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Walker BS, Schmidt RL, Tantravahi S, Kim K, Hanson KE. Cost-effectiveness of antifungal prophylaxis, preemptive therapy, or empiric treatment following allogeneic hematopoietic stem cell transplant. Transpl Infect Dis 2019; 21:e13148. [PMID: 31325373 DOI: 10.1111/tid.13148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Invasive fungal infection (IFI) is a life-threatening complication of allogeneic hematopoietic stem cell transplantation (HSCT) that is also associated with excess healthcare costs. Current approaches include universal antifungal prophylaxis, preemptive therapy based on biomarker surveillance, and empiric treatment initiated in response to clinical signs/symptoms. However, no study has directly compared the cost-effectiveness of these treatment strategies for an allogeneic HSCT patient population. METHODS We developed a state transition model to study the impact of treatment strategies on outcomes associated with IFIs in the first 100 days following myeloablative allogeneic HSCT. We compared three treatment strategies: empiric voriconazole, preemptive voriconazole (200 mg), or prophylactic posaconazole (300 mg) for the management of IFIs. Preemptive treatment was guided by scheduled laboratory surveillance with galactomannan (GM) testing. Endpoints were cost and survival at 100 days post-HSCT. RESULTS Empiric treatment was the least costly ($147 482) and was equally effective (85.2% survival at 100 days) as the preemptive treatment strategies. Preemptive treatments were slightly more costly than empiric treatment (GM cutoff ≥ 1.0 $147 910 and GM cutoff ≥ 0.5 $148 108). Preemptive therapy with GM cutoff ≥ 1.0 reduced anti-mold therapy by 5% when compared to empiric therapy. Posaconazole prophylaxis was the most effective (86.6% survival at 100 days) and costly ($152 240) treatment strategy with a cost of $352 415 per life saved when compared to empiric therapy. CONCLUSIONS One preemptive treatment strategy reduced overall anti-mold drug exposure but did not reduce overall costs. Prevention of IFI using posaconazole prophylaxis was the most effective treatment strategy and may be cost-effective, depending upon the willingness to pay per life saved.
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Affiliation(s)
| | - Robert L Schmidt
- ARUP Laboratories, Salt Lake City, UT, USA.,Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Srinivas Tantravahi
- Department of Medicine, Division of Hematology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Kibum Kim
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Kimberly E Hanson
- ARUP Laboratories, Salt Lake City, UT, USA.,Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA.,Department of Medicine, Infectious Diseases Division, University of Utah Health Sciences Center, Salt Lake City, UT, USA
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Perlin DS, Rautemaa-Richardson R, Alastruey-Izquierdo A. The global problem of antifungal resistance: prevalence, mechanisms, and management. THE LANCET. INFECTIOUS DISEASES 2017; 17:e383-e392. [DOI: 10.1016/s1473-3099(17)30316-x] [Citation(s) in RCA: 458] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 04/09/2017] [Accepted: 04/10/2017] [Indexed: 01/05/2023]
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Giacobbe DR, Del Bono V, Viscoli C, Mikulska M. Use of 1,3-β-D-glucan in invasive fungal diseases in hematology patients. Expert Rev Anti Infect Ther 2017; 15:1101-1112. [PMID: 29125373 DOI: 10.1080/14787210.2017.1401467] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) remain a leading cause of morbidity and mortality in hematology patients. Within a diagnostic-driven approach, the use of the serum (1,3)-ß-D-glucan (BDG) test represents a valid tool for the early diagnosis and treatment of IFD. Areas covered: The available literature on the use of BDG in hematology patients was systematically retrieved. Then, it was reviewed and discussed, to identify key issues pertaining to a clinically-oriented narrative presentation of the topic. Expert commentary: The use of BDG in hematology patients at risk for invasive aspergillosis (IA) is secondary to the use of galactomannan. However, since BDG is not specific for IA, it offers an advantage of diagnosing also other IFD, such as candidiasis and pneumocystosis. The limitations of BDG include high costs and lower sensitivity in hematology patients compared to other cohorts. The risk of false positive results is possibly lower in real life than in theory, since glucan-free equipment is available and modern dialysis membranes and blood products usually do not release BDG. Thus, in experienced hands and selected clinical situations, BDG is a useful diagnostic tool, particularly due to short turnover time to results and versatility in diagnosing different IFD.
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Affiliation(s)
- Daniele Roberto Giacobbe
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Valerio Del Bono
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Claudio Viscoli
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Malgorzata Mikulska
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
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Busca A, Lessi F, Verga L, Candoni A, Cattaneo C, Cesaro S, Dragonetti G, Delia M, De Luca A, Guglielmi G, Tumbarello M, Martino G, Nadali G, Fanci R, Picardi M, Potenza L, Nosari A, Aversa F, Pagano L. SEIFEM 2010-E: economic evaluation of posaconazole for antifungal prophylaxis in patients with acute myeloid leukemia receiving induction chemotherapy. Leuk Lymphoma 2017; 58:2859-2864. [PMID: 28508692 DOI: 10.1080/10428194.2017.1318438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Posaconazole demonstrated clinical superiority over fluconazole and itraconazole for prophylaxis of mold infections, although concerns exist regarding the high acquisition cost for posaconazole. In this respect, we sought to analyze the costs of antifungal prophylaxis in patients with acute myeloid leukemia (AML) who received prophylactic posaconazole (n = 510, 58%), itraconazole (n = 120, 14%) or fluconazole (n = 175, 20%) during induction chemotherapy. The estimated cost of antifungal prophylaxis as well as the costs of subsequent systemic antifungal therapy for treatening an invasive fungal infections (IFI) was higher in the posaconazole group compared to itraconazole and fluconazole groups. Based on the Monte Carlo simulations, the itraconazole group had the highest cost, followed by the posaconazole and fluconazole group, although the overall survival was higher in the posaconazole group as compared to the other groups. In conclusion, the cost of prophylaxis with posaconazole in AML patients compares favorably with conventional antifungal agents.
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Affiliation(s)
| | - Federica Lessi
- b Ematologia ed Immunologia Clinica, Azienda Ospedaliera di Padova , Italy
| | - Luisa Verga
- c Unità di Ematologia , Università di Milano, Ospedale S.Gerardo , Monza , Italy
| | - Anna Candoni
- d Division of Hematology and SCT Unit , University Hospital of Udine , Italy
| | - Chiara Cattaneo
- e Divisione di Ematologia , Spedali Civili di Brescia , Italy
| | - Simone Cesaro
- f Azienda Ospedaliera Universitaria Integrata , Verona , Italy
| | - Giulia Dragonetti
- g Istituto di Ematologia, Università Cattolica del Sacro Cuore , Roma , Italy
| | - Mario Delia
- h Sezione di Ematologia , Dipartimento dell'Emergenza e dei Trapianti d'Organo-Università di Bari , Italy
| | - Alessio De Luca
- i Farmacia ospedaliera Fondazione policlinico Universitario A. Gemelli Roma , Italy
| | - Gaspare Guglielmi
- i Farmacia ospedaliera Fondazione policlinico Universitario A. Gemelli Roma , Italy
| | - Mario Tumbarello
- j Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore , Roma , Italy
| | - Giordana Martino
- j Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore , Roma , Italy
| | - Gianpaolo Nadali
- k UOC Ematologia , Azienda Ospedaliera Universitaria Integrata di Verona , Italy
| | - Rosa Fanci
- l Unità Funzionale di Ematologia , Azienda Ospedaliera-Universitaria Careggi e Università di Firenze , Italy
| | - Marco Picardi
- m Dipartimento di Scienze Biomediche Avanzate Università degli Studi di Napoli Federico II , Napoli , Italy
| | - Leonardo Potenza
- n Dipartimento di Scienze Mediche e Chirurgiche Materno-infantili e dell'adulto , Università degli Studi di Modena e Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico , Modena , Italy
| | - Annamaria Nosari
- o Dipartimento di Ematologia ed Oncologia , Niguarda Cancer Center ASST Grande Ospedale Metropolitano Niguarda , Milano , Italy
| | - Franco Aversa
- p Sezione di Ematologia , Università di Parma , Italy
| | - Livio Pagano
- g Istituto di Ematologia, Università Cattolica del Sacro Cuore , Roma , Italy
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Barnes RA, White PL. PCR Technology for Detection of Invasive Aspergillosis. J Fungi (Basel) 2016; 2:jof2030023. [PMID: 29376940 PMCID: PMC5753136 DOI: 10.3390/jof2030023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/20/2016] [Accepted: 07/26/2016] [Indexed: 11/16/2022] Open
Abstract
The application of molecular technologies to aid diagnosis and management of infectious diseases has had a major impact and many assays are in routine use. Diagnosis of aspergillosis has lagged behind. Lack of standardization and limited commercial interest have meant that PCR was not included in consensus diagnostic criteria for invasive fungal disease. In the last ten years careful evaluation and validation by the Aspergillus European PCR initiative with the development of standardized extraction, amplification and detection protocols for various specimen types, has provided the opportunity for clinical utility to be investigated. PCR has the potential to not only exclude a diagnosis of invasive aspergillosis but in combination with antigen testing may offer an approach for the early diagnosis and treatment of invasive aspergillosis in high-risk populations, with the added benefit of detection of genetic markers associated with antifungal resistance.
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Affiliation(s)
- Rosemary A Barnes
- Department of Medical Microbiology and Infectious Diseases, Cardiff University School of Medicine, Cardiff CF14 4XN, UK.
| | - P Lewis White
- Public Health Wales Microbiology, Cardiff CF14 4 XW, UK.
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