Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective.

BACKGROUND: Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment. METHODS: To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis. RESULTS: In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually. CONCLUSIONS: Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.

Virus-induced acute respiratory distress syndrome: epidemiology, management and outcome.

The acute respiratory distress syndrome (ARDS) can be induced by viral diseases, with two virus types being responsible: respiratory viruses that cause community-acquired viral pneumonia and Herpesviridae that cause nosocomial viral pneumonia. Among the respiratory viruses that can affect the lung and cause ARDS, pandemic viruses head the list, with influenza viruses H5N1 and H1N1 2009 being the most recently identified. However, other viruses can cause severe ARDS. Notably, a novel coronavirus was responsible for the severe acute respiratory syndrome outbreak in 2003. Apart from these pandemic viruses, respiratory viruses are rarely responsible for viral pneumonia and ARDS. Other than antiviral drug (mainly oseltamivir) administration and avoidance of corticosteroids, management of ARDS due to these viruses does not differ from that for ARDS caused by other diseases. Among Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) are the two viruses causing nosocomial viral pneumonia that can evolve into ARDS. HSV is frequently recovered in the respiratory tract of mechanically ventilated patients and can sometimes be responsible for HSV bronchopneumonitis. Although not evaluated for this indication, acyclovir can be a therapeutic option for patients with HSV bronchopneumonitis and ARDS. CMV pneumonia can also occur in mechanically ventilated patients, but is difficult to diagnose because virus recovery does not necessarily mean viral disease. Ganciclovir can be considered for patients with ARDS and histology- or cytology-proven CMV pneumonia.

Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support.

OBJECTIVE: Myocarditis is a rare disease that may progress rapidly to refractory cardiogenic shock and death. In such situations, emergent initiation of mechanical circulatory assistance is the only therapeutic option to rescue these dying patients. This study was designed to evaluate the outcomes, health-related quality of life and frequencies of anxiety, depression and posttraumatic stress disorder symptoms in fulminant myocarditis patients rescued by mechanical circulatory assistance, since these major components of outcome evaluation after serious illnesses have not yet been assessed in this setting. DESIGN: A retrospective, single-center, observational study and a cross-sectional survey to assess health-related quality of life by the Short Form-36 questionnaire and frequencies of anxiety, depression and posttraumatic stress disorder symptoms by the Hospital Anxiety and Depression Scale and the Impact of Event Scale, respectively. SETTING: An 18-bed tertiary intensive care unit in a university hospital. PATIENTS: We analyzed the short- and long-term outcomes of 41 patients hospitalized at our institution between 2003 and 2009 and who received either a Thoratec BiVAD (Thoratec, Pleasanton, CA) (n = 6) or extracorporeal membrane oxygenation (n = 35) to combat refractory cardiogenic shock due to fulminant myocarditis. MEASUREMENTS AND MAIN RESULTS: Intensive care unit survival was 68%, and four (10%) patients underwent heart transplantation. Independent predictors of in-intensive care unit death were Simplified Acute Physiology Score II ≥56 (odds ratio = 10.23) and troponin Ic ≥12 µg/L (odds ratio = 7.49) at admission. Complete follow-up (median, 525 days) was available for 26 of 28 survivors. Compared to age- and sex-matched controls, Short Form-36 evaluation of health-related quality of life revealed satisfactory mental health and vitality but persistent physical and psychosocial-related difficulties. Lastly, anxiety, depression, and/or posttraumatic stress disorder symptoms were reported by 38%, 27% and 27% of the patients, respectively. CONCLUSIONS: Mechanical circulatory assistance rescued 68% of patients with refractory circulatory failure due to fulminant myocarditis. Greater disease severity and higher troponin Ic levels at extracorporeal membrane oxygenation initiation predicted poorer prognosis. Because up to one-third of the patients reported anxiety, depression, and/or posttraumatic stress disorder symptoms, strategies aimed at attenuating their emotional and psychologic distress might significantly improve their long-lasting well-being.