Cost-effectiveness of oral gemifloxacin versus intravenous ceftriaxone followed by oral cefuroxime with/without a macrolide for the treatment of hospitalized patients with community-acquired pneumonia

Oral vs. parenteral antibiotic therapy in adult patients with community-acquired pneumonia: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Antibiotic therapy is widely used for patients with community-acquired pneumonia (CAP), and yet whether the efficacy of antibiotics differs based on the treatment mode remains unclear. This study aimed to summarize the evidence regarding the efficacy and safety of oral vs. parenteral administration of antibiotic therapy for the treatment of patients with CAP.

METHODS

The databases of PubMed, EmBase, and the Cochrane Central Register of Controlled Trials were systematically searched for eligible randomized controlled trials (RCTs) from inception until 11 December 2021. The effectiveness of oral vs. parenteral administration of antibiotic therapy was estimated using a random-effects model. Additional sensitivity, subgroup, and publication bias analyses were performed.

RESULTS

Of 912 identified articles, 12 RCTs involving 2158 patients with CAP were included in our pooled analysis. This mostly included trials with low certainty and some concerns regarding risk of bias, including lack of allocation concealment and blinding of participants and personnel. Overall, oral antibiotic therapy did not affect the incidence of clinical success at the end of treatment (relative risk [RR], 1.01; 95% confidence interval [CI], 0.98-1.05; P = 0.417), clinical success at follow-up (RR, 1.02; 95% CI, 0.98-1.06; P = 0.301), or adverse events (RR, 0.87; 95% CI, 0.56-1.35; P = 0.527). Moreover, oral antibiotic therapy had a beneficial effect on the risk of all-cause mortality (RR, 0.58; 95% CI, 0.35-0.96; P = 0.034).

CONCLUSIONS

Oral administration of antibiotics is associated with a reduced risk of all-cause mortality compared with parenteral therapy based on RCTs with low to moderate quality. This finding should be verified in further large-scale RCTs.

Practical Concerns about the Metrics and Methods of Financial Outcome Measurement in Antimicrobial Stewardship Programs: A Narrative Review

Emerging pathogens in the meantime of paucity of new antibiotics discovery, put antimicrobial stewardship in the center of attention, to preserve the existing antimicrobial effect. Implementation of antimicrobial stewardship programs, however, needs approval from healthcare system managers. The approval process can be enhanced, when the beneficial effects of stewardship programs are supported by both clinical and financial evidence. Focusing on the financial outcome evaluation, the practitioners who run the stewardship programs, may choose certain methods and metrics, depending on the clinical setting scale and type, available human resources, and budget. The wise selection of the methods and metrics warrants a comprehensive insight of the existing methods and metrics, deployed by typically published works that set good examples to follow. This review is an attempt to provide such an insight along with typical relevant examples for each metric and method.

Pneumococcal Disease: A Systematic Review of Health Utilities, Resource Use, Costs, and Economic Evaluations of Interventions

BACKGROUND

Pneumococcal diseases cause substantial mortality, morbidity, and economic burden. Evidence on data inputs for economic evaluations of interventions targeting pneumococcal disease is critical.

OBJECTIVES

To summarize evidence on resource use, costs, health utilities, and cost-effectiveness for pneumococcal disease and associated interventions to inform future economic analyses.

METHODS

We searched MEDLINE, Embase, Web of Science, CINAHL, PsycINFO, EconLit, and Cochrane databases for peer-reviewed studies in English on pneumococcal disease that reported health utilities using direct or indirect valuation methods, resource use, costs, or cost-effectiveness of intervention programs, and summarized the evidence descriptively.

RESULTS

We included 383 studies: 9 reporting health utilities, 131 resource use, 160 economic costs of pneumococcal disease, 95 both resource use and costs, and 178 economic evaluations of pneumococcal intervention programs. Health state utility values ranged from 0 to 1 for both meningitis and otitis media and from 0.3 to 0.7 for both pneumonia and sepsis. Hospitalization was shortest for otitis media (range: 0.1-5 days) and longest for sepsis/septicemia (6-48). The main categories of costs reported were drugs, hospitalization, and household or employer costs. Resource use was reported in hospital length of stay and number of contacts with general practitioners. Costs and resource use significantly varied among population ages, disease conditions, and settings. Current vaccination programs for both adults and children, antibiotic use and outreach programs to promote vaccination, early disease detection, and educational programs are cost-effective in most countries.

CONCLUSION

This study has generated a comprehensive repository of health economic evidence on pneumococcal disease that can be used to inform future economic evaluations of pneumococcal disease intervention programs.

Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature

BACKGROUND

Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia.

METHODS

A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal.

RESULTS

Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies.

CONCLUSION

Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems. PROSPERO registration no: CRD42018097174.

Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea.

Cost-Effectiveness of Antibiotic Prophylaxis Strategies for Transrectal Prostate Biopsy in an Era of Increasing Antimicrobial Resistance

OBJECTIVES

To determine the optimal antibiotic prophylaxis strategy for transrectal prostate biopsy (TRPB) as a function of the local antibiotic resistance profile.

METHODS

We developed a decision-analytic model to assess the cost-effectiveness of four antibiotic prophylaxis strategies: ciprofloxacin alone, ceftriaxone alone, ciprofloxacin and ceftriaxone in combination, and directed prophylaxis selection based on susceptibility testing. We used a payer's perspective and estimated the health care costs and quality-adjusted life-years (QALYs) associated with each strategy for a cohort of 66-year-old men undergoing TRPB. Costs and benefits were discounted at 3% annually. Base-case resistance prevalence was 29% to ciprofloxacin and 7% to ceftriaxone, reflecting susceptibility patterns observed at the Minneapolis Veterans Affairs Health Care System. Resistance levels were varied in sensitivity analysis.

RESULTS

In the base case, single-agent prophylaxis strategies were dominated. Directed prophylaxis strategy was the optimal strategy at a willingness-to-pay threshold of $50,000/QALY gained. Relative to the directed prophylaxis strategy, the incremental cost-effectiveness ratio of the combination strategy was $123,333/QALY gained over the lifetime time horizon. In sensitivity analysis, single-agent prophylaxis strategies were preferred only at extreme levels of resistance.

CONCLUSIONS

Directed or combination prophylaxis strategies were optimal for a wide range of resistance levels. Facilities using single-agent antibiotic prophylaxis strategies before TRPB should re-evaluate their strategies unless extremely low levels of antimicrobial resistance are documented.

Cost-effectiveness and pricing of antibacterial drugs

Growing resistance to antibacterial agents has increased the need for the development of new drugs to treat bacterial infections. Given increasing pressure on limited health budgets, it is important to study the cost-effectiveness of these drugs, as well as their safety and efficacy, to find out whether or not they provide value for money and should be reimbursed. In this article, we systematically reviewed 38 cost-effectiveness analyses of new antibacterial agents. Most studies showed the new antibacterial drugs were cost-effective compared to older generation drugs. Drug pricing is a complicated process, involving different stakeholders, and has a large influence on cost-effectiveness. Value-based pricing is a method to determine the price of a drug at which it can be cost-effective. It is currently unclear what the influence of value-based pricing will be on the prices of new antibacterial agents, but an important factor will be the definition of ‘value’, which as well as the impact of the drug on patient health might also include other factors such as wider social impact and the health impact of disease.

What Is New in Antibiotic Therapy in Community-Acquired Pneumonia? An Evidence-Based Approach Focusing on Combined Therapy

Despite all published literature, controversies remain about the optimal antibiotic treatment in community-acquired pneumonia. The most debated issue is whether it is necessary to empirically start one or two antibiotics, i.e. whether or not to cover atypical agents. A review of the literature published from 2005 to present was completed, searching for new insights in antibiotic treatment in community-acquired pneumonia (CAP) focusing on monotherapy versus combined therapy. Forty-one articles were identified enrolling outpatients, and patients admitted to the ward and to the intensive care unit: 11 were meta-analyses, 8 clinical trials and 22 observational-prospective and retrospective-studies. Although controversies remain in the treatment of CAP, the use of combination therapy seems to be associated with a lower mortality in case of severe CAP that requires intensive care unit (ICU) admission, especially when a beta-lactam-macrolide association is delivered. Moreover, combination therapy is associated with better outcomes-although not always with a lower mortality-in cases of non-ICU patients with risk factors for a poor outcome, bacteraemic pneumococcal pneumonia and high suspicion of infection by atypical agents. In this setting, it appears that the best choice of treatment may be a beta-lactam-macrolide regimen.

Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults

BACKGROUND

Community-acquired pneumonia (CAP) is caused by various pathogens, traditionally divided into 'typical' and 'atypical'. Initial antibiotic treatment of CAP is usually empirical, customarily covering both typical and atypical pathogens. To date, no sufficient evidence exists to support this broad coverage, while limiting coverage is bound to reduce toxicity, resistance and expense.

OBJECTIVES

The main objective was to estimate the mortality and proportion with treatment failure using regimens containing atypical antibiotic coverage compared to those that had typical coverage only. Secondary objectives included the assessment of adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012 which includes the Acute Respiratory Infection Group's Specialized Register, MEDLINE (January 1966 to April week 1, 2012) and EMBASE (January 1980 to April 2012).

SELECTION CRITERIA

Randomized controlled trials (RCTs) of adult patients hospitalized due to CAP, comparing antibiotic regimens with atypical coverage (quinolones, macrolides, tetracyclines, chloramphenicol, streptogramins or ketolides) to a regimen without atypical antibiotic coverage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from included trials. We estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assessed heterogeneity using a Chi(2) test.

MAIN RESULTS

We included 28 trials, encompassing 5939 randomized patients. The atypical antibiotic was administered as monotherapy in all but three studies. Only one study assessed a beta-lactam combined with a macrolide compared to the same beta-lactam. There was no difference in mortality between the atypical arm and the non-atypical arm (RR 1.14; 95% CI 0.84 to 1.55), RR < 1 favors the atypical arm. The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae (L. pneumophilae) and non-significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of (total) adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were less common in the atypical arm (RR 0.70; 95% CI 0.53 to 0.92). Although the trials assessed different antibiotics, no significant heterogeneity was detected in the analyses.

AUTHORS' CONCLUSIONS

No benefit of survival or clinical efficacy was shown with empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta-lactams. Further trials, comparing beta-lactam monotherapy to the same combined with a macrolide, should be performed.

Isolation, identification of Streptococcus pneumoniae from infected rhesus monkeys and control efficacy

BACKGROUND

Streptococcus pneumoniae can cause a wide variety of illnesses. Primate animals can be infected by the pneumococcus. A disease occurred among rhesus monkeys in winter 2006.

METHODS

Routine clinical observation, necropsies, bacteriological examinations were conducted, and PCR, pathogenicity to BALB/c mice and antibiotic susceptibility test were examined additionally.

RESULTS

We conclude that the agent is S. pneumoniae. Based on the antibiotic susceptibility test, a dose of 20 mg/kg body weight daily of Erythromycin was given intramuscular injection for 5 days, resulting in the disappearance of clinical signs, and no newly case reappear be observed till today.

CONCLUSIONS

Therefore, it is suggested that the outbreak of respiratory disease in the rhesus monkeys was because of transmission of S. pneumoniae among rhesus monkeys. The antibiotic therapy finding underscores the utility of Erythromycin to cure the infected rhesus monkeys without causing side effects and without contributing to the further development of antibiotic resistance.

Role of gemifloxacin in the management of community-acquired lower respiratory tract infections

Respiratory tract infections (RTIs) form a substantial clinical and financial burden, with the increasing complication of antimicrobial resistance. This resistance may compromise the use of many empirically prescribed antimicrobials. The new respiratory fluoroquinolones have been developed to overcome this burgeoning resistance. This group includes gemifloxacin, an enhanced-affinity fluoroquinolone that has been approved for clinical use in several countries and is characterised as a potent dual-acting agent with excellent in vitro activity against Streptococcus pneumoniae (minimum inhibitory concentration for 90% of strains (MIC90)=0.03-0.06 microg/mL). Gemifloxacin given once daily for 5-7 days has been shown to be non-inferior to, or in some instances superior to, comparator agents for the treatment of common lower RTIs. Moreover, it is generally well tolerated and is as safe as many frequently empirically prescribed antimicrobials. In addition, studies have shown gemifloxacin to be a cost-effective agent for some lower RTIs.