Cost-minimization analysis of oral versus intravenous antibiotic treatment for Klebsiella pneumoniae liver abscess.

A cost-minimization analysis was conducted for Klebsiella pneumoniae liver abscess (KLA) patients enrolled in a randomized controlled trial which found oral ciprofloxacin to be non-inferior to intravenous (IV) ceftriaxone in terms of clinical outcomes. Healthcare service utilization and cost data were obtained from medical records and estimated from self-reported patient surveys in a non-inferiority trial of oral ciprofloxacin versus IV ceftriaxone administered to 152 hospitalized adults with KLA in Singapore between November 2013 and October 2017. Total costs were evaluated by category and payer, and compared between oral and IV antibiotic groups over the trial period of 12 weeks. Among the subset of 139 patients for whom cost data were collected, average total cost over 12 weeks was $16,378 (95% CI, $14,620-$18,136) for the oral ciprofloxacin group and $20,569 (95% CI, $18,296-$22,842) for the IV ceftriaxone group, largely driven by lower average outpatient costs, as the average number of outpatient visits was halved for the oral ciprofloxacin group. There were no other statistically significant differences, either in inpatient costs or in other informal healthcare costs. Oral ciprofloxacin is less costly than IV ceftriaxone in the treatment of Klebsiella liver abscess, largely driven by reduced outpatient service costs.Trial registration: ClinicalTrials.gov Identifier NCT01723150 (7/11/2012).

An assessment of the effectiveness of virginiamycin on liver abscess incidence and growth performance in feedlot cattle: a comprehensive statistical analysis.

The judicious use of commercial products in livestock operations can be part of a sustainable and environmentally friendly production scenario. This study was designed to gather published data of virginiamycin (VM) used in feedlot conditions of the United States and analyze its effectiveness and optimum dosage in reducing the liver abscess incidence (LAI). The dataset contained 26 studies that evaluated more than 7,156 animals of diverse breeds fed in several regions in the United States under different management. Statistical analyses included contingency tables to assess the nonparametric independence of the LAI, meta regression analysis to remove study effects and to evaluate LAI and animal performance, broken-line analysis to determine thresholds of VM dosage on LAI, and residual-based shading mosaic plots to illustrate the contingency analysis. There were 1,391 of 5,430 animals with LAI scores 1, 2, or 3 (LAI1-3) and 651 of 4,690 animals with LAI A+ (score 3). Our analyses suggested that there was a significant dependency (χ2P-value < 0.001) and significant asymmetry (McNemar's test P-value < 0.001) between LAI and VM treatment for both LAI1-3 and LAI A+. For the LAI1-3 group, only 22.5% of the treated animals had liver abscesses compared with 31.7% of the control animals. The metaregression analysis indicated that LAI1-3 was linearly reduced (P < 0.001) by about 0.42% per mg/kg of DM of VM. The lower 95% confidence interval of the intercept for LAI1-3 and LAI A+ obtained with a generalized nonlinear mixed regression was 18.7 and 20.3 mg/kg of DM, respectively. The broken-line regression analysis identified 2 thresholds for LAI (23.9 and 12.3 mg/kg of DM) at which the reduction in total LAI1-3 and LAI A+, respectively, would decrease faster as VM dosage increases (from 2.14% to 6% and from 1.91% to 4.33% per mg of VM per kg of DM, respectively). Additionally, our analyses indicated that after accounting for the study effects, VM significantly increased ADG at 2.08 g BW/d per mg/kg DM compared with 0.92 g BW/d per mg/kg DM for monensin (P < 0.001), suggesting that VM was about 2.3 times more effective in increasing ADG for the same dosage and feeding period length. All analyses yielded consistent results that led us to conclude that VM is effective in reducing LAI when fed between approximately 12 and 24 mg/kg of DM, and the maximum reduction might occur at approximately 24 mg/kg of DM or higher.

Oral versus intravenous antibiotics for patients with Klebsiella pneumoniae liver abscess: study protocol for a randomized controlled trial.

BACKGROUND: Klebsiella pneumoniae liver abscess is the most common etiology of liver abscess in Singapore and much of Asia, and its incidence is increasing. Current management includes prolonged intravenous antibiotic therapy, but there is limited evidence to guide oral conversion. The implicated K1/K2 capsule strain of Klebsiella pneumoniae is almost universally susceptible to ciprofloxacin, an antibiotic with high oral bioavailability. Our primary aim is to compare the efficacy of early (< one week) step-down to oral antibiotics, to continuing four weeks of intravenous antibiotics, in patients with Klebsiella liver abscess. METHODS/DESIGN: The study is designed as a multi-center randomized open-label active comparator-controlled non-inferiority trial, with a non-inferiority margin of 12%. Eligible participants will be inpatients over the age of 21 with a CT or ultrasound scan suggestive of a liver abscess, and Klebsiella pneumoniae isolated from abscess fluid or blood. Randomization into intervention or active control arms will be performed with a 1:1 allocation ratio. Participants randomized to active control will receive IV ceftriaxone 2 grams daily to complete a total of four weeks of IV antibiotics. Participants randomized to intervention will be immediately converted to oral ciprofloxacin 750 mg twice daily. At Week four, all participants will undergo abdominal imaging and be assessed for clinical response (CRP < 20 mg/l, absence of fever, plus scan showing that the maximal diameter of the abscess has reduced). If criteria are met, antibiotics are stopped; if not, oral antibiotics are continued, with reassessment for clinical response fortnightly. If criteria for clinical response are met by Week 12, the primary endpoint of clinical cure is met. A cost analysis will be performed to assess the cost saving of early conversion to oral antibiotics, and a quality of life analysis will be performed to assess whether treatment with oral antibiotics is less burdensome than prolonged IV antibiotics. DISCUSSION: Our results would help inform local and international practice guidelines regarding the optimal antibiotic management of Klebsiella liver abscess. A finding of non-inferiority may translate to the wider adoption of a more cost-effective strategy that reduces hospital length of stay and improves patient-centered outcomes and satisfaction. TRIAL REGISTRATION: Clinical trials gov NCT01723150.

Patient-physician discordance about benefits and risks in gastroenterology decision-making.

AIMS: To illustrate the characteristics of situations in gastroenterology when patients and physicians harbour different perspectives of medical costs and benefits, and how such different perspectives affect the outcome of medical decision-making. METHODS: Two exemplary scenarios are presented, in which threshold analysis yields different results depending on the varying values assigned to identical medical events. The occurrence of varying values is subsequently phrased in economical terms of varying utility functions that characterize patient vs. physician behaviour. RESULTS: Safety and therapy are the two major preferences that determine patient and physician utility functions. Patients and physicians make medical decisions based on two different utility functions. In comparison with their patients, gastroenterologists are more concerned with safety and inclined to spend more health care resources on safety than therapy because safety and the occurrence of medical complications affect their own professional status. In trying to maximize their own utility, gastroenterologists tend to spend more resources on safety than the patient him/herself might have spent given a free choice of management options. CONCLUSIONS: In instances of potential complications associated with risky medical interventions, patients may receive less medical therapy in exchange for more procedural safety.

Sequential intravenous/oral antibiotic vs. continuous intravenous antibiotic in the treatment of pyogenic liver abscess.

AIM: Pyogenic liver abscesses result in substantial morbidity and mortality. Antimicrobial regimens using sequential intravenous/oral therapy may reduce the length of hospital stay. In this retrospective analysis, the efficacy of continuous intravenous antibiotic therapy (group I) vs. sequential intravenous/oral antibiotic therapy (group II) was studied in patients with pyogenic liver abscess. METHODS: One hundred and twelve consecutive patients (55 in group I and 57 in group II) with pyogenic liver abscess were analysed. Clinical response, length of hospital stay and relapse rates were examined. RESULTS: Group II had a significantly shorter duration of intravenous antibiotic treatment (3.2 weeks vs. 5.9 weeks, P < 0.01) and a shorter length of hospital stay (28 days vs. 42 days, P < 0.01) when compared to group I. Oral antibiotics were prescribed for a median duration of 2.9 weeks in group II after discharge. No relapse occurred within 6 weeks after the completion of treatment in both groups. The cost of therapy was significantly lower in group II than in group I by 33%. CONCLUSIONS: A sequential intravenous/oral antibiotic regime is a safe and effective treatment for pyogenic liver abscess. This reduces the cost of therapy and the length of hospital stay.