Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review.

BACKGROUND: Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense. METHODS: A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS. RESULTS: Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features. CONCLUSION: Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

One-Stage Periprosthetic Joint Infection Reimbursement-Is It Worth The Effort?

BACKGROUND: One-stage protocols for the management of periprosthetic infection take an extended period of time requiring two separate preps and sets of instruments to ensure optimal sterility. While intraoperative service time is one part of the reimbursement algorithm, reimbursement has lagged behind for single-stage treatment with respect to the time and resources necessary to perform these complex treatment regimens. If one-stage results are shown to be acceptable, but not reimbursed appropriately, surgeons will be discouraged from managing periprosthetic joint infection (PJI) in a one-stage fashion. METHODS: The reimbursement and operative time for 50 PJI procedures were compared with 250 primary total hips and 250 primary total knees by the same 4 surgeons. RESULTS: The average reimbursement for a one-stage knee procedure was $2,597.08, with an average intraoperative service time of 259 minutes ($601.60/h). The average reimbursement for a primary total knee was $2,435.00, with an average intraoperative service time of 100 minutes ($1,461/h). The average reimbursement for a one-stage hip procedure was $2,826.17, with an average intraoperative service time of 311 minutes ($545.24/h). The average reimbursement for a primary total hip was $2,754.71 with an average intraoperative service time of 104 minutes ($1,589.26/h). CONCLUSION: One-stage procedures for PJI are reimbursed at approximately 1/3 the hourly rate of a primary procedure, which may discourage surgeons from selecting this treatment alternative even if recent studies confirm efficacy. Payers should be encouraged to reimburse physicians commensurate with the intraoperative service time needed to perform a one-stage procedure as adoption will decrease morbidity and save the healthcare system financially.

The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates.

BACKGROUND: To reduce the substantial clinical and financial burden of periprosthetic joint infection (PJI), some surgeons advocate for the use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA), although its effectiveness continues to be debated in the literature. The purpose of this study was to determine whether the routine use of ALBC is cost-effective in reducing PJI after primary TKA. METHODS: We retrospectively reviewed a consecutive series of patients undergoing cemented primary TKA at two hospitals within our institution from 2015 to 2017. We compared demographics, comorbidities, costs, and PJI rates between patients receiving ALBC and plain cement. We performed a multivariate regression analysis to determine the independent effect of ALBC on PJI rate. We calculated readmission costs for PJI and reduction in PJI needed to justify the added cost of ALBC. RESULTS: Of 2511 patients, 1077 underwent TKA with ALBC (43%), with no difference in PJI rates (0.56% vs 0.14%, P = .0662) or complications (1.2% vs 1.6%, P = .3968) but higher cement costs ($416 vs $117, P < .0001) and overall procedure costs ($6445 vs $5.968, P < .0001). ALBC had no effect on infection rate (P = .0894). Patients readmitted with PJI had higher overall 90-day episode-of-care claims costs ($49,341 vs $19,032, P < .001). To justify additional costs, ALBC would need to prevent infection in one of every 101 patients. CONCLUSION: Routine use of ALBC in primary TKA is not cost-effective, adding $299 to the cost of episode of care without a reduction in PJI rate. Further study is needed to determine whether select use of ALBC would be justified in high-risk patients.

Next-Generation Sequencing vs Culture-Based Methods for Diagnosing Periprosthetic Joint Infection After Total Knee Arthroplasty: A Cost-Effectiveness Analysis.

BACKGROUND: Periprosthetic joint infection (PJI) after total knee arthroplasty is challenging to diagnose. Compared with culture-based techniques, next-generation sequencing (NGS) is more sensitive for identifying organisms but is also less specific and more expensive. To date, there has been no study comparing the cost-effectiveness of these two methods to diagnose PJI after total knee arthroplasty. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine the cost-effectiveness from a societal perspective. The primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base case values, culture was not determined to be cost-effective compared to NGS, with an incremental cost-effectiveness ratio of $422,784 per QALY. One-way sensitivity analyses found NGS to be the cost-effective choice above a pretest probability of 45.5% for PJI. In addition, NGS was cost-effective if its sensitivity was greater than 70.0% and its specificity greater than 94.1%. Two-way sensitivity analyses revealed that the pretest probability and test performance parameters (sensitivity and specificity) were the largest factors for identifying whether a particular strategy was cost-effective. CONCLUSION: The results of our model suggest that the cost-effectiveness of NGS to diagnose PJI depends primarily on the pretest probability of PJI and the performance characteristics of the NGS technology. Our results are consistent with the idea that NGS should be reserved for clinical contexts with a high pretest probability of PJI. Further study is required to determine the indications and subgroups for which NGS offers clinical benefit.

A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip.

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

Professional Athletes Are Not at a Higher Risk of Infections After Anterior Cruciate Ligament Reconstruction: Incidence of Septic Arthritis, Additional Costs, and Clinical Outcomes From the French Prospective Anterior Cruciate Ligament Study (FAST) Cohort.

BACKGROUND: The rate of septic arthritis in the knee after anterior cruciate ligament (ACL) reconstruction varies in the literature but is generally less than 1%. It has been reported to be higher in professional athletes (5.7%). PURPOSE: The primary goal was to evaluate the rate of septic arthritis after ACL reconstruction in professional athletes compared with other patients. The secondary goals were to analyze the risk factors; increased cost of infections; return to sport, satisfaction, and functional results at 1-year follow-up; and resolution rate of infections at final follow-up. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This retrospective analysis of prospective data included a continuous series of patients who underwent isolated ACL reconstruction between 2012 and 2016. The main outcome criterion was the development of intra-articular infections in the operated knee. An infection was suggested clinically (knee pain with fever and/or chills) and confirmed bacteriologically in deep tissue samples obtained during revision surgery. All infected patients underwent an emergency reoperation with lavage and debridement along with dual antibiotic therapy first by an intravenous route and then orally for 6 weeks. RESULTS: A total of 1809 of 1859 patients included in the cohort during this period fulfilled inclusion criteria; there were 1632 (90.2%) who underwent primary reconstruction and 177 (9.8%) who underwent revision. The series included 1249 (69%) men and 560 (31%) women, with a mean age of 29.1 ± 9.8 years. Ninety-eight percent of the patients participated in a sport, including 90 (5.0%) at a professional level and 712 (39.4%) competitively. Septic arthritis of the knee developed after a mean 15.7 ± 5.5 days in 7 (0.38%) patients: 5 of 1632 (0.31%) who underwent primary reconstruction and 2 of 177 (1.13%) who underwent revision. Septic arthritis did not develop in any professional or competitive athletes; all affected patients were recreational athletes ( P = .02). The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery (odds ratio [OR], 15; P = .002) and hemarthrosis during the immediate postoperative period (OR, 127.2; P = .002). There were no recurrent infections after a mean follow-up of 2.8 ± 1.2 years. CONCLUSION: None of the professional athletes in this cohort had septic arthritis after ACL reconstruction. There are no particular precautions to be taken in this population. The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery and hemarthrosis during the immediate postoperative period. Similar to all studies published on the subject, there were very few infected patients, which limits the identification of risk factors. REGISTRATION: NCT02511158 (ClinicalTrials.gov identifier).

Trends in Periprosthetic Hip Infection and Associated Costs: A Population-Based Study Assessing the Impact of Hospital Factors Using National Data.

BACKGROUND: Periprosthetic joint infection (PJI) is an important cost driver in hip arthroplasty revisions, thus necessitating careful trend monitoring. Recent national trend data are lacking; we therefore assessed national PJI burden, trends in prevalence, and hospitalization costs. METHODS: We extracted data on hip arthroplasty revisions from the National Inpatient Sample (2003-2013; n = 465,209). Trends in PJI prevalence and hospitalization costs were (1) assessed for the full cohort and (2) stratified by hospital teaching status, hospital bed size (≤299, 300-499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran-Armitage trend test (PJI prevalence) and linear regression (hospitalization costs) determined significance of trends. Trends were adjusted for patient's age, gender, insurance type, race, Deyo-Charlson comorbidities, obesity, length of stay, and hospital characteristics. RESULTS: Overall, PJI prevalence was 15.0% (n = 70,011); adjusted prevalence increased from 13.1% in 2003 to 16.4% in 2013 (P < .0001), while adjusted median PJI hospitalization costs increased from $28,240 in 2003 to $31,529 in 2013 (P < .0001). Rural hospitals had the lowest PJI burden (12.5%; n = 4,525), while urban and teaching hospitals had the highest PJI burden (16.4%; n = 40,297). The stratified analyses, particularly in large hospitals (>500 beds), showed that PJI prevalence increased from 13.0% (2003) to 17.4% (2013; a 33.8% increase; P < .0001). Similarly, PJI revision hospitalization costs increased from a median of $27,490 (2003) to $31,312 (2013; a 14% increase; P < .0001). CONCLUSION: The burden of PJI in hip arthroplasty revision is increasing and-while additional research is needed-there appears to be a particular shift of revision burden to larger hospitals with increasing costs.

Septic Arthritis in Emergency Departments in the US: A National Study of Health Care Utilization and Time Trends.

OBJECTIVE: To assess the health care utilization and emergency department (ED) charges for septic arthritis. METHODS: We performed a retrospective cohort study of ED visits with septic arthritis as the primary diagnosis using the US Nationwide Emergency Department Sample data from 2009-2012. We examined ED charges, hospitalization, and associated time trends. Multivariable models were adjusted for demographics (age, sex, insurance status, residence, and household income), comorbidity, and hospital characteristics to assess factors associated with ED charges and hospitalization. RESULTS: Septic arthritis was responsible for 16,382 ED visits in 2012 in the US, which constituted 0.01% of all ED visits. The number of ED visits was stable from 2009-2012. Total ED charges were $34.6, $30.6, and $36.9 million in 2009, 2010, and 2012, respectively, and mean ED charges were $2,149, $1,866, and $2,257, respectively. The majority of the patients with an ED visit for septic arthritis were hospitalized: 82%, 83%, and 84% in 2009, 2010, and 2012, respectively. Metropolitan residence and western US location were associated with higher ED charges, and the highest income quartile, renal failure, or osteoarthritis were associated with lower ED charges. Female sex, metropolitan residence, metropolitan teaching hospital status, and medical comorbidity (diabetes mellitus, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary heart disease, gout, osteoarthritis, renal failure, and heart failure) were associated with a higher risk of hospitalization. CONCLUSION: Comorbidities were associated with a higher risk of hospitalization after an ED visit for septic arthritis, but not higher ED charges. No time trends in ED visit incidence, ED charges, or hospitalization rate for septic arthritis from 2009-2012 were noted.

The burden of septic arthritis on the U.S. inpatient care: A national study.

OBJECTIVE: To assess the health care burden of septic arthritis in the U.S. and examine the associated factors. METHODS: We used the U.S. Nationwide Emergency Department Sample (NEDS) data of patients hospitalized with septic arthritis as the primary diagnosis from 2009-12 to assess time-trends. Multivariable-adjusted models assessed demographics, comorbidity and hospital characteristics as potential predictors of duration of hospitalization, total hospital (inpatient and ED) charges and discharge to home. RESULTS: In 2009, 2010 and 2012 in the U.S., respectively, there were 13,087, 13,662 and 13,714 hospitalizations with septic arthritis as the primary diagnosis. Respective average hospital stay was 7.4 vs. 7.4 vs. 7.2 days; total hospital charges were $601 vs. $674 vs. $759 million; and proportion discharged home were 43% vs. 43% vs. 44%. Almost 25% each were discharged to a skilled facility or with home health. Age >50 years, Medicaid and self-pay as primary payer, Northeast U.S. hospital location, teaching hospital status, heart failure and diabetes were associated with longer hospitalization; hyperlipidemia, hypertension or gout were associated with a shorter hospital stay. Similar associations were noted for higher hospital charges. Age >50 years, higher income, Medicare insurance, heart failure, diabetes and longer hospital stay were associated with lower odds, and Western U.S. hospital location and gout with higher odds, of discharge to home. CONCLUSIONS: We noted an increase in hospital charges from 2009-12, but no time trends in duration or outcomes of hospitalization for septic arthritis. Comorbidity associations with outcomes indicate the potential for developing interventions to improve outcomes.

Epidemiology, disease spectrum and economic burden of non-typhoidal Salmonella infections in Taiwan, 2006-2008.

The purpose of this study was to understand the seasonal, geographical and clinical characteristics of Taiwanese patients hospitalized for non-typhoidal Salmonella (NTS) infections and their economic burden. Hospital data obtained from the Taiwan National Health Insurance (NHI) database between 2006 and 2008 were analysed. Infants had the highest annual incidence of 525 cases/100 000 person-years. Elderly patients aged >70 years had the highest in-hospital mortality rate (2·6%). Most (82·6%) gastroenteritis occurred in children aged <10 years. Septicaemia, pneumonia, arthritis and osteomyelitis occurred mainly in patients aged >50 years. A median medical cost for NTS-associated hospitalizations was higher for patients with septicaemia than for those with gastroenteritis. Seasonal variation of NTS-associated hospitalizations was correlated with temperature in different areas of Taiwan. In summary, infants had a high incidence of NTS-associated hospitalizations. However, the elderly had a higher in-hospital mortality rate and more invasive NTS infections than children.

National trends in health care utilization and racial and socioeconomic disparities in pediatric pyogenic arthritis.

PURPOSE: To determine national trends and putative racial and socioeconomic disparities in health care utilization in pediatric patients with pyogenic arthritis over a 13-year period. STUDY DESIGN: We assessed trends in length of hospital stay, hospital disposition, and inflation-adjusted charges for pediatric patients hospitalized with pyogenic arthritis based on 13 consecutive years (1988-2000) of the Nationwide Inpatient Sample. Patients with an International Classification of Diseases, Ninth Revision code of pyogenic arthritis were selected for this study. Trends in health care utilization were analyzed, stratified by age, prematurity, joint location, socioeconomic status, and race. RESULTS: The median length of stay (LOS) decreased from 10 to 5 days in 1988 and 2000, respectively (P < 0.05). Whites had a shorter mean LOS (7.8 days) than nonwhites (10.7 days; P < 0.05). For both whites and nonwhites, LOS decreased significantly (P < 0.05), but the difference between the 2 groups remained constant. For patients with a higher socioeconomic status, LOS was shorter (P'< 0.05). The percentage of patients discharged to home'health care increased from 3.8% in 1988 to 18.9% in 2000 (P'< 0.05), but the increase was much greater for whites than nonwhites (P < 0.05). Inflation adjusted total charges increased over time, from a median total charge of 10,098 dollars in 1988 to a median total charge of 11,155 dollars in 2000 (P < 0.05). CONCLUSIONS: There was a trend toward decreased health care utilization, but no decrease in charges for pediatric pyogenic arthritis from 1988 to 2000. Racial disparities still exist, with little improvement over time.

Natural history of Ross River virus-induced epidemic polyarthritis.

OBJECTIVE: To describe the natural history, treatment and cost of Ross River virus-induced epidemic polyarthritis (RRV disease). DESIGN: Questionnaire-based longitudinal prospective study. PARTICIPANTS AND SETTING: Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999. MAIN OUTCOME MEASURES: Scores on two validated quality-of-life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions. RESULTS: 67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality-of-life scores suggested stable chronic illness between six and 12 months after diagnosis. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2-22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as 1018 Australian dollars per patient. CONCLUSIONS: Symptom duration and frequency of long-term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Cost-effectiveness of antibiotic prophylaxis for bacterial arthritis.

The outcome of bacterial arthritis is generally poor: the mortality is 10 - 15% and there is loss of joint function in 25 - 50% of the survivors. The incidence of bacterial arthritis is low: 2 - 6 cases per 100,000 people per year. Risk factors are age, joint disease (especially rheumatoid arthritis [RA]), diabetes mellitus and the presence of a prosthetic joint. The predominant situations that can lead to bacterial arthritis are skin infections of the feet and rarely invasive medical or dental procedures. Due to the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated. However, due to the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and bacterial resistance. In a decision-analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be cost-effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not cost-effective, except possibly in a small group of patients with increased risk.

[Pyogenic infection after joint replacement operations: incidence and economic effects]. / Der pyogene Infekt nach Gelenkersatzoperationen: Inzidenz und ökonomische Auswirkungen.

Infection following arthroplasty is a rare but significant and threatening complication. The incidence is about 2%. Treatment of an infected joint replacement may be demanding, time consuming and expensive. For the treating institution there is a risk of substantial financial losses due to inadequate reimbursement. Calculated on the basis of approximately 150,000 implanted joint protheses/a, an infection rate of 2% and treatment costs of approximately 50,000 [symbol: see text]/infected case the economic burden is an estimated 150 million [symbol: see text]/a in Germany. This amount should justify a sound evaluation of costs related to infection in arthroplasty, which should be the effort of the health insurance organisations. Additionally specific research in the field of infection prevention must be sponsored. The system of reimbursement should be adequately adopted and corrected.

[The comparative costs of vancomycin treatment versus teicoplanin in osteoarticular infection caused by methicillin-resistant staphylococci]. / Le coût comparatif du traitement par vancomycine versus teicoplanine dans l'infection ostéoarticulaire à staphylocoques résistants à la méticilline.

This clinical and economical study compared two glycopeptides regimen i.e., vancomycin and teicoplanin in the treatment of osteoarticular infection involving methicillin-resistant staphylococcus. After randomization, 15 patients (group 1) received vancomycin (23 F per gram) in continuous infusion through a central venous catheter and 15 others (group 2) intramuscular teicoplanin (311-357 F a 400 mg vial). The clinical study focused on treatment tolerance in an in-patient setting as well as in a non in-patient one. The cost analysis focused on total expenses including those of antibiotics, those of medical devices for antibiotic administration and those of the complications caused by the antibiotics use. Total expenses per patient averaged 8744 F with vancomycin and 8555 F with teicoplanin (NS). The apparent money saving by using a cheap antibiotic (i.e. vancomycin) was illusionary as one took in account the expenses for medical devices e.g., central venous catheters required to administer vancomycin and the complications due to the use of these devices.

Antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease: a cost effectiveness analysis.

OBJECTIVE: To assess the cost effectiveness of antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease. METHODS: In a decision analysis, data from a prospective study on bacterial arthritis in 4907 patients with joint disease were combined with literature data to assess risks and benefits of antibiotic prophylaxis. Effectiveness and cost effectiveness calculations were performed on antibiotic prophylaxis for various patient groups. Grouping was based on (a) type of event leading to transient bacteraemia-that is, infections (dermal, respiratory/urinary tract) and invasive medical procedures-and (b) the patient's susceptibility to bacterial arthritis which was increased in the presence of rheumatoid arthritis, large joint prostheses, comorbidity, and old age. RESULTS: Of the patients with joint disease, 59% had no characteristics that increased susceptibility to bacterial arthritis, and 31% had one. For dermal infections, the effectiveness of antibiotic prophylaxis was maximally 35 quality adjusted life days (QALDs) and the cost effectiveness maximally $52 000 per quality adjusted life year (QALY). For other infections, the effectiveness of prophylaxis was lower and the cost effectiveness higher. Prophylaxis for invasive medical procedures seemed to be acceptable only in patients with high susceptibility: 1 QALD at a cost of $1300/QALY; however, the results were influenced substantially when the level of efficacy of the prophylaxis or cost of prophylactic antibiotics was changed. CONCLUSION: Prophylaxis seems to be indicated only for dermal infections, and for infections of the urinary and respiratory tract in patients with increased susceptibility to bacterial arthritis. Prophylaxis for invasive medical procedures, such as dental treatment, may only be indicated for patients with joint disease who are highly susceptible.

[Antibiotic prophylaxis of hematogenous bacterial arthritis]. / Antibiotische preventie van hematogene bacteriële artritis.

The outcome of bacterial arthritis is generally poor: the mortality is 10-15% and there is loss of joint function in 25-50% of the survivors. Adverse prognostic factors are advanced age, a pre-existent joint disease and an infection of a prosthetic joint. The incidence of bacterial arthritis is low: 2-6 per 100,000 persons per year. Risk factors are advanced age, a joint disease--especially rheumatoid arthritis--diabetes mellitus and presence of a prosthetic joint. Situations that can lead to bacterial arthritis are mainly skin infections of the feet and only rarely invasive medical or dental procedures. Because of the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated in guidelines. However, because of the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and increased resistance of bacteria. In a decision analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be (cost-)effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not (cost-)effective, except possibly in a small group of patients with increased risk.