Curtis D. Collins

Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia.

BACKGROUND Integration of rapid diagnostic testing via matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) with antimicrobial stewardship team (AST) intervention has the potential for early organism identification, customization of antibiotic therapy, and improvement in patient outcomes. The objective of this study was to assess the impact of this combined approach on clinical and antimicrobial therapy-related outcomes in patients with bloodstream infections. METHODS A pre-post quasi-experimental study was conducted to analyze the impact of MALDI-TOF with AST intervention in patients with bloodstream infections. The AST provided evidence-based antibiotic recommendations after receiving real-time notification following blood culture Gram stain, organism identification, and antimicrobial susceptibilities. Outcomes were compared to a historic control group. RESULTS A total of 501 patients with bacteremia or candidemia were included in the final analysis: 245 patients in the intervention group and 256 patients in the preintervention group. MALDI-TOF with AST intervention decreased time to organism identification (84.0 vs 55.9 hours, P < .001), and improved time to effective antibiotic therapy (30.1 vs 20.4 hours, P = .021) and optimal antibiotic therapy (90.3 vs 47.3 hours, P < .001). Mortality (20.3% vs 14.5%), length of intensive care unit stay (14.9 vs 8.3 days) and recurrent bacteremia (5.9% vs 2.0%) were lower in the intervention group on univariate analysis, and acceptance of an AST intervention was associated with a trend toward reduced mortality on multivariable analysis (odds ratio, 0.55, P = .075). CONCLUSION MALDI-TOF with AST intervention decreased time to organism identification and time to effective and optimal antibiotic therapy.

Cost-Effectiveness Analysis Evaluating Fidaxomicin versus Oral Vancomycin for the Treatment of Clostridium difficile Infection in the United States

OBJECTIVES Fidaxomicin is a novel treatment for Clostridium difficile infections (CDIs). This new treatment, however, is associated with a higher acquisition cost compared with alternatives. The objective of this study was to evaluate the cost-effectiveness of fidaxomicin or oral vancomycin for the treatment of CDIs. METHODS We performed a cost-utility analysis comparing fidaxomicin with oral vancomycin for the treatment of CDIs in the United States by creating a decision analytic model from the third-party payer perspective. RESULTS The incremental cost-effectiveness ratio with fidaxomicin compared with oral vancomycin was

Impact of an Antimicrobial Stewardship Program Comprehensive Care Bundle on Management of Candidemia

67,576/quality-adjusted life-year. A probabilistic Monte Carlo sensitivity analysis showed that fidaxomicin had an 80.2% chance of being cost-effective at a willingness-to-pay threshold of

Comparative cost-effectiveness of posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia

100,000/quality-adjusted life-year. Fidaxomicin remained cost-effective under all fluctuations of both fidaxomicin and oral vancomycin costs. The decision analytic model was sensitive to variations in clinical cure and recurrence rates. Secondary analyses revealed that fidaxomicin was cost-effective in patients receiving concominant antimicrobials, in patients with mild to moderate CDIs, and when compared with oral metronidazole in patients with mild to moderate disease. Fidaxomicin was dominated by oral vancomycin if CDI was caused by the NAP1/Bl/027 Clostridium difficile strain and was dominant in institutions that did not compound oral vancomycin. CONCLUSION Results of our model showed that fidaxomicin may be a more cost-effective option for the treatment of CDIs when compared with oral vancomycin under most scenarios tested.

Managing antimicrobial resistance in intensive care units.

To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia.

To Test or Not To Test: a Cost Minimization Analysis of Susceptibility Testing for Patients with Documented Candida glabrata Fungemias

PURPOSE A cost-effectiveness analysis was performed to investigate the financial impact of using posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia. METHODS A decision-analytic model was developed from a hospital perspective based on the use of posaconazole versus fluconazole or itraconazole prophylaxis in patients with prolonged neutropenia (i.e., longer than 7-10 days). Data reported in a multicenter study, medication-cost information, and reports of costs to treat invasive fungal infections were used to accurately populate the model. Sensitivity analyses enhanced the robustness of the model through variation of all probabilities and costs. RESULTS In the base case, patients initiated on posaconazole displayed a 45% reduction in overall cost as compared with patients initiated on fluconazole or itraconazole (

Pharmacoeconomic Analysis of Liposomal Amphotericin B versus Voriconazole for Empirical Treatment of Febrile Neutropenia

3051 versus

Management of oropharyngeal candidiasis with localized oral miconazole therapy: efficacy, safety, and patient acceptability.

5529, respectively). Sensitivity analyses determined that univariate changes in all model variables, including medication cost, duration of therapy, and cost of treating invasive fungal infections, did not impact overall results. A Monte Carlo simulation analysis found that use of posaconazole remains the best overall prophylactic strategy when taking into consideration the potential variance in all model assumptions. Posaconazole dominated the use of fluconazole or itraconazole because of previously demonstrated lower incidence of breakthrough fungal infections and lower overall treatment cost. CONCLUSION The decision model indicated that use of posaconazole as prophylaxis in patients with prolonged neutropenia should result in lower overall treatment costs relative to the cost of fluconazole or itraconazole.

Institutional Experience with Voriconazole Compared with Liposomal Amphotericin B as Empiric Therapy for Febrile Neutropenia

The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physicians success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.

Antimicrobial Use Among Patients Receiving Palliative Care Consultation

ABSTRACT This cost minimization analysis investigated the financial impact of the treatment of fungemias due to Candida glabrata from a hospital perspective using three competing alternatives: (i) performing in-house susceptibility testing on all C. glabrata isolates and changing patients to less expensive fluconazole therapy for isolates that test susceptible; (ii) susceptibility testing at outside laboratories with delayed deescalation to fluconazole if isolates test susceptible; and (iii) no routine susceptibility testing with full echinocandin treatment course. Sensitivity analyses and Monte Carlo simulation enhanced the robustness of the model through variation of all assumptions and costs. In the base case, the use of in-house testing displayed a cost advantage over the options of send-out testing and no susceptibility testing (