RESUMO
Complex infection with methicillin-resistant Staphylococcus aureus (MRSA) is associated with high healthcare and societal costs; thus, evaluation of the costs and health benefits of interventions is an important consideration in a modern healthcare system. This study estimated the cost consequences of the use of daptomycin compared with vancomycin for the first-line treatment of patients with proven MRSA-induced bacteraemia-infective endocarditis (SAB-IE) with a vancomycin minimum inhibitory concentration (MIC) >1mg/L in the UK. A decision model was developed to assess total healthcare costs of treatment, including inpatient, outpatient and drug costs. Data were sourced from the literature (treatment efficacy and safety), a physician survey (resource use) and publicly available databases (unit costs). Assuming the same length of stay for daptomycin and vancomycin, the total healthcare costs per patient were £17917 for daptomycin and £17165 for vancomycin. However, extrapolating from published studies and supported by a physician survey, daptomycin was found to require fewer therapeutic switches and a shorter length of stay. When the length of stay was reduced from 42 days to 28 days, daptomycin saved £4037 per person compared with vancomycin. In conclusion, daptomycin is an effective and efficient alternative antibiotic for the treatment of SAB-IE. However, the level of cost saving depends on the extent to which local clinical practice allows early discharge of patients before the end of their antibiotic course when responding to treatment.
Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Daptomicina/uso terapêutico , Endocardite/tratamento farmacológico , Custos de Cuidados de Saúde , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Vancomicina/uso terapêutico , Antibacterianos/economia , Bacteriemia/complicações , Bacteriemia/microbiologia , Análise Custo-Benefício , Daptomicina/economia , Endocardite/complicações , Endocardite/microbiologia , Humanos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana , Reino Unido , Vancomicina/economia , Vancomicina/farmacologiaRESUMO
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
BACKGROUND: Guidelines recommend that agents other than vancomycin be considered for some types of infection due to methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) to vancomycin is 2 µg/mL or more. Alternative therapeutic options include daptomycin and linezolid, 2 relatively new and expensive drugs, and trimethoprim/sulfamethoxazole (TMP/SMX), an old and inexpensive agent. OBJECTIVE: To compare the clinical efficacy and potential cost savings associated with use of TMP/SMX compared to linezolid and daptomycin. METHODS: A retrospective study was conducted at Detroit Medical Center. For calendar year 2009, unique adults (age >18 years) with infections due to MRSA with an MIC to vancomycin of 2 µg/mL were included if they received 2 or more doses of TMP/SMX and/or daptomycin and/or linezolid. Data were abstracted from patient charts and pharmacy records. RESULTS: There were 328 patients included in the study cohort: 143 received TMP/SMX alone, 89 received daptomycin alone, 75 received linezolid alone, and 21 patients received a combination of 2 or more of these agents. In univariate analysis, patients who received TMP/SMX alone had significantly better outcomes, including in-hospital (p = 0.003) and 90-day mortality (p < 0.001) compared to patients treated with daptomycin or linezolid. Patients receiving TMP/SMX were also younger (p < 0.001), had fewer comorbid conditions (p < 0.001), had less severe acute severity of illness (p < 0.001), and received appropriate therapy more rapidly (p = 0.001). In multivariate models the association between TMP/SMX treatment and mortality was no longer significant. Antimicrobial cost savings associated with using TMP/SMX averaged $2067.40 per patient. CONCLUSIONS: TMP/SMX monotherapy compared favorably to linezolid and daptomycin in terms of treatment efficacy and mortality. Use of TMP/SMX instead of linezolid or daptomycin could potentially significantly reduce antibiotic costs. TMP/SMX should be considered for the treatment of MRSA infection with MIC of 2 µg/mL to vancomycin.
Assuntos
Antibacterianos/uso terapêutico , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Infecções Estafilocócicas/tratamento farmacológico , Acetamidas/administração & dosagem , Acetamidas/economia , Acetamidas/uso terapêutico , Adulto , Fatores Etários , Idoso , Antibacterianos/administração & dosagem , Antibacterianos/economia , Estudos de Coortes , Redução de Custos , Daptomicina/administração & dosagem , Daptomicina/economia , Daptomicina/uso terapêutico , Custos de Medicamentos , Feminino , Humanos , Linezolida , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Análise Multivariada , Oxazolidinonas/administração & dosagem , Oxazolidinonas/economia , Oxazolidinonas/uso terapêutico , Estudos Retrospectivos , Índice de Gravidade de Doença , Infecções Estafilocócicas/economia , Infecções Estafilocócicas/microbiologia , Fatores de Tempo , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Combinação Trimetoprima e Sulfametoxazol/economia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Vancomicina/administração & dosagem , Vancomicina/farmacologiaRESUMO
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
The development of mechanisms of resistance of many Gram-positive bacterial strains that cause complicated skin and soft tissue infections, as well as sepsis and bacteremia, has necessitated the search for new drugs that will improve treatment strategies. Daptomycin is a cyclic lipopeptide antibacterial that was launched for the treatment of complicated skin and soft tissue infections caused by Gram-positive organisms. The drug's mechanism of action is different from that of any other antibiotic. It binds to bacterial membranes and causes a rapid depolarization of membrane potential. This loss of membrane potential causes inhibition of protein, DNA and RNA synthesis, which results in bacterial cell death. The in vitro spectrum of activity of daptomycin encompasses most clinically relevant aerobic Gram-positive pathogenic bacteria. Compared to other antibiotics with a similar antibacterial spectrum, daptomycin does not cause nephrotoxicity. Taking these and other characteristics into consideration, daptomycin appears to be a good alternative to other drugs used in the treatment of complicated skin and soft tissue infections and in Gram-positive bacteremial infections.