Using economic evidence to inform choice of antimicrobial therapy
New systematic review evaluates the cost-effectiveness of antimicrobial therapy for inpatients with carbapenem-resistant Klebsiella pneumoniae
Klebsiella pneumoniae is a major cause of hospital-acquired infections, mainly responsible for pneumonia, endocarditis, septicaemia and extra-intestinal, urinary tract, bloodstream and surgical wound infections.
The emergence of antimicrobial resistance, in particular the rise of carbapenem-resistant isolates, is a serious concern for the management of infections caused by Klebsiella pneumoniae because treatment alternatives are limited. Indeed, carbapenems are often used as a last resort when battling resistant bacterial strains.
Carbapenem-resistant Klebsiella pneumoniae (CRKP) are ranked as ‘Priority 1: Critical’ pathogens in the World Health Organization’s ‘Global priority list of antibiotic-resistant bacteria to guide research, discovery, and development of new antibiotics’. Globally, CRKP were responsible for 1% of hospital infections in 2001, which rose to 30% in 2008.
“Multiresistant bacterial infections are likely to be one of the biggest health problems worldwide. CRKP are responsible for the mortality of 40% of patients following 30 days of infection, for example. Unfortunately, antimicrobial therapy entails the use of high-cost antimicrobials”, explains lead author of the systematic review, Wendel Mombaque dos Santos.
Antimicrobials represent a particular class of medicines that have a significant impact on health spending. The direct cost of drug treatment per patient infected with CRKP has been conservatively estimated at nearly US$4100.
“The impact of infections on direct healthcare costs is approximately US$20 billion annually. The financial burden may be even greater in low-income and middle-income countries. In light of this, cost-effectiveness studies are important for evaluating both the cost and effectiveness of viable alternative treatments”, said dos Santos.
The new systematic review of economic evidence, ‘Cost-effectiveness of antimicrobial treatment for inpatients with carbapenem-resistant Klebsiella pneumoniae infection’, involved an international team of authors who screened and synthesised studies published between 1999 and 2016 in English, Spanish or Portuguese from South Asia, the United States and Europe.
Methodological quality of studies was assessed using the JBI critical appraisal checklist for economic evaluations. After screening an initial 3,712 titles and abstracts, and assessing 46 full-text articles, eight studies were included in the systematic review.
The review addressed 16 different antimicrobials for the treatment of CRKP infection, but the moderate quality and limited number of studies resulted in high uncertainty of the values of the cost-effectiveness ratio. Further, the studies included in this review did not include analyses exclusively for CRKP.
The results of this study found that there was no gold standard treatment for CRKP infection, hence treatment was generally directed by colonisation pressure and resistance profiles. Dos Santos adds: “What this systematic review does provide, however, are different comparisons between 16 antimicrobials to be adopted as initial treatment.”
“Ofloxacin appears to be the most cost-effective treatment; however, this conclusion must be taken in the context of the small number of studies, variability between studies, and the low quality of studies”, said dos Santos.
The need for more research on the cost-effectiveness of the treatment of CRKP infection is clearly demonstrated by this latest systematic review, which provides recommendations for research so that data can be used to construct a solid economic model for the cost-effectiveness of treatment.
Given the high cost of antimicrobials used to treat CRKP infection, systematic reviews of economic evaluations can be useful to support clinical decisions that enable choices of treatments to be made, based on effectiveness and cost, with the aim of ensuring the sustainability of the health system.
Co-author Edoardo Aromataris elaborates: “Knowing the costs of treatment is important for decision makers and needs to be considered along with the economic burden of the condition being treated. Systematic reviews examining cost-effectiveness of interventions, though often complex to undertake, are important to establish the available evidence in this regard".
“Reviews of economic evaluations based on cost-effectiveness studies have the possibility of assuming a fundamental role in the adoption of clinical and care protocols, since they will always consider the effectiveness of treatment and the available treatment resource, allowing adaptation to different contexts”, adds dos Santos.
Read systematic review and editorial in the December issue of JBISRIR