Pharmacoeconomic analysis of empirical therapy with ceftazidime alone or combination antibiotics for febrile neutropenia in cancer patients

Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia.

METHODS

A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus.

RESULTS

Forty-seven articles from 43 studies met selection criteria.

RECOMMENDATIONS

Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.

Cost-utility of the 21-gene recurrence score assay in node-negative and node-positive breast cancer

The 21-gene recurrence score (Oncotype DX: RS) appears to augment clinico-pathologic prognostication and is predictive of adjuvant chemotherapy benefit in node-negative (N-) and node-positive (N+), endocrine-sensitive breast cancer. RS is a costly assay that is associated with good 'value for money' in N- disease, while economic evaluations in N+ disease based on most recent data have not been conducted. We examined the cost-utility (CU) of a RS-guided adjuvant strategy, compared to current practice without RS in N- and N+, endocrine-sensitive, breast cancer from a Canadian health care system perspective. A generic state-transition model was developed to compute cumulative costs and quality-adjusted life years (QALYs) over a 25-year horizon. Patient outcomes with and without chemotherapy in RS-untested cohorts and in those with low, intermediate and high RS were examined based on the reported prognostic and predictive impact of RS in N- and N+ disease. Chemotherapy utilization (current vs. RS-guided), unit costs and utilities were derived from a Nova Scotia Canadian population-based cohort, local unit costs and the literature. Costs and outcomes were discounted at 3% annually, and costs were reported in 2011 Canadian dollars ($). Probabilistic and one-way sensitivity analyses were conducted for key model parameters. Compared to a non-RS-guided strategy, RS-guided adjuvant therapy was associated with $2,585 and $864 incremental costs, 0.27 and 0.06 QALY gains, and resultant CUs of $9,591 and $14,844 per QALY gained for N- and N+ disease, respectively. CU estimates were robust to key model parameters, and were most sensitive to chemo utilization proportions. RS-guided adjuvant therapy appears to be a cost-effective strategy in both N- and N+, endocrine-sensitive breast cancer with resultant CU ratios well below commonly quoted thresholds.

The cost-utility of adjuvant chemotherapy using docetaxel and cyclophosphamide compared with doxorubicin and cyclophosphamide in breast cancer

PURPOSE

The adoption of a chemotherapeutic regimen in oncologic practice is a function of both its clinical and its economic impacts on cancer management. For breast cancer, U.S. Oncology trial 9735 reported significant improvements in disease-free and overall survival favoring adjuvant tc (docetaxel 75 mg/m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks for 4 cycles) compared with ac (doxorubicin 60 mg/ m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks for 4 cycles). We carried out an economic evaluation to examine the cost-utility of adjuvant tc relative to ac, in terms of cost per quality-adjusted life year (qaly) gained, given the improved breast cancer outcomes and higher costs associated with the tc regimen.

METHODS

A Markov model was developed to calculate the cumulative costs and qalys gained over a 10-year horizon for hypothetical cohorts of women with breast cancer treated with ac or with tc. Event rates, costs, and utilities were derived from the literature and local resources. Efficacy and adverse events were based on results reported from U.S. Oncology trial 9735. The model takes a third-party direct payer perspective and reports its results in 2008 Canadian dollars. Costs and benefits were both discounted at 3%.

RESULTS

At a 10-year horizon, tc was associated with $3,960 incremental costs and a 0.24 qaly gain compared with ac, for a favorable cost-utility of $16,753 per qaly gained. Results were robust to model assumptions and input parameters.

CONCLUSIONS

Relative to ac, tc is a cost-effective adjuvant chemotherapy regimen, with a cost-effectiveness ratio well below commonly applied thresholds.

Health-related quality of life anticipated with different management strategies for paediatric febrile neutropaenia

Background:

To describe (1) anticipated health-related quality of life during different strategies for febrile neutropaenia (FN) management and (2) attributes of those preferring inpatient management.

Methods:

Respondents were parents of children 0–18 years and children 12–18 years receiving cancer treatment. Anticipated health-related quality of life was elicited for four different FN management strategies: entire inpatient, early discharge, outpatient oral and outpatient intravenous (i.v.) therapy. Tools used to measure health-related quality of life were visual analogue scale (VAS), willingness to pay and time trade off.

Results:

A total of 155 parents and 43 children participated. For parents, median VAS scores were highest for early discharge (5.9, interquartile range 4.4–7.2) and outpatient i.v. (5.9, interquartile range 4.4–7.3). For children, median scores were highest for early discharge (6.1, interquartile range 4.6–7.2). In contrast, the most commonly preferred strategy for parents and children was inpatient in 55.0% and 37.2%, respectively. Higher current child health-related quality of life was associated with a stronger preference for outpatient management.

Conclusion:

Early discharge and outpatient i.v. management are associated with higher anticipated health-related quality of life, although the most commonly preferred strategy was inpatient care. This data may help with determining more cost-effective strategies for paediatric FN.

The direct medical costs associated with suspected heparin-induced thrombocytopenia

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction associated with heparin exposure. Sunnybrook Health Sciences Centre, a tertiary-care adult academic hospital, has cared for an average of 100 cases of suspected HIT per year. Although the management of suspected HIT is resource intensive, few studies have assessed the cost burden associated with HIT, and none have assessed the costs of suspected HIT.

OBJECTIVE

The objective of this study was to identify and quantify the direct medical costs associated with suspected (confirmed and negative) HIT at a hospital in Canada.

METHODS

A cost-of-illness analysis was conducted in patients with suspected HIT during 2005. Resource utilization variables included (i) laboratory tests to investigate HIT; (ii) HIT-safe anticoagulant use; (iii) diagnostic imaging related to HIT or its treatment; and (iv) additional hospital days attributed to HIT. The average costs per case of confirmed HIT, confirmed HIT with thrombosis (HITT) and negative HIT were calculated in $Can, year 2007 values.

RESULTS

Confirmed HITT cases incurred substantially greater costs ($Can34 155, range 358-202 069; n = 12) than confirmed HIT cases without thrombosis ($Can4575, range 39-16 373; n = 8). The average cost of care for a negative HIT case was $Can119 (range 39-4181; n = 88).

CONCLUSIONS

This is the first study to quantify the costs associated with suspected HIT cases. These cases increase the costs of hospital care and provide further justification for HIT prevention strategies.

Evaluation of direct medical costs of hospitalization for febrile neutropenia

BACKGROUND

Treatment of febrile neutropenia (FN) is costly, because it typically involves hospitalization. As cancer rates continue to increase, the number of patients suffering from FN will also increase, making it important to quantify the costs of treating this condition accurately and comprehensively.

METHODS

A consecutive sample of patients admitted to an inpatient hematology/oncology ward at a tertiary care hospital for the treatment of chemotherapy-induced FN was enrolled in this study. Patients were followed prospectively during hospitalization, and information on medical resource utilization including length of stay, medications, and laboratory and diagnostic tests was collected. Costs, extracted from hospital and provincial databases, were used to calculate the overall cost per FN episode, from the hospital perspective.

RESULTS

Fifty-one episodes of FN that occurred in 46 patients were included in the study. Approximately 52% of these episodes occurred in women, and 65% of these episodes occurred in patients with hematologic malignancies. The mean +/- standard deviation age of patients was 60.3 +/- 13.4 years. The mean length of stay per episode was 6.8 +/- 4.9 days. The mean overall cost per episode was 6324 +/- 4783 in 2007 Canadian dollars.

CONCLUSIONS

Hospitalization for the treatment of FN is expensive. The results of this study could be used in future economic evaluations of preventive measures and treatments for FN, including primary prophylactic administration of hematopoietic growth factors and outpatient treatment of this condition.

Piperacillin/tazobactam plus ceftazidime versus sulbactam/ampicillin plus aztreonam as empirical therapy for fever in severely neutropenic pediatric patients

BACKGROUND

The efficacy and safety of piperacillin/tazobactam plus ceftazidime (PIPC/TAZ+CAZ) versus sulbactam/ampicillin plus aztreonam (SBT/ABPC+AZT) as empirical therapy for febrile neutropenia were assessed in children with hematologic disease and solid tumor.

PROCEDURE

A prospective randomized study was performed to evaluate the clinical response of 70 febrile episodes in the PIPC/TAZ+CAZ arm and 64 evaluable febrile episodes in the SBT/ABPC+AZT arm of the study. Clinical efficacy was evaluated at 120 hours, with treatment outcome criteria defined as follows. Success was defined as disappearance of fever, clinical improvement, eradication of the infecting organism, and maintenance of a response for at least 7 days after discontinuation of treatment.

RESULTS

An infection was documented microbiologically in 14 episodes (20%) in the PIPC/TAZ+CAZ arm and in 8 episodes (13%) in the SBT/ABPC+AZT arm. The success rate was 57.1% in the PIPC/TAZ+CAZ arm and 62.5% in the SBT/ABPC+AZT arm (P>0.05). No major adverse effects were observed in the study.

CONCLUSIONS

PIPC/TAZ+CAZ and SBT/ABPC+AZT are effective and safe for initial empirical treatment of febrile episodes in neutropenic pediatric patients. The clinical efficacy of SBT/ABPC+AZT is equivalent or superior to that of PIPC/TAZ+CAZ, the effect of which is already proven against febrile neutropenia. Therefore, SBT/ABPC+AZT may be a treatment of choice for febrile neutropenia in pediatric cancer patients.

Outpatient therapy for febrile neutropenia

PURPOSE OF REVIEW

The management of febrile neutropenia has evolved significantly with the development of risk stratification and recognition of the efficacy of oral antibiotics in low-risk patients. There remains uncertainty concerning the need for hospitalization and role of early hospital discharge. We review recent evidence in this field and identify outstanding issues for future research.

RECENT FINDINGS

Studies have confirmed the utility of the MASCC risk index. Preliminary findings suggest that early hospital discharge is feasible in low-risk patients with solid tumours and lymphomas, at least in specialist centres. Median hospital stays may be reduced to 48 h with no increase in serious medical complications. Readmission rates remain low.

SUMMARY

All patients with febrile neutropenia should undergo risk stratification on admission, and low-risk patients should be considered eligible for combination oral antibiotics from the outset. Those patients who show signs of fever resolution and subjective improvement are eligible for early discharge. More research is required with regard to patients with haematological malignancies and/or receiving prophylactic antibiotics, and in the development of factors predictive of successful early discharge. Further data are required regarding whether strategies involving early discharge can be safely implemented at centres outside those which have pioneered these approaches.

Economic burden of haematological adverse effects in cancer patients: a systematic review

OBJECTIVE

Patients receiving cancer treatments commonly experience haematological adverse effects (AEs) related to chemotherapy or molecularly targeted therapies, which may be associated with high healthcare costs. The objective of this review was to summarise the published literature on the economic burden of neutropenia, thrombocytopenia and anaemia as AEs of cancer treatment.

METHODS

A systematic search of the medical literature published between 1990 and 2006 was conducted using PubMed/MEDLINE, EMBASE, BIOSIS, related article links and supplemental searches. References selected for inclusion were prospective or retrospective studies specifically designed to examine the burden of illness, direct medical costs, indirect costs and/or cost drivers associated with neutropenia, thrombocytopenia and anaemia in adult cancer patients. All costs are reported as originally published and adjusted to 2006 US dollars.

RESULTS

In the US, the cost of neutropenia ranged from $US 1893 (2006 value $US 2632) per outpatient episode to $US 38,583 ($US 49,917) per febrile neutropenia hospitalisation. For countries outside the US, the cost of neutropenia appeared to be lower. The cost of thrombocytopenia ranged from $US 1035 ($US 1395) to $US 5328 ($US 7635) per cycle or episode in the US. Costs attributable to anaemia ranged from $US 18,418 ($US 22,775) to $US 69,478 ($US 93,454) per year in the US. The costs of AEs for patients with haematological malignancies appeared to be up to 2-3 times higher than those for patients with solid tumours. Economic studies of the cost of haematological AEs specific to new molecularly targeted treatments for haematological malignancy have not been published.

CONCLUSIONS

Chemotherapy-related haematological AEs result in a substantial economic burden on patients, payers, caregivers and society in general. Because of their burden, the frequency and severity of these toxicities should be one of the key factors in the selection of optimal treatments for patients with cancer, especially those with haematological malignancies. Future research is needed to assess the economic burden of AEs associated with new molecularly targeted treatments for haematological malignancies.

Cefepime versus ceftazidime + amikacin as empirical therapy for febrile neutropenia in children with cancer: a prospective randomized trial of the treatment efficacy and cost

The efficacy, safety, and cost of cefepime and ceftazidime + amikacin as empirical therapy in children with febrile neutropenia is compared. A prospective randomized study in children with cancer was conducted. Patients were randomly assigned to receive either cefepime 150 mg/kg/day or ceftazidime 150 mg/kg/day combined with amikacin 15 mg/kg/day. Treatment modification was defined as all the changes in the empirical antimicrobials after the first 72 h. Overall treatment success was defined as cure of febrile episode with or without modification. Costs of hospitalization, antimicrobial drugs, and supportive therapy were calculated. Fifty febrile netropenic episodes were evaluated. Infectious agents were microbiologically identified in 28% of episodes. The incidence of gram-negative and gram-positive isolates was equal. Overall treatment success was 100% and success of initial empirical therapy without modification was 52 and 40% in the cefepime and cefepime + amikacin groups, respectively. The response rate after glycopeptides were added to the regimen was 64 and 52 % in the cefepime and cefepime + amikacin arms, respectively. Glycopeptide and antifungal drugs were added more frequently in the ceftazidime + amikacin group. Duration of fever, hospitalization, and antimicrobial drug administration were longer in the ceftazidime + amikacin arm. The costs of the antimicrobial drugs, hospitalization, and total cost were lower in the cefepime arm. Cefepime monotherapy is as effective as ceftazidime + amikacin combination in febrile neutropenia of pediatric cancer patients and must be preferred due to shorter defervescence of fever, shorter hospitalization, and lower therapy cost.

Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study

Neutropenic sepsis remains a potentially life-threatening complication of anticancer chemotherapy. However, it is possible to identify patients who are at low risk for serious complications and for whom less-intensive, more-convenient treatment may be appropriate. The aim of this study was to assess the efficacy and safety of oral antibiotics in conjunction with early hospital discharge in comparison with standard in-patient intravenous antibiotics in patients with low-risk neutropenic fever. In all, 126 episodes of low-risk neutropenic fever occurred in 102 patients. Patients were randomised to receive either: an oral regimen of ciprofloxacin (750 mg 12 hourly) plus amoxicillin-clavulanate (675 mg 8 hourly) for a total of 5 days, or a standard intravenous regimen of gentamicin and tazocin (piperacillin/tazobactam) until hospital discharge. Patients randomised to oral antibiotics were eligible for discharge following 24 h of hospitalisation, if clinically stable and symptomatically improved. The efficacy of the two arms was similar: initial treatment was successful without antibiotic modification in 90% of episodes in the intravenous arm and 84.8% of episodes in the oral arm, P=0.55, absolute difference between the groups 5.2%; 95% confidence interval (CI) for the difference -7 to 17.3%. Only one episode in the oral arm was associated with significant clinical deterioration: this occurred within the initial in-patient assessment period. The median in-patient stay was 4 days in the intravenous arm (range 2-8) and 2 days in the oral arm (range 1-16 days), P&<0.0005. The reduction in hospital stay led to significant cost-savings in the oral arm. In conclusion, this study suggests that oral antibiotics in conjunction with early hospital discharge for patients who remain stable after a 24 h period of in-patient monitoring offers a feasible and cost-effective alternative to conventional management of low-risk neutropenic fever.

Outpatient therapy for febrile neutropenia: clinical and economic implications

Although febrile episodes in neutropenic patients remain a potentially life-threatening complication of anticancer chemotherapy, considerable progress has been achieved in understanding this issue. Febrile neutropenic patients represent a heterogeneous population that displays a very variable risk for serious medical complications. It has also been ascertained that in low-risk patients, the standard of care can be safely and effectively shifted from traditional hospital-based, parenteral, empiric, broad-spectrum antibacterial therapy to outpatient treatment, even for the entire duration of the febrile episode. Furthermore, in the last years some risk assessment models have been developed to identify, at the onset of febrile episodes, low-risk neutropenic patients who are most likely to have a favourable outcome (and who can effectively and safely be treated on an outpatient basis). With respect to traditional hospital-based therapy, the outpatient treatment of low-risk patients is associated with several advantages, including a conspicuous cost saving. Some strategies for inpatient therapy, such as switching from intravenous to oral antibacterials and early discharge, can allow some cost containment; however, the most substantial decrease in costs can be obtained by using outpatient treatment over the entire febrile episode, especially by using oral antibacterials. In spite of the considerable number of clinical studies published over the past 20 years, only limited pharmacoeconomic data on this issue are available. Future comparative studies between outpatient and inpatient treatment of febrile neutropenia, in addition to clinical outcomes (e.g. survival, time to clinical response), should therefore include the following: (i) a detailed analysis of total costs, specifying the setting of outpatient treatment and the method of administration of antimicrobial agents (home nursing, self administration or treatment at infusion centres or at a low-care unit of the hospital); (ii) cost of inpatient treatment if outpatient therapy fails; and (iii) out-of-pocket expenses incurred by the patients.

Cost effective approaches to antimicrobial use in oncology patients

PURPOSE OF REVIEW

In the current era of cost containment, the management of the oncology patient who presents with neutropenia and fever remains a challenge. This article will review which measures of cost are helpful in determining cost effective antibiotic use in patients with febrile neutropenia.

RECENT FINDINGS

The majority of direct medical costs associated with treating febrile neutropenic patients are room and board costs. The most recent cost analysis reports a mean cost/day of US$1598.

SUMMARY

Over the past two decades, infection-related mortality rates have decreased from 50% to rates as low as 10%. In contrast to the numerous studies comparing clinical outcomes of patients receiving different antimicrobial regimens for febrile neutropenia, the recent literature revealed limited studies that evaluate economic data. Typically, new antibiotic regimens show equal efficacy to the standard regimens but are often more expensive. If efficacy rates and safety are the same for an antibiotic, the cost is often used to select the product.

Decision analysis modelling of costs and outcomes following cefepime monotherapy in Canada

OBJECTIVE

To evaluate the comparative cost of treatment and intermediate outcomes (percentage resistant organisms, days in hospital, etc) among cefepime and alternative parenteral antibiotics used for empiric monotherapy.

DESIGN

Decision analysis model, based on published literature, clinical trial results and information from infectious disease clinicians.

SETTING

A Canadian tertiary care hospital.

INTERVENTION

Comparison of cefepime, ceftazidime, ceftriaxone, cefotaxime and ciprofloxacin in the treatment of lower respiratory tract infections, urinary tract infections, skin/soft tissue infections, septicemia and febrile neutropenia.

MAIN RESULTS

Cefepime treatment results in the lowest average cost per patient when used as initial empiric therapy for lower respiratory tract infections and for skin/soft tissue infections. Cefepime therapy is among the lowest cost treatments for the other infectious disease conditions and has the lowest cost for a weighted 'average' condition. Sensitivity analysis indicates that model results are most sensitive to duration of hospitalization.

CONCLUSIONS

Initial empiric monotherapy with cefepime for serious infectious disease conditions may result in cost savings compared with alternative parenteral agents.