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Cost-effectiveness of micafungin as an alternative to fluconazole empiric treatment of suspected ICU-acquired candidemia among patients with sepsis: a model simulation.

Zilberberg MD, Kothari S, Shorr AF - Crit Care (2009)

Bottom Line: Echinocandins, a new class of antifungal agents, are effective against resistant candidal species.Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY.Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.

View Article: PubMed Central - HTML - PubMed

Affiliation: School of Public Health and Health Sciences, University of Massachusetts, Arnold House, Amherst, MA 01003, USA. mzilberb@schoolph.umass.edu

ABSTRACT

Introduction: Recent epidemiologic literature indicates that candidal species resistant to azoles are becoming more prevalent in the face of increasing incidence of hospitalizations with candidemia. Echinocandins, a new class of antifungal agents, are effective against resistant candidal species. As delaying appropriate antifungal coverage leads to increased mortality, we evaluated the cost-effectiveness of 100 mg daily empiric micafungin (MIC) vs. 400 mg daily fluconazole (FLU) for suspected intensive care unit-acquired candidemia (ICU-AC) among septic patients.

Methods: We designed a decision model with inputs from the literature in a hypothetical 1000-patient cohort with suspected ICU-AC treated empirically with either MIC or FLU or no treatment accompanied by a watchful waiting strategy. We examined the differences in the number of survivors, acquisition costs of antifungals, and lifetime costs among survivors in the cohort under each scenario, and calculated cost per quality adjusted life year (QALY). We conducted Monte Carlo simulations and sensitivity analyses to determine the stability of our estimates.

Results: In the base case analysis, assuming ICU-AC attributable mortality of 0.40 and a 52% relative risk reduction in mortality with appropriate timely therapy, compared with FLU (total deaths 31), treatment with MIC (total deaths 27) would result in four fewer deaths at an incremental cost/death averted of $61,446. Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY. The estimates were most sensitive to the QALY adjustment factor and the risk of candidemia among septic patients.

Conclusions: Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.

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Related in: MedlinePlus

Tornado diagram. The solid vertical line represents the total incremental lifetime costs per quality-adjusted life year (QALY) for survivors using micafungin compared with fluconazole as empiric treatment of suspected intensive care unit (ICU)-acquired candidemia as calculated in the base case scenario. The horizontal bars represent the range of this difference when the corresponding single input is varied across its designated range with all other input parameters held constant. All costs inflated to 2008 $US using medical component of the consumer product index; a 3% annual discount applied. BSI = blood stream infection; C&S = culture and sensitivity; CG = Candida glabrata; CK = Candida krusei, MYC = micafungin.
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Figure 2: Tornado diagram. The solid vertical line represents the total incremental lifetime costs per quality-adjusted life year (QALY) for survivors using micafungin compared with fluconazole as empiric treatment of suspected intensive care unit (ICU)-acquired candidemia as calculated in the base case scenario. The horizontal bars represent the range of this difference when the corresponding single input is varied across its designated range with all other input parameters held constant. All costs inflated to 2008 $US using medical component of the consumer product index; a 3% annual discount applied. BSI = blood stream infection; C&S = culture and sensitivity; CG = Candida glabrata; CK = Candida krusei, MYC = micafungin.

Mentions: Each of the models assessing incremental costs per QALY was most sensitive to the QALYs generated by survivors (Figure 2, and data not shown). In a univariate analysis varying the number of QALYs gained (0.44 to 0.80) resulted in the range of cost/QALY of $21,337 to $38,795 in the case of FLU and $22,221 to $40,402 for MIC each vs. the watchful waiting strategy, and $27,310 to $49,655 for MIC vs. FLU. The MIC vs. FLU analysis was also sensitive to the proportion of all BSIs attributed to Candida species (Figure 2), and varying this single input across its corresponding range resulted in a cost/QALY range of $30,151 to $49,262. Even if the empiric MIC strategy results in only one additional life saved in the 1000-patient cohort compared with FLU, the cost/QALY remained $59,610.


Cost-effectiveness of micafungin as an alternative to fluconazole empiric treatment of suspected ICU-acquired candidemia among patients with sepsis: a model simulation.

Zilberberg MD, Kothari S, Shorr AF - Crit Care (2009)

Tornado diagram. The solid vertical line represents the total incremental lifetime costs per quality-adjusted life year (QALY) for survivors using micafungin compared with fluconazole as empiric treatment of suspected intensive care unit (ICU)-acquired candidemia as calculated in the base case scenario. The horizontal bars represent the range of this difference when the corresponding single input is varied across its designated range with all other input parameters held constant. All costs inflated to 2008 $US using medical component of the consumer product index; a 3% annual discount applied. BSI = blood stream infection; C&S = culture and sensitivity; CG = Candida glabrata; CK = Candida krusei, MYC = micafungin.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2717466&req=5

Figure 2: Tornado diagram. The solid vertical line represents the total incremental lifetime costs per quality-adjusted life year (QALY) for survivors using micafungin compared with fluconazole as empiric treatment of suspected intensive care unit (ICU)-acquired candidemia as calculated in the base case scenario. The horizontal bars represent the range of this difference when the corresponding single input is varied across its designated range with all other input parameters held constant. All costs inflated to 2008 $US using medical component of the consumer product index; a 3% annual discount applied. BSI = blood stream infection; C&S = culture and sensitivity; CG = Candida glabrata; CK = Candida krusei, MYC = micafungin.
Mentions: Each of the models assessing incremental costs per QALY was most sensitive to the QALYs generated by survivors (Figure 2, and data not shown). In a univariate analysis varying the number of QALYs gained (0.44 to 0.80) resulted in the range of cost/QALY of $21,337 to $38,795 in the case of FLU and $22,221 to $40,402 for MIC each vs. the watchful waiting strategy, and $27,310 to $49,655 for MIC vs. FLU. The MIC vs. FLU analysis was also sensitive to the proportion of all BSIs attributed to Candida species (Figure 2), and varying this single input across its corresponding range resulted in a cost/QALY range of $30,151 to $49,262. Even if the empiric MIC strategy results in only one additional life saved in the 1000-patient cohort compared with FLU, the cost/QALY remained $59,610.

Bottom Line: Echinocandins, a new class of antifungal agents, are effective against resistant candidal species.Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY.Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.

View Article: PubMed Central - HTML - PubMed

Affiliation: School of Public Health and Health Sciences, University of Massachusetts, Arnold House, Amherst, MA 01003, USA. mzilberb@schoolph.umass.edu

ABSTRACT

Introduction: Recent epidemiologic literature indicates that candidal species resistant to azoles are becoming more prevalent in the face of increasing incidence of hospitalizations with candidemia. Echinocandins, a new class of antifungal agents, are effective against resistant candidal species. As delaying appropriate antifungal coverage leads to increased mortality, we evaluated the cost-effectiveness of 100 mg daily empiric micafungin (MIC) vs. 400 mg daily fluconazole (FLU) for suspected intensive care unit-acquired candidemia (ICU-AC) among septic patients.

Methods: We designed a decision model with inputs from the literature in a hypothetical 1000-patient cohort with suspected ICU-AC treated empirically with either MIC or FLU or no treatment accompanied by a watchful waiting strategy. We examined the differences in the number of survivors, acquisition costs of antifungals, and lifetime costs among survivors in the cohort under each scenario, and calculated cost per quality adjusted life year (QALY). We conducted Monte Carlo simulations and sensitivity analyses to determine the stability of our estimates.

Results: In the base case analysis, assuming ICU-AC attributable mortality of 0.40 and a 52% relative risk reduction in mortality with appropriate timely therapy, compared with FLU (total deaths 31), treatment with MIC (total deaths 27) would result in four fewer deaths at an incremental cost/death averted of $61,446. Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY. The estimates were most sensitive to the QALY adjustment factor and the risk of candidemia among septic patients.

Conclusions: Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.

Show MeSH
Related in: MedlinePlus