds ratio, 0.55, P = .075). CONCLUSION: MALDI-TOF with AST intervention decreased time to organism identification and time to effective and optimal antibiotic therapy.

Cost-effectiveness analysis evaluating fidaxomicin versus oral vancomycin for the treatment of Clostridium difficile infection in the United States.

OBJECTIVES: Fidaxomicin is a novel treatment for Clostridium difficile infections (CDIs). This new treatment, however, is associated with a higher acquisition cost compared with alternatives. The objective of this study was to evaluate the cost-effectiveness of fidaxomicin or oral vancomycin for the treatment of CDIs. METHODS: We performed a cost-utility analysis comparing fidaxomicin with oral vancomycin for the treatment of CDIs in the United States by creating a decision analytic model from the third-party payer perspective. RESULTS: The incremental cost-effectiveness ratio with fidaxomicin compared with oral vancomycin was $67,576/quality-adjusted life-year. A probabilistic Monte Carlo sensitivity analysis showed that fidaxomicin had an 80.2% chance of being cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. Fidaxomicin remained cost-effective under all fluctuations of both fidaxomicin and oral vancomycin costs. The decision analytic model was sensitive to variations in clinical cure and recurrence rates. Secondary analyses revealed that fidaxomicin was cost-effective in patients receiving concominant antimicrobials, in patients with mild to moderate CDIs, and when compared with oral metronidazole in patients with mild to moderate disease. Fidaxomicin was dominated by oral vancomycin if CDI was caused by the NAP1/Bl/027 Clostridium difficile strain and was dominant in institutions that did not compound oral vancomycin. CONCLUSION: Results of our model showed that fidaxomicin may be a more cost-effective option for the treatment of CDIs when compared with oral vancomycin under most scenarios tested.

Antibiotic Use in Patients With ß-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain-Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment.

BACKGROUND: ß-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with ß-lactam allergies are often treated with non-ß-lactam alternative antibiotics. An institutional ß-lactam side chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for patients with ß-lactam allergies. METHODS: This single-center, retrospective cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following implementation. The primary outcome was the incidence of ß-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes. RESULTS: A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significantly greater use of ß-lactams in the intervention cohort (70.4% vs 89.3%; P < .001) and decreased use of alternative therapy (58.1% vs 36%; P < .001). There was no difference in overall allergic reactions between cohorts (2.4% vs 1.6%; P = .738) or in reactions caused by ß-lactams (1.3% vs 0.9%; P = .703). Inpatient mortality increased (0% vs 6.4%; P < .001); however, no deaths were due to allergic reactions. Healthcare facility-onset Clostridioides difficile infections decreased between cohorts (1.2% vs 0.2%; P = .032). CONCLUSIONS: Implementation of a ß-lactam side chain-based cross-reactivity chart and enhanced allergy assessment was associated with increased use of ß-lactams in patients with pneumonia without increasing allergic reactions.

Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities.

BACKGROUND: Antimicrobial stewardship program (ASP) surveillance at our hospital is supplemented by an internally developed surveillance database. In 2013, the database incorporated a validated, internally developed, prediction rule for patient mortality within 30 days of hospital admission. This study describes the impact of an expanded ASP review in patients at the highest risk for mortality. METHODS: This retrospective, quasi-experimental study analyzed adults who received antimicrobials with the highest mortality risk score. Study periods were defined as 2011-Q3 2013 (historical group) and Q4 2013-2018 (intervention group). Primary and secondary outcomes were assessed for confounders and analyzed using both unadjusted and propensity score weighted analyses. Interrupted time-series analyses also analyzed key outcomes. RESULTS: A total of 3282 and 5456 patients were included in the historical and intervention groups, respectively. There were significant reductions in median antimicrobial duration (5 vs 4 days; P < .001), antimicrobial days of therapy (8 vs 7; P < .001), antimicrobial cost ($96 vs $85; P = .003), length of stay (LOS) (6 vs 5 days; P < .001), intensive care unit (ICU) LOS (3 vs 2 days; P < .001), total hospital cost ($10 946 vs $9119; P < .001), healthcare facility-onset vancomycin-resistant Enterococcus (HO-VRE) incidence (1.3% vs 0.3%; P ≤ .001), and HO-VRE infections (0.6% vs 0.2%; P = .018) in the intervention cohort. CONCLUSIONS: Reductions in antimicrobial use, hospital and ICU LOS, HO-VRE, HO-VRE infections, and costs were associated with incorporation of a novel mortality prediction rule to guide ASP surveillance and intervention.

Managing antimicrobial resistance in intensive care units.

The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physician's success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.

Open-source institutional guideline recommendations during the COVID-19 pandemic.

PURPOSE: The global coronavirus disease 2019 (COVID-19) pandemic and the search for ways in which to provide the best available care have created unprecedented times in terms of rapidly evolving reports of available treatment options. The primary objective of our analysis was to categorize online, open-source guidance to determine how US institutions approached their recommendations for management of patients with COVID-19 in the early weeks of the pandemic. METHODS: A search for open-source, online institutional guidelines for the treatment of COVID-19 was conducted using predefined criteria. The search was limited to the United States and conducted from April 12 through 14, 2020, and again on April 22, 2020. Searches were conducted at 2 points in time in order to identify changes in treatment recommendations due to evolving literature or institutional experience. Treatment recommendations, including guidance on antiviral therapy, corticosteroid and interleukin-6 inhibitor use, and nutritional supplementation were compared. RESULTS: Of the 105 institutions that met initial screening criteria, 14 institutions (13.3%) had online COVID-19 guidance available. Supportive care and clinical trial enrollment were the primary recommendations in all evaluated guidance. Recommendations to consider antimicrobial and adjunctive therapy varied. Eighty-six percent of guidelines contained recommendations for use, or consideration of use, of hydroxychloroquine. Guidance from 2 institutions mentioned use of hydroxychloroquine and azithromycin in combination. Of the 13 institutions listing hydroxychloroquine dosing recommendations, 62% recommended maintenance dosing of 200 mg twice daily. Infectious diseases or other specialty consultation was required by 89% of institutions using interleukin-6 inhibitors for COVID-19 management. CONCLUSION: Overall, the analysis revealed variability in treatment or supplemental pharmacologic therapy for the management of COVID-19.

Perspectives from the frontline: A pharmacy department's response to the COVID-19 pandemic.

PURPOSE: The global coronavirus disease 2019 (COVID-19) pandemic has created unprecedented strains on healthcare systems around the world. Challenges surrounding an overwhelming influx of patients with COVID-19 and changes in care dynamics prompt the need for care models and processes that optimize care in this medically complex patient population. The purpose of this report is to describe our institution's strategy to deploy pharmacy resources and standardize pharmacy processes to optimize the management of patients with COVID-19. METHODS: This retrospective, descriptive report characterizes documented pharmacy interventions in the acute care of patients admitted for COVID-19 during the period April 1 to April 15, 2020. Patient monitoring, interprofessional communication, and intervention documentation by pharmacy staff was facilitated through the development of a COVID-19-specific care bundle integrated into the electronic medical record. RESULTS: A total of 1,572 pharmacist interventions were documented in 197 patients who received a total of 15,818 medication days of therapy during the study period. The average number of interventions per patient was 8. The most common interventions were regimen simplification (15.9%), timing and dosing adjustments (15.4%), and antimicrobial therapy and COVID-19 treatment adjustments (15.2%). Patients who were admitted to an intensive care unit care at any point during their hospital stay accounted for 66.7% of all interventions documented. CONCLUSION: A pharmacy department's response to the COVID-19 pandemic was optimized through standardized processes. Pharmacists intervened to address a wide scope of medication-related issues, likely contributing to improved management of COVID-19 patients. Results of our analysis demonstrate the vital role pharmacists play as members of multidisciplinary teams during times of crisis.

Analysis to determine cost-effectiveness of procalcitonin-guided antibiotic use in adult patients with suspected bacterial infection and sepsis.

PURPOSE: Results of a study incorporating real-world results into a predictive model to assess the cost-effectiveness of procalcitonin (PCT)-guided antibiotic use in intensive care unit patients with sepsis are reported. METHODS: A single-center, retrospective cross-sectional study was conducted to determine whether reductions in antibiotic therapy duration and other care improvements resulting from PCT testing and use of an associated treatment pathway offset the costs of PCT testing. Selected base-case cost outcomes in adults with sepsis admitted to a medical intensive care unit (MICU) were assessed in preintervention and postintervention cohorts using a decision analytic model. Cost-minimization and cost-utility analyses were performed from the hospital perspective with a 1-year time horizon. Secondary and univariate sensitivity analyses tested a variety of clinically relevant scenarios and the robustness of the model. RESULTS: Base-case modeling predicted that use of a PCT-guided treatment algorithm would results in hospital cost savings of $45 per patient and result in a gain of 0.0001 quality-adjusted life-year. After exclusion of patients in the postintervention cohort for PCT test ordering outside of institutional guidelines, the mean inpatient antibiotic therapy duration was significantly reduced in the postintervention group relative to the preintervention group (6.2 days versus 4.9 days, p = 0.04) after adjustment for patient sex and age, Charlson Comorbidity Index score, study period, vasopressor use, and ventilator use. Total annual hospital cost savings of $4,840 were predicted. CONCLUSION: Real-world implementation of PCT-guided antibiotic use may have improved patients' quality of life while decreasing hospital costs in MICU patients with undifferentiated sepsis.

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group.

PURPOSE: Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. SUMMARY: The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. CONCLUSION: An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided.

Institutional experience with voriconazole compared with liposomal amphotericin B as empiric therapy for febrile neutropenia.

STUDY OBJECTIVE: To assess the effectiveness, safety, and cost of empiric treatment of febrile neutropenia before and after implementing an algorithm in which voriconazole was substituted for liposomal amphotericin B (L-AmB). DESIGN: Retrospective cohort analysis. SETTING: An 850-bed tertiary care hospital, which is also a referral site for patients with acute leukemia. PATIENTS: Fifty-five adult patients who started empiric antifungal therapy for febrile neutropenia between January 1, 2002, and December 31, 2003, encompassing 58 treatment episodes (defined as a hospitalization during which empiric antifungal therapy was administered). MEASUREMENTS AND MAIN RESULTS: Medical charts, including patients' pharmacy and laboratory data, were reviewed. Twenty-six and 32 episodes of L-AmB and voriconazole use, respectively, were identified. No significant differences between the L-AmB and voriconazole groups were noted at baseline. Rates of fever resolution (54% vs 59%, p=0.791) and breakthrough invasive fungal infections (11% vs 12%, p>0.999) were similar for the L-AmB and voriconazole episodes. Premature drug discontinuation due to the prescriber's perceived lack of efficacy occurred most frequently in the voriconazole group (25% vs 8%, p=0.160). Survival was significantly higher in the voriconazole than in the L-AmB group (100% vs 77%, p=0.006). Adverse effects that were significantly more common in the L-AmB group than in the voriconazole group were elevated serum creatinine levels (27% vs 3%, p=0.017) and electrolyte disturbances (19% vs 0%, p=0.014). Adverse effects reported more frequently in the voriconazole group than in the L-AmB group were visual disturbances (9% vs 0%, p=0.245) and elevated hepatic enzyme levels (9% vs 8%, p>0.999). Mean drug expenditures/episode for initial empiric antifungal therapy were lower for voriconazole than for L-AmB ($1593 vs $4144, or $153 vs $380/day). CONCLUSION: Our institution's algorithm incorporating voriconazole into the empiric management of febrile neutropenia was associated with effectiveness outcomes comparable to those observed with L-AmB as well as a lower frequency of adverse effects and overall expenditures for antifungal drugs.

Pharmacoeconomic analysis of liposomal amphotericin B versus voriconazole for empirical treatment of febrile neutropenia.

BACKGROUND: Liposomal amphotericin B (LAmB) has demonstrated similar efficacy to conventional amphotericin B for antifungal treatment in patients with febrile neutropenia; however, it is not without toxicities and is associated with a high acquisition cost. Despite this high cost, LAmB has been shown to have a pharmacoeconomic advantage over less expensive agents. Voriconazole is a potential alternative for empirical antifungal treatment of febrile neutropenia. The objective of this study was to assess the economic outcomes of voriconazole versus LAmB in patients with fever and neutropenia. METHODS: A decision analytical model was developed from a hospital perspective based on a 2-year (2002-2003) review of outcomes and prescribing practices in febrile neutropenic patients at a tertiary care medical centre. Literature reports and expert opinion were used to further populate the model. Sensitivity analyses and Monte Carlo simulation enhanced the robustness of the model through variation of all probabilities and costs that populated the model. RESULTS: Sixty-three cases were evaluated in the retrospective review. Thirty-two were initially given voriconazole and 31 were given LAmB. Patient demographic data were similar in each group. In the base case, patients initially given voriconazole displayed a 27% reduction in overall treatment cost over patients initially given LAmB (14,950 vs 20,591 $US). Sensitivity analysis determined that the cost advantage in the voriconazole arm was maintained over a wide range of costs and probabilities. Variance in the cost of nephrotoxicity and medication cost did not significantly alter results. Monte Carlo simulation determined the voriconazole arm to be the optimal path in 65% of cases. CONCLUSION: The decision model indicated that use of voriconazole as the preferred antifungal agent in adult haematology patients with febrile neutropenia should result in lower overall treatment costs relative to LAmB.

Are antiseptic-coated central venous catheters effective in a real-world setting?

BACKGROUND: Catheter-related bloodstream infections are common, costly, and morbid. Randomized controlled trials indicate that antiseptic-coated central venous catheters reduce infection rates. OBJECTIVE: To assess the clinical and economic effectiveness of antiseptic-coated catheters for critically ill patients in a real-world setting. METHODS: Central venous catheters coated with chlorhexidine/silver-sulfadiazene were introduced in all patients requiring central venous access in adult intensive care units at the University of Michigan Health System, a large, tertiary care teaching hospital. A pretest-posttest cohort design measured the primary outcome of catheter-related bloodstream infection rate, comparing the 2 years prior to the intervention with the 2 years following the intervention. We also evaluated cost-effectiveness and changes in vancomycin use. RESULTS: The intervention was associated with a 4% per month relative reduction in the incidence of catheter-related bloodstream infection, after controlling for the effects of time. Overall, a 35% relative risk reduction (P < .0003) in the catheter-related bloodstream infection rate occurred in the posttest phase. The use of antiseptic-coated catheters reduced costs more than $100,000 annually. Vancomycin use was less in units in which antiseptic catheters were used compared with wards in which these catheters were not used. CONCLUSION: Antiseptic-coated catheters appear to be clinically effective and economically efficient in a real-world setting.