RESUMO
BACKGROUND: Beta-lactams are the mainstay for treating methicillin-susceptible Staphylococcus aureus (MSSA) infections complicated by bacteremia due to superior outcomes compared with vancomycin. With approximately 11% of inpatients reporting a penicillin (PCN) allergy, many patients receive suboptimal treatment for MSSA bacteremia. OBJECTIVE: Evaluate the cost-effectiveness of penicillin skin testing (PST) in adult patients with self-reported PCN allergy in an inpatient setting undergoing treatment for MSSA bacteremia. METHODS: A decision analytic model was developed comparing an acute care PST intervention to a scenario with no confirmatory allergy testing. The primary outcome was the incremental cost-effectiveness ratio (ICER) from the health-sector perspective over a 1-year time horizon using quality-adjusted life years (QALYs) as the measure for effectiveness. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty of the ICER estimation. RESULTS: Over a 1-year time horizon, PST services applied to all MSSA bacteremia patients reporting a PCN-allergy would result in a cost per patient of $12,559 and 0.73 QALYs while no PST services would have a higher cost per patient of $13,219 and 0.66 QALYs per patient. This resulted in a cost-effectiveness estimate of -$9,429 per QALY gained. Varying the cost of implementing PST services determined a break-even point of $959.98 where any PST cost less than this amount would actually be cost saving. CONCLUSIONS: Patients reporting a PCN allergy on admission may receive sub-optimal alternative therapies to beta-lactams, such as vancomycin, for MSSA bacteremia. This economic analysis demonstrates that inpatient PST services confirming PCN allergy are cost-effective for patients with MSSA bacteremia.
Assuntos
Antibacterianos/efeitos adversos , Bacteriemia/economia , Análise Custo-Benefício , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/economia , Penicilinas/efeitos adversos , Testes Cutâneos/economia , Infecções Estafilocócicas/complicações , Adulto , Bacteriemia/diagnóstico , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Humanos , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/microbiologiaRESUMO
Vancomycin-resistant enterococci (VRE) are a growing health problem, and uncertainties exist regarding the optimal therapy for bloodstream infection due to VRE. We conducted systematic comparative evaluations of the impact of different antimicrobial therapies on the outcomes of patients with bloodstream infections due to VRE. A retrospective study from January 2008 to October 2010 was conducted at Detroit Medical Center. Unique patients with blood cultures due to VRE were included and reviewed. Three major therapeutic classes were analyzed: daptomycin, linezolid, and ß-lactams. Three multivariate models were conducted for each outcome, matching for a propensity score predicting the likelihood of receipt of one of the therapeutic classes. A total of 225 cases of bacteremia due to VRE were included, including 86 (38.2%) cases of VR Enterococcus faecalis and 139 (61.8%) of VR Enterococcus faecium. Bacteremia due to VR E. faecalis was more frequent among subjects treated with ß-lactams than among those treated with daptomycin or linezolid. The median dose of daptomycin was 6 mg/kg of body weight (range, 6 to 12 mg/kg). After controlling for propensity score and bacteremia due to VR E. faecalis, differences in mortality were nonsignificant among the treatment groups. Therapy with daptomycin was associated with higher median variable direct cost per day than that for linezolid. This large study revealed the three therapeutic classes (daptomycin, linezolid, and ß-lactams) are similarly efficacious in the treatment of bacteremia due to susceptible strains of VRE.
Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Bacteriemia/economia , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/economia , Resistência a Vancomicina/efeitos dos fármacos , Enterococos Resistentes à Vancomicina/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/microbiologia , Estudos de Coortes , Daptomicina/economia , Daptomicina/uso terapêutico , Feminino , Infecções por Bactérias Gram-Positivas/microbiologia , Custos Hospitalares , Humanos , Linezolida/economia , Linezolida/uso terapêutico , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Índice de Gravidade de Doença , beta-Lactamas/economia , beta-Lactamas/uso terapêuticoRESUMO
CONTEXT: Early diagnosis of gram-negative bloodstream infections, prompt identification of the infecting organism, and appropriate antibiotic therapy improve patient care outcomes and decrease health care expenditures. In an era of increasing antimicrobial resistance, methods to acquire and rapidly translate critical results into timely therapies for gram-negative bloodstream infections are needed. OBJECTIVE: To determine whether mass spectrometry technology coupled with antimicrobial stewardship provides a substantially improved alternative to conventional laboratory methods. DESIGN: An evidence-based intervention that integrated matrix-assisted laser desorption and ionization time-of-flight mass spectrometry, rapid antimicrobial susceptibility testing, and near-real-time antimicrobial stewardship practices was implemented. Outcomes in patients hospitalized prior to initiation of the study intervention were compared to those in patients treated after implementation. Differences in length of hospitalization and hospital costs were assessed in survivors. RESULTS: The mean hospital length of stay in the preintervention group survivors (n = 100) was 11.9 versus 9.3 days in the intervention group (n = 101; P = .01). After multivariate analysis, factors independently associated with decreased length of hospitalization included the intervention (hazard ratio, 1.38; 95% confidence interval, 1.01-1.88) and active therapy at 48 hours (hazard ratio, 2.9; confidence interval, 1.15-7.33). Mean hospital costs per patient were $45 709 in the preintervention group and $26 162 in the intervention group (P = .009). CONCLUSIONS: Integration of rapid identification and susceptibility techniques with antimicrobial stewardship significantly improved time to optimal therapy, and it decreased hospital length of stay and total costs. This innovative strategy has ramifications for other areas of patient care.
Assuntos
Anti-Infecciosos/uso terapêutico , Bacteriemia/economia , Infecções por Bactérias Gram-Negativas/economia , Custos Hospitalares/estatística & dados numéricos , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Infecciosos/economia , Anti-Infecciosos/farmacologia , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Análise Custo-Benefício , Intervenção Médica Precoce/economia , Medicina Baseada em Evidências/economia , Feminino , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Hospitalização/economia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Testes de Sensibilidade Microbiana/economia , Pessoa de Meia-Idade , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/economia , Texas , Fatores de TempoRESUMO
OBJECTIVE: To assess the efficiency of daptomycin as firstline therapy (D) versus daptomycin as salvage therapy after vancomycin (VâD ) or linezolid (LâD) failure in gram-positive bacteraemia and complicated skin and skin-structure infections (cSSTIs). METHODS: Cost-effectiveness analysis of 161 bacteraemia and 84 cSSTIs patients comparing the above mentioned therapeutic alternatives was performed using the data from 27 Spanish hospitals involved in the EUCORE study. Direct medical costs were considered. Patients were observed from the first antibiotic dose for infection until either the end of daptomycin therapy or exitus. A multivariate Monte Carlo probabilistic sensitivity analysis was applied for costs (lognormal distribution) and effectiveness (normal distribution). RESULTS: In terms of effectiveness there were no statistical differences between groups but referring total costs per patient, there were significant differences. Sensitivity analysis confirmed that D dominates over LâD between 44.2%-62.1% of simulations in bacteraemia and between 48.2%-67.5% in cSSTIs. In comparison to VâD, D dominance was detected in 29.2%-33.2% of simulations in bacteraemia and between 48.2%-59.3% in cSSTIs. CONCLUSIONS: Daptomycin as first-line therapy dominates over daptomycin as salvage therapy after linezolid failure both in bacteraemia and cSSTIs. Comparing daptomycin as first-line therapy with its use after vancomycin failure, in cSSTIs the former is dominant. In bacteremia daptomycin as first line therapy is as effective as daptomycin as salvage therapy after vancomycin failure and implies lower costs.
Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Daptomicina/economia , Daptomicina/uso terapêutico , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Dermatopatias Infecciosas/tratamento farmacológico , Acetamidas/economia , Acetamidas/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/economia , Bacteriemia/microbiologia , Análise Custo-Benefício , Interpretação Estatística de Dados , Bactérias Gram-Positivas/efeitos dos fármacos , Infecções por Bactérias Gram-Positivas/economia , Infecções por Bactérias Gram-Positivas/microbiologia , Hospitais , Humanos , Linezolida , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Método de Monte Carlo , Oxazolidinonas/economia , Oxazolidinonas/uso terapêutico , Terapia de Salvação , Dermatopatias Infecciosas/economia , Dermatopatias Infecciosas/microbiologia , Espanha , Falha de Tratamento , Vancomicina/economia , Vancomicina/uso terapêutico , Adulto JovemRESUMO
OBJECTIVE: To perform a cost-effectiveness analysis of pediatric pneumococcal vaccination in Spain. METHODS: A deterministic population-based model in the form of a decision-tree with a 1-year time horizon was used to estimate the impact of vaccination with Synflorix® or Prevenar13® in children aged less than 2 years in Spain from the perspective of the National Health System. Epidemiological data were obtained from the hospital discharge minimum data set (MDS) and the literature. Data on costs were obtained from national health costs databases. The main outcomes measured were the number of cases avoided of invasive pneumococcal disease, acute otitis media (AOM) and myringotomies, and hospital admissions for pneumonia. All costs were expressed in 2010 euros. Effectiveness was measured as the number of quality-adjusted life years (QALYs) gained. RESULTS: The efficacy of Synflorix® in preventing episodes of AOM caused by non-typeable Haemophilus influenzae could lead to additional prevention of 41,513 episodes of AOM, 36,324 antibiotic prescriptions and 382 myringotomy procedures and 143 QALYs gained compared with Prevenar13®. The total vaccination cost with Synflorix® would result in savings of 22 million euros. CONCLUSIONS: Pneumococcal vaccination with Synflorix® in comparison with Prevenar13® in children aged less than 2 years old in Spain could achieve a higher number of QALYs and a substantial cost offset. Vaccination with Synflorix® would be a dominant strategy in terms of cost-effectiveness.
Assuntos
Infecções Pneumocócicas/prevenção & controle , Vacinas Pneumocócicas/economia , Vacinação/economia , Bacteriemia/economia , Bacteriemia/microbiologia , Bacteriemia/prevenção & controle , Análise Custo-Benefício , Árvores de Decisões , Feminino , Vacina Pneumocócica Conjugada Heptavalente , Hospitalização/economia , Humanos , Lactente , Masculino , Ventilação da Orelha Média/economia , Modelos Teóricos , Programas Nacionais de Saúde/economia , Otite Média/economia , Otite Média/microbiologia , Otite Média/prevenção & controle , Infecções Pneumocócicas/economia , Anos de Vida Ajustados por Qualidade de Vida , Espanha/epidemiologia , Vacinas Conjugadas/economiaRESUMO
Rapid organism detection of Staphylococcus aureus bacteremia and communication to clinicians expedites antibiotic optimization. We evaluated clinical and economic outcomes of a rapid polymerase chain reaction methicillinresistant S. aureus/S. aureus blood culture test (rPCR). This singlecenter study compared inpatients with S. aureus bacteremia admitted from 1 September 2008 through 31 December 2008 (prerPCR) and those admitted from 10 March 2009 through 30 June 2009 (postrPCR). An infectious diseases pharmacist was contacted with results of the rPCR; effective antibiotics and an infectious diseases consult were recommended. Multivariable regression assessed clinical and economic outcomes of the 156 patients. Mean time to switch from empiric vancomycin to cefazolin or nafcillin in patients with methicillinsusceptible S. aureus bacteremia was 1.7 days shorter postrPCR (P = .002). In the postrPCR methicillinsusceptible and methicillinresistant S. aureus groups, the mean length of stay was 6.2 days shorter (P = .07) and the mean hospital costs were $21,387 less (P = .02). rPCR allows rapid differentiation of S. aureus bacteremia, enabling timely, effective therapy and is associated with decreased length of stay and health care costs.
Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Prescrições de Medicamentos/normas , Tratamento Farmacológico/normas , Reação em Cadeia da Polimerase/métodos , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/isolamento & purificação , Antibacterianos/economia , Antibacterianos/farmacologia , Bacteriemia/economia , Bacteriemia/microbiologia , Técnicas Bacteriológicas/métodos , Sangue/microbiologia , Prescrições de Medicamentos/economia , Tratamento Farmacológico/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação , Testes de Sensibilidade Microbiana , Infecções Estafilocócicas/diagnóstico , Staphylococcus aureus/efeitos dos fármacos , Resultado do TratamentoAssuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/economia , Bacteriemia/tratamento farmacológico , Bacteriemia/economia , Bacteriemia/microbiologia , Cateteres de Demora/microbiologia , Análise Custo-Benefício , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/economia , Infecção Hospitalar/microbiologia , Endocardite Bacteriana/tratamento farmacológico , Endocardite Bacteriana/economia , Endocardite Bacteriana/microbiologia , Humanos , Testes de Sensibilidade Microbiana , Infecções Estafilocócicas/microbiologia , Resultado do TratamentoRESUMO
Studies from around the world have shown that hospital-acquired infections increase the costs of medical care due to prolongation of hospital stay, and increased morbidity and mortality. The aim of this study was to determine the extra costs associated with hospital-acquired bacteraemias in a Belgian hospital in 2001 using administrative databases and, in particular, coded discharge data. The incidence was 6.6 per 10000 patient days. Patients with a hospital-acquired bacteraemia experienced a significantly longer stay (average 21.1 days, P<0.001), a significantly higher mortality (average 32.2%, P<0.01), and cost significantly more (average 12853 euro, P<0.001) than similar patients without bacteraemia. At present, the Belgian healthcare system covers most extra costs; however, in the future, these outcomes of hospital-acquired bacteraemia will not be funded and prevention will be a major concern for hospital management.