Costs and cost-effectiveness of management of possible serious bacterial infections in young infants in outpatient settings when referral to a hospital was not possible: Results from randomized trials in Africa

Introduction

Serious bacterial neonatal infections are a major cause of global neonatal mortality. While hospitalized treatment is recommended, families cannot access inpatient treatment in low resource settings. Two parallel randomized control trials were conducted at five sites in three countries (Democratic Republic of Congo, Kenya, and Nigeria) to compare the effectiveness of treatment with experimental regimens requiring fewer injections with a reference regimen A (injection gentamicin plus injection procaine penicillin both once daily for 7 days) on the outpatient basis provided to young infants (0–59 days) with signs of possible serious bacterial infection (PSBI) when the referral was not feasible. Costs were estimated to quantify the financial implications of scaleup, and cost-effectiveness of these regimens.

Methods

Direct economic costs (including personnel, drugs and consumable costs) were estimated for identification, prenatal and postnatal visits, assessment, classification, treatment and follow-up. Data on time spent by providers on each activity was collected from 83% of providers. Indirect marginal financial costs were estimated for non-consumables/capital, training, transport, communication, administration and supervision by considering only a share of the total research and health system costs considered important for the program. Total economic costs (direct plus indirect) per young infant treated were estimated based on 39% of young infants enrolled in the trial during 2012 and the number of days each treated during one year. The incremental cost-effectiveness ratio was calculated using treatment failure after one week as the outcome indicator. Experimental regimens were compared to the reference regimen and pairwise comparisons were also made.

Results

The average costs of treating a young infant with clinical severe infection (a sub-category of PSBI) in 2012 was lowest with regimen D (injection gentamicin once daily for 2 days plus oral amoxicillin twice daily for 7 days) at US$ 20.9 (95% CI US$ 16.4–25.3) or US$ 32.5 (2018 prices). While all experimental regimens B (injection gentamicin once daily plus oral amoxicillin twice daily, both for 7 days), regimen C (once daily of injection gentamicin injection plus injection procaine penicillin for 2 days, thereafter oral amoxicillin twice daily for 5 days) and regimen D were found to be more cost-effective as compared with the reference regimen A; pairwise comparison showed regimen D was more cost-effective than B or C. For fast breathing, the average cost of treatment with regimen E (oral amoxicillin twice daily for 7 days) at US$ 18.3 (95% CI US$ 13.4–23.3) or US$ 29.0 (2018 prices) was more cost-effective than regimen A. Indirect costs were 32% of the total treatment costs.

Conclusion

Scaling up of outpatient treatment for PSBI when the referral is not feasible with fewer injections and oral antibiotics is cost-effective for young infants and can lead to increased access to treatment resulting in potential reductions in neonatal mortality.

Clinical trial registration

The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.

Cost effectiveness of local collagen-gentamicin as prophylaxis for sternal wound infections in different risk groups

OBJECTIVES

In a randomized trial addition of local collagen-gentamicin in the sternal wound reduced the rate of sternal wound infection (SWI) to about 50% compared to intravenous prophylaxis alone. The aim of the present study was to evaluate the economic rationale for its use in every-day clinical practice. This includes the question whether high-risk groups that may have particular benefit should be identified.

DESIGN

For each patient with SWI in the trial the costs attributable to the SWI were calculated. Risk factors for SWI were identified and any heterogeneity of the effect of the prophylaxis examined.

RESULTS

The mean cost of a SWI was about 14500 Euros. A cost effectiveness analysis showed that the prophylaxis was cost saving. The positive net balance was even higher in risk groups. Assignment to the control group, overweight, diabetes, younger age, mammarian artery use, left ventricular ejection fraction <35% and longer operation time were independent risk factors for infection.

CONCLUSION

The addition of local collagen-gentamicin to intravenous antibiotic prophylaxis was dominant, i.e. resulted in both lower costs and fewer wound infections.

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

INTRODUCTION

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

METHODS

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82.

RESULTS

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

CONCLUSIONS

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

A clinical and economic study of community-acquired pneumonia between single versus combination therapy

BACKGROUND

Pneumonia is one of the leading causes of morbidity and mortality among children in many developing countries. It is reported that 12.9 million children under 5 years of age died world-wide in 1990 and one-third of these deaths or 4.3 million annually were attributed to acute respiratory infection with pneumonia.

OBJECTIVES

On this basis, a study was conducted in a district hospital to study the therapy outcomes of antibiotic regimens used in pediatric community-acquired pneumonia (CAP) management and to conduct a cost-effectiveness analysis (CE) between IV ampicillin versus combination therapy of IV ampicillin and IV gentamicin.

METHOD

A prospective, randomized, controlled, single blind study was conducted in a pediatric ward in a 80-bed district hospital. Pediatric patients diagnosed with CAP aged 2 months to 5 years old were randomly and equally divided into two treatment arms: ampicillin versus ampicillin plus gentamicin. The dose of IV ampicillin used in this study was 100 mg/kg/day divided every 6 h and 5 mg/kg of IV gentamicin as a single daily dose. Both clinical and economic evaluations were carried out to compare both treatment arms.

RESULTS

With the inclusion and exclusion criteria, only 40 patients diagnosed with CAP were included in the study. The results showed that the two treatment arms were significantly different (P < 0.05) in terms of duration of patients on ampicillin, number of days of hospitalization and time to switch to oral therapy. A significant difference was noted between the two treatment modalities in terms of effectiveness and cost (P < 0.05).

CONCLUSION

Overall, the endpoint of this study showed that the total cost per patient of ampicillin-treated group is cheaper than the total cost with the combination therapy (ampicillin plus gentamicin) and reduced unnecessary exposure to adverse effects or toxicities. Besides that, addition of gentamicin in the treatment modalities will only increase the cost of treatment without introducing any changes in the treatment outcome.

Liquid gentamicin in bone cement: a laboratory study of a potentially more cost-effective cement spacer

BACKGROUND

Liquid gentamicin is approved by the Food and Drug Administration, is readily available, and is much less costly than tobramycin, the more commonly used antibiotic in cement spacers. The purpose of the present study was to test the mechanical properties, elution characteristics, and antibacterial activity of liquid gentamicin in an acrylic bone cement spacer.

METHODS

Standardized specimens consisting of Palacos cement combined with liquid gentamicin, powdered tobramycin, or no antibiotic were fashioned, and the three groups were tested with regard to compressive and tensile strength, elution characteristics (with use of radioimmunoassays), and antibacterial activity (with use of bioassays).

RESULTS

The ultimate compression strength decreased by 49% (from 64.65 +/- 3.89 MPa to 32.96 +/- 3.33 MPa) and the ultimate tension strength decreased by 46% (from 35.85 +/- 2.97 MPa to 19.20 +/- 0.36 MPa) when the specimens containing 480 mg of liquid gentamicin were compared with the controls. The addition of tobramycin had no significant effect compared with the controls. The majority of gentamicin was released from the cement during the initial twenty-four hours (mean concentration, 26.4 mcg/mL). The mean concentrations at three and six weeks were 4.15 and 0.65 mcg/mL, respectively. The bioassays confirmed the bactericidal activity of the gentamicin released from the cement.

CONCLUSIONS

Liquid gentamicin in bone cement is potent and bactericidal. Although the mechanical properties of the cement are significantly diminished by the addition of liquid gentamicin, the temporary nature of the cement spacer makes its use potentially worthwhile given the substantial cost savings to the hospital and the patient.

Choice of antibiotics for infection prophylaxis in emergency cesarean sections in low-income countries: a cost-benefit study in Mozambique

BACKGROUND

There is a need to assess the cost-benefit of different models of antibiotic administration for the prevention of post cesarean infection, particularly in resource-scarce settings.

DESIGN

Randomized, nonblinded comparative study of a single combined preoperative dose of gentamicin and metronidazole vs. a post cesarean scheme for infection prophylaxis.

METHODS

Pregnant women (n = 288) with indication for emergency cesarean section were randomly allotted to two groups. Group 1 (n = 143) received the single, combined dose of prophylactic antibiotics and group 2 (n = 145) received, over 7 days, the postoperative standard scheme of antibiotics followed in the department. Both groups were followed up during 7 days for detection of signs of wound infection, endometritis, peritonitis and urinary tract infection.

MAIN OUTCOME MEASURES

Prevalence of postoperative infection, mean hospital stay and costs of antibiotics used.

RESULTS

Women completing the study (n = 241) were distributed into group 1 (n = 116) and group 2 (n = 125). No significant difference was found neither in the prevalence of postoperative infection nor in the mean hospital stay. No death occurred. The cost of the single dose of prophylactic antibiotics was less than one-tenth of the cost of the standard postoperative scheme.

CONCLUSION

In our setting, the administration of a single dose of 160 mg of gentamicin in combination with 500 mg of metronidazole before emergency cesarean section for prevention of infection is clinically equivalent to existing conventional week-long postoperative therapy, but at approximately one-tenth of the cost.

[Comparative clinical-economic analysis of antibiotic therapy in pyogenic inflammatory diseases of the lower extremities]

A randomized comparative investigation was carried out in two equal groups of patients with pyo-inflammatory diseases of lower extremities (the total number 50 patients) in order to study effectiveness and tolerance to Netilmycin (1st group) and Gentamycin (2nd group) given in combination with Cefasolin. Clinical symptoms were estimated immediately after operation, in 3, 6 and 10-12 days after it. Bacteriological investigations were fulfilled immediately after operation, in 72 h and in 6-10 days after the beginning of antibacterial therapy. Clinical and biochemical investigations of blood were fulfilled before and in 10 days after the beginning of the treatment. Effectiveness of the treatment in the first group was 100%, in the second group--80%. In the second group the antibiotics were changed in 20% of cases and the average duration of hospitalization among the patients of this group was reliably longer that in the first group. The eradication rating of Netilmycin was higher than that of Gentamycin (25 strains from 25 and 20 from 25 respectively). Gentamycin had a pronounced nephrotoxic effect (elevation of the level of creatinin and urea of blood in dynamics by 21% and 32%), as compared with Netilmycin (9% and 3%). Total expenses to antibiotic therapy in the first group made up 97,650 rub, and in the second group 106,245 rub. Netilmycin in combination with Cefasolin was more effective for acute pyo-inflammatory diseases of lower extremities than a combination of Gentamycin with Cefasolin, it more rapidly resulted in reduction of clinical signs of inflammation, was better endured and more economical.

Piperacillin-tazobactam is more effective than ceftriaxone plus gentamicin in febrile neutropenic patients with hematological malignancies: a randomized comparison

GOALS

Efficacy and costs of empirical antibacterial therapy in febrile neutropenic patients are important issues. Several strategies have been reported to be similarly effective: monotherapy with cefepime, ceftazidime or a carbapenem or duotherapy with an antipseudomonal beta-lactam antibiotic or ceftriaxone in combination with an aminoglycoside. Piperacillin-tazobactam monotherapy is promising, but its role in this setting still has to be defined.

PATIENTS AND METHODS

Of 212 consecutive febrile episodes in 130 neutropenic patients with hematological malignancies randomized to receive either piperacillin-tazobactam (4.5 g every 8 h; group A) or ceftriaxone (2 g once daily plus gentamicin 5 mg/kg once daily; group B), 183 episodes (98 group A, 85 group B) were evaluable for response.

RESULTS

Defervescence within 72 h without modification of the antibiotic therapy was achieved in 56/98 episodes (57.1%) in group A and in 30/85 (35.3%) in group B (P=0.0047). If fever persisted, teicoplanin plus gentamicin (group A) or teicoplanin plus ciprofloxacin (group B) were added. All patients still febrile then received meropenem, teicoplanin and amphotericin B. With these modifications of antibiotic therapy, 89.8% of patients in group A had responded at 21 days but only 71.8% in group B (P=0.005). The mean total antibiotic drug cost in group A was only 39.4% of that in group B (euro 445 versus euro 1129; P=0.010).

CONCLUSION

Piperacillin-tazobactam monotherapy is significantly more effective and cost-efficient than ceftriaxone plus gentamicin as first-line therapy in febrile neutropenic patients with hematological malignancies.

[Health Economical Evaluation of antibiotic prophylaxis against postoperative endophthalmitis]

BACKGROUND

Two independent epidemiological studies recently suggested the prophylactic relevance of an intraocular antibiosis against endophthalmitis after cataract surgery. The resulting intervention programme, however, has not only ethical drawbacks, but also has a health economical dimension, which will be focussed in this paper.

MATERIAL AND METHODS

A cost analysis is performed to compare the direct costs saved by prevention of endophthalmitis cases and the costs generated by the prophylaxis itself. Furthermore, the clinics' indirect costs due to treatment of unprevented endophthalmitis cases are estimated.

RESULTS

The overall gain in direct costs turns out to be about 368 000 Euro p. a., the indirect costs from the clinics' view can be reduced by about 260 000 Euro p. a. due to prevention of endophthalmitis cases by the antibiotic intervention.

CONCLUSIONS

From an economical point of view, antibiotic prophylaxis can be suggested; the risk of longitudinally reduced antibiotic effectiveness of the antibiotic agents, however, strongly calls for an overall health political decision rather than for an immediate implementation of the corresponding intervention programme.

A pilot study evaluating the safety and microbiologic efficacy of an economically viable antimicrobial lozenge in patients with head and neck cancer receiving radiation therapy

BACKGROUND

Mucositis occurs in almost all radiotherapy-treated head and neck cancer patients, in approximately 75% of patients receiving hematopoietic marrow transplantation, and in approximately 40% of all patients who receive chemotherapy. Mucositis is painful, may affect all oral functions, and is a dose- and rate-limiting toxicity of therapy for cancer. Radiation-associated mucositis (onset, intensity, and duration) has been shown in recent clinical trials to be modified by the use of antibacterial/antifungal lozenges.

PURPOSE

The aim of this collaborative two-center phase II study was to assess the toxicity and microbiologic efficacy of an economically viable antimicrobial lozenge in the management of patients receiving radiation therapy for head and neck cancer.

MATERIALS AND METHODS

Seventeen patients scheduled to receive radical or postoperative radiotherapy were provided with bacitracin, clotrimazole, and gentamicin (BCoG) lozenges (one lozenge dissolved in the mouth qid from day 1 of radiotherapy until completion). Ease of use and palatability of the lozenges, patients' symptoms (swallowing and pain), and quantitative and qualitative microbiologic evaluation of an oral rinse collection was conducted at least once weekly during radiation therapy.

RESULTS

No significant side effects were reported from the use of the lozenges. The lozenges were well tolerated at the beginning of treatment by all patients, with some minor difficulty associated with oral discomfort toward the end of the treatment. Microbiologic evaluation showed consistent elimination of yeast organisms in all patients. In four patients there was no growth of gram-negative bacilli on culture, whereas in two patients, fluctuating counts were seen, and one patient had increased counts. The remaining patients had significant reduction in the gram-negative bacilli counts.

CONCLUSIONS

This study demonstrated that the BCoG lozenge is tolerable and microbiologically efficacious, achieving elimination of Candida in all patients and reduction in gram-negative flora in most patients. A phase III study is underway to evaluate the clinical efficacy of this lozenge.

Once daily dosing of gentamicin in infants and children

BACKGROUND

Aminoglycosides are frequently used in children. The standard daily dosing (SDD) in infants and children is twice or three times daily depending on age. The aim of this paper is to review the current data regarding the safety and effectiveness of once daily dosing (ODD) of gentamicin in children.

METHODS

A Medline search was conducted for comparison studies between ODD and SDD of gentamicin in children in term of pharmacokinetic indices and toxicity.

RESULTS

Overall 13 studies describing ODD of gentamicin in children were found suitable for this review. In most studies steady state peak serum gentamicin concentrations were significantly higher in the ODD groups. Steady state trough concentrations >2 microg/ml were documented in 5 to 55% of patients treated with the SDD as compared with 0 to 24% in the ODD groups. The mode of dosing did not affect the volume of distribution; however, the t1/2 was significantly longer in the ODD groups. ODD was found to be cost-saving. In a few studies the efficacy of ODD was similar to that of SDD.

CONCLUSIONS

These studies suggest that ODD compared with SDD of gentamicin is theoretically more efficacious and has no higher toxicity at 48 to 96 h in neonates and at 3 to 10 days of therapy in older infants and children.

Safety of intravenous bolus administration of gentamicin in pediatric patients

OBJECTIVE

To determine the safety of gentamicin administered intravenously as a bolus.

METHODS

All patients (n = 123, ages: up to 18y, 121; 21y, 1; 31y, 1) who received gentamicin intravenously as a bolus over a four-month period were studied retrospectively. Patient demographics, type of infection, dosing regimen, length of therapy, peak and trough serum concentrations, blood urea nitrogen, serum creatinine, and urine output were reviewed. Patients were stratified into four groups and data analyzed statistically.

RESULTS

Mean initial dose (5.32 +/- 2.38 mg/kg/d) was consistent with established guidelines for age and kidney development, with subsequent adjustments based on serum concentrations. Susceptible organisms were eradicated with a mean length of therapy of 6.9 +/- 6.9 days (range 1-35). Patients received a median of nine doses: 42% received doses every eight hours and 33% received doses every 24 hours. No relationship between dosing and abnormal serum creatinine were found (p = 0.69). The estimated cost savings mainly from less nursing time and lower equipment and supply use were $50/patient with bolus administration of gentamicin.

CONCLUSIONS

Intravenous bolus administration was safe in pediatric patients and was associated with lower costs.

Gentamicin dosing in neonatal patients

OBJECTIVE

To compare trough and peak serum gentamicin concentrations in neonatal patients using two dosing regimens.

METHOD

A retrospective audit of gentamicin serum concentrations obtained with the current neonatal gentamicin-dosing regimen (regimen 1) was conducted. Results were then compared with the introduction of a new regimen (regimen 2). Preliminary results necessitated a change to a further dosage schedule (regimen 3), where data was again collected.

RESULTS

For regimen 1, 79% of patients achieved satisfactory trough concentrations, 30% achieved satisfactory peak concentrations, and 16% achieved a satisfactory combined trough and peak concentration. For regimen 2, 80% of patients achieved satisfactory trough concentrations, 63% achieved satisfactory peak concentrations, and 48% achieved a satisfactory combined trough and peak concentration. For regimen 3, 76% of patients achieved satisfactory trough concentrations, 56% achieved satisfactory peak concentrations, and 45% achieved a satisfactory combined trough and peak concentration.

CONCLUSION

Regimen 3 shows a marked improvement in serum gentamicin concentrations. However neonates in the 32-38 weeks post-conceptional age group achieved higher trough and peak serum gentamicin levels than expected. Therefore the dosage interval in this group of neonates will be increased from 18 hourly to 24 hourly dosing, and regimen reaudited.

Comparative review of topical ophthalmic antibacterial preparations

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations. Fusidic acid and bacitracin are selective for gram-positive bacteria whereas polymyxin B targets gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones. The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye. Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers. Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

Individualized pharmacokinetic monitoring results in less aminoglycoside-associated nephrotoxicity and fewer associated costs

STUDY OBJECTIVE

To examine the impact of individualized pharmacokinetic monitoring (IPM) on the development of aminoglycoside-associated nephrotoxicity (AAN).

DESIGN

Retrospective case-control study.

SETTING

Two teaching hospitals.

SUBJECTS

Two thousand four hundred five patients who received aminoglycosides.

INTERVENTION

Aminoglycoside therapy dosed by either IPM or physicians' directions.

MEASUREMENTS AND MAIN RESULTS

Patients receiving IPM were significantly less likely to develop AAN by both univariate (7.9% vs 13.2%, p=0.02) and multivariate methods (odds ratio 0.42, p=0.002). Female sex was protective against AAN. Age 50 years and above, high initial aminoglycoside trough, long duration of therapy, and concurrent piperacillin, clindamycin, or vancomycin increased risk of AAN. We estimated that IPM decreased AAN costs by $90,995/100 patients.

CONCLUSION

Individualized pharmacokinetic monitoring significantly decreased the frequency of AAN and its associated economic costs.

[Once-daily dosage of aminoglycosides--a therapeutic simplification and an economical benefit]

Conventionally, aminoglycosides have been administered in two or three daily doses. Numerous in-vitro and animal experiments and several clinical trials favour a once-daily dosage regimen of aminoglycosides, which provides a more rapid concentration-dependent bacterial killing and is probably less toxic than two or three dosage regimens. In this article the pharmacological and microbiological background for once-daily aminoglycoside administration is reviewed, and some controlled trials are discussed. Recommendations for clinical practice are given.

Once- versus twice-daily gentamicin dosing in neonates >/=34 Weeks' gestation: cost-effectiveness analyses

OBJECTIVES

To compare performance and cost analysis of two gentamicin regimens in infants >/=34 weeks' gestation requiring antibiotics for a 72-hour rule-out sepsis evaluation. A once-daily dosing (ODD) regimen of 4 mg/kg was compared with a standard twice-daily dosing (TDD) regimen of 2.5 mg/kg every 12 hours.

SETTING AND DESIGN

Infants at two university-affiliated Level III nurseries were prospectively temporally allocated to receive ODD (n = 27) or TDD (n = 28) as part of their 72-hour empirical antibiotic regimen. Performance of dosing regimens was based on target serum gentamicin concentrations (SGC) established prospectively as a peak of 5 to 10 microgram/mL and a trough of </=2 microgram/mL. SGC were determined by fluorescence polarization immunoassay on day 3 of therapy. Cost data were obtained by distributing a questionnaire to 15 pediatric pharmacy practice sites. Inquiries were made regarding hospital cost of drug acquisition, drug supplies, drug preparation and administration, and serum concentration analysis. Performance and cost data were then used to do a cost-effectiveness analysis.

RESULTS

Mean peak concentrations were higher with ODD (7.9 +/- 0.2 microgram/mL) than TDD (6.7 +/- 0.3 microgram/mL). Half of the patients in the TDD group had trough concentrations >2 microgram/mL, compared with none in the ODD group. Overall, 57% of the SGCs in the TDD group were outside the target concentration range versus 7% in the ODD group. Based on questionnaire results, a total 72-hour process cost of ODD versus TDD was compared for regimens with and without use of SGC analysis. If SGCs are obtained, more than 75% of the cost associated with gentamicin therapy is attributable to SGC analysis. Based on a cost-effectiveness analysis, ODD was the dominant dosing strategy in all categories analyzed.

CONCLUSIONS

ODD of gentamicin at 4 mg/kg in neonates >/=34 weeks' gestation is the preferable treatment strategy based on: 1) significantly improved SGC performance compared with TDD; 2) elimination of the need for routine SGC collection in infants on short courses of therapy; and 3) significant antibiotic-associated hospital cost savings when compared with conventional therapy of TDD and SGC analysis.

Utilizing collaborative practice to achieve quality outcomes in gentamicin administration

An individualized weight-based gentamicin dosing program is used at this community hospital to achieve stable serum drug levels with optimal clinical outcomes. This program requires extensive communication between disciplines and because of its complexity, was identified by the nursing staff as being confusing to initiate and maintain. The authors report the work of an interdisciplinary team to streamline the ordering and administering process and to promote staff satisfaction in using the dosing program.

Pharmacokinetics of once-daily gentamicin dosing in pediatric patients

BACKGROUND/PURPOSE

To achieve cost-effective health care in adults, once-daily aminoglycosides administration has been used and judged to be safe and efficacious. A similar strategy in children requires the characterization of pharmacokinetic parameters and the development of a therapeutic monitoring protocol for this antibiotic regimen.

METHODS

A prospective, controlled, randomized (2:1) study was undertaken in 50 pediatric patients between June 1995 and September 1997. Children between 6 months and 18 years who required gentamicin therapy based on independent clinical assessment were eligible if they had normal renal function, no aminoglycoside allergies, were not neutropenic, or did not have cystic fibrosis. Measurements included a peak, 4-hour, 8-hour, and trough gentamicin levels to determine volume of distribution (Vd) and elimination constant (Ke). Ototoxicity and nephrotoxicity were monitored by pre- and postaudiology examinations and serial calculated creatinine clearance determinations, respectively.

RESULTS

Thirty-three patients received 7.5 mg/kg every 24 hours, and 17 patients received 2.5 mg/kg every 8 hours. Most frequent indications for treatment were ruptured appendicitis (n = 19) followed by wound infections caused by trauma (n = 4), but the spectrum of treatment was broad including enteric, genitourinary, central nervous system, biliary, ophthalmologic, and orthopedic infections. Pharmacokinetic data indicated that 24-hour dosing resulted in higher peak levels compared with 8-hour dosing (20.4 +/- 45.4 v 7.2 +/- 6.2 mg/L, P < .0001) and lower trough levels (0.29 +/- .02 v 0.69 +/- 0.13, P < .0001), whereas rate of elimination constant and volume of distribution were not significantly different. No nephrotoxicity or ototoxicity has been noted in either group.

CONCLUSIONS

These data confirm that once-daily dosing of gentamicin is a safe method of treatment that provides equivalent pharmacokinetics compared with traditional dosing and enhances bactericidal effect based on higher peak levels, avoids toxicity, and allows cost savings.

Routine monitoring of gentamicin serum concentrations in pediatric patients with normal renal function is unnecessary

OBJECTIVE

Due to increasing demands for cost containment within the healthcare system, we evaluated the need for routine gentamicin concentrations (i.e., peak and trough with third dose).

DESIGN

Single-institution study performed concurrently with hospitalization.

SETTING

A 225-bed pediatric teaching hospital.

PARTICIPANTS

The study population consisted of 150 hospitalized pediatric patients (53% medicine, 47% surgical patients) from 3 months to 15 years old with normal serum creatinine.

OUTCOME MEASURES

If the administered dose produced diagnoses-appropriate peak concentrations of at least 4 micrograms/mL or 5 micrograms/mL in bacteremia/septicemia and at least 6 micrograms/mL or 8 micrograms/mL in patients with pneumonia if trough serum gentamicin concentrations were less than 2 micrograms/mL, if the patient was noted by the attending physician to be clinically responding as well as objectively having a decreased white blood cell count and was afebrile, and if there was not an increase of 0.5 mg/dL or more in serum creatinine during the course of therapy.

RESULTS

Patients received a mean dose of gentamicin 2.51 +/- 0.14 mg/kg i.v. q8h, which resulted in a mean peak concentration of 6.1 +/- 1.7 micrograms/mL (range 2.4-11.7) and a mean trough concentration of 0.5 +/- 0.3 microgram/mL (range 0.1-1.8). Peak and trough concentrations were at least 4 micrograms/mL and less than 2 micrograms/mL in 96% and 100% of patients, respectively. No patient required a dosage change due to lack of clinical response.

CONCLUSIONS

Our data do not support the routine monitoring of gentamicin concentrations in pediatric patients older than 3 months of age who are receiving appropriate standard doses of gentamicin and have normal renal function.

Pharmacoeconomic impact of once-daily aminoglycoside administration

A retrospective cost analysis compared hospital costs of standard gentamicin dosing and once-daily regimens in 1127 patients. Hospital costs compared were drug/supply/preparation/administration (DSPA; $4.56/500 mg once-daily dose and $3.32/100 mg every 8 hrs standard dose); therapeutic drug monitoring (TDM) ($25/gentamicin level); and nephrotoxicity management. The mean length of therapy was 4.5 days with both regimens. The mean number of blood samples drawn to measure drug levels was 0.65 for once-daily dosing and 1.7 for standard dosing. Mean DSPA and TDM costs/patient for a 4.5-day course of once-daily therapy were $20.52 and $16.25, respectively ($36.77/course of therapy). In comparison, estimated mean DSPA and TDM costs for 4.5 days standard therapy were $44.82 and $42.50, respectively ($87.32/course of therapy). We observed an overall reduction in nephrotoxicity from approximately 4% to 1.2% with the once-daily program, resulting in a nephrotoxicity management cost reduction from $182 to $55/patient exposed to aminoglycosides. The once-daily program resulted in a 58% reduction in aminoglycoside-associated hospital cost and a nephrotoxicity management savings of 70%/patient.

The economic impact of once-daily versus conventional administration of gentamicin and tobramycin

This retrospective, observational study was designed to compare once-daily with conventional aminoglycoside administration for costs while determining equivalency in efficacy and toxicity. 100 consecutive patients who had been treated with once-daily aminoglycosides after 1st August 1993, were evaluated via retrospective chart review. For comparison, 100 consecutive patients who were treated with conventional regimens of aminoglycosides, over the same calender period 1 year earlier (beginning on 1st August 1992), were evaluated in a similar manner. Aminoglycoside antibacterials, excluding amikacin, were administered as a single daily dose of 6 mg/kg. 89 patients were cured or improved with once-daily administration versus 90 patients with conventional administration. One patient in each group developed definite aminoglycoside-induced renal toxicity. The total cost [in 1993 Canadian dollars ($Can)] per patient for once-daily and conventionally administered aminoglycosides was $Can97.62 and $ Can199.43, respectively. Thus, once-daily administration of aminoglycosides is as effective and well tolerated, while considerably less expensive than, aminoglycoside treatment utilising conventional regimens.

Prospective evaluation of antibiotic prophylaxis prior to cystometrogram and/or cystogram studies: oral versus intramuscular routes

OBJECTIVE

To compare empiric single-dose gentamicin versus culture-specific oral antibiotics as prophylaxis before cystometrogram and/or cystogram. Comparisons with regards to infection, patient preference, and cost were made.

DESIGN

Prospective randomized control trial.

SETTING

Inpatient and outpatient rehabilitation hospital.

PATIENTS

Seventy received oral antibiotics and 72 received intramuscular gentamicin.

INTERVENTION

Cystometrograms and/or cystograms were performed.

MAIN OUTCOME MEASURE

Patient interviewed and chart reviewed for infection. Convenience and comfort were rated by patient.

RESULTS

Oral antibiotics and gentamicin have similar efficacy. Patients rated the gentamicin more convenient (p < .001) and comfortable (p < .01) than oral antibiotics. Gentamicin is less expensive.

CONCLUSION

Gentamicin should be used as the method of choice for cystometrogram/cystogram prophylaxis.

Pharmacoeconomics of aztreonam-clindamycin versus gentamicin-clindamycin in the treatment of penetrating abdominal injury

STUDY OBJECTIVE

To evaluate the pharmacoeconomic implications of using aztreonam-clindamycin (A-C) versus gentamicin-clindamycin (G-C) from the perspective of the hospital and pharmacy directors.

DESIGN

Pharmacoeconomic analysis performed at one of the sites participating in the prospective, randomized, double-blind, comparative, multicenter efficacy study.

SETTING

Referral hospital with level 1 trauma center.

PATIENTS

Eight-five adults with a suspected penetrating intraabdominal injury requiring laparotomy.

INTERVENTIONS

Patients were randomized to receive aztreonam 2 g intravenously every 8 hours or gentamicin 2 mg/kg intravenous load followed by 5 mg/kg/day intravenously initially adjusted to peak concentrations of 6-8 micrograms/ml. All patients received clindamycin 900 mg intravenously every 8 hours.

MEASUREMENTS AND MAIN RESULTS

Charge data were gathered from the hospital billing system and converted to cost data using an institutional cost:charge ratio of 0.6. Study drug and aminoglycoside monitoring costs were also calculated. Overall, 43 (97%) of 44 patients receiving A-C had a favorable clinical response compared with 35 (85.4%) of 41 receiving G-C (p = 0.052). The mean hospital cost of $66,336 for 7 infected patients was significantly higher than that of $8014 in 78 noninfected patients (p < 0.0001). Mean hospital costs of $12,058 and $13,742 for A-C and G-C groups, respectively, were not significantly different (p > 0.05) despite having only a single failure (total cost $162,666) in the A-C group. Similarly, mean pharmacy costs of $1411 and $1604, respectively, were not significantly different (p > 0.05).

CONCLUSIONS

Hospital costs for infected patients with penetrating abdominal trauma exceed those of noninfected patients by 5-fold. Despite a lower infection rate in the A-C group, neither hospital nor pharmacy costs were significantly different compared with those in the G-C group.

A comparison of once-daily and 8-hour gentamicin dosing in the treatment of postpartum endometritis

OBJECTIVE

To evaluate whether once-daily gentamicin dosing is as effective as the traditional 8-hour regimen for the treatment of postpartum endometritis.

METHODS

Postpartum women with endometritis were randomized to receive gentamicin 5 mg/kg as a single daily dose or 1.75 mg/kg every 8 hours. All subjects also received clindamycin. Each participant had a peak serum gentamicin level of at least 5.0 micrograms/mL within the first 24 hours. The dosing regimens were compared by analyzing the number of hours that patients were febrile, the length of hospital stay, occurrence of complications, pharmacy costs, and nursing time required to administer the regimens.

RESULTS

The study group (n = 62) and the control group (n = 65) were similar in demographic characteristics and the presence of endometritis risk factors. No differences were found between the groups in the number of patients who completed therapy without complications, required changes in antibiotics, or required readmission for endometritis. The groups did not differ in the number of hours that patients remained febrile after the start of therapy or in the length of hospital stay. No patient in the study group had an initial peak serum concentration less than 5.0 micrograms/mL, whereas 24 patients in the control group had initial peak serum concentrations less than 5.0 micrograms/mL and required dose adjustment, a statistically significant difference (P < .001). Pharmacy costs averaged $16.12 +/- 5.68 for the study group and $41.75 +/- 17.41 for the control group, also a significant difference (P < .001). Nurse tasking time averaged 13.62 +/- 2.56 minutes for the study group and 28.06 +/- 8.77 minutes for the control group (P < .001).

CONCLUSION

In patients with postpartum endometritis, once-daily gentamicin dosing provides consistently high peak serum levels of gentamicin, requires less nurse tasking time, costs less, and is as effective as the 8-hour dosing regimen.

Once-daily aminoglycoside dosing: impact on requests and costs for therapeutic drug monitoring

Recently, much interest has focused on the use of once-daily aminoglycosides (ODA) in the medical literature. In late 1992, we implemented a hospital-wide ODA program for adult patients at our 850-bed community-teaching hospital. In the first phase of implementation, therapeutic drug monitoring (TDM) was accomplished with the use of a random serum concentration and a nomogram that had been developed at our institution. In the second phase, serum drug concentrations were eliminated on patients with normal renal function. The fully implemented program resulted in a 40% decrease in the request for gentamicin and tobramycin serum concentrations as compared with historic ordering patterns for conventional aminoglycoside dosing regimens. In addition, the incidence of nephrotoxicity was also reduced from 3 to 5% with conventional aminoglycoside dosing, to 1.2 and 1.3% for phases 1 and 2, respectively. Furthermore, the elimination of TDM requests totaling 300 for gentamicin and 50 for tobramycin per month is expected to result in an annual institutional savings of > $100,000.

Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial

Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a high probability for deep infections and amputations. Delayed healing times are often described. The aim of this study was to compare the clinical effect and economic cost of cadexomer iodine with standard treatment in diabetic feet with cavity ulcers. Patients with deep, exudative foot ulcers were included in a 12-week open, randomised, comparative study. When ulcers stopped exudating, vaseline gauze was used in both groups until the end of the study. Costs were estimated for dressing material, staff and transportation. Clinically relevant improvement was seen in 12 patients treated with cadexomer iodine and in 13 patients treated with standard treatment. The average weekly cost was SEK 903 and SEK 1,421, respectively, of which the major part was costs for staff and transportation related to frequency of dressing changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no clinical difference compared to topical treatment consisting of gentamicin solution, streptodornase/streptokinase, or dry saline gauze but was associated with considerably lower weekly treatment costs.

Randomised study comparing imipenem/cilastatin to ceftriaxone plus gentamicin in cancer chemotherapy-induced neutropenic fever

Prompt initiation of empiric antibiotic therapy is the cornerstone in the therapy of chemotherapy-induced neutropenic sepsis in cancer patients. Ceftriaxone plus gentamicin (ceftriaxone/gentamicin) is the most widely used combination of empiric antibiotics in the Department of Medical Oncology, Singapore General Hospital. However, imipenem/cilastatin has been shown to be a practical alternative. To compare the efficacy and cost effectiveness of monotherapy with our usual combination antibiotic therapy, 50 evaluable neutropenic cancer patients admitted for fever were randomised to empiric imipenem/cilastatin or ceftriaxone/gentamicin. Ceftriaxone/gentamicin was started in 24 patients. The initial clinical response rate to ceftriaxone/gentamicin was 62.5% and 84.6% to imipenem/cilastatin (P = 0.075). The average cost of antibiotics per patient started on ceftriaxone/gentamicin including cost of change of antibiotics was S$63 per day of antibiotic use and for imipenem/cilastatin it was S$252 (P < 0.02). In conclusion, although more patients receiving imipenem/cilastatin had an initial clinical response than those receiving ceftriaxone/gentamicin, this difference was not statistically significant. It would appear that imipenem/cilastatin is equivalent to ceftriaxone/gentamicin for the treatment of neutropenic sepsis. However, ceftriaxone/gentamicin was more cost effective.

Cost of gentamicin assays carried out by microbiology laboratories

AIMS

To assess the current range of prices charged for gentamicin assays in United Kingdom laboratories; and to examine the laboratories' likely response to increases or decreases in the demand for the service.

METHODS

A postal survey of the 420 members of the Association of Medical Microbiologists was used to establish the range of prices charged for aminoglycoside assays. Additionally, eight private institutions were contacted to determine what the private sector was charging for aminoglycoside assays. Reagent costs in the NHS laboratories were calculated by dividing the total cost of all aminoglycoside assay kits by the number of samples analysed.

RESULTS

The NHS and the private institutions both showed a wide price variation. Prices charged to an in-hospital requester for a peak and trough assay ranged from 5.00 pounds to 68.20 pounds (n = 44), and to an external private hospital, under a bulk service contract, from 5.00 pounds to 96.00 pounds (n = 47). Prices charged by private laboratories ranged from 49.00 pounds to 84.00 pounds (n = 8). There was a log linear correlation in the NHS laboratories between the reagent costs per assay and the number of assays performed per year, and most laboratories thought that their price per assay would be sensitive to increases or decreases in demand. Laboratories which had purchased their assay machines had lower reagent costs per assay but higher repair and maintenance costs. Overall, number of assays performed and method of payment for assay machinery only accounted for 44.8% of the observed variation in assay kit costs.

CONCLUSIONS

The price range for gentamicin assays in the United Kingdom is wide and is only partially explained by the number of assays performed. Most laboratories believe that they would experience a reduction in unit cost as output increases. The currently offered range of prices is, in part, due to variation in the laboratories' approach to costing the service provided and some laboratories charge prices which do not even cover the cost of assay kits. Overall, we believe that prices charged should be as close as possible to the marginal cost of the tests performed.

The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads

Fifty-two patients enrolled in the Septopal study of infected nonunions were prospectively examined in a randomized, controlled, closed study. Patients were divided into two groups. Group 1 consisted of 24 patients treated with debridement and intravenous antibiotics for four weeks. Group 2 consisted of 28 patients treated with debridement, gentamicin-polymethylmethacrylate (Septopal) beads, and perioperative broad-spectrum parenteral antibiotics. Both groups were treated with similar methods for reconstruction of the nonunions. The demographics of the two groups were similar. The average patient age in Group 1 was 38.4 years, and in Group 2, 37.1 years. Group 1 included 21 men and three women and Group 2, 23 men and five women. The nonunions in both groups ranged from simple hypertrophic nonunions to atrophic unions to segmental defects. The end results were good in both groups. Twenty patients in Group 1 and 25 patients in Group 2 had their infections successfully arrested (83.3% and 89.3%, respectively). Nonunions were successfully healed in the two groups, with similar results (Group 1, 83.3%; Group 2, 85.7%). Infected nonunions responded equally well to either systemic treatment with long-term intravenous antibiotics or local treatment with gentamicin-polymethylmethacrylate beads.

Antibiotic pharmacoeconomics: an attempt to find the real cost of hospital antibiotic prescribing

Antibiotics account for a large part of all hospital pharmacy budgets, but the actual cost of their prescription is unknown. These costs include intravenous administration, labour, serum antibiotic assay, monitoring of haematological and biochemical indices, disposal of sharps and adverse effects. An in-house method of costing antibiotic therapy is presented, to quantify these hidden expenses. Since not only an awareness, but an accurate quantification, of hidden costs is required, a study of various hospital procedures relating directly to antibiotic therapy was undertaken in an acute medical ward; this involved the identification of particular staff members performing various procedures, consumables used and time taken. The cost of five-day courses of gentamicin, penicillin G, ampicillin, flucloxacillin, cefuroxime, ceftotaxime and erythromycin has been calculated; drug and hidden costs for each are presented graphically for comparison. The breakdown cost for gentamicin is presented to illustrate the method. The costing of adverse effects has not been attempted. We suggest that costings of this sort are used in cost-benefit analysis of antibiotic use. These calculations have been incorporated into a computer spreadsheet and this costing service will be offered to clinical areas of our hospital.

Antibiotics in febrile neutropenia: a randomized prospective comparison of two combinations

BACKGROUND

Problems of initial empirical antibiotic therapy in febrile neutropenia are further complicated by other factors such as cost and the pattern of infective organisms in a particular institution. We, therefore, conducted a randomized study comparing the efficacy of two sets of antibiotics which differed in their spectrum of action, availability and price.

METHODS

Sixty episodes of febrile neutropenia in 40 patients who were not on any prophylactic antibiotics were randomized into one of two arms--cefotaxime and gentamicin or ciprofloxacin and gentamicin. Depending upon the response by 72 hours, they were crossed over to the other arm or continued with the same combination. Empirical antifungal therapy was added in those who did not become afebrile.

RESULTS

Infection was documented either clinically, bacteriologically or radiologically in 42% of the febrile episodes. The commonest organism isolated was Klebsiella and the commonest organism producing bacteraemia was the Staphylococcus. The temperature was reduced to normal without cross-over in 53% of the febrile episodes with cefotaxime and gentamicin and in 60% with ciprofloxacin and gentamicin (p > 0.05). After cross-over the temperature came down in 30% of the episodes with cefotaxime and gentamicin (initial combination) and 40% with ciprofloxacin and gentamicin (initial combination; p > 0.05). The overall response rate without empirical antifungal therapy was 83% in the patients on cefotaxime and gentamicin (initial combination; p > 0.05). While both the arms of the study had a 100% response rate, there was no significant difference between the efficacy of the antibiotic combinations. The ciprofloxacin-gentamicin combination is one-third as expensive as cefotaxime-gentamicin and is more readily available.

CONCLUSION

We recommend the use of ciprofloxacin and gentamicin as the initial drug combination and cefotaxime and gentamicin only when the former is not effective.

A comparison of the costs of ceftazidime therapy and gentamicin combinations in three UK hospitals

This study compares the utilization costs of ceftazidime therapy with those of gentamicin in combination with other antibacterial drugs. The results show that the relatively high purchase cost of ceftazidime compared to combinations is more than counterbalanced by the additional materials used for drug administration and serum antibiotic assays, even when other drugs were combined with ceftazidime. The average drug and equipment costs were 230.13 pounds for ceftazidime regimens and 253.94 pounds for gentamicin regimens. It is also shown that ceftazidime therapy is associated with a reduction in personnel time compared to gentamicin regimens. The average times per patient for administration and assay were 1 h 43 min for ceftazidime and 4 h 57 min for gentamicin regimens. We conclude that ceftazidime regimens are cheaper than gentamicin regimens when all drug and equipment costs are quantified. Moreover, the use of ceftazidime will release staff time for other purposes.