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Is Procalcitonin-Guided Antimicrobial Use Cost-Effective in Adult Patients with Suspected Bacterial Infection and Sepsis?

Published online by Cambridge University Press:  05 January 2015

Michelle Harrison  and
Curtis D. Collins
Michelle Harrison
Affiliation:
Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, Michigan.
Curtis D. Collins*
Affiliation:
Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, Michigan.
*
Address correspondence to Curtis Collins, PharmD, MS, BCPS AQ-ID, FASHP, St. Joseph Mercy Health System, 5301 East Huron River Dr., Ann Arbor, Michigan 48106, USA (cdc008@yahoo.com).
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Abstract

OBJECTIVE

Procalcitonin has emerged as a promising biomarker of bacterial infection. Published literature demonstrates that use of procalcitonin testing and an associated treatment pathway reduces duration of antibiotic therapy without impacting mortality. The objective of this study was to determine the financial impact of utilizing a procalcitonin-guided treatment algorithm in hospitalized patients with sepsis.

DESIGN

Cost-minimization and cost-utility analysis.

PATIENTS

Hypothetical cohort of adult ICU patients with suspected bacterial infection and sepsis.

METHODS

Utilizing published clinical and economic data, a decision analytic model was developed from the U.S. hospital perspective. Effectiveness and utility measures were defined using cost-per-clinical episode and cost per quality-adjusted life years (QALYs). Upper and lower sensitivity ranges were determined for all inputs. Univariate and probabilistic sensitivity analyses assessed the robustness of our model and variables. Incremental cost-effectiveness ratios (ICERs) were calculated and compared to predetermined willingness-to-pay thresholds.

RESULTS

Base-case results predicted the use of a procalcitonin-guided treatment algorithm dominated standard care with improved quality (0.0002 QALYs) and decreased overall treatment costs ($65). The model was sensitive to a number of key variables that had the potential to impact results, including algorithm adherence (<42.3%), number and cost of procalcitonin tests ordered (≥9 and >$46), days of antimicrobial reduction (<1.6 d), incidence of nephrotoxicity and rate of nephrotoxicity reduction.

CONCLUSION

The combination of procalcitonin testing with an evidence-based treatment algorithm may improve patients’ quality of life while decreasing costs in ICU patients with suspected bacterial infection and sepsis; however, results were highly dependent on a number of variables and assumptions.

Infect Control Hosp Epidemiol 2014;00(0): 1–8

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 36 , Issue 3 , March 2015 , pp. 265 - 272
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

DISCLOSURE. An earlier version of this manuscript was presented at ID Week 2014

References

REFERENCES

1.Wacker, C, Prkno, A, Brunkhorst, FM, Schlattmann, P. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis 2013;13:426–435.Google Scholar
2.Uzzan, B, Cohen, R, Nicolas, P, et al. Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 2006;34:1996–2003.CrossRefGoogle ScholarPubMed
3.Nobre, V, Harbarth, S, Graf, JD, et al. Use of procalcitonin to shorten antibiotic treatment duration in septic patients: a randomized trial. Am J Respir Crit Care Med 2008;177:498–505.Google Scholar
4.Hohn, A, Schroeder, S, Gehrt, A, et al. Procalcitonin-guided algorithm to reduce length of antibiotic therapy in patients with severe sepsis and septic shock. BMC Infect Dis 2013;13:158.CrossRefGoogle ScholarPubMed
5.Hochreiter, M, Köhler, T, Schweiger, AM, et al. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial. Crit Care 2009;13:R83.Google Scholar
6.Schroeder, S, Hochreiter, M, Koehler, T, et al. Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study. Langenbecks Arch Surg 2009;394:221–226.CrossRefGoogle ScholarPubMed
7.Stolz, D, Smyrnios, N, Eggimann, P, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009;34(6):1364–1375.Google Scholar
8.Bouadma, L, Luyt, CE, Tubach, F, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010;375:463–474.Google Scholar
9.Soni, NJ, Samson, DJ, Galaydick, JL, et al. Procalcitonin-guided antibiotic therapy: a systematic review and meta-analysis. J Hosp Med 2013;8:530–540.Google Scholar
10.Matthaiou, DK, Ntani, G, Kontogiorgi, M, et al. An ESICM systematic review and meta-analysis of procalcitonin-guided antibiotic therapy algorithms in adult critically ill patients. Intensive Care Med 2012;38:940–949.Google Scholar
11.Prkno, A, Wacker, C, Brunkhorst, FM, Schlattmann, P. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock—a systematic review and meta-analysis. Crit Care 2013;17:R291.CrossRefGoogle ScholarPubMed
12.Soni, NJ, et al. Procalcitonin-guided antibiotic therapy executive summary. Comparative effectiveness review no. 78. AHRQ Publication No. 12(13)-EHC124-EF. Rockville, MD: Agency for Healthcare Research and Quality. http://effectivehealthcare.ahrq.gov/ehc/products/219/1274/CER78_Prolactin_ExecutiveSummary_20121001.pdf. Published October 2012. Accessed June 14, 2014.Google Scholar
13.Jensen, JU, Hein, L, Lundgren, B, et al. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in in the intensive care unit: a randomized trial. Crit Care Med 2011;39:2048–2058.Google Scholar
14.Feazel, LM, Malhotra, A, Perencevich, EN, et al. Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis. J Antimicrob Chemother 2014;69:1748–1754.Google Scholar
15.Smith, KJ, Wateska, A, Nowalk, MP, et al. Cost-effectiveness of procalcitonin-guided antibiotic use in community acquired pneumonia. J Gen Intern Med 2013;28:1157–1164.CrossRefGoogle ScholarPubMed
16.Michaelidis, CI, Zimmerman, RK, Nowalk, MP, Fine, MJ, Smith, KJ. Cost-effectiveness of procalcitonin-guided antibiotic therapy for outpatient management of acute respiratory tract infections in adults. J Gen Intern Med 2014;29:579–586.CrossRefGoogle ScholarPubMed
17.Heyland, DK, Johnson, AP, Reynolds, SC, Muscedere, J. Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation. Crit Care Med 2011;39:1792–1799.Google Scholar
18.Deliberato, RO, Marra, AR, Sanches, PR, et al. Clinical and economic impact of procalcitonin to shorten antimicrobial therapy in septic patients with proven bacterial infection in an intensive care setting. Diagn Microbiol Infect Dis 2013;76:266–271.CrossRefGoogle Scholar
19.U.S. Bureau of Labor Statistics. Consumer price index—all urban consumers medical care services. http://www.bls.gov/cpi/data.htm. Published 2014. Accessed June 17, 2014.Google Scholar
20.Centers for Medicare & Medicaid Services 2014, Clinical diagnostic laboratory fee schedule. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html. Published 2014. Accessed June 17, 2014.Google Scholar
21.Dellinger, RP, Levy, MM, Rhodes, A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637.Google Scholar
22.Red Book Online. Micromedex 2.0. Thomson Reuters 1974–2012. http://www.thomsonhc.com /micromedex2.com. Published July 2014. Accessed July 10, 2014.Google Scholar
23.Chastre, J, Wolff, M, Fagon, JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003;290:2588–2598.Google Scholar
24.Elyasi, S, Khalili, H, Hatamkhani, S, Dashti-Khavidaki, S. Prevention of vancomycin induced nephrotoxicity: a review of preclinical data. Eur J Clin Pharmacol 2013;69:747–754.Google Scholar
25.Cano, EL, Haque, NZ, Welch, VL, et al. Incidence of nephrotoxicity and association with vancomycin use in intensive care unit patients with pneumonia: retrospective analysis of the IMPACT-HAP Database. Clin Ther 2012;34:149–157.CrossRefGoogle ScholarPubMed
26.van Hal, SJ, Paterson, DL, Lodise, TP. Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter. Antimicrob Agents Chemother 2013;57:734–744.Google Scholar
27.Chertow, GM, Burdick, E, Honour, M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 2005;16:3365–3370.Google Scholar
28.Lucado, J, Gould, C, Elixhauser, A. Statistical brief #124: Healthcare Cost and Utilization Project (HCUP) Clostridium difficile infections (CDI) in hospital stays, 2009. http://hcup-us.ahrq.gov/reports/statbriefs/sb124.jsp. Published January 2012. Accessed December 12, 2014.Google Scholar
29.Fridkin, S, Baggs, J, Hagan, R, et al. Vital signs: improving antimicrobial use among hospitalized patients. MMWR 2104;63:194–200; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed March 25, 2014.Google Scholar
30.Angus, DC, Linde-Zwirble, WT, Clermont, G, et al. Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis. Crit Care Med 2003;31:1–11.Google Scholar
31.Stranges, PM, Hutton, DW, Collins, CD. Cost-effectiveness analysis evaluating fidaxomicin versus oral vancomycin for the treatment of Clostridium difficile infection in the United States. Value Health 2013;16:297–304.CrossRefGoogle ScholarPubMed
32.Liem, YS, Bosch, JL, Hunink, MG. Preference-based quality of life of patients on renal replacement therapy: a systematic review and meta-analysis. Value Health 2008;11:733–741.Google Scholar
33.Wyld, M, Morton, RL, Hayen, A, Howard, K, Webster, AC. A systematic review and meta-analysis of utility-based quality of life in chronic kidney disease treatments. PLoS Med 2012;9:e1001307.Google Scholar
34.Elixhauser, A, Friedman, B, Stranges, E. Statistical Brief #122: Septicemia in U.S. Hospitals, 2009. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb122.jsp. Published October 2011. Accessed December 12, 2014.Google Scholar
35.Angus, DC, Linde-Zwirble, WT, Lidicker, J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303–1310.Google Scholar
36.Albrich, WC, Dusemund, F, Bucher, B, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL). Arch Intern Med 2012;172:715–722.Google Scholar
37.Schuetz, P, Raad, I, Amin, DN. Using procalcitonin-guided algorithms to improve antimicrobial therapy in ICU patients with respiratory infections and sepsis. Curr Opin Crit Care 2013;19:453–460.Google Scholar
38.Burgess, LD, Drew, RH. Comparison of the incidence of vancomycin-induced nephrotoxicity in hospitalized patients with and without concomitant piperacillin-tazobactam. Pharmacotherapy 2014;34:670–676.Google Scholar
39.Malani, AN, Richards, PG, Kapila, S, et al. Clinical and economic outcomes from a community hospital’s antimicrobial stewardship program. Am J Infect Control 2013;41:145–148.CrossRefGoogle ScholarPubMed
40.Feazel, LM, Malhotra, A, Perencevich, EN, et al. Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis. J Antimicrob Chemother 2014;69:1748–1754.Google Scholar