[Infectious exacerbation of chronic obstructive pulmonary disease: prospects for high-dose levofloxacin therapy]

This open comparative randomized study of efficacy, safety, and pharmacoeconomic characteristics of hilifox-750 (750 mg daily for 5 days) and amoxiclav 2X (875/125 mg twice daily for 10 days) included 60 patients with chronic obstructive pulmonary disease (COPD). Duration of the study was 6 months. Medians of age and smoking index in the group treated with hilifox-750 were 63.5 yr (59, 67) and 30 packs/yr (15, 60) respectively. The treatment reduced cough, apnea, sputum volume and pyoptysis with comparative rates of normalization of body temperature and peripheral leukocyte counts in both groups. Helifox-750 promoted decrease in coughing and apnea within the first three days of therapy. 28 (93%) and 26 (87%) patients recovered by day 4 of helifox and amoxiclav therapy (F-test p = 0.67). Both drugs showed comparable bacteriological efficacy. They were not different in terms of side effect frequency that were mild, resolved spontaneously and did not require withdrawal of therapy. Helifox had advantages over amoxiclav in that it reduced duration of antibacterial therapy to 5 days and of temporary incapacity to 12 days (vs 14); moreover, it needs to be taken only once daily.

Treatment of tuberculosis in South Kazakhstan: clinical and economical aspects

BACKGROUND AND OBJECTIVE

Since 1990, the tuberculosis incidence rate in Eastern Europe and post-Soviet republics has been increasing in many countries including Kazakhstan. This problem is particularly important in Kazakhstan regions with limited financial resources, among them - in South Kazakhstan province. The aim of this study was to investigate the main clinical and antibiotic-related economic aspects of tuberculosis treatment in South Kazakhstan province.

MATERIAL AND METHODS

In total, 502 patients participated in the study. They were hospitalized to the tuberculosis dispensary of Sayram district (South Kazakhstan province) in 2007-2013. Statistical analysis included logistic regression for better treatment outcomes and analysis of antibiotic treatment costs.

RESULTS

Two-thirds of patients had infiltrative tuberculosis (67%). Positive treatment outcomes were determined in 85% of cases. The patients were mostly treated with cycloserine, protionamide, capreomycin, and ofloxacin. The majority of antibiotic costs were related to the treatment with capreomycin. In case of the positive results of the test for Mycobacterium tuberculosis, antibiotic expenses were almost 3 times greater than in case of negative test results (P<0.001).

CONCLUSIONS

The majority of patients had extensively drug-resistant tuberculosis. The negative results of the test for Mycobacterium tuberculosis at discharge were not related to pretreatment factors. Antibiotic-related costs were significantly higher in case of the positive results of the test of Mycobacterium tuberculosis, but were not associated with gender, residence place, hospitalization recurrence, or main blood test results before treatment.

Hospital visits and costs following outpatient treatment of CAP with levofloxacin or moxifloxacin

BACKGROUND

Hospital admissions (inpatient and emergency room) are a major source of medical costs for community-acquired pneumonia (CAP) initially treated in the outpatient setting. Current CAP treatment guidelines do not differentiate between outpatient treatment with levofloxacin and moxifloxacin.

OBJECTIVE

Compare health care resource use and medical costs to payers for CAP outpatients initiating treatment with levofloxacin or moxifloxacin.

RESEARCH DESIGN AND METHODS

CAP episodes were identified in the PharMetrics database between 2Q04 and 2Q07 based on: pneumonia diagnosis, chest X-ray and treatment with levofloxacin or moxifloxacin. Subsequent 30-day risk of pneumonia-related hospital visits and 30-day health care costs to payers for levofloxacin vs. moxifloxacin treatment were estimated after adjusting for pre-treatment demographics, health care resource use and pneumonia-specific risk factors using propensity score and exact factor matching.

RESULTS

A total of 15,472 levofloxacin- and 6474 moxifloxacin-initiated CAP patients were identified. Among 6352 matched pairs, levofloxacin treatment was associated with a 35% reduction in the odds of pneumonia-related hospital visits (odds ratio = 0.65, P = 0.004), lower per-patient costs for pneumonia-related hospital visits (102 dollars vs. 210 dollars, P = 0.001), lower pneumonia-related total costs (medical services and prescription drugs, 363 dollars vs. 491 dollars, P < 0.001) and lower total costs (1308 dollars vs. 1446 dollars, P < 0.001) vs. moxifloxacin over the 30-day observation period.

LIMITATIONS

Although observational analyses of claims data provide large sample sizes and reflect routine care, they do have several inherent limitations. Since randomization of subjects is not possible, adequate statistical techniques must be used to ensure that patient characteristics are well-balanced between treatment groups. In addition, data may be missing or miscoded.

CONCLUSIONS

CAP outpatients initiated with levofloxacin generated substantially lower costs to payers compared to matched patients initiated with moxifloxacin. The cost savings for patients initiated with levofloxacin were largely attributable to reduced rates of pneumonia-related hospitalization or ER visits.

Comparative analysis of length of stay, total costs, and treatment success between intravenous moxifloxacin 400 mg and levofloxacin 750 mg among hospitalized patients with community-acquired pneumonia

OBJECTIVE

This study aimed to evaluate the length of stay (LOS), costs, and treatment consistency among patients hospitalized with community-acquired pneumonia (CAP) initially treated with intravenous (IV) moxifloxacin 400 mg or IV levofloxacin 750 mg.

METHODS

Adults with CAP receiving IV moxifloxacin or IV levofloxacin for > or =3 days were identified in the Premier Perspective comparative database. Primary outcomes were LOS and costs. Secondary outcomes included treatment consistency, which was defined as 1) no additional IV moxifloxacin or levofloxacin after > or =1 day off study drug; 2) no switch to another IV antibiotic; and 3) no addition of another IV antibiotic.

RESULTS

A total of 7720 patients met inclusion criteria (6040 receiving moxifloxacin; 1680 receiving levofloxacin). Propensity matching created two cohorts (1300 patients each) well matched for demographic, clinical, hospital, and payor characteristics. Before the patients were matched, mean LOS (5.87 vs. 5.46 days; P = 0.0004) and total costs per patient ($7302 vs. $6362; P < 0.0001) were significantly greater with moxifloxacin. After the patients were matched, mean LOS (5.63 vs. 5.51 days; P = 0.462) and total costs ($6624 vs. $6473; P = 0.476) were comparable in both cohorts. Treatment consistency was higher for moxifloxacin before (81.0% vs. 78.9%; P = 0.048) and after matching (82.8% vs. 78.0%; P = 0.002).

CONCLUSIONS

In-hospital treatment of CAP with IV moxifloxacin 400 mg or IV levofloxacin 750 mg was associated with similar hospital LOS and costs in propensity-matched cohorts.

A cost-minimisation analysis comparing moxifloxacin with levofloxacin plus ceftriaxone for the treatment of patients with community-acquired pneumonia in Germany: results from the MOTIV trial

OBJECTIVE

This study presents a cost-minimisation analysis of moxifloxacin compared to combination treatment with levofloxacin and ceftriaxone in patients hospitalised with community-acquired pneumonia (CAP) in Germany.

RESEARCH DESIGN AND METHODS

In the MOTIV study, 738 adult patients with CAP requiring hospitalisation and initial parenteral antibiotic therapy were randomised to sequential IV/oral therapy with either moxifloxacin (n = 368), or levofloxacin and ceftriaxone (n = 365). The primary effectiveness endpoint was the proportion of patients demonstrating clinical improvement 5-7 days after the completion of study treatment. Subgroup analysis considered patients with severe CAP according to pneumonia severity index (PSI) risk class IV and V, microbiologically proven infection, a history of chronic obstructive pulmonary disease, and a history of cardiovascular disease. The analysis included the cost of study medication, hospital stay, readmission and inpatient procedures and diagnostics. Event frequency in the study was multiplied by German unit costs to estimate per-patient expenditure. The analysis was conducted from a hospital perspective. Sensitivity analysis investigated the effect of costing from an insurer perspective.

RESULTS

No significant difference was found in the percentage of successfully treated patients. Average per patient cost was euro 2190 for the moxifloxacin group, and euro 2619 for the levofloxacin + ceftriaxone group (difference -euro 430, 95% CI: -euro 138, -euro 740; p < 0.05). Variability in total costs was wide, with some patients accruing up to euro 18,000. Medication cost was significantly lower with moxifloxacin than levofloxacin + ceftriaxone (-euro 470, 95% CI: -euro 522, -euro 421), and accounted for between 15 and 30% of total costs.

CONCLUSIONS

In this analysis of patients hospitalised with CAP in Germany, treatment with moxifloxacin was significantly less costly than treatment with levofloxacin and ceftriaxone.

A comparison of levofloxacin and moxifloxacin use in hospitalized community-acquired pneumonia (CAP) patients in the US: focus on length of stay

OBJECTIVE

Length of stay (LOS) and hospitalization costs were compared among patients admitted for community-acquired pneumonia (CAP) and initially treated with either levofloxacin 750 mg intravenous (IV) or with moxifloxacin 400 mg IV. Hospital-related complications and relationship of LOS and comorbidities were descriptively examined.

METHODS

A retrospective database study was conducted of adult patients admitted for CAP and given levofloxacin 750 mg IV or moxifloxacin 400 mg IV through the first 3 days of hospitalization, using the Premier Perspective comparative database. Cohorts were matched 1:1 by hospital geographic location, by coarse caliper propensity scores using all baseline covariates, and by Mahalanobis metric matching based on age and severity (All Patient Refined-Diagnosis-related Groups Severity of Illness (APR-DRG SOI) index). Comparisons between groups were further adjusted for characteristics that remained imbalanced after matching using generalized estimating equation methodology.

RESULTS

The initial sample of 3868 patients (levofloxacin = 827; moxifloxacin = 3041) was reduced to 1594 (797 patients per treatment group) after matching. Analyses of matched cohorts showed that the mean hospital LOS was significantly shorter for patients treated with levofloxacin 750 mg IV than for those patients treated with moxifloxacin 400 mg IV (5.8 vs. 6.4 days, respectively; least squares mean difference = 0.54 days; p = 0.020). Hospitalization costs were also lower for the levofloxacin 750 mg IV-treated patients (least squares mean difference = US$129; p = 0.753). There were no significant differences in the percentage of patients experiencing complications.

LIMITATIONS

Although claims databases provide large sample sizes and reflect routine care, they do have several inherent limitations. Since randomization of subjects is not possible, adequate statistical techniques must be used to ensure treatment groups are balanced with respect to patient and clinical characteristics. In addition, data may be missing or miscoded.

CONCLUSIONS

This retrospective study suggests that among patients hospitalized with CAP, initial treatment with levofloxacin 750 mg IV is associated with a significantly shorter mean hospital LOS compared with treatment with moxifloxacin 400 mg IV. The clinical implications of a shorter hospital LOS include improved patient and economic outcomes.

Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies

OBJECTIVE

Effectiveness differences between outpatient pelvic inflammatory disease (PID) treatment regimens are uncertain, but significant differences in cost exist.

GOAL

To examine the influence of antibiotic costs on PID therapy cost-effectiveness.

STUDY DESIGN

The authors used a Markov decision model to estimate the cost-effectiveness of recommended antibiotic regimens for PID and performed a value of information analysis to guide future research.

RESULTS

Antibiotic costs vary between USD 43 and USD188. Pairwise comparisons, assuming a hypothetical 1% relative risk reduction in PID complications with the more expensive regimen, showed economically reasonable cost-effectiveness ratios. Value of information and sample size considerations support further investigation to detect 10% PID complication rate differences between regimens with >or=USD 50 cost differences.

CONCLUSIONS

Within the cost range of recommended regimens, use of more expensive antibiotics would be economically reasonable if relatively small decreases in PID complication rates exist. Further investigation of effectiveness differences between regimens is needed.

Respiratory tract infections: at-risk patients, who are they?☆Implications for their management with levofloxacin

At this symposium, the bacterial aetiologies of community-acquired pneumonia and acute exacerbations of chronic bronchitis were evaluated. By reviewing the clinical criteria for the identification of at-risk patients and the recommendations for antimicrobial drug selection in treatment guidelines, the role of levofloxacin in clinical practice was explored. In addition, consideration was also given to the economic impact of using levofloxacin in at-risk patients.

Respiratory tract infections: at-risk patients, who are they?Implications for their management with levofloxacin

Two of the most serious respiratory tract infections are community-acquired pneumonia (CAP) and acute exacerbations of chronic bronchitis (AECB). The most common pathogens found in patients with these infections are Haemophilus influenzae and Streptococcus pneumoniae. Pseudomonas aeruginosa is also relatively common, particularly in elderly patients with AECB. S. pneumoniae and P. aeruginosa are also of concern in relation to the development of resistance to antimicrobial drugs. The administration of antibiotics at doses that result in concentrations exceeding the mutant prevention concentration at the site of infection is one strategy to prevent the development of drug-resistant pathogens. AECB is associated with a high risk of in-hospital mortality, particularly in patients treated in the intensive care unit. CAP is also associated with significant risks and often requires treatment under hospital supervision. Several patient-related factors help identify those patients who are most at risk of mortality and morbidity. Treatment should be tailored towards the severity of the disease. The fluoroquinolones, such as levofloxacin, are an effective treatment option for AECB and CAP. Compared with many other antibiotics, resistance to levofloxacin remains low for most infecting pathogens. The oral bioavailability of levofloxacin is over 99%, enabling simple switching from intravenous to oral therapy during treatment. It is also preferentially distributed to compartments in the lung, thus achieving high concentrations at the site of respiratory tract infections. Combined with cover of the major infecting pathogens found in patients with AECB and CAP, and a cost-effective treatment compared with many alternative therapies, levofloxacin is an attractive option for the treatment of at-risk patients with these respiratory tract infections.

An economic evaluation of two ototopical treatments for acute otitis media in tympanostomy tube patients

OBJECTIVE

The goal of this research was to determine the cost-effectiveness of ciprofloxacin 0.3%/dexamethasone 0.1% (CD) otic suspension versus ofloxacin 0.3% otic solution (OFX) for treatment of acute otitis media in tympanostomy tube patients.

METHODS

A decision-analytic model was used to emulate the ototopical treatment of acute otitis media in patients with tympanostomy tubes. The economic outcome was the cost per otorrhea-free day (OFD) achieved per episode of care. Three tiers of antimicrobial therapy were modeled, with each successive tier representing the retreatment of clinical failures from the preceding tier. First-tier therapy compared CD and OFX using outcome measures obtained from a randomized clinical trial (n = 599). Second-tier therapy modeled the use of amoxicillin/clavulanate (ACA) using outcome measures obtained from a physician survey and medical literature. Third-tier therapy was modeled as pathogen-specific and curative. It could follow one of three pathways: 1) intramuscular ceftriaxone; 2) oral fluconazole; or 3) hospitalization for intravenous antibiotics. Third-tier outcomes were based on a physician survey. Cost data were obtained from standard references and presented from a payer perspective.

RESULTS

The expected therapeutic costs were 249.40 dollars for the CD pathway and 265.44 dollars for the OFX pathway. The estimated number of OFDs per episode of care was 25.88 for the CD pathway and 23.86 for the OFX pathway. The cost-effectiveness ratios for CD and OFX therapies were 9.64 dollars and 11.13 dollars per OFD, respectively.

CONCLUSION

CD is both more effective and less costly than OFX for the treatment of acute otitis media in patients with tympanostomy tubes.

Moxifloxacin versus levofloxacin for treatment of acute rhinosinusitis: a retrospective database analysis of treatment duration, outcomes, and charges

OBJECTIVE

Antibiotics are clinically indicated for acute bacterial rhinosinusitis, but they may be prescribed inappropriately. This retrospective study examined how labeled recommendations for duration of moxifloxacin and levofloxacin treatment of acute bacterial rhinosinusitis compare with real-world practice, and compared the failure and recurrence rates, and associated charges.

METHODS AND MAIN OUTCOME MEASURES

The PharMetrics Patient-Centric claims database was searched over a 3-year period for episodes of acute rhinosinusitis treated within 5 days with moxifloxacin or levofloxacin. The duration of antibiotic treatment prescribed was compared with the labeled recommendation. Failure rates (a second antibiotic claim to treat acute rhinosinusitis within 30 days of the first claim), recurrence rates (subsequent antibiotic claims to treat any rhinosinusitis more than 30 days after the original or second [in the case of failure] claim), and treatment charges from the perspective of the payer (health insurer) were also compared using multivariate analysis.

RESULTS

The initial duration prescribed of moxifloxacin was shorter than for levofloxacin (-1.65 days, p < 0.0001), reflecting the shorter labeled recommendation (10 days versus 10-14 days). The durations of monotherapy (-2.06 days, p < 0.0001) and of all antibiotic treatment (-1.97 days, p < 0.0001) were also significantly shorter for episodes treated initially with moxifloxacin. The odds ratio for treatment failure (0.718; 95% confidence interval = 0.598-0.863; p = 0.0004) and the hazard ratio for recurrence (0.652; p = 0.0005) were both significantly lower for moxifloxacin than for levofloxacin, and resulted in lower total treatment charges (-$37.94 +/- 13.65; p = 0.0055).

CONCLUSION

The shorter treatment durations seen for moxifloxacin in this database of real-world care reflect the label-recommended duration for acute rhinosinusitis. Despite this shorter duration of therapy, moxifloxacin resulted in better outcomes than levofloxacin in terms of the risk of treatment failure and recurrence. In addition, the total charges were lower for patients treated with moxifloxacin.

A cost-minimization analysis comparing azithromycin-based and levofloxacin-based protocols for the treatment of patients hospitalized with community-acquired pneumonia: results from the CAP-IN trial

BACKGROUND

A randomized trial was performed comparing azithromycin and levofloxacin for treating moderately to severely ill patients hospitalized with community-acquired pneumonia. This is a cost-minimization analysis comparing those regimens.

METHODS

The cost-minimization analysis compares 81 patients receiving sequential therapy with IV azithromycin plus IV ceftriaxone followed by oral azithromycin with 82 patients receiving IV levofloxacin followed by oral levofloxacin, all with complete economic data over approximately 30 days, including information about hospitalization, study medications, home care, postdischarge utilization, and lost productivity. Units of utilization were multiplied by unit prices in order to estimate cost per patient. These total costs were compared using a two-sample t test.

RESULTS

Direct medical costs of the azithromycin group were 2,481 US dollars less than the corresponding costs in the levofloxacin group (p = 0.03; 95% confidence interval, 238 US dollars to 4,724 US dollars). Most of the cost difference (2,300 US dollars) is attributable to hospital days, with the majority of these days being spent on the general medicine wards. The precise magnitude of the cost advantage attributable to azithromycin, if any, depends on both the reduction in length of hospital stay and its associated daily cost.

CONCLUSIONS

Azithromycin was no more costly than levofloxacin, and perhaps less so. Cost is but one of many factors that should be considered by clinicians in decisions involving any individual patient.

A randomized comparison of oral chloramphenicol versus ofloxacin in the treatment of uncomplicated typhoid fever in Laos

We conducted a randomized open trial of oral chloramphenicol (50mg/kg/day in four divided doses for 14 days) versus ofloxacin (15 mg/kg/day in two divided doses for 3 days) in 50 adults with culture-confirmed uncomplicated typhoid fever in Vientiane, Laos. Patients had been ill for a median (range) of 8 (2-30) days. All Salmonella enterica serotype typhi isolates were nalidixic acid-sensitive, four (8%) were chloramphenicol-resistant and three (6%) were multidrug-resistant. Median (range) fever clearance times were 90 (24-224) hours in the chloramphenicol group and 54 (6-93) hours in the ofloxacin group (P<0.001). One patient in the chloramphenicol group developed an ileal perforation. Three days ofloxacin was more effective than 14 days chloramphenicol for the in-patient treatment of typhoid fever, irrespective of antibiotic susceptibility, and was of similar cost.

Patient stratification in the management of acute bacterial exacerbation of chronic bronchitis: the role of levofloxacin 750 mg

This is the first prospective clinical trial in which patients with acute bacterial exacerbation of chronic bronchitis have been stratified by degree of underlying illness. Uncomplicated patients were randomised to levofloxacin 750 mg once daily (q.d.) for 3 days or azithromycin q.d. for 5 days. Complicated patients were randomised to levofloxacin 750 mg q.d. for 5 days or amoxicillin 875 mg/clavulanate 125 mg twice daily for 10 days. Regardless of therapy, complicated patients demonstrated lower clinical and microbiological success than uncomplicated patients. Clinical success for clinically evaluable patients was similar for levofloxacin and azithromycin (93.0 versus 90.1%, respectively), and levofloxacin and amoxicillin/clavulanate (79.2 versus 81.7%, respectively). For microbiologically evaluable patients, clinical response to levofloxacin for 3 days was superior to azithromycin for 5 days (96.3 versus 87.4%, respectively), and levofloxacin for 5 days was similar to amoxicillin/clavulanate for 10 days (81.4 versus 80.9%, respectively). Microbiological eradication was superior for levofloxacin for 3 days compared with azithromycin for 5 days (93.8 versus 82.8%, respectively), and similar for levofloxacin and amoxicillin/clavulanate for 10 days (81.4 versus 79.8%, respectively). In conclusion, levofloxacin 750 mg for 3 days was comparable to azithromycin for 5 days for uncomplicated patients with acute bacterial exacerbation of chronic bronchitis, while 5 days of 750 mg levofloxacin was comparable to 10 days of amoxicillin/clavulanate for complicated acute bacterial exacerbation of chronic bronchitis.

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes

OBJECTIVE

The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT).

METHODS

This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX.

RESULTS

Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars.

CONCLUSION

In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.

Cost-effectiveness of full-course oral levofloxacin in severe community-acquired pneumonia

Oral levofloxacin is as efficient as sequential antibiotic treatment in community-acquired pneumonia (CAP). The current authors assessed whether oral levofloxacin treatment of patients with severe CAP, followed-up for 30 days, would save money. Over a 12-month period, 129 hospitalised patients with severe non-intensive care unit CAP were randomly assigned to receive either oral levofloxacin or sequential antibiotic treatment. Direct and indirect costs were compared over a 30-day period from several perspectives. CAP resolved in 71 out of 77 oral levofloxacin (92%) and in 34 out of 37 sequential antibiotic treatment patients (92%). Patients' characteristics, treatment duration, hospital length of stay and mortality were similar in both groups. Drug acquisition costs were 1.7-times smaller in oral levofloxacin patients, who were less often transferred to rehabilitation centres, but they used more physicians' visits during follow-up and their total costs were lower. As only a minority of patients was still active, inability to work and, hence, indirect costs were similar in both groups. In this study, oral levofloxacin for severe non-intensive care unit community-acquired pneumonia was equally effective as sequential antibiotic treatment, but did not lead to major costs savings except for drug acquisition costs. External factors linked with patients' characteristics and/or medical practice are likely to play a role and should be addressed.

Clinical implications of 750 mg, 5-day levofloxacin for the treatment of community-acquired pneumonia

OBJECTIVE

To evaluate the time to symptom resolution and i.v.-to-p.o. transition in community-acquired pneumonia (CAP) patients treated with 750 mg or 500 mg levofloxacin.

RESEARCH DESIGN

A retrospective, subset analysis of a multicenter, randomized, double-blind, controlled trial comparing 750 mg levofloxacin for 5 days to 500 mg levofloxacin for 10 days for the treatment of CAP.

PATIENTS AND METHODS

A total of 528 CAP patients were included. Baseline symptoms were re-evaluated on Day 3 of therapy, and time to i.v.-to-p.o. transition was recorded for inpatients.

RESULTS

For the overall population, 67.4% of patients receiving 750 mg levofloxacin had resolution of fever by Day 3 of therapy, compared to 54.6% of 500 mg treated patients (P = 0.006). Patients who started on 750 mg levofloxacin i.v. (N = 108) transitioned to p.o. in an average of 2.68 days while those starting on 500 mg i.v. (N = 124) transitioned in 2.95 days (P = 0.144). The median time for i.v.-to-p.o. switch was 2.35 days and 2.75 days for patients receiving 750 mg and 500 mg levofloxacin, respectively (P = 0.098, log rank test). By Day 3 of therapy, 68% of patients receiving the 750 mg dose had transitioned from i.v. to p.o. levofloxacin, compared with 61% of the 500 mg group (P = 0.280). The safety profiles were comparable for the two regimens.

CONCLUSIONS

The 750 mg levofloxacin dose resulted in a greater proportion of patients with resolution of CAP symptoms by Day 3 when compared with 500 mg therapy. Consequently, the 750 mg regimen trended toward more rapid transition to p.o., potentially resulting in lower overall drug costs. Time to switch from i.v. to p.o. was determined by the investigators' discretion rather than a set protocol. Additionally, length of stay data was not collected in this study, which can significantly impact overall healthcare costs. Further research is required to fully understand the economic impact of the 750 mg, 5-day levofloxacin regimen.

Ofloxacin plus rifampicin versus doxycycline plus rifampicin in the treatment of brucellosis: a randomized clinical trial [ISRCTN11871179]

Background

The combination therapies recommended by the World Health Organization for treatment of brucellosis are doxycycline plus rifampicin or doxycycline plus streptomycin. Although highly successful results have been obtained with these two regimens, relapse rates as high as 14.4%. The most effective and the least toxic chemotherapy for human brucellosis is still undetermined. The aim of the present study was to investigate the efficacy, adverse effects and cost of ofloxacin plus rifampicin therapy, and doxycycline plus rifampicin therapy and evaluate in the treatment of brucellosis.

Methods

The open trial has been carried out prospectively by the two medical centers from December 1999 to December 2001 in Duzce region Turkey. The diagnosis was based on the presence of signs and symptoms compatible with brucellosis including a positive agglutination titre (≥1/160) and/or a positive culture. Doxycycline and rifampicin group consisted of 14 patients who were given doxycycline 200 mg/day plus rifampicin 600 mg/day during 45 days and this group Ofloxacin plus rifampicin group was consisted of 15 patients who were given ofloxacin 400 mg/day plus rifampicin 600 mg/day during 30 days.

Results

Regarding clinical and/or demographic characteristics no significant difference was found between two groups of patients that underwent two different therapeutic regimens. At the end of the therapy, two relapses were seen in both groups (p = 0.695). Although duration of therapy was two weeks shorter in group treated with rifampicin plus ofloxacin, the cure rate was similar in both groups of examinees. Fever dropped more rapidly in the group that treated with rifampicin plus ofloxacin, 74 ± 30 (ranges 48–216) vs. 106 ± 26 (ranges 48–262) hours (p = 0.016).

Conclusions

Ofloxacin plus rifampicin therapy has advantages of shorter treatment duration and provided shorter course of fever with treatment than in doxycycline plus rifampicin therapy. However, cost of ofloxacin plus rifampicin treatment is higher than doxycycline plus rifampicin treatment. Because of the similar effects, adverse effects and relapses rates between two regimens, we still advice doxycycline plus rifampicin for the treatment of brucellosis for countries, which have limited resources.

Drug costs and bacterial susceptibility after implementing a single-fluoroquinolone use policy at a university hospital

The University of Kentucky Hospital investigated the feasibility of choosing a sole fluoroquinolone for its formulary in an effort to reduce costs without affecting clinical outcomes. A three-step process was used to plan, implement, and monitor the selection program. Based on the range of clinical indications, safety profile, local susceptibility, cost, and dosing convenience, levofloxacin was chosen over ciprofloxacin and gatifloxacin as the sole fluoroquinolone. Since the implementation of the program in May 2001, susceptibility to levofloxacin has been maintained or increased for the most common pathogens. In addition, University Hospital has saved nearly 100,000 dollars in antibiotic acquisition costs during the first 12 months after the switch. This assessment did not take into account effects in clinical outcomes, such as clinical failures (such as readmission rates), mortality, and adverse events, or measure changes in overall medical expenditures beyond drug acquisition costs. In the future, monitoring of overall patient care and medical care costs, in addition to susceptibility patterns and drug costs, will allow for a better understanding of the long-term benefits of this switch.

Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money

CONTEXT

Current Israeli guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommend nitrofurantoin for 5 days. Some physicians nevertheless opt for ofloxacin, which should be prescribed for 3 days according to universally accepted guidelines.

OBJECTIVE

To evaluate the economic consequences of longer than recommended durations of antibiotic therapy in the empiric treatment of uncomplicated UTI in women.

DESIGN, SETTING AND PATIENTS

Data were derived from the electronic records of one of the four health maintenance organizations in Israel. The sample included all women aged 18-75 years who were diagnosed with acute cystitis or UTI from January 2001 to June 2002 and were empirically treated with antibiotics. Of the 7738 patients identified, 1138 received nitrofurantoin and 1054 ofloxacin. The excess expenditure accrued due to longer than recommended therapy with these drugs was evaluated.

RESULTS

The rate of adherence was 22.23% for nitrofurantoin (95% CI=19.81%, 24.65%), and 4.08% for ofloxacin (95% CI=2.88%, 5.28%). The average excess expenditure per case was 5.78 USD (US Dollar) with ofloxacin and 3.43 USD with nitrofurantoin, resulting in an annual loss to the health maintenance organizations of approximately 19,000 USD. When extrapolated to the national population of 6.5 million, the loss due to inappropriate treatment of adult women is 190,000 USD.

CONCLUSIONS

The lack of adherence to national and international guidelines with regard to the recommended duration of antibiotic treatment of UTI in women resulted in a significant and avoidable waste of health system resources. This study suggests that drug utilization analyses that concentrate solely on the choice of drug may be overlooking important information.

Effect of fluoroquinolone expenditures on susceptibility of Pseudomonas aeruginosa to ciprofloxacin in U.S. hospitals

The effect of fluoroquinolone use on the susceptibility of Pseudomonas aeruginosa to fluoroquinolones in U.S. hospitals was studied. Benchmarking surveys were sent annually to pharmacists practicing in U.S. hospitals from 1993 to 1999. Data collected included hospital characteristics, antimicrobial expenditures and use, antimicrobial stewardship activities, and bacterial susceptibilities. Antimicrobial expenditures were normalized for the number of occupied beds (OBs) per year. General linear modeling and repeated-measures mixed-effects modeling were used to determine factors predictive of P. aeruginosa susceptibility to fluoroquinolones. A total of 174 hospitals provided data for fluoroquinolone expenditures and susceptibility of P. aeruginosa; the median number of years of data was 3 (range, 1-6), representing 416 hospital years. Community hospitals contributed a majority of the data. Median fluoroquinolone expenditures increased gradually from $230 per OB in 1993 to $400 per OB in 1998. A 55% increase to $620 per OB occurred in 1999, largely because of increased spending on levofloxacin. Susceptibility to ciprofloxacin was commonly used to assess fluoroquinolone susceptibility. The median susceptibility of P. aeruginosa to ciprofloxacin decreased from 84% to 71%. Increasing expenditures for ofloxacin and levofloxacin, but not ciprofloxacin, were associated with decreasing P. aeruginosa susceptibility to ciprofloxacin. In the final multivariable model, each study year after 1993 and every increase in ofloxacin expenditure of $100 per OB were associated with decreases in P. aeruginosa susceptibility. Data from a benchmarking survey of U.S. hospitals for 1993-1999 revealed increases in levofloxacin expenditures, total fluoroquinolone expenditures, expenditures for nonfluoroquinolone antipseudomonal antimicrobials, and total antimicrobial expenditures in 1999. Increases in expenditures for levofloxacin and ofloxacin were associated with a significant decrease in P. aeruginosa susceptibility to ciprofloxacin.

A novel method of estimating cost of therapy by using patient population characteristics: analysis of fluoroquinolones in various populations with different distributions of renal function

INTRODUCTION

Formulary decisions regarding a given drug class are often made in the absence of patient outcome and/or sophisticated pharmacoeconomic data. Analyses that consider factors beyond simple acquisition costs may be useful in such situations. For example, the cost implications of using manufacturers' recommendations for dosing in patients with renal dysfunction may be important, depending on the distribution of various levels of renal function within a patient population.

METHODS

Using four 1000-patient populations representing different renal function distributions and a fifth population of our medical center's distribution, we determined the costs of therapy for intravenous and oral levofloxacin, gatifloxacin, and moxifloxacin for a 10-day course of therapy for community-acquired pneumonia. Costs considered were average wholesale prices (AWPs), 50% of AWP, or same daily price, plus intravenous dose preparation and administration costs when applicable. Costs for each renal function distribution were examined for significant differences with an analysis-of-variance test. Also, costs of failing to adjust dosing regimens for decreased renal function were determined.

RESULTS

Differences in fluoroquinolone costs (AWP, 50% AWP, or when matched as the same daily price) among the populations were found. When considering same daily prices, differences among populations ranged from about 35,000 dollars with intravenous gatifloxacin to more than 51,000 dollars for intravenous levofloxacin (all fluoroquinolones, p>0.05). Within a population, differences in costs among the intravenous fluoroquinolones ranged from 47,000-99,000 dollars. Rank orders of the drugs and population costs of therapy were affected by the pricing structure used and varied by the specific population and drug. Differences among the fluoroquinolones or populations were much smaller (<2100 dollars) when considering oral regimens. Costs potentially incurred by failing to adjust dosing for renal function were substantial.

CONCLUSION

Formulary decisions can be facilitated by considering factors such as patient characteristics and related dosing in addition to simple acquisition costs. In our example, consideration of the distribution of renal function within a given patient population and related dosing for these fluoroquinolones revealed potentially important differences within the class.

Pharmacoeconomics of a pharmacist-managed program for automatically converting levofloxacin route from i.v. to oral

The economic and clinical outcomes of a pharmacist-managed proactive program that used predetermined clinical criteria for converting levofloxacin therapy from i.v. to oral without physician approval were examined. A prospective observational study (POS) assessing the standard of care was conducted over two months and was compared with a proactive conversion program (PCP). A cost-minimization analysis was performed from the provider's perspective. The analysis was divided into cost levels 1, 2, and 3. During the POS and PCP, 49 and 82 patients were evaluated, respectively. The percentage of patients meeting conversion criteria in each group was similar (61% POS versus 65% PCP) (p = 0.827). Candidates met criteria for conversion on day 2 in both groups. The average days that conversion occurred during the POS and PCP were days 7 and 3, respectively (p = 0.010). In those patients, the length of stay was significantly shorter for the PCP (6 versus 9.5 days) (p = 0.031). Level-1, level-2, and level-3 costs were significantly less during the PCP than during the POS for patients who met conversion criteria ($77 versus $133, $91 versus $151, and $13,931 versus $17,198, respectively). Two patients in the PCP were switched back to i.v. levofloxacin due to noninfection-related complications. The overall clinical success rate for evaluable conversion candidates was 100% during the PCP. A pharmacist-managed proactive program that used predetermined clinical criteria for converting levofloxacin therapy from i.v. to p.o. without physician approval reduced length of stay and institutional health care costs without compromising clinical outcomes.

Treatment of chronic suppurative otitis media with ofloxacin in hydroxypropyl methylcellulose ear drops: a clinical/bacteriological study in a rural area of Malawi

Chronic suppurative otitis media in young children is a major problem in Africa, with socio-economic consequences at a later age. Common treatment regimens with antibiotics are expensive and often not practically feasible. Therefore, a project was started to develop a low-cost and effective treatment in a rural area of Malawi by studying the clinical efficacy of an inexpensive application regimen of ofloxacin (0.075%) in hydroxypropyl methylcellulose (1.5%) ear drops. In earlier studies with this treatment regimen, it was possible to cure approximately 70% of ears. The aim of this study was to find out whether the bacteriological spectrum cultured from wet ears before and after treatment, and patterns of resistance to antibiotics, played a role in the percentage of cures. Patients with long-standing chronic suppurative otitis media were clinically assessed and treated with suction cleaning and instillation of ear drops on days 1, 3, 7 and 10. Bacterial swabs were taken for culture and sensitivity tests for ofloxacin were on days 1 and 10 from the ears that were still discharging. After 21 weeks, the ears were assessed again clinically. Clinical cure was considered to be complete cessation of otorrhea. Ninety of 104 tested patients (124 ears) completed the study. About 73% of the ears had become dry by day 10. This dropped to 42% after 21 weeks. Before treatment, most ears (91%) harbored fecal bacteria, Proteus mirabilis (74%) and enterococci (60%) being the most frequently isolated microbes. The second group of frequently cultured bacteria were water bacteria e.g. Pseudomonas species and other non-fermenters (69%), whereas the classical otitis media pathogens were detected only in 15% of ears. Before treatment, 9.7% of strains were resistant to ofloxacin, most (30/35) of which were cultured from ears that were eventually cured. After treatment, fecal and water bacteria were still the most frequently found, with 36% new strains and an overall sensitivity to ofloxacin of 58%. Bacterial resistance did not appear to play an important role in the outcome of treatment. These data rather suggest a very high risk of infection due to poor hygiene conditions. Medical treatment can only have a longer-lasting effect if accompanied by community-based programs that focus on improvement of hygiene. A public health approach is necessary alongside a medical approach for the management of CSOM.

Comparison of therapeutic interchange with standard educational tools for influencing fluoroquinolone prescribing

The abilities of therapeutic interchange (TI) and standard educational tools (SET) to change prescribing habits were compared. We evaluated the replacement of ciprofloxacin with levofloxacin in a four-hospital health system during a 14-month study period. Two hospitals used TI and two SET. The demographics, sites of infection, and severity of illness were analyzed for 554 patients treated at SET hospitals and 1323 patients treated at TI hospitals during a total of 2040 hospitalizations over a 14-month period. In TI hospitals, 97% of patients received levofloxacin, whereas 43% received levofloxacin in SET hospitals (p < 0.001). Clinical outcomes were not significantly different for the two groups, although more patients in the SET hospitals received combination antimicrobial therapy. Differences in savings per patient were significant between TI hospitals ($60) and SET hospitals ($37) (p < 0.001). The total annualized savings for all four hospitals was $156,444. TI was more effective than SET in facilitating changes in prescribing patterns in a health care system and resulted in significant cost savings to hospitals and payers.

Intravenous-to-oral transition therapy in community-acquired pneumonia: the INOVA Health System experience

Economic pressures on the delivery of health care have necessitated a focus on reducing costs and resource utilization while maintaining or improving the quality of care. A growing consensus holds that switching from intravenous to oral therapy is a cost-effective and clinically sound approach for a significantly large group of patients with community-acquired pneumonia (CAP). Drug utilization studies within the INOVA Health System revealed that levofloxacin is a cost-effective alternative to ciprofloxacin in infectious disease and that use of risk prediction criteria can reduce inappropriate hospitalizations for CAP, thereby reducing costs. In addition, the INOVA experience demonstrates that the strategy used to implement new antibiotic regimens such as switch-therapy regimens is an important factor in cost reduction: a therapeutic interchange mandate is more successful than standard educational techniques in changing treatment patterns.

A controlled trial of a critical pathway for treating community-acquired pneumonia: the CAPITAL study. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin

Recent clinical trials in patients with community-acquired pneumonia (CAP) demonstrated that switching from intravenous to oral antibiotic therapy is safe once clinical improvement is evident, thereby facilitating early hospital discharge. This study evaluated the use of a critical pathway to improve the efficiency of treating CAP in 1743 patients at 19 teaching and community hospitals in Canada. Hospitals were randomized to continue conventional management of CAP (10 hospitals) or implement a critical pathway (9 hospitals). The main clinical outcome measure was patients' scores (assessed 6 wks after hospital presentation) on the Short-Form 36 Physical Component Summary, a quality-of-life questionnaire. Secondary clinical outcome measures included occurrence of complications, readmission rates, and mortality. The primary economic outcome measure was resource utilization, measured by the number of bed days/patient managed (BDPM). Clinical outcomes were good in both groups, with no significant differences between the two management strategies. However, use of the clinical pathway was associated with a 1.7-day reduction in BDPM and fewer admissions of low-risk patients.

Implementing a program for switching from i.v. to oral antimicrobial therapy

Management Case Studies describe approaches to real-life management problems in health systems. Each installment is a brief description of a problem and how it was dealt with. The cases are intended to help readers deal with similar experiences in their own work sites. Problem solving, not hypothesis testing, is emphasized. Successful resolution of the management issue is not a criterion for publication--important lessons can be learned from failures, too.

Approaches to drug therapy, formulary, and pathway management in a large community hospital

Use of a clinical pathway for the management of community-acquired pneumonia (CAP) at a large community hospital is described. The pathway was developed and implemented by a multidisciplinary team. Fluoroquinolone therapeutic interchange and intravenous (i.v.) to oral (p.o.) conversion were part of the pathway; through literature review, levofloxacin was chosen as the preferred quinolone. Outcomes (length of stay [LOS] and readmission rates for pathway and nonpathway patients with CAP, economic impact of the fluoroquinolone interchange protocol, and resistance patterns) were evaluated. For pathway patients in 1998, LOS was 1.2 days shorter and the readmission rate was lower. Projected drug cost savings as a result of the fluoroquinolone interchange protocol were more than $22,000 annually. Pharmacists' interventions in antimicrobial prescribing for CAP patients can lead to cost efficiency and positively affect patient outcomes.

Use of a physician order entry system to identify opportunities for intravenous to oral levofloxacin conversion

Experience with a program for identifying, through a physician order entry system, potentially inappropriate use of expensive intravenous (i.v.) drugs, including levofloxacin, is described. The program identifies patients who are receiving i.v. levofloxacin and simultaneously receiving oral medications or an oral diet. A computerized report of such patients is printed every morning at the hospital and distributed to pharmacists according to their nursing station assignments. The pharmacists document their daily interventions to encourage switching from i.v. to oral therapy, and data are compiled and posted at the end of each month. From January 1 through September 30, 1999, the first 10 months of the program, the cost per day of levofloxacin therapy per patient decreased substantially. The program helped the institution decrease the number of patients receiving i.v. levofloxacin.

Pharmacodynamics and pharmacokinetics of levofloxacin

Principles of antibiotic pharmacodynamics include factors that are important for effective eradication of bacteria as well as the suppression of resistance. For effective eradication of bacteria and a good clinical outcome, a ratio for the area under the plasma concentration-time curve relative to the minimum inhibitory concentration (AUC/MIC) of greater than 100 is needed for gram-negative organisms, and a level of greater than 30 is required for gram-positive organisms. Pharmacodynamic principles can also be used to devise the optimal administration regimen for specific antimicrobial agents. Pharmacodynamic analysis of the activity of levofloxacin against Streptococcus pneumoniae revealed that, 99% of the time, actual hospitalized patients achieve an AUC/MIC of greater than 30. This indicates that levofloxacin will be very effective in treating S. pneumoniae infections in the majority of patients. Cost of treatment is an increasing concern voiced by healthcare providers and users alike. This has led to a much greater emphasis placed upon the cost of individual drugs used in the management of infections. However, when evaluating the cost of an antibiotic, it is extremely important that not only are the direct acquisition costs assessed, but consideration also given to other aspects incurring a financial burden, such as drug preparation cost, supplies, costs of treating adverse events or any treatment failures. It is only by having such a full assessment of costs that realistic financial comparisons can be made between different antibiotics.

Comparison of topical 0.3% ofloxacin to fortified tobramycin-cefazolin in the therapy of bacterial keratitis

BACKGROUND

In this study we compared topical ofloxacin with a combination of fortified tobramycin sulphate and cefazolin sodium solutions in the treatment of culture-proved bacterial keratitis.

METHODS

30 eyes of culture-proved bacterial corneal ulcers of moderate severity were included in a prospective randomized, controlled, double-masked study for comparison. The cases were randomly allocated to treatment with 0.3% ofloxacin solution (Group I) and combination of fortified antibiotics (1.5% tobramycin and 5% cefazolin solutions--Group II as control) along with supportive cycloplegic, vitamins and antiglaucoma therapy. Time for healing of ulcer and subjective symptoms were main outcome measures. Student's t-test was used to compare the results.

RESULTS

Staphylococcus aureus and coagulase-negative staphylococci were the two most common organisms isolated. Resolution of the ulcer was achieved in 93% and 87% in the treated and the control group, respectively. The mean duration of symptomatic relief was 7.8 +/- 1.54 days in the treated group and 8.33 +/- 1.44 days in the control group; for epithelial healing it was 15.0 +/- 3.86 days in the treated group and 15.46 +/- 3.86 days in the control group. Post resolution the best corrected visual acuity of 20/200 or better was achieved in all but one eye each in both groups.

CONCLUSIONS

Both ofloxacin 0.3% and combined fortified tobramycin 1.5% and cefazolin 5% topical drops were comparable for treating cases of bacterial corneal ulcer of moderate severity. However, considering the easy availability and cost effectiveness of ofloxacin, a monotherapy with ofloxacin may be preferred over the combined, fortified tobramycin and cefazolin therapy.

An economic evaluation of levofloxacin versus cefuroxime axetil in the outpatient treatment of adults with community-acquired pneumonia

OBJECTIVE

To examine treatment costs of community-acquired pneumonia (CAP) in adult outpatients given oral (p.o.) levofloxacin or cefuroxime axetil as initial therapy.

STUDY DESIGN

Patients with a primary diagnosis of CAP were enrolled in a multicenter, prospective, randomized, open-label, active-controlled Phase III clinical trial. Both inpatients and outpatients were assigned to 1 of 2 treatment groups: (1) intravenous (i.v.) or p.o. levofloxacin; or (2) i.v. ceftriaxone and/or p.o. cefuroxime axetil.

METHODS

To make legitimate and meaningful cost comparisons between similar types of patients receiving drugs via the same route of administration (i.e., orally), this outpatient economic study examined the resource utilization of the 211 patients enrolled as outpatients who received oral formulations as initial treatment (levofloxacin, 103 patients; cefuroxime axetil, 108 patients). Resource utilization data and clinical trial data were collected concurrently. To generate cost estimates, Medicare cost estimates for resources were multiplied by the resource units used by patients in each treatment arm.

RESULTS

Cost estimates indicated a total cost difference that favored the levofloxacin group (base case: $169; sensitivity analysis: $223 [P = .008]). The results for the base case were not significant (P = .094). In addition, within the cost categories, there was a statistically significant study drug cost differential favoring levofloxacin ($86; P = .0001 for both the base case and sensitivity analysis).

CONCLUSION

Oral levofloxacin is less costly than oral cefuroxime axetil in the outpatient treatment of adults with CAP.

Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin

OBJECTIVE

The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy.

METHODS

Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient.

RESULTS

The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from $457 to $994 per patient.

CONCLUSIONS

The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

Influence of fluoroquinolone purchasing patterns on antimicrobial expenditures and Pseudomonas aeruginosa susceptibility

The influence of using ofloxacin in place of ciprofloxacin on hospital fluoroquinolone expenditures, total antimicrobial expenditures, and susceptibility of Pseudomonas aeruginosa to fluoroquinolones was studied. Hospitals with fluoroquinolone expenditures of at least $1 per occupied bed per year were administered annual surveys covering the years 1993 through 1996. The two most recent consecutive years of data were compared among hospitals that used ciprofloxacin as their primary fluoroquinolone during both years (group 1), hospitals whose ofloxacin purchases increased from accounting for < or =25% of total fluoroquinolone expenditures during year 1 to accounting for >25% during year 2 (group 2), and hospitals whose ofloxacin purchases accounted for at least 25% of total fluoroquinolone expenditures for both years (group 3). A total of 109 hospitals were included in the study. Most hospitals spent more on fluoroquinolones and total antimicrobials in year 2 than year 1. Group 3 hospitals had a significant increase in expenditures for fluoroquinolones and non-fluoroquinolone antipseudomonal antimicrobials. Group 2 hospitals did not realize antimicrobial cost savings and had higher rates of Pseudomonas aeruginosa resistance than hospitals that used ciprofloxacin. Whether a hospital changed its pattern of ciprofloxacin and ofloxacin purchasing was not significantly associated with expenditures for fluoroquinolones, nonfluoroquinolone antimicrobial agents, or all antimicrobials. Susceptibility of P. aeruginosa to ciprofloxacin was lower in hospitals with greater proportions of ofloxacin use. Individual hospital, ciprofloxacin expenditures, and study year were found to be predictive of P. aeruginosa susceptibility to ciprofloxacin among all pooled hospitals.

Cost-effectiveness comparison of sequential ofloxacin versus standard switch therapy

OBJECTIVE

To compare the cost-effectiveness of sequential intravenous-to-oral ofloxacin versus intravenous-to-oral standard switch therapy for the treatment of patients with sepsis who are hospitalized with bacterial infections.

DESIGN

Cost-effectiveness analysis from a provider perspective, including resources important to an integrated healthcare network, of a randomized, open-label, controlled, clinical trial.

SETTING

Millard Fillmore Health System, Buffalo, NY.

PATIENTS

Hospitalized adults requiring parenteral antibiotics for a complicated urinary tract infection, lower respiratory tract infection, or skin and soft tissue infection.

INTERVENTIONS

Sequential intravenous-to-oral ofloxacin or standard intravenous-to-oral switch antibiotics.

OUTCOME MEASURES

Clinical outcomes and direct costs associated with hospitalization, primary physician services, specialist physician services, and outpatient care.

RESULTS

Eighty-two of 89 patients randomized into the two treatment groups were evaluable. Standard switch therapy failed with 12 patients versus 10 patients receiving ofloxacin. Complete economic data were available for 74 patients. Sequential ofloxacin therapy resulted in a 1-day-shorter antibiotic-related hospitalization without evidence of recurrent infection during the posttherapy follow-up evaluations. An average cost savings of $399 per patient was achieved in the sequential ofloxacin group. Although this difference did not attain statistical significance (probably due to the large variance), it is an economically significant finding. The cost-effectiveness ratios were $5735 per successful outcome for the standard switch therapy group versus $5126 per successful outcome in the sequential ofloxacin group.

CONCLUSIONS

Sequential ofloxacin was as effective and consistently less expensive than standard switch antibiotics in the initial evaluation and in the sensitivity analysis of room cost and drug acquisition cost. Standard switch therapy would have to be greater than 25% more effective than sequential ofloxacin therapy to change the economic decision.

Randomized comparative trial and cost analysis of 3-day antimicrobial regimens for treatment of acute cystitis in women

OBJECTIVE

To determine the efficacy, safety, and costs associated with four different 3-day regimens for the treatment of acute uncomplicated cystitis in women.

DESIGN

A prospective randomized trial with a cost analysis.

STUDY POPULATION

Women with acute cystitis attending a student health center.

INTERVENTIONS

Treatment with 3-day oral regimens of trimethoprim-sulfamethoxazole, 160 mg/800 mg twice daily, macrocrystalline nitrofurantoin, 100 mg four times daily, cefadroxil, 500 mg twice daily, or amoxicillin, 500 mg three times daily.

RESULTS

Six weeks after treatment, 32 (82%) of 39 women treated with trimethoprim-sulfamethoxazole were cured compared with 22 (61%) of 36 treated with nitrofurantoin (P = .04 vs trimethoprim-sulfamethoxazole), 21 (66%) of 32 treated with cefadroxil (P = .11 vs trimethoprim-sulfamethoxazole), and 28 (67%) of 42 treated with amoxicillin (P = .11 vs trimethoprim-sulfamethoxazole). Persistence of significant bacteriuria was less common with trimethoprim-sulfamethoxazole (3%) and cefadroxil (0%) compared with nitrofurantoin (16%; P = .05 vs trimethoprim-sulfamethoxazole) and amoxicillin (14%; P = .11 vs trimethoprim-sulfamethoxazole). Persistence of bacteriuria was associated with amoxicillin-resistant strains in the amoxicillin group but nitrofurantoin-susceptible strains in the nitrofurantoin group. Trimethoprim-sulfamethoxazole was more successful in eradicating Escherichia coli from rectal cultures soon after therapy and from urethral and vaginal cultures at all follow-up visits compared with the other treatment regimens. Adverse effects were reported by 16 (35%) of 46 patients receiving trimethoprim-sulfamethoxazole, 18 (43%) of 42 receiving nitrofurantoin, 12 (30%) of 40 receiving cefadroxil, and 13 (25%) of 52 receiving amoxicillin. The mean costs per patient were less with trimethoprim-sulfamethoxazole ($114) and amoxicillin ($131) compared with nitrofurantoin ($155) and cefadroxil ($155).

CONCLUSIONS

A 3-day regimen of trimethoprim-sulfamethoxazole is more effective and less expensive than 3-day regimens of nitrofurantoin, cefadroxil, or amoxicillin for treatment of uncomplicated cystitis in women. The increased efficacy of trimethoprim-sulfamethoxazole is likely related to its antimicrobial effects against E coli in the rectum, urethra, and vagina.

Cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis

BACKGROUND

The new Centers for Disease Control and Prevention treatment guidelines for Chlamydia trachomatis include two recently available drugs, azithromycin and ofloxacin. The best choice for initial therapy remains controversial.

OBJECTIVES

We wanted to perform a cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis.

METHODS

Using information gathered from a MEDLINE search of the English language literature from 1966 to 1994, employing the key words "cervicitis," "C. trachomatis," "erythromycin," "tetracycline," "doxycycline," "ofloxacin," and "azithromycin," we developed a decision analysis model specific for a nonpregnant woman with uncomplicated Chlamydia trachomatis cervicitis. Options in this model included an initially cured infection, a failed initial cure resulting in persistent cervicitis, or pelvic inflammatory disease treated either on an inpatient or outpatient basis. Probability estimates for each option were derived from previously published reports. A cost-effectiveness analysis was performed for three end points: cost per cure with initial therapy, cost per case of pelvic inflammatory disease averted, and cost per hospitalization averted. Sensitivity analyses were done by varying the cure rates for each antibiotic and the complication rates for failed therapy. The costs incurred for treatment were also varied.

RESULTS

Using the high estimate for initial cure rates, doxycycline and tetracycline were the most cost-effective agents. Azithromycin was the next most cost-effective agent, followed by ofloxacin and erythromycin. To achieve an equivalent final cost, the probability of initial cure with azithromycin must exceed that of doxycycline by 3 percentage points. As the cost of azithromycin decreases, the difference in initial cure rates between the two drugs to achieve an equivalent final cost becomes smaller.

CONCLUSIONS

Doxycycline remains the drug of choice in the treatment of Chlamydia trachomatis cervicitis. The results favor the use of azithromycin rather than doxycycline when there is concern for compliance to the standard doxycycline regimen. A lower cost for azithromycin could favor its use as the drug of choice.

Fluconazol plus ofloxacin in prophylaxis of infections in patients with acute leukemia: a comparative study

In a retrospective study the incidence of infections, number of afebrile days, duration of antimicrobial chemotherapy, and cost of antibacterials and antimycotics were compared in two groups of patients. One was a group of 57 patients who received no prophylaxis during induction remission therapy of acute leukemia treated in 1989-1990, the second was a group of 22 patients treated in 1991 where prophylaxis with fluconazol and ofloxacin was administered. For ethical reasons pertaining since 1991, when prophylaxis became mandatory, the study was not randomized. A decrease in the number of febrile days, the cost of antimicrobials and the duration of treatment with antibiotics and antimycotics was observed in the group receiving fluconazol and ofloxacin.