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Use of cefixime in an IV to oral stepdown program to reduce antimicrobial costs |
Elbe D, Frighetto L, Nickoloff D, Jewesson P |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Cefixime in an intravenous (IV) to oral stepdown programme for ceftriaxone. 400mg cefixime wasadministrated once daily. Ceftriaxone was prescribed as 1,000mg or 2,000mg once daily.
Economic study type Cost-effectiveness analysis.
Study population Male and female patients receiving cefixime and patients receiving ceftriaxone.
Setting Hospital. The economic study was carried out in Vancouver, BC, Canada.
Dates to which data relate The main effectiveness data were obtained from a single study conducted in 1998. Resource (primarily time and motion) and cost data were mainly taken from 1991-1996 sources. The price year was 1998.
Source of effectiveness data The estimates of the number of times cefixime was used as a stepdown agent, the appropriateness or acceptance of cefixime use, clinical cure or improvement, adverse reactions and clinical failures were obtained from a single study.
Link between effectiveness and cost data The costing was retrospectively undertaken on the same patient sample as that used in the cost effectiveness analysis.
Study sample One hundred and ten patients were included in the study. Overall, 50 (25 male) patients received cefixime. The mean age was 60 years. The median duration of stay was 17 days. The source of cefixime prescription was: 20 (40%) stepdown from ceftriaxone (65% male, mean age: 55 years, mean duration of stay: 33 days), 19 (38%) stepdown from other IV antibiotic(s), 10 (20%) cefixime used as initial antibiotic therapy and 1 (2%) conversion from other oral antibiotic(s). Overall, 60 patients received ceftriaxone: 11 (73% male, mean age: 68 years, mean duration of stay: 36 days) involved stepdown to an alternative oral agent and 49 (59% male, mean age: 58 years, mean duration of stay: 35 days) involved no stepdown. Power calculations to determine the sample size were not undertaken.
Study design Retrospective cohort study. The duration of the follow-up was not explicitly stated but is likely to have been until discharge. The loss to follow-up was 4 patients in the cefixime group: 2 died of factors considered unrelated to infection and 2 received less than 3 days of antibiotic therapy.
Analysis of effectiveness The analysis of the clinical study was based on treatment completers only. The primary health outcomes were number of times cefixime was used as a stepdown agent, appropriateness or acceptance of cefixime use, clinical cure or improvement and adverse reactions
Effectiveness results Cefixime was used as a stepdown agent in 78% of all cefixime treatment courses (51% of which were stepdown from ceftriaxone and 49% were stepdown from parenteral agents including ceftizoxime, cefuroxime and ceftazidime). Appropriateness and acceptance of cefixime use were 52% and 22%, respectively. Overall 93% achieved either a clinical improvement (57%) or a cure (37%) and 7% experienced a relapse. Adverse reactions were identified in 48% cefixime-treated patients. Appropriateness of ceftriaxone to cefixime, ceftriaxone to other oral drug and ceftriaxone no stepdown were 85%, 100% and 96% respectively. Clinical cure or improvement was achieved in 90% ceftriaxone to cefixime stepdown patients (11 cured and 7 improved).
Clinical conclusions A high rate of clinical cure or improvement in the cefixime group indicates that cefixime is effective when used alone or as a stepdown agent for the types of infections observed in this study.
Measure of benefits used in the economic analysis The author did not develop a summary measure of benefit. The principal benefit was expressed in terms of cost avoidance.
Direct costs Acquisition, preparation and delivery costs for cefixime, ceftriaxone and all other antibiotics were included in the analysis. Antibiotic costs were extracted from "Antibiotic Cost Comparison Card" and from time and motion studies. The quantities were reported separately from the prices. The quantity/cost boundary adopted was the hospital. Discounting was not undertaken. The price year was not clearly stated.
Statistical analysis of costs Chi-squared analysis (two tailed) was performed.
Currency Costs were expressed in dollars ($) and, although not specifically stated, it is presumed that these were Canadian rather than US dollars.
Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis Cost results A total cost of $13,533 across the 39 stepdown treatment courses was avoided.
Synthesis of costs and benefits The antibacterial cost avoidance was $347 per treatment course realised.
Authors' conclusions Cefixime has a potential role as a stepdown agent for ceftriaxone. The study has shown that costs can be avoided without apparent negative impact on patient care.
CRD COMMENTARY - Selection of comparators The reason for the choice of comparator is clear. Cefixime possesses an antimicrobial spectrum of activity similar to that of ceftriaxone. As an oral formulation of ceftriaxone was not available and the daily cost of cefixime was approximately 95% lower than ceftriaxone, a ceftriaxone to cefixime stepdown programme could provide significant cost savings. You, as a user of this database, should consider whether these are widely used health technologies in your own setting.
Validity of estimate of measure of benefit The estimate of measure of benefit was cost avoidance. The data do not appear to have been used selectively.
Validity of estimate of costs Resource quantities were reported separately from the prices. Adequate details of the method of quantity/cost estimation were given. As noted by the authors, this study did not include any additional cost avoidance resulting from early patient discharge which could be greater than cost avoidance from the antibiotic therapy itself.
Other issues As the authors noted, the issue of generalisabilityto other settings should be viewed with caution as the data considered in this study are institution-specific. Appropriate comparisons were made with other studies, particular in terms of parenteral to oral stepdown from ceftriaxone to cefixime or other antibiotic stepdown programmes and complication rates. Results do not appear to have been presented selectively. However, the study might suffer from the small number of inpatient treatment courses recorded (50).
Implications of the study As noted by the authors, a direct comparative trial of ceftriaxone to cefixime stepdown versus ceftriaxone to ciprofloxacin stepdown would be required.
Bibliographic details Elbe D, Frighetto L, Nickoloff D, Jewesson P. Use of cefixime in an IV to oral stepdown program to reduce antimicrobial costs. Hospital Formulary 1998; 33(1): 54-63 Indexing Status Subject indexing assigned by CRD MeSH Administration, Oral; Adult; Bacterial Infections /prevention & Cefotaxime /administration & Cephalosporins /economics /administration & Cost-Benefit Analysis; Female; Injections, Intravenous; Male; control; dosage; dosage /economics /therapeutic use AccessionNumber 21998000213 Date bibliographic record published 31/05/1999 Date abstract record published 31/05/1999 |
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