ABSTRACT
BACKGROUND: Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources. OBJECTIVES: To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia. METHODS: The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies. RESULTS: Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained. CONCLUSIONS: The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.
Subject(s)
Cost-Benefit Analysis/methods , Drug and Narcotic Control/methods , Migraine Disorders/drug therapy , Migraine Disorders/economics , Oxazolidinones/classification , Sumatriptan/classification , Tryptamines/classification , Australia/epidemiology , Cost-Benefit Analysis/trends , Drug and Narcotic Control/economics , General Practitioners/economics , Humans , Migraine Disorders/epidemiology , Nonprescription Drugs/classification , Nonprescription Drugs/economics , Nonprescription Drugs/therapeutic use , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Pharmacists/economics , Prescription Drugs/classification , Prescription Drugs/economics , Prescription Drugs/therapeutic use , Serotonin 5-HT1 Receptor Agonists/classification , Serotonin 5-HT1 Receptor Agonists/economics , Serotonin 5-HT1 Receptor Agonists/therapeutic use , Sumatriptan/economics , Sumatriptan/therapeutic use , Tryptamines/economics , Tryptamines/therapeutic useABSTRACT
BACKGROUND: Bloodstream infections are a leading cause of death in the United States. Methicillin-resistant Staphylococcus aureus (MRSA) encompasses >50% of all S aureus strains in infected hospitalized patients and increases mortality, length of stay and healthcare costs. The objective of this study was to evaluate the treatment of MRSA bacteremia with daptomycin, linezolid and vancomycin. METHODS: Patients with MRSA bacteremia between June 2008 and November 2010 were reviewed retrospectively. A microbiology laboratory report identified patients with ≥ 1 positive MRSA blood culture. Patients ≥ 18 years receiving daptomycin, linezolid or vancomycin for ≥ 7 consecutive days were included. Polymicrobial blood cultures and patients treated concomitantly with >1 anti-MRSA agent were excluded. RESULTS: Of 122 patients included, 53 received daptomycin, 15 received linezolid and 54 received vancomycin. Clinical and microbiologic cure rates were similar between daptomycin, linezolid and vancomycin (58.5% versus 60% versus 61.1%; 93.6% versus 100% versus 90%, respectively). Thirteen patients (daptomycin 4/24 versus linezolid 1/9 versus vancomycin 8/49, P = 0.5960) had recurrence while 12 patients had re-infection (daptomycin 5/42 versus linezolid 0/9 versus vancomycin 7/49, P = 0.4755). Treatment failure occurred in 11 patients treated with daptomycin, 4 with linezolid and 9 with vancomycin (P = 0.662). Compared with daptomycin and vancomycin, linezolid-treated patients had higher mortality (P = 0.0186). CONCLUSIONS: No difference in clinical or microbiologic cure rates was observed between groups. Daptomycin and vancomycin appear equally efficacious for MRSA bacteremia, whereas linezolid therapy was associated with higher mortality.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Methicillin-Resistant Staphylococcus aureus , Staphylococcal Infections/drug therapy , Acetamides/economics , Acetamides/therapeutic use , Adult , Aged , Anti-Bacterial Agents/economics , Bacteremia/economics , Daptomycin/economics , Daptomycin/therapeutic use , Female , Health Care Costs , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Intensive Care Units/economics , Intensive Care Units/statistics & numerical data , Length of Stay/economics , Length of Stay/statistics & numerical data , Linezolid , Male , Middle Aged , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Retrospective Studies , Staphylococcal Infections/economics , Staphylococcal Infections/mortality , Tennessee/epidemiology , Treatment Outcome , Vancomycin/economics , Vancomycin/therapeutic useABSTRACT
OBJECTIVE: The economic implications from the US Medicare perspective of adopting alternative treatment strategies for acute bacterial skin and skin structure infections (ABSSSIs) are substantial. The objective of this study is to describe a modeling framework that explores the impact of decisions related to both the location of care and switching to different antibiotics at discharge. METHODS: A discrete event simulation (DES) was developed to model the treatment pathway of each patient through various locations (emergency department [ED], inpatient, and outpatient) and the treatments prescribed (empiric antibiotic, switching to a different antibiotic at discharge, or a second antibiotic). Costs are reported in 2012 USD. RESULTS: The mean number of days on antibiotic in a cohort assigned to a full course of vancomycin was 11.2 days, with 64% of the treatment course being administered in the outpatient setting. Mean total costs per patient were $8671, with inpatient care accounting for 58% of the costs accrued. The majority of outpatient costs were associated with parenteral administration rather than drug acquisition or monitoring. Scenarios modifying the treatment pathway to increase the proportion of patients receiving the first dose in the ED, and then managing them in the outpatient setting or prescribing an oral antibiotic at discharge to avoid the cost associated with administering parenteral therapy, therefore have a major impact and lower the typical cost per patient by 11-20%. Since vancomycin is commonly used as empiric therapy in clinical practice, based on these analyses, a shift in treatment practice could result in substantial savings from the Medicare perspective. CONCLUSIONS: The choice of antibiotic and location of care influence the costs and resource use associated with the management of ABSSSIs. The DES framework presented here can provide insight into the potential economic implications of decisions that modify the treatment pathway.
Subject(s)
Anti-Bacterial Agents/economics , Anti-Bacterial Agents/therapeutic use , Patient Discharge/statistics & numerical data , Skin Diseases, Bacterial/drug therapy , Soft Tissue Infections/drug therapy , Acetamides/economics , Acetamides/therapeutic use , Acute Disease , Administration, Intravenous , Daptomycin/economics , Daptomycin/therapeutic use , Health Expenditures/statistics & numerical data , Humans , Linezolid , Oxazolidinones/economics , Oxazolidinones/therapeutic use , United States , Vancomycin/economics , Vancomycin/therapeutic useABSTRACT
INTRODUCTION: We compared the economic impacts of linezolid and vancomycin for the treatment of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA)-confirmed nosocomial pneumonia. METHODS: We used a 4-week decision tree model incorporating published data and expert opinion on clinical parameters, resource use and costs (in 2012 US dollars), such as efficacy, mortality, serious adverse events, treatment duration and length of hospital stay. The results presented are from a US payer perspective. The base case first-line treatment duration for patients with MRSA-confirmed nosocomial pneumonia was 10 days. Clinical treatment success (used for the cost-effectiveness ratio) and failure due to lack of efficacy, serious adverse events or mortality were possible clinical outcomes that could impact costs. Cost of treatment and incremental cost-effectiveness per successfully treated patient were calculated for linezolid versus vancomycin. Univariate (one-way) and probabilistic sensitivity analyses were conducted. RESULTS: The model allowed us to calculate the total base case inpatient costs as $46,168 (linezolid) and $46,992 (vancomycin). The incremental cost-effectiveness ratio favored linezolid (versus vancomycin), with lower costs ($824 less) and greater efficacy (+2.7% absolute difference in the proportion of patients successfully treated for MRSA nosocomial pneumonia). Approximately 80% of the total treatment costs were attributed to hospital stay (primarily in the intensive care unit). The results of our probabilistic sensitivity analysis indicated that linezolid is the cost-effective alternative under varying willingness to pay thresholds. CONCLUSION: These model results show that linezolid has a favorable incremental cost-effectiveness ratio compared to vancomycin for MRSA-confirmed nosocomial pneumonia, largely attributable to the higher clinical trial response rate of patients treated with linezolid. The higher drug acquisition cost of linezolid was offset by lower treatment failure-related costs and fewer days of hospitalization.
Subject(s)
Acetamides/economics , Cross Infection/economics , Methicillin-Resistant Staphylococcus aureus , Models, Economic , Oxazolidinones/economics , Pneumonia, Staphylococcal/economics , Vancomycin/economics , Acetamides/administration & dosage , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/economics , Cost-Benefit Analysis/methods , Cross Infection/drug therapy , Double-Blind Method , Humans , Linezolid , Methicillin-Resistant Staphylococcus aureus/drug effects , Oxazolidinones/administration & dosage , Pneumonia, Staphylococcal/drug therapy , Prospective Studies , Vancomycin/administration & dosageABSTRACT
This retrospective observational medical chart review aimed to describe country-specific variations across Europe in real-world meticillin-resistant Staphylococcus aureus (MRSA) complicated skin and soft-tissue infection (cSSTI) treatment patterns, antibiotic stewardship activity, and potential opportunities for early switch (ES) from intravenous (i.v.) to oral formulations and early discharge (ED) from hospital using standardised data collection and criteria and economic implications of these opportunities. Patients were randomly sampled from 12 countries (Austria, Czech Republic, France, Germany, Greece, Ireland, Italy, Poland, Portugal, Slovakia, Spain and the UK), aged ≥18 years, with documented MRSA cSSTI, hospitalised between 1 July 2010 and 30 June 2011, discharged alive by 31 July 2011. Of 1502 patients, 1468 received MRSA-targeted therapy. Intravenous-to-oral switch rates ranged from 2.0% to 20.2%, i.v. length of therapy from 10.1 to 18.6 days and hospital length of stay (LoS) from 15.2 to 25.0 days across Europe. Of 341 sites, 82.9% had antibiotic steering committees, 23.7% had i.v.-to-oral switch antibiotic protocols and 12.9% had ED protocols for MRSA cSSTI. ES and ED eligibility ranged from 12.0% (Slovakia) to 56.3% (Greece) and from 10% (Slovakia) to 48.2% (Portugal), respectively. Potential cost savings per ED-eligible patient ranged from 414 (Slovakia) to 2703 (France). MRSA cSSTI treatment patterns varied widely across countries, but further reductions in i.v. therapy, hospital LoS and associated costs could be realised. These data provide insight into clinical practice patterns across diverse European healthcare systems and identify potential opportunities for local clinicians and policy-makers to improve clinical care and cost-effectiveness of this therapeutic area.
Subject(s)
Acetamides/therapeutic use , Anti-Bacterial Agents/therapeutic use , Methicillin-Resistant Staphylococcus aureus/drug effects , Oxazolidinones/therapeutic use , Soft Tissue Infections/drug therapy , Staphylococcal Skin Infections/drug therapy , Vancomycin/therapeutic use , Acetamides/economics , Administration, Oral , Adult , Aged , Anti-Bacterial Agents/economics , Drug Administration Schedule , Europe , Female , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Injections, Intravenous , Length of Stay/economics , Length of Stay/statistics & numerical data , Linezolid , Male , Methicillin-Resistant Staphylococcus aureus/growth & development , Middle Aged , Oxazolidinones/economics , Patient Discharge , Practice Guidelines as Topic , Retrospective Studies , Soft Tissue Infections/economics , Soft Tissue Infections/microbiology , Soft Tissue Infections/pathology , Staphylococcal Skin Infections/economics , Staphylococcal Skin Infections/microbiology , Staphylococcal Skin Infections/pathology , Vancomycin/economicsABSTRACT
OBJECTIVES: Enterococcus species are the fourth leading cause of bacteremia. Resistance rates are rising and delays in appropriate initial antimicrobial therapy have been associated with increased mortality. Empiric treatment of patients with suspected enterococcal bacteremia varies and significant cost differences exist between alternatives. The objective of this study was to determine the cost-effectiveness of various empiric treatments for patients with suspected enterococcal bacteremia. METHODS: A decision-analytic model was constructed from the hospital perspective to assess the cost-effectiveness of alternative empiric treatment options for enterococcal bacteremia, including antimicrobials active against vancomycin-resistant enterococcus (VRE). The model was populated from available literature sources and included resistance patterns, associated mortality with early versus delayed effective treatment, and the cost of treatment. Univariate sensitivity analyses tested the robustness of the model to determine the degree to which model uncertainties influenced outcomes. We also undertook a probabilistic sensitivity analysis varying parameters in 10,000 Monte Carlo simulations. MAIN RESULTS: The incremental cost-effectiveness ratio was $791 and $749/quality-adjusted-life-year utilizing empiric daptomycin and linezolid, respectively. The model also predicted an incremental cost/life saved of $11,703 by utilizing empiric daptomycin and $11,084 with linezolid utilization. Ampicillin was dominated (i.e., less effective and associated with increased costs) by both VRE-active agents and vancomycin. A probabilistic Monte Carlo sensitivity analysis showed that an agent with VRE activity had a 100% chance of being cost-effective at traditionally used willingness-to-pay thresholds. The decision-analytic model was sensitive to variations in E. faecium mortality and short-term postdischarge survival rates. CONCLUSION: Results of our model showed that empiric utilization of an antimicrobial with activity against VRE may be a cost-effective option for the treatment of suspected enterococcal bacteremia when compared with vancomycin or ß-lactam therapy.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Enterococcus/drug effects , Models, Economic , Acetamides/economics , Acetamides/therapeutic use , Anti-Bacterial Agents/economics , Bacteremia/economics , Bacteremia/microbiology , Cost-Benefit Analysis , Daptomycin/economics , Daptomycin/therapeutic use , Decision Support Techniques , Drug Resistance, Bacterial , Enterococcus/isolation & purification , Humans , Linezolid , Monte Carlo Method , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Quality-Adjusted Life Years , Vancomycin/economics , Vancomycin/therapeutic useSubject(s)
Tuberculosis, Multidrug-Resistant/epidemiology , Tuberculosis/drug therapy , Acetamides/economics , Compassionate Use Trials , Congresses as Topic , Diarylquinolines/therapeutic use , Drug Resistance, Multiple , Guidelines as Topic , Humans , Linezolid , Mycobacterium tuberculosis/drug effects , Oxazolidinones/economics , South Africa/epidemiology , Tuberculosis/transmission , Tuberculosis Vaccines , Tuberculosis, Multidrug-Resistant/transmission , VentilationABSTRACT
OBJECTIVE: To determine the relationship between benefit design, out-of-pocket costs, and prescription reversals, and the impact of reversals on rehospitalizations and total healthcare costs among Medicare members prescribed oral linezolid. STUDY DESIGN: Medicare members from a national health plan prescribed oral linezolid posthospitalization for skin and soft tissue infection (SSTI) or pneumonia were followed retrospectively. METHODS: Members were identified by an oral linezolid prescription between June 1, 2007, and April 30, 2011, where the index event was a prescription fill or reversal less than 2 days before or 10 days after discharge. Associations between out-of-pocket costs and reversal, and between reversal and rehospitalization 30 days postindex, were compared for prescription fills versus reversals. A generalized linear model calculated adjusted total healthcare costs per member controlling for age, sex, geographic region, and clinical characteristics. RESULTS: Reversal rates rose progressively from 2% for members with out-of-pocket costs of $0 to 27% for members with out-of-pocket costs higher than $100 (P < .0001). Infection-related rehospitalizations were 23% versus 9% for members with a prescription reversal versus a fill (P < .0001). While postdischarge prescription drug costs were $1228.78 lower (P <.0001), adjusted mean medical costs were $2061.69 higher (P = .0033) and total healthcare costs were $1280.93 higher (P = .0349) for reversal versus fill members. CONCLUSIONS: Higher out-of-pocket costs were associated with higher rates of reversal, and reversals were associated with higher rates of rehospitalization and adjusted total healthcare costs among Medicare members prescribed oral linezolid posthospitalization for SSTI or pneumonia.
Subject(s)
Acetamides/economics , Anti-Infective Agents/economics , Drug Substitution/economics , Financing, Personal/statistics & numerical data , Oxazolidinones/economics , Acetamides/therapeutic use , Administration, Oral , Adolescent , Adult , Aged , Aged, 80 and over , Anti-Infective Agents/therapeutic use , Databases, Factual , Health Maintenance Organizations , Humans , Linear Models , Linezolid , Medicare Part D , Middle Aged , Oxazolidinones/therapeutic use , Patient Readmission , Pneumonia, Bacterial/drug therapy , Retrospective Studies , Soft Tissue Infections/drug therapy , United States , Young AdultABSTRACT
As the number of CA-MRSA skin and soft tissue infections continues to grow, it's important to know which patients are at greatest risk and which evidence-based treatment protocols to turn to when needed.
Subject(s)
Methicillin-Resistant Staphylococcus aureus/isolation & purification , Staphylococcal Infections/diagnosis , Staphylococcal Infections/drug therapy , Acetamides/economics , Acetamides/therapeutic use , Administration, Topical , Anti-Bacterial Agents/economics , Anti-Bacterial Agents/therapeutic use , Clindamycin/economics , Clindamycin/therapeutic use , Community-Acquired Infections/diagnosis , Community-Acquired Infections/drug therapy , Continuity of Patient Care , Cross Infection/diagnosis , Ethnicity , Humans , Linezolid , Medical History Taking , Mupirocin/administration & dosage , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Patient Education as Topic , Physical Examination , Practice Guidelines as Topic , Rifampin/therapeutic use , Risk Factors , Secondary Prevention , Skin/injuries , Staphylococcal Infections/transmission , Trimethoprim, Sulfamethoxazole Drug Combination/economics , Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic useABSTRACT
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.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Methicillin-Resistant Staphylococcus aureus/drug effects , Staphylococcal Infections/drug therapy , Acetamides/administration & dosage , Acetamides/economics , Acetamides/therapeutic use , Adult , Age Factors , Aged , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/economics , Cohort Studies , Cost Savings , Daptomycin/administration & dosage , Daptomycin/economics , Daptomycin/therapeutic use , Drug Costs , Female , Humans , Linezolid , Male , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Microbial Sensitivity Tests , Middle Aged , Multivariate Analysis , Oxazolidinones/administration & dosage , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Retrospective Studies , Severity of Illness Index , Staphylococcal Infections/economics , Staphylococcal Infections/microbiology , Time Factors , Treatment Outcome , Trimethoprim, Sulfamethoxazole Drug Combination/administration & dosage , Trimethoprim, Sulfamethoxazole Drug Combination/economics , Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use , Vancomycin/administration & dosage , Vancomycin/pharmacologyABSTRACT
Linezolid is a novel oxazolidinone antibacterial agent with a broad clinical application, especially in methicillin-resistant Staphylococcus aureus skin and soft-tissue infections and skin and skin-structure infections. Pharmacoeconomic advantages include decreased hospital duration, reduction in intravenous antibiotic use and early discharge opportunities that contribute to an overall reduction in healthcare resources. Linezolid's oral formulation has a pharmacokinetic profile that is similar to its intravenous formulation, which creates opportunities for early discharge not available to comparators like vancomycin and daptomycin. Both vancomycin and daptomycin require intravenous therapy, which compounds the resources required in treating methicillin-resistant S. aureus skin and soft tissue/skin and skin structure infections. Pharmacoeconomic studies have demonstrated an overall reduction in total direct costs to the payer in favor of linezolid over its comparators. Its overall reduction in healthcare utilization makes it an appropriate alternative to the standard therapy, vancomycin.
Subject(s)
Acetamides/therapeutic use , Anti-Bacterial Agents/therapeutic use , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Oxazolidinones/therapeutic use , Staphylococcal Skin Infections/drug therapy , Acetamides/administration & dosage , Acetamides/economics , Administration, Oral , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/economics , Cost-Benefit Analysis , Economics, Pharmaceutical , Health Care Costs , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Length of Stay , Linezolid , Oxazolidinones/administration & dosage , Oxazolidinones/economics , Soft Tissue Infections/drug therapy , Soft Tissue Infections/economics , Soft Tissue Infections/microbiology , Staphylococcal Skin Infections/economics , Staphylococcal Skin Infections/microbiology , Vancomycin/administration & dosage , Vancomycin/economics , Vancomycin/therapeutic useABSTRACT
OBJECTIVE: To review the evidence for pharmacologic agents available in the treatment of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. DATA SOURCES: A search of PubMed (1975-July 2012) was conducted using a combination of the terms methicillin-resistant Staphylococcus aureus, pneumonia, nosocomial, vancomycin, linezolid, telavancin, ceftaroline, tigecycline, and quinupristin/dalfopristin. STUDY SELECTION AND DATA EXTRACTION: Randomized comparative clinical trials, meta-analyses, and review articles published in English were included. A manual review of the bibliographies of available literature was conducted and all relevant information was included. Observational and in vitro studies were incorporated as indicated. DATA SYNTHESIS: Pharmacotherapy for the treatment of nosocomial MRSA pneumonia is limited. Vancomycin has been the treatment of choice for several years. Linezolid has demonstrated similar efficacy to vancomycin in randomized clinical trials and recent data have suggested that it may be superior in some cases, although there are limitations to this conclusion. Telavancin has also demonstrated similar clinical efficacy to vancomycin; however, the drug is not commercially available in the US. Other agents with MRSA activity include ceftaroline, clindamycin, quinupristin/dalfopristin, and tigecycline, although the evidence for their use in nosocomial pneumonia is limited. CONCLUSIONS: Based on the currently available evidence and cost-effectiveness, vancomycin should continue to be the drug of choice for most patients with nosocomial MRSA pneumonia. Linezolid is a reasonable alternative for patients with treatment failure while receiving vancomycin, isolates with vancomycin minimum inhibitory concentrations over 2 µg/mL, allergic reactions, or vancomycin-induced nephrotoxicity.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Methicillin-Resistant Staphylococcus aureus/drug effects , Pneumonia, Staphylococcal/drug therapy , Acetamides/administration & dosage , Acetamides/economics , Acetamides/therapeutic use , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/economics , Cost-Benefit Analysis , Cross Infection/drug therapy , Cross Infection/economics , Cross Infection/microbiology , Humans , Linezolid , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Microbial Sensitivity Tests , Oxazolidinones/administration & dosage , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Pneumonia, Staphylococcal/economics , Pneumonia, Staphylococcal/microbiology , Vancomycin/administration & dosage , Vancomycin/economics , Vancomycin/therapeutic useABSTRACT
BACKGROUND: Treatment options for drug-resistant tuberculosis (DR-TB) are limited. Linezolid has been successfully used to treat DR-TB in adults, but there are few case reports of its use in children for TB. The reported rate of adverse events in adults is high. METHODS: We conducted a retrospective review of children with DR-TB treated with linezolid-containing regimens from February 2007 to March 2012 at two South African hospitals. RESULTS: Seven children (three human immunodeficiency virus [HIV] infected) received a linezolid-containing regimen. All had culture-confirmed DR-TB; five had previously failed second-line anti-tuberculosis treatment. Four children were cured and three were still receiving anti-tuberculosis treatment, but had culture converted. None of the non-HIV-infected children experienced adverse events while receiving linezolid. Three HIV-infected children had adverse events, one of which was life-threatening; linezolid was permanently discontinued in this case. Adverse events included lactic acidosis (n = 1), pancreatitis (n = 2), peripheral neuropathy (n = 1) and asymptomatic bone marrow hypoplasia (n = 1). CONCLUSION: Linezolid-containing regimens can be effective in treating children with DR-TB even after failing second-line treatment. Adverse events should be monitored, especially in combination with medications that have similar adverse effects. Linezolid remains costly, and a reduced dosage and duration may result in fewer adverse events and lower cost.
Subject(s)
Acetamides/therapeutic use , Antitubercular Agents/therapeutic use , Oxazolidinones/therapeutic use , Tuberculosis, Multidrug-Resistant/drug therapy , Tuberculosis, Pulmonary/drug therapy , Acetamides/adverse effects , Acetamides/economics , Adolescent , Age Factors , Anti-HIV Agents/therapeutic use , Antitubercular Agents/adverse effects , Antitubercular Agents/economics , Child , Child, Preschool , Coinfection , Cost Savings , Drug Costs , Drug Interactions , Drug Therapy, Combination , Extensively Drug-Resistant Tuberculosis/drug therapy , Female , HIV Infections/complications , HIV Infections/drug therapy , Humans , Infant , Linezolid , Male , Mycobacterium tuberculosis/isolation & purification , Oxazolidinones/adverse effects , Oxazolidinones/economics , Retrospective Studies , South Africa , Sputum/microbiology , Time Factors , Treatment Outcome , Tuberculosis, Multidrug-Resistant/complications , Tuberculosis, Multidrug-Resistant/diagnosis , Tuberculosis, Multidrug-Resistant/economics , Tuberculosis, Multidrug-Resistant/microbiology , Tuberculosis, Pulmonary/complications , Tuberculosis, Pulmonary/diagnosis , Tuberculosis, Pulmonary/economics , Tuberculosis, Pulmonary/microbiologyABSTRACT
OBJECTIVES: An audit was performed to determine whether linezolid (Zyvox, Pharmacia Limited, Sandwich, UK) was being used in accordance with local guidelines and if this had an effect on admissions for diabetes foot ulceration. METHODS: Seven hundred and four patient records from 2005 to 2010 in the Diabetes Foot Clinic, Royal Infirmary of Edinburgh were audited for methicillin-resistant Staphylococcus aureus (MRSA) infections, admissions and antibiotic use. RESULTS: Seventeen percent (nâ=â119) of patients had proven MRSA infections. Of these, 28% (nâ=â33) were prescribed linezolid, 94% (nâ=â31) for up to 14 days and none for >28 days. Eight (24%) had repeated courses. Ninety-one percent (nâ=â30) either avoided admission or were discharged early with resolution of infection. Four out of 33 patients had reversible blood abnormalities. The total cost for linezolid over this period was £58â000. However, 420 bed days, costing £500/day, were avoided, producing a total saving of £210â000 on inpatient costs. CONCLUSIONS: Linezolid guidelines reduced lengths of stay, inpatient costs and overuse of this expensive but effective treatment.
Subject(s)
Acetamides/administration & dosage , Acetamides/economics , Diabetic Foot/drug therapy , Health Care Costs , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Oxazolidinones/administration & dosage , Oxazolidinones/economics , Staphylococcal Skin Infections/drug therapy , Diabetic Foot/microbiology , Drug Utilization/statistics & numerical data , Humans , Length of Stay , Linezolid , Staphylococcal Skin Infections/microbiology , Staphylococcus aureus , United KingdomABSTRACT
Linezolid is identified as an effective drug with which to treat patients failing multidrug-resistant (MDR)-tuberculosis (TB) treatment. However, cost and safety are the concerns. In India, the average price of a 600-mg pill of linezolid is less than one US dollar, much cheaper than most of the third-line drugs. A prospective study of 29 MDR-TB treatment failure patients (16 with laboratory-proven extensively drug-resistant (XDR)-TB and the remaining 13 with MDR-TB with resistance to any quinolone but sensitive to injectables) was carried out in Delhi, India. All patients received daily unsupervised therapy with linezolid, one injectable agent, one fluoroquinolone and two or more other drugs. Patients received a median of six anti-mycobacterial agents. Besides linezolid, capreomycin, moxifloxacin, levofloxacin and amoxycillin-clavulanic acid were used in 41.4%, 58.6%, 41.4%, and 79.3% of patients. Out of a total of 29 patients, 89.7% patients achieved sputum smear and culture conversion; 72.4% showed interim favourable outcome; 10.3% died, 6.8% failed and 10.3% patients defaulted. Linezolid had to be stopped in three (10.3%) patients due to adverse reactions. The outcome of treatment of 16 XDR-TB patients was comparable to the other 13 MDR-TB patients. Linezolid is an effective, cheap and relatively safe drug for patients failing MDR-TB treatment, including those with confirmed XDR-TB.
Subject(s)
Acetamides/administration & dosage , Acetamides/economics , Drug Costs , Extensively Drug-Resistant Tuberculosis/drug therapy , Extensively Drug-Resistant Tuberculosis/economics , Oxazolidinones/administration & dosage , Oxazolidinones/economics , Acetamides/adverse effects , Adolescent , Adult , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/adverse effects , Anti-Bacterial Agents/economics , Anti-Infective Agents/administration & dosage , Anti-Infective Agents/adverse effects , Anti-Infective Agents/economics , Antitubercular Agents/administration & dosage , Antitubercular Agents/adverse effects , Antitubercular Agents/economics , Drug Therapy, Combination , Female , Fluoroquinolones/administration & dosage , Fluoroquinolones/adverse effects , Fluoroquinolones/economics , Humans , India , Linezolid , Male , Middle Aged , Oxazolidinones/adverse effects , Prospective Studies , Treatment Outcome , Young AdultABSTRACT
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.
Subject(s)
Anti-Bacterial Agents/economics , Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Daptomycin/economics , Daptomycin/therapeutic use , Gram-Positive Bacterial Infections/drug therapy , Skin Diseases, Infectious/drug therapy , Acetamides/economics , Acetamides/therapeutic use , Adolescent , Adult , Aged , Aged, 80 and over , Bacteremia/economics , Bacteremia/microbiology , Cost-Benefit Analysis , Data Interpretation, Statistical , Gram-Positive Bacteria/drug effects , Gram-Positive Bacterial Infections/economics , Gram-Positive Bacterial Infections/microbiology , Hospitals , Humans , Linezolid , Microbial Sensitivity Tests , Middle Aged , Monte Carlo Method , Oxazolidinones/economics , Oxazolidinones/therapeutic use , Salvage Therapy , Skin Diseases, Infectious/economics , Skin Diseases, Infectious/microbiology , Spain , Treatment Failure , Vancomycin/economics , Vancomycin/therapeutic use , Young AdultABSTRACT
BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) complicated skin and skin structure infection (cSSSI) is a prominent infection encountered in hospital and outpatient settings that is associated with high resource use for the health-care system. OBJECTIVE: A decision analytic (DA) model was developed to evaluate the cost-effectiveness analysis (CEA) of linezolid, daptomycin, and vancomycin in MRSA cSSSI. METHODS: Bayesian methods for evidence synthesis were used to generate efficacy and safety parameters for a DA model using published clinical trials. CEA was done from the US health-care perspective. Efficacy was defined as a successfully treated patient at the test of cure without any adverse reaction. Primary outcome was the incremental cost-effectiveness ratio between linezolid and vancomycin, daptomycin and vancomycin, and linezolid and daptomycin in MRSA cSSSI. Univariate and probabilistic sensitivity analyses were performed to test the robustness of the model. RESULTS: The total direct costs of linezolid, daptomycin, and vancomycin were $18,057, $20,698, and $23,671, respectively. The cost-effectiveness ratios for linezolid, daptomycin, and vancomycin were $37,604, $44,086, and $52,663 per successfully treated patient, respectively. Linezolid and daptomycin were dominant strategies compared to vancomycin. However, linezolid was dominant when compared to daptomycin. The model was sensitive to the duration of daptomycin and linezolid treatment. CONCLUSION: Linezolid and daptomycin are potentially cost-effective based on the assumptions of the DA model; however, linezolid appears to be more cost-effective compared to daptomycin and vancomycin for MRSA cSSSIs.
Subject(s)
Acetamides/economics , Anti-Infective Agents/economics , Bayes Theorem , Daptomycin/economics , Drug Costs , Methicillin-Resistant Staphylococcus aureus/pathogenicity , Models, Economic , Outcome and Process Assessment, Health Care/economics , Oxazolidinones/economics , Staphylococcal Skin Infections/economics , Vancomycin/economics , Acetamides/therapeutic use , Adolescent , Adult , Aged , Aged, 80 and over , Anti-Infective Agents/therapeutic use , Cost-Benefit Analysis , Daptomycin/therapeutic use , Decision Support Techniques , Diagnostic Tests, Routine/economics , Drug Therapy, Combination , Health Services Research , Hospital Costs , Humans , Linezolid , Middle Aged , Oxazolidinones/therapeutic use , Staphylococcal Skin Infections/diagnosis , Staphylococcal Skin Infections/drug therapy , Staphylococcal Skin Infections/microbiology , Treatment Outcome , United States , Vancomycin/therapeutic use , Young AdultABSTRACT
UNLABELLED: Severe infections with multiresistant bacteria (MRB) are a medical challenge and a financial burden for hospitals. The adequate antibiotic therapy is a key issue in multiresistant bacteria management. Several major cost drivers have been identified. Remarkably drug acquisition costs are not necessarily included. Most significant are the length of stay in hospital, the hours of mechanical ventilation and the time treated on an intensive care unit. - In a systematic review of the literature the following aspects were investigated: - Do generic treatment strategies contribute in cost savings? - Are there specific results for recent antibiotics? - Early adequate and effective antimicrobial treatment, switch from i.v. to oral therapy, adjusted duration of therapy and adherence to guidelines have been found to be successful strategies. - Looking at specific antibiotics, the best evidence for cost-effectiveness is found for Linezolid in treatment of cSSTI as well as in HAP. Daptomycin shows good economic results in bloodstream infections, so possibly being a cost-effective alternative to vancomycin. Looking at tigecycline the published data show neither higher costs nor savings compared to imipeneme. Doripenem as one of the newest therapy options has proven to be highly cost-saving in HAP when compared with imipenem. However, most analyses are based on pharmacoeconomic modelling rather than on directly analysing trial data or real life clinical populations. - CONCLUSION: Using modern antibiotics in whole is not more expensive than using established therapies. Modern antibiotics are cost-effective and sometimes even cost-saving. This is especially true if an effective therapy is initiated as early as possible.