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Continuous vs intermittent infusion of cefuroxime for the treatment of community-acquired pneumonia |
Ambrose P G, Quintiliani R, Nightingale C H, Nicolau D 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 Infusion of cefuroxime for the treatment of community-acquired pneumonia (CAP).
Economic study type Cost-effectiveness analysis.
Study population Adult patients with a primary diagnosis of CAP.
Setting Community teaching hospital. The study was carried out at the Hartford Hospital, Hartford, Connecticut, USA.
Dates to which data relate The dates to which effectiveness and resource use data relate and the price year were not reported.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken on the same patient sample as that used in the effectiveness study. The costing was carried out prospectively alongside the effectiveness study.
Study sample 25 patients with an initial diagnosis of CAP were evaluated in each treatment group. Patients who met the following criteria were included in the study: presence of new pulmonary infiltrate on chest roentgenogram and either clinical history consistent with pneumonia or physical findings suggestive of pneumonia. Patients were excluded from the study if they were under 18 years of age, were pregnant or nursing, had a known hypersensitivity to penicillins or cephalosporins, required additional antimicrobial agents with activity against the suspected pathogen, had neutropenia or harboured a pathogen that was resistant to cefuroxime. One patient in the II group was excluded from the study because of fatal cardiac arrest on day 1 of hospitalisation. Three patients were excluded from the CI group: one patient withdrew consent, one patient had a change in diagnosis, and one patient inadvertently removed intravenous infusion lines. No power calculations were reported.
Study design This was a prospective non-randomised controlled trial with concurrent controls carried out at a single centre. All patients were evaluated again 21-28 days after completion of treatment.
Analysis of effectiveness The analysis of the clinical study was based on the intention to treat principle. The primary health outcomes studied included the percentage of bacterial culture specimens obtained, duration of IV therapy, hospital length of stay, duration of outpatient oral antibiotic therapy, and the total amount of intravenous cefuroxime administered to patients. At analysis, groups were comparable in terms of age, gender, weight, renal function, diagnostic data, and severity of illness index.
Effectiveness results Bacterial culture specimens were obtained in 88% and 82% of the II and CI groups, respectively. The duration of IV antibiotic therapy was 93.4 hours in the II group compared to 82.6 hours in the CI group, (p=0.40). The duration of combined IV/inpatient oral therapy was 131.9 hours in the II group and 115.4 hours in the CI group, (p=0.39). Length of hospital stay was 136.2 hours in the II group and 124.6 hours in the CI group, (p=0.56). The duration of outpatient antibiotic therapy was 142.5 hours in the II group and 188.2 hours in the CI group, (p=0.05). The total amount of IV cefuroxime administered in the CI group (5,953 mg) compared with the II group (8,021 mg) was significantly less, (p=0.04).
Clinical conclusions CI therapy does not forfeit quality of care and decreases the amount of antibiotic used and, potentially, the duration of treatment.
Modelling No modelling was undertaken.
Measure of benefits used in the economic analysis Clinical cure or improvement at the end of IV therapy was used as the benefit measure.
Direct costs Costs were not discounted given the short time frame of the study (less than 1 year). Quantities and costs were reported separately. Direct costs measured antimicrobial costs which included acquisition, preparation, administration costs and costs of retreatment. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. The costs of supplies and labour were based on time and motion studies performed at Hartford Hospital. The price year was not stated.
Statistical analysis of costs The unpaired Student's t-test was used to compare cost data.
Sensitivity analysis No sensitivity analysis was reported.
Estimated benefits used in the economic analysis No significant differences were observed in the time to resolution of signs and symptoms. Clinical cure or improvement at the end of IV therapy occurred in 96% of patients in the II group and in 95% of patients in the CI group. No additional treatment failures were identified in either group 30 days after discontinuation of IV therapy. No substantial difference in the rate of phlebitis was found between the two groups.
Cost results Mean total costs of IV therapy amounted to $83.9 in the II group and to $63.6 in the CI group (p=0.04).
Synthesis of costs and benefits The cost per cure was $93.72 for CI therapy and $121.94 for II therapy (p=0.04).
Authors' conclusions CI therapy permits a reduction of expenditures without forfeiting quality of care, through decreases in the amount of antibiotic used, administration and preparation costs and, potentially, duration of treatment.
CRD COMMENTARY - Selection of comparators rationale for the choice of comparator was clear.
Validity of estimate of measure of benefit sample size of the study was too small to compare efficacy of CI and II therapy formally. The assessment of microbiologic outcome was limited because cultures from only 18% of patients whose sputa and/or blood was cultured yielded an etiologic agent. The limited identification of a bacterial etiology was likely, due to the method of sample selection. The duration of IV therapy was also influenced by hospital policy to switch patients rapidly from IV to oral therapy.
Validity of estimate of costs direct costs were included. The issue of generalisability was not specifically considered. Costs associated with the treatment of phlebitis were not included.
Implications of the study The authors noted that this was a pilot study and that large, randomised controlled trials are needed to verify the equivalence of efficacy between treatment regimens.
Source of funding Supported by grant 1280-98 from Hartford Hospital, Hartford, Connecticut.
Bibliographic details Ambrose P G, Quintiliani R, Nightingale C H, Nicolau D P. Continuous vs intermittent infusion of cefuroxime for the treatment of community-acquired pneumonia. Infectious Diseases in Clinical Practice 1998; 7(9): 463-470 Other publications of related interest 1. Gotfried M H, Killian A D, Servi R J, Danziger L H, Rodvold K A. IV cefuroxime plus oral clarithromycin or IV erythromycin for the treatment of community-acquired pneumonia in hospitalised patients: a pilot study. Clinical Drug Investigation 1997;14(1):23-34.
2. Siegel R E, Halpern N A, Almenoff P L, Lee A, Cashin R, Greene J G. A prospective randomized study of inpatient IV antibiotics for community-acquired pneumonia: the optimal duration of therapy. Chest 1996;110(4):965-971.
Indexing Status Subject indexing assigned by NLM MeSH Communicable Diseases; Guidelines as Topic; Humans; Pharmacy Service, Hospital /standards; Societies, Medical; United States AccessionNumber 21999000029 Date bibliographic record published 30/11/1999 Date abstract record published 30/11/1999 |
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