Cost-effectiveness of linezolid and vancomycin in the treatment of surgical site infections

OBJECTIVE

This decision-analytic study was intended to determine the expected cost-effectiveness of linezolid compared to vancomycin for treating surgical site infections (SSIs) caused by methicillin-resistant Staphyloccocus aureus (MRSA) from the perspective of a tertiary-care academic medical center.

RESEARCH DESIGN AND METHODS

This study is a cost-effectiveness analysis based on a modeling approach for the treatment of MRSA SSIs. Three clinical scenarios were considered in the decision analysis: (1) treatment with intravenous (IV) vancomycin during hospitalization and after discharge with home-care follow-up; (2) treatment with IV vancomycin during hospitalization, followed by oral linezolid after discharge; (3) treatment with oral linezolid during hospitalization and after discharge. Cost data was obtained from internal and external sources. Cure rate probabilities for MRSA SSIs were obtained from records at the medical center and from results of a randomized, multicenter trial. Healthcare costs for each scenario were obtained from the medical center, healthcare buying groups, and national databases. The robustness of the baseline cost-effectiveness determination was evaluated using sensitivity analyses over a broad range of costs and probabilities.

RESULTS

Treatment with oral linezolid during hospitalization and after discharge (scenario 3) was associated with lower costs (8923, 11,479, and 12,481 dollars, respectively) and greater effectiveness (0.867, 0.787, and 0.707, respectively) compared to the IV vancomycin/oral linezolid switch (scenario 2) and IV vancomycin (scenario 1), so it dominated the latter options in the base-case, incremental cost-effectiveness analysis (10,292, 14,486, and 17,653 dollars per MRSA SSI cure, respectively). Furthermore, the sensitivity analysis demonstrated that the IV vancomycin/oral linezolid (scenario 2) option would be the expected cost-effective choice only if the length of hospitalization for this scenario was less than 6 days or if the probability of cure with oral linezolid (scenario 3) was less than or equal to 0.72; otherwise, the oral linezolid option was dominant. A major limitation of this study is the utilization of probability estimates from both institutional and published research sources. Additionally, the success rates for linezolid were obtained from one relatively small randomized, open-label trial.

CONCLUSIONS

Using decision-analytic modeling, treatment with oral linezolid during hospitalization and after discharge is expected to be the most cost-effective approach for treating SSIs caused by MRSA.

The economic effect of oral linezolid versus intravenous vancomycin in the outpatient setting: the payer perspective

Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy. The object of this study was to determine the health economic and resource utilization effects of outpatient treatment with oral linezolid relative to IV vancomycin. Longitudinal claims data from 80 health care plans were used. Patients 18 years and older, who did not have osteomyelitis, with a pharmacy claim for linezolid or vancomycin between January 1, 2002 and March 31, 2004 were eligible. Clinical and resource utilization data were collected for 12 months before and 35 days after treatment. Patients treated with linezolid were matched with controls treated with vancomycin, based on propensity scoring. Direct medical costs paid by health plans were compared. A total of 1,048 matched pairs were identified. Demographic and clinical characteristics were comparable between groups. Patients with linezolid claims had lower resource utilization versus those with vancomycin claims during follow-up, including fewer mean physician office visits (4.1+/-5.7 vs. 8.4+/-13.8 visits; P< .001); lab/diagnostic claims (6.3+/-18.0 vs. 10.4 +/-15.2 claims; P< .001); pharmacy claims (7.3+/-8.1 vs. 13.6+/-17.4 claims; P< .001); emergency room visits (9.7% vs. 13.9%; P= .003) and hospitalization (15.3% vs. 19.1%; P= .024). Patients receiving vancomycin were more likely to be hospitalized or have an emergency room visit than patients receiving linezolid. Mean total adjusted cost was 4,707 dollars less for linezolid compared with vancomycin (8,401dollars vs. 13,108 dollars; P< .001). Similar trends were observed for patients matched based on complicated skin and soft tissue infection diagnosis. Outpatient treatment with oral linezolid was associated with significantly lower resource utilization and total medical costs compared with IV vancomycin.

Impact of linezolid on economic outcomes and determinants of cost in a clinical trial evaluating patients with MRSA complicated skin and soft-tissue infections

BACKGROUND

In clinical trials, linezolid has demonstrated higher clinical cure rates and shorter hospital duration for patients than has vancomycin for the treatment of complicated skin and soft-tissue infections (cSSTIs).

OBJECTIVE

To assess economic outcomes of linezolid versus vancomycin and evaluate determinants of treatment costs for cSSTIs.

METHODS

Economic data were obtained from US subjects enrolled in a multinational, open-label, clinical trial of cSSTIs caused by suspected or proven methicillin-resistant Staphylococcus aureus (MRSA). Subjects were randomized to receive intravenous or oral linezolid or intravenous vancomycin for 7-21 days. Costs for each patient were evaluated by applying nationally representative per diem hospital costs by hospital ward. Intravenous administration costs were applied to the duration of intravenous treatment. Factors contributing to the cost of therapy were evaluated using multivariate regression analysis.

RESULTS

Seven hundred seventeen US patients were included in the study. Demographics were similar between treatment groups. Length of stay and duration of intravenous therapy were shorter for linezolid-treated patients. Mean +/- SD cost for intent-to-treat population patients treated with linezolid versus vancomycin was 4865 US dollars +/- 4367 versus 5738 US dollars +/- 5190, respectively (p = 0.017), and in the MRSA population was 4881 US dollars +/- 3987 versus 6006 US dollars +/- 5039, respectively (p = 0.041). Factors significantly associated with increased cost included vancomycin therapy, age, and comorbidities, including diabetes. After adjusting for all other factors, treatment with linezolid was associated with significantly lower treatment costs compared with vancomycin.

CONCLUSIONS

Linezolid therapy was associated with improved clinical outcomes and significantly lower treatment costs than was vancomycin. The largest cost advantage was demonstrated in patients with documented MRSA cSSTIs.

Pharmacoeconomic Evaluation of Linezolid Versus Teicoplanin in Bacteremia by Gram-Positive Microorganisms*

OBJECTIVE

The objective of this study was to compare the efficiency of linezolid versus teicoplanin in the treatment of bacteremia produced by Gram-positive microorganisms through a pharmacoeconomic analysis based on clinical results obtained from a previous clinical trial.

METHODS

We applied an analysis of cost-effectiveness elaborated through a pharmacoeconomic model. We defined each unit of effectiveness as 'each successfully cured of infections with bacteremia.' We used the program Pharma-Decision (version Hospital 1.1) that allows to build interactive pharmacoeconomic models. Effectiveness data of both antibiotics were obtained from a published clinical trial, while resources consumed were obtained from the same source and from a consensus provided by a local expert panel. Only direct costs were included in the analysis without taking into consideration indirect costs. The perspective chosen was hospital assistance and the time horizon was set to 28 days. All costs are expressed in Euros.

RESULTS

Linezolid demonstrated a better clinical outcome with less associated costs compared to teicoplanin (88.5 versus 56.7% of cured patients and 5,557.04 versus 6,327.43 <euro> per treated patient, respectively), thus resulting in a lower cost-effectiveness ratio for linezolid versus teicoplanin (6,279.1 versus 11,159.5 <euro> per cured patient with a 95% CI of 5,960.2-6,510.4 and 10,865.2-12,647.3, respectively) which results in a the dominant position for linezolid. The sensitivity analysis showed that linezolid was always the most efficient option even when modifying the value of variables with higher uncertainty.

CONCLUSIONS

Linezolid is a more efficient option than teicoplanin because it presents higher rate of effectiveness with lower consumption of resources, thus being a dominant alternative in the treatment of Gram-positive infection with bacteremia.

The safety and efficacy of linezolid in orthopaedic practice for the treatment of infection due to antibiotic-resistant organisms

Linezolid is the first of a new class of antibacterial agents, the oxazolidinones. It is particularly effective against Gram-positive infections and little resistance has been reported, even amongst methicillin- and vancomycin-resistant bacteria. The compound's excellent oral bioavailability and reasonable safety profile, along with the increasing incidence of resistant infections, means that linezolid offers a valuable alternative to more traditional therapies such as vancomycin. Although no large randomised trials have been carried out in patients with orthopaedic infections such as osteomyelitis and septic arthritis, early results are encouraging. However, the apparent increase in observed adverse events, particularly bone marrow suppression, seen with prolonged administration, means that treatment of such patients must be undertaken with careful surveillance, at least until these complications are better understood.

Cost-effectiveness of linezolid versus vancomycin in mechanical ventilation-associated nosocomial pneumonia caused by methicillin-resistant staphylococcus aureus

Linezolid, an oxazolidinone-class antimicrobial agent, is a new drug; its use has frequently been questioned due to its high price. However, recent trials have demonstrated that the use of linezolid in mechanical ventilation-associated nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus (VAP-MRSA) may be justified due to its improved efficacy compared to vancomycin. Price and cost have different magnitudes, and clinical efficacy should always be considered in the decision-making process. Our objective was to determine whether linezolid treatment was more cost-effective than vancomycin for treating VAP-MRSA.

METHODOLOGY

Elaboration of an economic model from a metanalysis of previous clinical trials comparing both drugs, through a cost-effectiveness analysis. Costs of the treatments were calculated using Brazilian parameters and were compared to the results obtained in the metanalysis. In order to compare the results with real life conditions, costs were calculated for both name brand and for generic vancomycin.

RESULTS

The cost (May/2004) per unit (vial, ampoule or bag) was R$ 47.73 for the name-brand vancomycin, R$ 14.45 for generic vancomycin and R$ 214.04 for linezolid. Linezolid's efficacy in VAP-MRSA according to the metanalysis was 62.2% and vancomycin's efficacy was 21.2%. The total cost per cured patient was R$ 13,231.65 for the name-brand vancomycin, R$ 11,277.59 for generic vancomycin and R$ 7,764.72 for linezolid.

CONCLUSION

Despite the higher price per unit, linezolid was more cost-effective than vancomycin.

Clinical and economic outcomes of oral linezolid versus intravenous vancomycin in the treatment of MRSA-complicated, lower-extremity skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus

BACKGROUND

Resistant bacteria often complicate the management of skin and soft tissue infections of the lower extremities. This open-label study compared oral linezolid and intravenous vancomycin for management of complicated skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Patients aged 18 years or older with proven MRSA-related complicated skin and soft-tissue infections requiring surgical intervention were randomized to receive oral linezolid (n=30) or intravenous vancomycin (n=30) for 7 to 21 days. Clinical and microbiological outcomes, duration of hospitalization and drug treatment, and outpatient charges were determined.

RESULTS

Linezolid was associated with greater rates of clinical cure and improvement (P=.015), a 3-day shorter median length of stay (P=.003), and reduced outpatient charges (P<.001). Vancomycin therapy was associated with more treatment failures and subsequent lower-extremity amputations (P=.011).

CONCLUSIONS

Clinical outcomes were significantly better with linezolid than with vancomycin. Additionally, linezolid was associated with reduced length of stay and outpatient charges.

[Expensive modern therapy options in intensive care medicine in Germany-- are they being used? Results of a questionnaire]

BACKGROUND

The use of new, high-priced therapies in intensive care medicine should be assessed by a questionnaire.

METHODS

Questionnaires were sent to 849 intensive care units in Germany. The use of three new strategies were asked: treatment of methicilline resistant staphylococcus aureus (MRSA) patients (using linezolid), of severe bleeding (using rFVIIa), and of severe sepsis (using activated protein C [aPC]).

RESULTS

Approximately 39 % of the questionnaires were answered and analyzed. All three new strategies were only rarely or very rarely used in Germany even in universities and hospitals with more than 1000 beds. This appears to be very astonishing because all substances were subject to extensive marketing campaigns, received scientific prices (linezolid) or were strongly recommended by some scientific societies (aPC). One major concern to the use of the new approaches was based on the high pricing. Prices were assessed as excessive or very excessive. In spite of a mass of information about the substances, a lot of the intensivists reviewed the scientific basis as weak and not justifying the use of the costly substances.

CONCLUSIONS

Modern, costly pharmaceutical approaches in intensive care medicine are widely not accepted in Germany. Especially a tight financial corset hinders most intensivists to use these strategies that may be life-saving in some patients. A solution to this problem is urgently required that can be reached only in intensive exchange with all who are responsible for this dilemma.

Linezolid: a pharmacoeconomic review of its use in serious Gram-positive infections

Linezolid (Zyvox), the first available oxazolidinone antibacterial agent, has good activity against Gram-positive pathogens, including multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium. Randomised multicentre trials in patients with various types of serious Gram-positive infections showed that clinical cure rates with linezolid were similar to those with vancomycin or teicoplanin. In some subgroup analyses, which must be interpreted with a degree of caution, clinical advantages were noted for linezolid (e.g. versus vancomycin in confirmed MRSA nosocomial pneumonia and MRSA-complicated skin and soft tissue infections). Although generally well tolerated, gastrointestinal adverse effects are relatively common with linezolid and it has been associated with thrombocytopenia and myelosuppression. The oral bioavailability of linezolid is approximately 100%, thus allowing sequential intravenous-to-oral administration without changing the drug or dosage regimen. Healthcare resource use data from various countries indicate that this practical advantage translates into at least a trend towards reduced length of hospital stay compared with vancomycin, which may offset its several-fold higher acquisition cost. Modelled analyses from the US, despite some limitations, indicate that, compared with vancomycin, linezolid is associated with lower total hospitalisation costs for the treatment of patients with cellulitis and has a favourable incremental cost-effectiveness ratio of approximately US30,000 dollars per QALY gained (2001 value) for patients with ventilator-associated pneumonia. Broadly similar results have also been reported in modelled analyses from other countries. In conclusion, for patients with serious Gram-positive infections, including those caused by suspected or proven multidrug-resistant pathogens such as MRSA, linezolid is an effective and generally well tolerated therapeutic option. Linezolid is currently the only antibacterial agent with good activity against MRSA that can be administered orally (as well as intravenously). It may be particularly useful as an alternative to vancomycin in patients who have impaired renal function, poor or no intravenous access, require outpatient therapy, or who have been unable to tolerate glycopeptides. Healthcare resource use studies and pharmacoeconomic analyses generally support the use of linezolid in some subgroups of patients, although results should be interpreted with due consideration of the study limitations.

[Linezolid, an agent from a new class of antibiotics]

Linezolid is the first of a new class of antibacterial agents, the oxazolidinones, to become available. Linezolid has a unique mechanism of action in its inhibition of bacterial protein synthesis in Gram-positive and a number of anaerobic bacteria. Because of this unique mechanism of action, linezolid exhibits no cross-resistance with other antibiotics and is effective against methicillin-resistant staphylococci, penicillin-resistant pneumococci and vancomycin-resistant enterococci. The excellent bioavailability after oral administration (almost 100%) makes it suitable for outpatient treatment and treatment by general practitioners. In the Netherlands, however, the indications for linezolid are limited by its high cost, the availability of other effective antibiotics for the treatment of sensitive micro-organisms, and the toxicity associated with a prolonged treatment period. Resistance to the new agent was reported rather quickly after the introduction of linezolid.

An economic evaluation of a European cohort from a multinational trial of linezolid versus teicoplanin in serious Gram-positive bacterial infections: the importance of treatment setting in evaluating treatment effects

In a recent multinational trial, hospital resource use and total cost of treatment were compared between linezolid and teicoplanin for severe Gram-positive bacterial infections among 227 European hospitalised patients. The results show that the linezolid group had a 3.2-day (6.3 for linezolid versus 9.5 for teicoplanin groups) shorter mean intravenous antibiotic treatment duration. Certain baseline variables, particularly the inpatient location at enrolment and the presence of outpatient/home parenteral antibiotic therapy (OHPAT), had substantial effects on length of stay (LOS) and cost of treatment. After adjusting for the between-treatment difference in these two variables and other baseline variables, the results showed non-significant shorter LOS and lower mean total cost of treatment for the linezolid group among patients with no access to OHPAT.

[The role of linezolid in the therapy of infections caused by multiresistant gram-positive cocci]

Gram-positive cocci are becoming more and more common agents of nasocomial infections, primarily enterococci and staphylococci in the field of surgical site and bloodstream infection. At the same time, the frequency of multiresistant enterococci and methicillin-resistant staphylococci has increased, whereas glycopeptide-resistant enterococcal strains and, recently, staphylococci with reduced susceptibility to glycopeptides have appeared, so making the use of glycopeptides as the "last-chance drugs" ineffective. Under those circumstances, the synthesis of new potent antibiotics, such as oxazolidinones, is both desirable and welcome. Linezolid possesses a high activity against all multiresistant gram-positive cocci, favourable pharmacokinetics, a good safety profile, a complete bioavailability after and administration permitting switch therapy, a low capacity of inducing resistance, and both clinical and microbiologic efficacy as demonstrated by a number of clinical trials conducted on thousands of patients. So, linezolid is an important therapeutic option in the treatment of infections caused by multiresistant enterococcal and staphylococcal strains.

Linezolid compared with teicoplanin for the treatment of suspected or proven Gram-positive infections

The efficacy, safety and tolerability of linezolid was compared with teicoplanin in a randomized, controlled, open-label, multicentre study of 430 patients with suspected or proven Gram-positive infection. Patients received intravenous (iv) +/- oral linezolid 600 mg every 12 h (n = 215) or iv or intramuscular teicoplanin (n = 215) for up to 28 days. Clinical outcomes in the intent-to-treat (ITT) and clinically-evaluable populations and microbiological success rates in microbiologically evaluable patients were assessed at follow-up (test of cure). Investigator assessed clinical cure rates at end of treatment (EOT) in ITT patients treated with linezolid (95.5%) were superior to those of teicoplanin (87.6%) for all infections combined, indicating a 7.9% statistically significant treatment advantage for linezolid (P = 0.005, 95% CI: 2.5, 13.2). Clinical cure rates by baseline diagnosis were consistently higher at EOT for the linezolid versus teicoplanin groups with skin and soft tissue infection (96.6% versus 92.8%), pneumonia (96.2% versus 92.9%) and bacteraemia (88.5% versus 56.7%). The 31.8% treatment advantage in bacteraemic patients (but not for those seen in the other infection categories) for linezolid-treated patients was statistically significant (P = 0.009, 95% CI: 10.2, 53.4). Bacterial eradication rates for linezolid exceeded those of teicoplanin for all infection sites combined but this did not reach statistical significance (81.9% versus 69.8%, respectively; P = 0.056). Adverse event rates were similar between the treatment groups, were mild to moderate in severity, and resolved quickly following treatment. The linezolid group experienced a higher incidence of drug related adverse events (30% versus 17%; P = 0.002), and notably of gastrointestinal effects (13.0% versus 1.9%, P = 0.001). However, antibiotic discontinuation rates as a result of drug related adverse events were similar (4.7% in the linezolid group versus 3.7%). Linezolid was clinically superior to teicoplanin in the treatment of Gram-positive infections.

Linezolid for treatment of ventilator-associated pneumonia: A cost-effective alternative to vancomycin*

OBJECTIVES

To determine the incremental cost-effectiveness of linezolid compared with vancomycin for treatment of ventilator-associated pneumonia due to Staphylococcus aureus.

DESIGN

Decision model analysis of the cost and efficacy of linezolid vs. vancomycin for treatment of ventilator-associated pneumonia. The primary outcome was the incremental cost-effectiveness of linezolid in terms of cost per added quality-adjusted life-year gained. Other outcomes were the marginal costs per hospital survivor and per year of life saved generated by using linezolid. Model estimates were derived from prospective trials of linezolid for ventilator-associated pneumonia and from other studies describing the costs and outcomes for ventilator-associated pneumonia.

SETTING AND PATIENTS

Hypothetical cohort of 1,000 patients diagnosed with ventilator-associated pneumonia.

INTERVENTIONS

In the model, patients received either linezolid or vancomycin.

MEASUREMENTS AND MAIN RESULTS

The incremental cost-effectiveness of linezolid was calculated as the additional quality-adjusted life-years resulting from therapy with linezolid divided by the sum of the incremental costs arising because of use of linezolid (e.g., higher direct costs for linezolid, costs per in-hospital care of survivors, and posthospitalization costs). Despite its higher cost, linezolid was cost-effective for treatment of ventilator-associated pneumonia. The cost per quality-adjusted life-year equals approximately 30,000 dollars. The model was moderately sensitive to the estimated efficacy of linezolid over vancomycin. Nonetheless, even with all inputs simultaneously skewed against, linezolid remains a cost-effective option (cost per quality-adjusted life-year approximately 100,000 dollars). Based on Monte Carlo simulation, the results of our analysis are robust across a range of model inputs and assumptions (95% confidence interval for cost per quality-adjusted life-year ranges from 23,637 dollars to 42,785 dollars).

CONCLUSIONS

Linezolid is a cost-effective alternative to vancomycin for the treatment of ventilator-associated pneumonia.

Cost analysis of switching from IV vancomycin to PO linezolid for the management of methicillin-resistant Staphylococcus species

BACKGROUND

Infections with methicillin-resistant Staphylococcus species (MRSS) are associated with higher treatment costs than infections with methicillin-sensitive Staphylococcus species in the United States--partly because of an increased length of hospital stay (LOS).

OBJECTIVE

This study used pharmacoeconomic modeling to evaluate the costs and outcomes associated with the use of i.v. vancomycin compared with p.o. linezolid in the treatment of MRSS-infected patients.

METHODS

A retrospective chart review was used to determine the number of cases with confirmed or presumed MRSS infections treated with i.v. vancomycin during calendar-year 2000 at the Veterans Affairs Greater Los Angeles Healthcare System inpatient facility. Patients who were eligible for a switch to p.o. linezolid with or without early discharge to home were identified. Cost differences associated with conversion from i.v. to p.o. therapy (compared with continued i.v. therapy) were estimated based on a mean decreased LOS and a decrease in the costs associated with catheter-related adverse events. Rates and costs of catheter-related adverse events were based on estimates from the literature. Sensitivity analyses were performed by variation of the estimated mean LOS decrease in the SD and by variation of the estimates for incidence and costs related to catheter complications. Costs were measured in year 2000 US dollars, and differences were not assessed for statistical significance.

RESULTS

Of 177 patients treated with i.v. vancomycin, 103 (58%) were eligible for conversion to p.o. linezolid and 55 (31%) were eligible for early discharge from the hospital with continuation of p.o. therapy. Early discharge was associated with a mean (SD) LOS decrease of 3.3 (2.9) days. Annual mean total cost savings in patients eligible for conversion from i.v. vancomycin to p.o. linezolid with early discharge were $294,750 (range, $35,730-$553,790). For cases eligible for inpatient conversion from i.v. vancomycin to p.o. linezolid therapy (n=48), the mean total annual cost difference was an increase of $6340 for p.o. linezolid (range, -$12,910 to $11,900).

CONCLUSION

These results--although partly based on estimates from the literature, rather than direct measurements--support the use of p.o. linezolid with or without early discharge as a potential cost-savings alternative for eligible patients treated with a full course of i.v. vancomycin for suspected or confirmed MRSS infection.

Novelties in the field of antimicrobial compounds for the treatment of lower respiratory tract infections

Emergence of antimicrobial resistance is a growing problem and a public health threat. New drugs must be designed with emerging needs in mind: specific resistant and hard-to-treat organisms. But the difficulty to find real new drugs is a major problem. Only the oxazolidinones, the cationic peptides and the lipopeptide antibiotics can be truly regarded as structurally novel drugs, although the peptide deformylase inhibitors and, possibly, the pleuromutilins can be considered a potential advancement in the field. Obviously, these antibiotics must be reserved only to cases of documented ineffectiveness of the common antimicrobial agents.

Comparison of linezolid with oxacillin or vancomycin in the empiric treatment of cellulitis in US hospitals

In this decision-model analysis, the authors compared overall clinical efficacy and total cost of empiric treatment of hospitalized cellulitis patients prescribed linezolid and oxacillin or vancomycin. The authors hypothesized that, when used appropriately, empiric linezolid treatment is an effective, potentially cost-saving antibiotic compared with treatment initiated with oxacillin or vancomycin. Data on efficacy, duration of antibiotic treatment, and hospital stay for first-line treatment success were obtained from two clinical trials. Other medical resource use data were obtained from an expert panel of clinicians. US hospital direct medical costs were determined using standard costing techniques. Overall efficacy and total cost of treatment were estimated for combinations of the risk of being infected with methicillin-resistant pathogens. Sensitivity analyses were performed to test the impact of changes in major assumptions. Overall first-line efficacy is better for empiric treatment initiated with linezolid than with oxacillin or vancomycin across the spectrum of the risk of being infected with methicillin-resistant bacteria. The average total cost of treatment is lower for treatment initiated with linezolid than with vancomycin across the spectrum, or than with oxacillin when the risk of being infected with methicillin-resistant pathogens is 18.7 % or higher. Linezolid appears to be at least as effective as vancomycin or oxacillin for empiric treatment of hospitalized cellulitis patients. Linezolid is likely to be less costly compared with vancomycin at all resistance rates and with oxacillin when the risk of infection with methicillin-resistant pathogens is greater than 18.7 %, a resistance rate commonly seen in US hospitals.

Early switch and early discharge opportunities in intravenous vancomycin treatment of suspected methicillin-resistant staphylococcal species infections

BACKGROUND

Patients with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MR-CoNS) infections are usually treated with intravenous (IV) vancomycin and remain hospitalized for the duration of IV therapy. Oral linezolid has excellent bioavailability and activity against MRSA and MR-CoNS and offers the potential for outpatient treatment of MRSA and MR-CoNS infections.

OBJECTIVE

To determine the potential for early switch (ES) from IV vancomycin to oral linezolid and subsequent early discharge (ED) in hospitalized, adult patients treated for an MRSA or MR-CoNS infection.

METHODS

We conducted a retrospective cohort study at the Veterans Administration Greater Los Angeles Healthcare System from January 1 through December 31, 2000. Potential reductions in vancomycin use, hospital length of stay (LOS), and economic savings were determined.

RESULTS

A total of 103 of 177 (58%) treatment courses for MRSA or MR-CoNS infections were potentially eligible for ES, with annual and mean decreases in vancomycin use of 535 defined daily doses and 5.2 days per event. Of the ES cohort, 55 of 103 (53%) courses were potentially eligible for ED, with an annual and mean reduction in LOS of 181 days and 3.3 days per event. The total potential savings was $220,181, at an average of $3,478 per event.

CONCLUSION

Early switch to oral linezolid for treatment of MRSA or MR-CoNS infections could reduce vancomycin use, hospital length of stay, and economic costs.

Hospital resource use and cost of treatment with linezolid versus teicoplanin for treatment of serious gram-positive bacterial infections among hospitalized patients from South America and Mexico: results from a multicenter trial

BACKGROUND

Linezolid is a novel oxazolidinone antibiotic that is effective for the treatment of gram-positive bacterial infections. The oral formulation has the potential to reduce length of stay (LOS) when used as a substitute for parenteral glycopeptide antibiotics. In a recent multinational trial comparing linezolid (i.v. followed by oral administration) with teicoplanin (i.v. alone or switched to i.m. administration), linezolid was found to have better efficacy (P = 0.005) and similar safety for treating serious gram-positive infections.

OBJECTIVE

The purpose of this study was to compare hospital resource use (primarily LOS) and cost of treatment between linezolid and teicoplanin for hospitalized patients with serious gram-positive infections in South America and Mexico using data from the multinational trial.

METHODS

In a multinational, Phase IIIb, open-label, comparator-controlled trial, data were collected from hospitalized patients in centers in 6 South America can countries and Mexico with suspected or confirmed serious gram-positive infections. Patients were randomly assigned to receive i.v. linezolid 600 mg BID (for the entire treatment period [7-28 days] or switched to oral linezolid 600 mg BID) or i.v. teicoplanin (for the entire treatment period or switched to i.m. teicoplanin) dosed per approved prescription information. Data on direct medical resource utilization were collected for each patient, including duration and doses of study medication, location of hospitalization and LOS, comedications, tests and procedures, and outpatient service usage. Unit costs for the medical resources were obtained from secondary sources.

RESULTS

A total of 203 patients (97 treated with linezolid and 106 treated with teicoplanin) were enrolled from these 7 countries. The unadjusted results showed that compared with teicoplanin, patients treated with linezolid had a 3.1-day shorter mean i.v. antibiotic treatment duration (P < 0.001), a 2.0- to 2.2-day shorter median and mean LOS (P = 0.03), and a 311 US dollars lower mean total cost of treatment (P = NS). After controlling for age, race, sex, site of infection, inpatient location when the antibiotic treatment started, number of historical and current comorbidities, and whether the patient had a diagnosis of systemic inflammatory response syndrome or sepsis, the multivariate adjusted results were similar to the unadjusted results. The linezolid group had a 1.6-day shorter adjusted LOS or 66% greater odds of early discharge (P = 0.049) and a 335 US dollars lower adjusted mean total cost of treatment (P = NS).

CONCLUSION

Linezolid was associated with shorter LOS and duration of IV antibiotic treatment than teicoplanin for serious gram-positive infections in the population studied. Linezolid therapy has the potential to reduce the total cost of treatment.

Cost-minimization analysis and audit of antibiotic management of bone and joint infections with ambulatory teicoplanin, in-patient care or outpatient oral linezolid therapy

Bone and joint infections are significant causes of morbidity, mortality and healthcare costs. The cost of treatment for such infections is driven primarily by the length of hospital stay. Many of these infections will require treatment with prolonged periods of parenteral antibiotic therapy. Clinicians and healthcare managers are being attracted increasingly by administering treatment in the ambulatory setting as this offers clinical, economic and quality of life advantages from both the hospital's and patient's perspective. Our retrospective audit of managing 55 treatment episodes of bone and joint infections with teicoplanin delivered in the outpatient or home setting revealed that the mean cost of care per episode of infection was less with treatment in the ambulatory setting ( pound 1749.15) compared with the in-patient setting ( pound 11 400) or compared with the hypothetical situation of treatment with oral linezolid in the home setting ( pound 2546). Teicoplanin therapeutic drug monitoring appears to be valuable in establishing optimal serum levels, which appear to correlate with good clinical outcomes. The potential for alternative day or thrice weekly dosing with teicoplanin may offer further cost advantages whilst maintaining equivalent clinical effectiveness.

Linezolid: implications for neurosurgical infections

Nosocomial infections affect a significant number of intensive care unit (ICU) patients including those in the neurosurgical ICU. Gram-positive organisms are responsible for many of these infections and often these pathogens are resistant to some of the older antimicrobial agents. Two new classes of antibiotics have been developed: streptogramins and oxazolidinones. Linezolid is an oxazolidinone, which has been shown to be effective against methicillin- and vancomycin-resistant Gram-positive pathogens. It may be administered orally or parenterally, and displays favorable pharmacokinetic properties, with rapid and complete absorption after oral administration. Linezolid is generally well tolerated with mild gastrointestinal related adverse effects. Linezolid provides a useful alternative in the treatment of Gram-positive infections, particularly those caused by resistant organisms. It has tremendous clinical utility, especially in the ICU where infections and multi-drug resistant rates are high and treatment options become limited.

Ergot and triptan overuse in Austria--an evaluation of clinical data and cost

Austria is one of the countries, in which ergots are still the most commonly used acute anti-migraine drugs. Overuse and chronification is a clinical problem for ergots, but also for the recently developed triptans. In a retrospective study for the year 1999 we evaluated clinical data from all Austrian neurological hospitals including cost of withdrawal as well as the estimated cost for ergots and triptans on the pharmaceutical retail market. We identified a total of 96 patients that underwent withdrawal, all of whom because of ergot overuse, and some with considerable long-term side-effects. The cost of withdrawal (more than 1300 000) together with direct cost of medication amounted to more than 11 million. In contrast, cost of medication for triptans was 12.8 million for the same year, without any cost for withdrawal. If only cost aspects were to be considered in the prescription of acute anti-migraine drugs, our data would suggest to choose ergots rather than triptans. However, as scientific evidence is clearly in favour of triptans, decision making for the prescribing clinicians is more complex and will primarily focus on optimizing patient care, but also depend on the respective socio-economic situation.