Prevalence, healthcare resource utilization and overall burden of fungal meningitis in the United States

PURPOSE

Previous epidemiological and cost studies of fungal meningitis have largely focused on single pathogens, leading to a poor understanding of the disease in general. We studied the largest and most diverse group of fungal meningitis patients to date, over the longest follow-up period, to examine the broad impact on resource utilization within the United States.

METHODOLOGY

The Truven Health Analytics MarketScan database was used to identify patients with a fungal meningitis diagnosis in the United States between 2000 and 2012. Patients with a primary diagnosis of cryptococcal, Coccidioides, Histoplasma, or Candida meningitis were included in the analysis. Data concerning healthcare resource utilization, prevalence and length of stay were collected for up to 5 years following the original diagnosis.

RESULTS

Cryptococcal meningitis was the most prevalent type of fungal meningitis (70.1 % of cases over the duration of the study), followed by coccidioidomycosis (16.4 %), histoplasmosis (6.0 %) and candidiasis (7.6 %). Cryptococcal meningitis and candidiasis patients accrued the largest average charges ($103 236 and $103 803, respectively) and spent the most time in the hospital on average (70.6 and 79 days). Coccidioidomycosis and histoplasmosis patients also accrued substantial charges and time in the hospital ($82 439, 48.1 days; $78 609, 49.8 days, respectively).

CONCLUSION

Our study characterizes the largest longitudinal cohort of fungal meningitis in the United States. Importantly, the health economic impact and long-term morbidity from these infections are quantified and reviewed. The healthcare resource utilization of fungal meningitis patients in the United States is substantial.

Epidemiology, Risk Factors, and Outcomes of Candida albicans Versus Non-albicans Candidemia in Nonneutropenic Patients

Background:

Candidemia is a major cause of morbidity and mortality in hospitalized patients.

Objectives:

To describe the epidemiology of and risk factors for non-albicans candidemia (NAC) in nonneutropenic adults and the impact of NAC on patient outcomes and treatment cost.

Methods:

We conducted a retrospective cohort analysis comparing demographics and risk factors for Candida albicans candidemia (CAC) versus NAC in 144 nonneutropenic patients with candidemia over a 6 year period (1997–2002) at Detroit Receiving Hospital.

Results:

Candida species distribution included albicans (50%), parapsilosis (13%), tropicalis (10%), and glabrata (13%). Predominant species varied by patient care unit, with C. glabrata more common in the medical intensive care unit (ICU) and C. parapsilosis in the burn ICU. In multivariate analysis, NAC was associated with the absence of antibiotic use at the onset of candidemia, recent history of solid tumor, and male sex, NAC was not associated with an increase in mortality or length of stay compared with CAC, but was found to have a higher cost of antifungal therapy ($2030 vs $780; p = 0.05).

Conclusions:

The epidemiology of candidemia is complex and varies among the different patient care units. Specifically, patients appear less likely to develop NAC if they are receiving antibiotics at the onset of candidemia. Increased awareness of risk factors for NAC can be used to guide adequate initial antifungal therapy.

Excess Mortality, Hospital Stay, and Cost Due to Candidemia: A Case-Control Study Using Data From Population-Based Candidemia Surveillance

Objective:

To determine the mortality, hospital stay, and total hospital charges and cost of hospitalization attributable to candidemia by comparing patients with candidemia with control-patients who have otherwise similar illnesses. Prior studies lack broad patient and hospital representation or cost-related information that accurately reflects current medical practices.

Design:

Our case-control study included case-patients with candidemia and their cost-related data, ascertained from laboratory-based candidemia surveillance conducted among all residents of Connecticut and Baltimore and Baltimore County, Maryland, during 1998 to 2000. Control-patients were matched on age, hospital type, admission year, discharge diagnoses, and duration of hospitalization prior to candidemia onset.

Results:

We identified 214 and 529 sets of matched case-patients and control-patients from the two locations, respectively. Mortality attributable to candidemia ranged between 19% and 24%. On multivariable analysis, candidemia was associated with mortality (OR, 5.3 for Connecticut and 8.5 for Baltimore and Baltimore County;P< .05), whereas receiving adequate treatment was protective (OR, 0.5 and 0.4 for the two locations, respectively;P< .05). Candidemia itself did not increase the total hospital charges and cost of hospitalization; when treatment status was accounted for, having received adequate treatment for candidemia significantly increased the total hospital charges and cost of hospitalization ($6,000 to $29,000 and $3,000 to $22,000, respectively) and the length of stay (3 to 13 days).

Conclusion:

Our findings underscore the burden of candidemia, particularly regarding the risk of death, length of hospitalization, and cost associated with treatment (Infect Control Hosp Epidemiol2005;26:540-547).

Clinical and economic burden of invasive fungal diseases in Europe: focus on pre-emptive and empirical treatment of Aspergillus and Candida species

Invasive fungal diseases (IFDs) have been widely studied in recent years, largely because of the increasing population at risk. Aspergillus and Candida species remain the most common causes of IFDs, but other fungi are emerging. The early and accurate diagnosis of IFD is critical to outcome and the optimisation of treatment. Rapid diagnostic methods and new antifungal therapies have advanced disease management in recent years. Strategies for the prevention and treatment of IFDs include prophylaxis, and empirical and pre-emptive therapy. Here, we review the available primary literature on the clinical and economic burden of IFDs in Europe from 2000 to early 2011, with a focus on the value and outcomes of different approaches.

De-escalation from micafungin is a cost-effective alternative to traditional escalation from fluconazole in the treatment of patients with systemic Candida infections

BACKGROUND

Systemic Candida infections (SCI) occur predominantly in intensive care unit patients and are a common cause of morbidity and mortality. Recently, changes in Candida epidemiology with an increasing prevalence of SCI caused by Candida non-albicans species have been reported. Resistance to fluconazole and azoles in general is not uncommon for non-albicans species. Despite guidelines recommending initial treatment with broad-spectrum antifungals such as echinocandins with subsequent switch to fluconazole if isolates are sensitive (de-escalation strategy), fluconazole is still the preferred first-line antifungal (escalation) in many clinical practice settings. After diagnosis of the pathogen, the initial therapy with fluconazole is switched to a broad-spectrum antifungal if a non-albicans is identified.

METHODS

The cost-effectiveness of initial treatment with micafungin (de-escalation) vs fluconazole (escalation) in patients with SCI was estimated using decision analysis based on clinical and microbiological data from pertinent studies. The model horizon was 42 days, and was extrapolated to cover a lifetime horizon. All costs were analyzed from the UK NHS perspective. Several assumptions were taken to address uncertainties; the limitations of these assumptions are discussed in the article.

RESULTS

In patients with fluconazole-resistant isolates, initial treatment with micafungin avoids 30% more deaths and successfully treats 23% more patients than initial treatment with fluconazole, with cost savings of £1621 per treated patient. In the overall SCI population, de-escalation results in 1.2% fewer deaths at a marginal cost of £740 per patient. Over a lifetime horizon, the incremental cost-effectiveness of de-escalation vs escalation was £15,522 per life-year and £25,673 per QALY.

CONCLUSIONS

De-escalation from micafungin may improve clinical outcomes and overall survival, particularly among patients with fluconazole-resistant Candida strains. De-escalation from initial treatment with micafungin is a cost-effective alternative to escalation from a UK NHS perspective, with a differential cost per QALY below the 'willingness-to-pay' threshold of £30,000.

PNA FISH: present and future impact on patient management

Inappropriate and inaccurate antimicrobial therapy can lead to adverse patient outcomes and also the development of antimicrobial resistance. Peptide nucleic acid (PNA) fluorescence in situ hybridization (FISH) gives rapid reporting with highly sensitive and specific results to clinicians within 3 h after blood cultures turn positive, thereby offering targeted therapeutics where necessary. It is simple to establish compared with real-time PCR and has resulted in significant cost savings for hospitals. PNA FISH is a promising future technology for the microbiology laboratory that will impact on patient management and clinical guidelines. This article will review the clinical data supporting these new technologies.

The impact of esophageal candidiasis on hospital charges and costs across patient subgroups

OBJECTIVE

Assess the impact of esophageal candidiasis on US hospital inpatient charges, length of stay (LOS), and costs across clinically relevant subgroups.

METHODS

Total hospital charge (THC) and LOS data extracted from the 2005 National Inpatient Sample (NIS) were compared for patients with and without esophageal candidiasis within the top 20 most commonly assigned Diagnosis Related Groups (DRGs) for the disease. Total hospital costs were estimated using hospital charges in the 2005 Medicare Provider Analysis and Review (MEDPAR) file and hospital cost-to-charge ratios published in the Center for Medicare and Medicaid Service's (CMS) 2005 Inpatient Prospective Payment System Standardization File.

RESULTS

Across 274 DRGs, 45 727 esophageal candidiasis patients were identified. Mean age was 50.8 years; 52.5% were female, 59.3% Caucasian. Median LOS was 7 days; median THC was $25 649. Of all esophageal candidiasis cases identified, 65% fell into the top 20 most commonly assigned DRGs. Within this subset, HIV-related DRGs accounted for 22% of the esophageal candidiasis cases. The difference in mean THC and LOS for esophageal candidiasis patients in HIV-related DRGs was not significant. However, total hospital costs were higher for esophageal candidiasis patients in this subset ($11 886 vs. $10 534, p < 0.01). The remaining 78% of esophageal candidiasis cases were assigned to 19 non-HIV-related DRGs. Mean LOS, THC, and total hospital costs were significantly higher for esophageal candidiasis patients within these 19 non-HIV-related DRGs, (8.4 vs. 6.1; $35 704 vs. $23 874, and $10 917 vs. $7474, p < 0.01 in all cases).

CONCLUSIONS

Esophageal candidiasis affects a wide range of patient groups; it increases LOS and total charges within non-HIV-related hospitalizations. Although the costs presented in this study are estimates, they do suggest a significant increase in cost among esophageal candidiasis cases. Future studies on treatment and preventive care strategies for esophageal candidiasis should not be limited to HIV patients, but instead performed across a wider range of disease settings.

Candidemia in the in-patient setting: treatment options and economics

Candidemia is the most common nosocomial fungal infection in the US. More than one in four adults who acquire candidemia in the hospital setting die prior to discharge. In addition to high case-fatality rates and other adverse clinical outcomes in survivors, candidemia is associated with a substantial economic burden. High costs associated with complex diagnostics and procedures contribute to this burden, as do new pharmacotherapeutic approaches. Despite the high costs of many antifungal agents recommended for the treatment of candidemia, unambiguous clinical evidence to guide treatment selection does not exist. This article reviews the clinical and economic burdens of candidemia, describes candidemia cost drivers and discusses existing pharmacoeconomic data regarding the cost-effectiveness of candidemia rapid identification and treatment approaches.

Invasive Candida species infection: the importance of adequate empirical antifungal therapy

Candida species are a common cause of bloodstream and invasive infection in critically ill and immunosuppressed patients. Furthermore, invasive Candida infection carries a poor prognosis and may initially be mistaken for bacterial infection. An article in this issue of the Journal investigates the relationship between adequacy of initial empirical therapy and outcome from invasive Candida infection. This study shows that adequate empirical therapy is received by only a quarter of patients, and that inappropriate therapy is associated with increased mortality. These findings highlight the importance of appropriate empirical therapy in invasive Candida infection.

High- versus low-dose fluconazole therapy for empiric treatment of suspected invasive candidiasis among high-risk patients in the intensive care unit: a cost-effectiveness analysis

BACKGROUND

High-dose fluconazole is an alternative for patients with candidemia caused by Candida glabrata or other Candida species with decreased fluconazole susceptibility. However, empiric high-dose fluconazole is not currently recommended and may result in higher drug costs and toxicity.

OBJECTIVE

To determine the cost-effectiveness of using empiric high-dose fluconazole in intensive care unit (ICU) with suspected invasive candidiasis.

DESIGN

Decision analytic model.

TARGET POPULATION

ICU patients with suspected invasive candidiasis.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTIONS

Low-dose fluconazole (loading dose of 800 mg followed by 400 mg daily) vs. high-dose fluconazole (loading dose of 1600 mg followed by 800 mg daily). Generic fluconazole costs were used for the analysis.

OUTCOME MEASURES

Incremental life expectancy and incremental cost per discounted life year (DLY) saved. RESULT OF BASE-CASE ANALYSIS: Based on current national levels of fluconazole resistance and ability to correctly identify patients with candidemia, high-dose fluconazole was the more effective but more expensive treatment strategy. Empiric high-dose fluconazole therapy decreased the mortality rate by 0.15% compared to low-dose strategy with a cost-effectiveness rate of $55,526 per DLY saved.

RESULTS OF SENSITIVITY ANALYSIS

Empirical high-dose fluconazole was an acceptable treatment strategy (using $100,000 per DLY saved as threshold) unless the physical age of an ICU survivor was 66 years or older. Empirical high-dose fluconazole was an acceptable treatment strategy using $50,000 per DLY saved with minor changes in parameters estimates.

LIMITATIONS

The estimates of our model may not be applicable to all ICU patients. Other hospitals with differences in fluconazole resistance, prevalence of invasive candidiasis, or duration of fluconazole therapy may produce different results.

CONCLUSION

These results suggest that empiric high-dose fluconazole therapy should reduce the mortality associated with invasive candidiasis at an acceptable cost.

Economic analysis of inadequate fluconazole therapy in non-neutropenic patients with candidaemia: a multi-institutional study

Mortality significantly increases in patients with candidaemia who receive inappropriate fluconazole therapy. The goals of this study were to compare hospital length of stay and costs for non-neutropenic patients with candidaemia treated with fluconazole based on the empirical dose and time until initiation of therapy. A retrospective cohort study was conducted of patients with candidaemia who were prescribed fluconazole at the onset of candidaemia or later. Hospital-related costs were compared based on time to initiation of fluconazole therapy and empirical fluconazole dose. A total of 192 non-neutropenic patients (55% male; mean age+/-standard deviation, 56+/-17 years) were identified. Isolated Candida species included C. albicans (59%), C. glabrata (15%), C. parapsilosis (11%), C. tropicalis (6%), C. krusei (3%) or other Candida spp. (6%). Time to initiation of fluconazole was Day 0 (35.4%), Day 1 (14.1%), Day 2 (26.6%) or Day >or=3 (23.9%). Thirty-two patients (17%) received a dose of fluconazole >or=6 mg/kg on Day 0. Total costs were lowest for patients started on fluconazole on the culture day with adequate doses ($35,459+/-25,988) compared with all other patients ($52,158+/-53,492) (P=0.0088). After controlling for covariates, each 1-day delay in fluconazole therapy was associated with increased total hospital costs of $6392+/-3000 (P=0.0344), and an adequate fluconazole dose was associated with decreased total hospital costs of $18,744+/-7173 (P=0.0097). A delay or an inadequate dose or fluconazole in patients with candidaemia was associated with increased hospital costs. Improved methods to diagnose patients with candidaemia quickly are needed.

Excess costs of hospital care associated with neonatal candidemia

BACKGROUND

Nosocomial bloodstream infections are associated with increased hospital costs in adult and pediatric patients. Candida is an increasingly important nosocomial pathogen within intensive care nurseries. The purpose of this study was to determine the attributable cost of candidemia in neonates.

METHODS

This case-control study included all neonates with candidemia receiving care in hospitals in Connecticut and in Baltimore County and the city of Baltimore, MD. We identified 47 cases and 130 control patients. Multivariable linear regression was used to control for state, birth weight and mortality to determine the effect of candidemia on length of stay, cost per day and total hospital costs.

RESULTS

Candidemia was associated with a $28,000 increase in total hospital costs in multivariable analysis. This increase in total cost was the result of both an increase in costs per day and length of hospital stay. Other cost-increasing variables included in the analysis were: state of origin (Connecticut), survival and decreasing birth weight.

CONCLUSIONS

This represents the first study of the adjusted costs of candidemia in neonates. In addition to high mortality, candidemia was associated with increased hospital costs. This cost analysis could be helpful in determining the financial benefits of preventing candidemia in high risk neonates.

[Restropective investigation about the treatment of candidaemia in a French university hospital in 2004]

This study aimed to retrospectively evaluate the adequate use of antifungal drugs in the treatment of the candidaemia. A collection of clinical, biological and therapeutic data was carried out for the patients who had a positive blood culture for Candida species during the year 2004. The antifungal therapy was compared to the guidelines of the French Conference of consensus named "Prise en charge des candidoses et aspergilloses invasives de l'adulte". The degree of conformity was classified as follows: complying, partly complying (molecule in conformity but delay of treatment or unsuited dosing) and not complying with the guidelines. The analysis was performed, according to the guidelines, before and after knowledge of Candida species growing from the blood culture. On 29 candidaemia, the found species were: Candida albicans 55%, Candida glabrata 14%, Candida krusei 10%, Candida parapsilosis and Candida lusitaniae 7%, Candida pelliculosa and Candida tropicalis 3.5%. Only 19 candidaemia were included in this study because blood cultures were known positive for Candida on the day of death (N=7) or medical charts were not available (N=3). For treatment before identification of Candida species, 37% were complying, 37% in partly complying and 26% not complying with the guidelines. For the treatment after identification of the species, 26% were complying, 63% partly complying and 11% not complying with the guidelines. As a whole, antifungal therapy was totally or partly complying in 74 to 89% of candidaemia in adult patients. Lower dosages of fluconazole explained most of the treatments that partly complied with guidelines.

Surgical critical care: Fungal infections in surgical patients

OBJECTIVE

To review the epidemiology, risk factors, diagnosis, treatment, and prevention of Candida infections in surgical intensive care unit patients.

DESIGN

: Selected review of the literature.

SETTING

Critically ill patients either in an intensive care unit or having undergone a major surgical procedure.

INTERVENTIONS

None.

MAIN RESULTS

Candida infections are the third most common cause of bloodstream infection in the intensive care unit, with increasing numbers of infections due to nonalbicans species. The diagnosis of an invasive fungal infection is difficult, and the risk factors must be recognized and minimized. There is no general consensus about what signs, symptoms, and cultures define a fungal infection. A new 1,3 beta-glucan blood test may assist is the definition of invasive fungal infection. Treatment of fungal infections is now possible with a variety of antifungal agents, with different spectrums of activity, mechanisms of action, and adverse events. Prevention (prophylaxis) is a reasonable strategy in highly selected patients with a significant risk of fungal infection.

CONCLUSION

New antifungal agents and diagnostic tests may improve the outcome of surgical intensive care unit patients with invasive fungal infections. However, agreement about definitions of fungal infection makes study and conclusions of prevention and treatment trials difficult to interpret.

Candidaemia and antifungal therapy in a French University Hospital: rough trends over a decade and possible links

Background

Evidence for an increased prevalence of candidaemia and for high associated mortality in the 1990s led to a number of different recommendations concerning the management of at risk patients as well as an increase in the availability and prescription of new antifungal agents. The aim of this study was to parallel in our hospital candidemia incidence with the nature of prescribed antifungal drugs between 1993 and 2003.

Methods

During this 10-year period we reviewed all cases of candidemia, and collected all the data about annual consumption of prescribed antifungal drugs

Results

Our centralised clinical mycology laboratory isolates and identifies all yeasts grown from blood cultures obtained from a 3300 bed teaching hospital. Between 1993 and 2003, 430 blood yeast isolates were identified. Examination of the trends in isolation revealed a clear decrease in number of yeast isolates recovered between 1995–2000, whereas the number of positive blood cultures in 2003 rose to 1993 levels. The relative prevalence of Candida albicans and C. glabrata was similar in 1993 and 2003 in contrast to the period 1995–2000 where an increased prevalence of C. glabrata was observed. When these quantitative and qualitative data were compared to the amount and type of antifungal agents prescribed during the same period (annual mean defined daily dose: 2662741; annual mean cost: 615629 €) a single correlation was found between the decrease in number of yeast isolates, the increased prevalence of C. glabrata and the high level of prescription of fluconazole at prophylactic doses between 1995–2000.

Conclusion

Between 1993 and 2000, the number of cases of candidemia halved, with an increase of C. glabrata prevalence. These findings were probably linked to the use of Fluconazole prophylaxis. Although it is not possible to make any recommendations from this data the information is nevertheless interesting and may have considerable implications with the introduction of new antifungal drugs.

Cost savings with implementation of PNA FISH testing for identification of Candida albicans in blood cultures

Antifungal expenditures are substantial for many hospitals. Using caspofungin for the treatment of candidemia accounts for a sizable proportion of the costs. A cost minimization study that used a decision analytic model was done to compare in-hospital diagnosis and treatment costs using the Candida albicans peptide nucleic acid fluorescence in situ hybridization (PNA FISH) test versus the C. albicans screen test for differentiating C. albicans from non-albicans Candida species bloodstream infections. Assuming physician notification of yeast identity concurrent with blood culture positivity, potential savings resulting from use of the C. albicans PNA FISH test compared with the C. albicans screen test averaged $1837 per patient treated, although laboratory costs for doing the C. albicans PNA FISH test ($82.72) exceeded those for the C. albicans screen test ($2.83). Savings were realized through a decrease in antifungal drug costs, particularly caspofungin. Incorporating the C. albicans PNA FISH test as part of the initial identification algorithm for yeasts recovered from blood can result in substantial savings for hospitals.

The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: a propensity analysis

BACKGROUND

Candida species are the fourth most common cause of bloodstream infection and are the leading cause of invasive fungal infection among hospitalized patients in the United States. However, the frequency and outcomes attributable to the infection are uncertain. This retrospective study set out to estimate the incidence of candidemia in hospitalized adults and children in the United States and to determine attributable mortality, length of hospital stay, and hospital charges related to candidemia.

METHODS

We used the Nationwide Inpatient Sample 2000 for adult patients and the Kids' Inpatient Database 2000 for pediatric patients. We matched candidemia-exposed and candidemia-unexposed patients by the propensity scores for the probability of candidemia exposure, which were derived from patient characteristics. Attributable outcomes were calculated as the differences in estimates of outcomes between propensity score-matched patients with and without candidemia.

RESULTS

In the United States in 2000, candidemia was diagnosed in an estimated 1118 hospital admissions of pediatric patients and 8949 hospital admissions of adult patients, yielding a frequency of 43 cases per 100,000 pediatric admissions (95% confidence interval [CI], 35-52 cases per 100,000 pediatric admissions) and 30 cases per 100,000 adult admissions (95% CI, 26-34 cases per 100,000 adult admissions). In pediatric patients, candidemia was associated with a 10.0% increase in mortality (95% CI, 6.2%-13.8%), a mean 21.1-day increase in length of stay (95% CI, 14.4-27.8 days), and a mean increase in total per-patient hospital charges of 92,266 dollars (95% CI, 65,058 dollars-119,474 dollars). In adult patients, candidemia was associated with a 14.5% increase in mortality (95% CI, 12.1%-16.9%), a mean 10.1-day increase in length of stay (95% CI, 8.9-11.3 days), and a mean increase in hospital charges of 39,331 dollars (95% CI, 33,604 dollars-45,602 dollars).

CONCLUSION

The impact of candidemia on excess mortality, increased length of stay, and the burden of cost of hospitalization underscores the need for improved means of prevention and treatment of candidemia in adults and children.

Caspofungin versus amphotericin B for candidemia: A pharmacoeconomic analysis

BACKGROUND

In a randomized, comparative, clinical trial, caspofungin was found to be as effective as amphotericin B deoxycholate (ampho B) for treating candidemia (favorable outcomes in 71.7% and 62.8% of patients, respectively) and exhibited a generally better safety profile, particularly with respect to impaired renal function (IRF) (P = 0.02).

OBJECTIVE

The goal of this study was to examine whether cost savings generated from the reduced rates of IRF observed in the clinical trial would be enough to offset the higher acquisition cost of caspofungin relative to ampho B.

METHODS

We developed an economic model in which 100 hypothetical patients with candidemia were treated with caspofungin or ampho B. Rates of IRF and duration of drug therapy were taken from the clinical trial. Information on the cost of treating IRF was obtained through a search of MEDLINE using the terms amphotericin and cost, amphotericin and resource, amphotericin and hospital, and amphotericin and toxicity; and the medical subject headings kidney failure, acute/drug therapy; kidney failure, acute/epidemiology; kidney failure, acute/etiology; kidney/drug effects; cost of illness; costs and cost analysis; kidney failure, acute, and economics; and kidney failure, acute/economics. In addition, the Web site was searched for relevant references, and the Merck publication alert system was used. Antifungal drug costs were estimated using data from IMS Health. Costs were reported in year-2003 US dollars.

RESULTS

In the base case, the model projected that using caspofungin instead of ampho B would result in substantially lower treatment costs for IRF, which would more than offset the higher drug acquisition cost (cost-offset percentage, 122%), leading to a net mean savings of 758.60 US dollars per patient. These results were not very sensitive to the difference in daily drug cost, but were sensitive to the mean cost attributable to treating IRF. As that varied, the cost-offset percentage varied from 61% (substantial cost offset) to 183% (cost savings).

CONCLUSIONS

The results of this economic model suggest that, based only on differences in drug acquisition cost and renal toxicity, the use of caspofungin instead of ampho B in patients with candidemia may be a cost-saving strategy from the perspective of a hospital.

Daily antibiotic cost of nosocomial infections in a Turkish university hospital

BACKGROUND

Many studies associated nosocomial infections with increased hospital costs due to extra days in hospital, staff time, extra investigations and drug treatment. The cost of antibiotic treatment for these infections represents a significant part of hospital expenditure. This prospective observational study was designed to determine the daily antibiotic cost of nosocomial infections per infected adult patient in Akdeniz University Hospital.

METHODS

All adult patients admitted to the ICUs between January 1, 2000, and June 30, 2003 who had only one nosocomial infection during their stay were included in the study. Infection sites and pathogens, antimicrobial treatment of patient and it's cost were recorded. Daily antibiotic costs were calculated per infected patient.

RESULTS

Among the 8460 study patients, 817 (16.6%) developed 1407 episodes of nosocomial infection. Two hundred thirty three (2.7%) presented with only one nosocomial infection. Mean daily antibiotic cost was 89.64 dollars. Daily antibiotic cost was 99.02 dollars for pneumonia, 94.32 dollars for bloodstream infection, 94.31 dollars for surgical site infection, 52.37 dollars for urinary tract infection, and 162.35 dollars for the other infections per patient. The treatment of Pseudomonas aeruginosa infections was the most expensive infection treated. Piperacillin-tazobactam and amikacin were the most prescribed antibiotics, and meropenem was the most expensive drug for treatment of the nosocomial infections in the ICU.

CONCLUSIONS

Daily antibiotic cost of nosocomial infections is an important part of extra costs that should be reduced providing rational antibiotic usage in hospitals.

Economic Impact of Candida Colonization and Candida Infection in the Critically Ill Patient

The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53-1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16-1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72-2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99-1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.

Burden of hospitalization of patients with Candida and Aspergillus infections in Australia

OBJECTIVES

This study examined the burden of hospitalization of patients with Aspergillus and Candida infections in Australia from 1995 to 1999.

METHODS

Data were extracted from the National Hospital Morbidity Database. A hospitalization with an aspergillosis diagnosis was defined as any discharge with a diagnosis of aspergillosis. A hospitalization with a candidiasis diagnosis was defined as any discharge with a diagnosis of disseminated, invasive, or non-invasive candidiasis. Outcome measures included number of hospitalizations, length of stay (LOS), cost (AUS$), and mortality.

RESULTS

4583 hospitalizations with an aspergillosis diagnosis and 57,758 hospitalizations with a candidiasis diagnosis were identified. These hospitalizations were associated with a total of 813,398 hospital days, AUS$563 million in cost, and 4967 in-hospital deaths during the study period. The mean LOS for a hospitalization with an aspergillosis diagnosis was 12 days, cost AUS$9,334, and was associated with 8% mortality. For disseminated, invasive, and non-invasive candidiasis, the respective mean LOS were 31, 17, and 12 days; costs were AUS$33,274, AUS$12,954, and AUS$7,694; and mortality was 26%, 9%, and 8%.

CONCLUSIONS

Hospitalizations with diagnoses for fungal infections were associated with lengthy hospital stays, high costs, and high mortality.

Systemic Antifungal Therapy: New Options, New Challenges

The frequency of invasive fungal infections has increased dramatically in recent decades because of an expanding population at risk. Until now, treatment options for invasive mycoses have been primarily amphotericin B and the azoles, fluconazole and itraconazole. Traditional agents are limited by an inadequate spectrum of activity, drug resistance, toxicities, and drug-drug interactions. The recent approval of caspofungin and voriconazole clearly has expanded the number of existing antifungal drugs available. However, the enthusiasm that accompanies their availability is counterbalanced by limited clinical experience, high drug acquisition costs, and distinctive toxicities. The pharmacologic characteristics, extent of clinical experience (efficacy and toxicity), and drug acquisition costs among available systemic antifungal agents are compared, with emphasis on the new agents. Also, recommendations on the role of each agent are provided according to the most common indications for systemic antifungal therapy: invasive candidiasis, invasive aspergillosis, and febrile neutropenia.

The direct cost and incidence of systemic fungal infections

OBJECTIVES

In this study we determined the incidence and direct inpatient and outpatient costs of systemic fungal infections (candidiasis, aspergillosis, cryptococcosis, histoplasmosis) in 1998.

METHODS

Using primarily the National Hospital Discharge Survey (NHDS) for incidence and the Maryland Hospital Discharge Data Set (MDHDDS) for costs, we surveyed four systemic fungal infections in patients who also had HIV/AIDS, neoplasia, transplant, and all other concomitant diagnoses. Using a case-control method, we compared the cases with controls (those without fungal infections with the same underlying comorbidity) to obtain the incremental hospitalization costs. We used the Student's t-test to determine significance of incremental hospital costs. We modeled outpatient costs on the basis of discharge status to calculate the total annual cost for systemic fungal infections in 1998.

RESULTS

For 1998, the projected average incidence was 306 per million US population, with candidiasis accounting for 75% of cases. The estimated total direct cost was $2.6 billion and the average per-patient attributable cost was $31,200. The most commonly reported comorbid diagnoses with fungal infections (HIV/AIDS, neoplasms, transplants) accounted for only 45% of all infections.

CONCLUSIONS

The cost burden is high for systemic fungal infections. Additional attention should be given to the 55% with fungal disease and other comorbid diagnoses.

The impact of candidemia on length of hospital stay, outcome, and overall cost of illness

Although numerous studies have examined trends in nosocomial fungal infections, few have specifically addressed the cost of care associated with candidemia. This study analyzes the direct medical costs associated with treating candidemia in the United States. The study design was a cost-of-illness analysis estimating the average cost of candidemia for a single episode of care. Data were obtained from three sources: the 1993 Healthcare Cost and Utilization Project of the Agency for Health Care Policy and Research, the relevant literature, and a clinical expert in systemic fungal infections. The estimated cost (1997 U.S.$) of an episode of care for candidemia is $34,123 per Medicare patient and $44,536 per private insurance patient. The major cost associated with candidemia is that of an increased hospital stay. The estimated cost of care for candidemia may change in the future because of the use of more expensive antifungal treatments with improved safety and efficacy profiles.

Esophageal candidiasis in patients infected with the human immunodeficiency virus. A decision analysis to assess cost-effectiveness of alternative management strategies

BACKGROUND

Currently no consensus exists concerning the timing of upper endoscopy and the choice of antifungal therapy for patients infected with the human immunodeficiency virus who also have esophageal candidiasis. The objective of this research was to determine the clinical and economic effects of alternative management strategies for these patients.

METHODS

Decision analysis was used to evaluate the outcomes, costs, and cost-effectiveness of two strategies for the diagnostic workup and treatment of patients infected with the human immunodeficiency virus with dysphagia and/or odynophagia: (1) empiric--a strategy to treat all patients empirically with an oral antifungal agent for up to 4 weeks; and (2) initial esophagogastroduodenoscopy (EGD)--a strategy to perform EGD on all patients and to treat only those with esophageal candidiasis with an oral antifungal agent for up to 4 weeks. Within each strategy, three antifungal regimens were evaluated: ketoconazole, 200 mg daily; fluconazole, 100 mg daily; and ketoconazole, 200 mg daily, for 2 weeks followed by fluconazole, 200 mg daily, for 2 weeks in nonresponders. Information on the probability of esophageal candidiasis in patients with esophageal symptoms and the efficacy of antifungal therapy was obtained from the literature. The costs for diagnostic workup were estimated using both teaching hospital charges and Medicare reimbursement payments. The costs of antifungal therapy were estimated from local pharmacy charges. The average cost per complete response and incremental cost-effectiveness were calculated and subjected to sensitivity analysis.

RESULTS

Using the best available evidence for antifungal efficacy, empiric fluconazole was the most cost-effective strategy for all probabilities of esophageal candidiasis that were more than 0.55. Using teaching hospital charges in our base-case analysis, the average costs per complete response for empiric fluconazole and initial EGD and fluconazole were $2706 and $3141, respectively. The incremental cost-effectiveness of initial EGD and fluconazole compared with empiric fluconazole was $3792 per additional complete response. When the cost-effectiveness of the two strategies was compared as the cost of diagnostic workup was varied, initial EGD and fluconazole became the dominant strategy when the diagnostic workup cost fell below $710, a figure that is less than the current Medicare reimbursement payment.

CONCLUSIONS

From the perspective of the payer of medical care, empiric fluconazole is the most cost-effective strategy for the initial management of patients infected with the human immunodeficiency virus with esophageal symptoms.

Miconazole: a cost-effective antifungal genitourinary irrigant

Miconazole was used as a fungistatic genitourinary irrigant in the management of 10 patients with persistent candiduria. All patients were in the older age group, with a mean age of 77.6 years, and they were debilitated by a variety of medical problems, including major surgery, neoplasia, recurrent bacterial infection, diabetes or other metabolic dysfunction. Miconazole at a concentration of 50 mcg. per ml. was administered continuously during 24 hours for 5 consecutive days via a urethral catheter. Candiduria resolved in 8 of the 10 patients, with 1 requiring a second course of miconazole at a concentration of 100 mcg. per ml. Two patients manifested other foci of infection, necessitating intravenous and intravesical amphotericin B. Stability studies showed that the miconazole irrigation solutions maintain their antifungal activity for 11 days at room temperature. The 5-day cost (drug and materials) of the miconazole irrigation at 50 mcg. per ml. was $17.75 versus $76.75 for an equal course of therapy with amphotericin B. In addition, compared to amphotericin B as an antifungal genitourinary irrigant, miconazole is prepared more easily, requires less labor and preparation time, and does not require refrigeration or protection from light. These clinical observations indicate that miconazole is a cost-effective antifungal genitourinary irrigant.