Economic evaluation of outpatient parenteral antimicrobial therapy: a systematic review

<p><b>Introduction</b>: Outpatient parenteral antimicrobial therapy (OPAT) consists of providing antimicrobial therapy by parenteral infusion without hospitalization. A systematic review was performed to compare OPAT and hospitalization as health care modalities from an economic perspective.</p> <p><b>Areas covered</b>: We identified 1455 articles using 13 electronic databases and manual searches. Two independent reviewers identified 35 studies conducted between 1978 and 2016. We observed high heterogeneity in the following: countries, infection site, OPAT strategies and outcomes analyzed. Of these, 88% had a retrospective observational design and one was a randomized trial. With respect to economic analyses, 71% of the studies considered the cost-consequences, 11% cost minimization, 6% cost-benefit, 6% cost-utility analyses and 6% cost effectiveness. Considering all 35 studies, the general OPAT cost saving was 57.19% (from −13.03% to 95.47%). Taking into consideration only high-quality studies (6 comparative studies), the cost saving declined by 16.54% (from −13.03% to 46.86%).</p> <p><b>Expert commentary</b>: Although most studies demonstrate that OPAT is cost-effective, the magnitude of this effect is compromised by poor methodological quality and heterogeneity. Economic assessments of the issue are needed using more rigorous methodologies that include a broad range of perspectives to identify the real magnitude of economic savings in different settings and OPAT modalities.</p

MICs Distribution (μg/mL) of 143 <i>Candida albicans</i> bloodstream isolates against amphotericin B, 5-flucytosine, fluconazole, itraconazole, voriconazole and caspofungin.

<p>MICs Distribution (μg/mL) of 143 <i>Candida albicans</i> bloodstream isolates against amphotericin B, 5-flucytosine, fluconazole, itraconazole, voriconazole and caspofungin.</p

Resistance Surveillance in <i>Candida albicans</i>: A Five-Year Antifungal Susceptibility Evaluation in a Brazilian University Hospital

<div><p><i>Candida albicans</i> caused 44% of the overall candidemia episodes from 2006 to 2010 in our university tertiary care hospital. As different antifungal agents are used in therapy and also immunocompromised patients receive fluconazole prophylaxis in our institution, this study aimed to perform an antifungal susceptibility surveillance with the <i>C</i>.<i>albicans</i> bloodstream isolates and to characterize the fluconazole resistance in 2 non-blood <i>C</i>.<i>albicans</i> isolates by sequencing <i>ERG11</i> gene. The study included 147 <i>C</i>. <i>albicans</i> bloodstream samples and 2 fluconazole resistant isolates: one from oral cavity (LIF 12560 fluconazole MIC: 8μg/mL) and one from esophageal cavity (LIF-E10 fluconazole MIC: 64μg/mL) of two different patients previously treated with oral fluconazole. The <i>in vitro</i> antifungal susceptibility to amphotericin B (AMB), 5-flucytosine (5FC), fluconazole (FLC), itraconazole (ITC), voriconazole (VRC), caspofungin (CASP) was performed by broth microdilution methodology recommended by the Clinical and Laboratory Standards Institute documents (M27-A3 and M27-S4, CLSI). All blood isolates were classified as susceptible according to CLSI guidelines for all evaluated antifungal agents (MIC range: 0,125–1.00 μg/mL for AMB, ≤0.125–1.00 μg/mL for 5FC, ≤0.125–0.5 μg/mL for FLC, ≤0.015–0.125 μg/mL for ITC, ≤0.015–0.06 μg/mL for VRC and ≤0.015–0.125 μg/mL for CASP). In this study, we also amplified and sequenced the <i>ERG11</i> gene of LIF 12560 and LIF-E10 <i>C</i>.<i>albicans</i> isolates. Six mutations encoding distinct amino acid substitutions were found (E116D, T128K, E266D, A298V, G448V and G464S) and these mutations were previously described as associated with fluconazole resistance. Despite the large consumption of antifungals in our institution, resistant blood isolates were not found over the trial period. Further studies should be conducted, but it may be that the very prolonged direct contact with the oral antifungal agent administered to the patient from which was isolated LIF E-10, may have contributed to the development of resistance.</p></div

MIC range (μg/mL) of LIF 12560 and LIF-E10 against amphotericin B, 5-flucytosine, fluconazole, itraconazole and voriconazole.

<p>MIC range (μg/mL) of LIF 12560 and LIF-E10 against amphotericin B, 5-flucytosine, fluconazole, itraconazole and voriconazole.</p

Nucleotide mutations and amino acid substitutions.

<p>Nucleotide mutations and amino acid substitutions.</p

SPECT/CT with radiolabeled somatostatin analogues in the evaluation of systemic granulomatous infections

<div><p>Abstract Objective: To evaluate SPECT/CT with radiolabeled somatostatin analogues (RSAs) in systemic granulomatous infections in comparison with gallium-67 (67Ga) citrate scintigraphy. Materials and Methods: We studied 28 patients with active systemic granulomatous infections, including tuberculosis, paracoccidioidomycosis, pneumocystosis, cryptococcosis, aspergillosis, leishmaniasis, infectious vasculitis, and an unspecified opportunistic infection. Of the 28 patients, 23 had started specific treatment before the study outset. All patients underwent whole-body SPECT/CT imaging: 7 after injection of 99mTc-EDDA-HYNIC-TOC, and 21 after injection of 111In-DTPA-octreotide. All patients also underwent 67Ga citrate imaging, except for one patient who died before the 67Ga was available. Results: In 20 of the 27 patients who underwent imaging with both tracers, 27 sites of active disease were detected by 67Ga citrate imaging and by SPECT/CT with an RSA. Both tracers had negative results in the other 7 patients. RSA uptake was visually lower than 67Ga uptake in 11 of the 20 patients with positive images and similar to 67Ga uptake in the other 9 patients. The only patient who did not undergo 67Ga scintigraphy underwent 99mTc-EDDA-HYNIC-TOC SPECT/CT-guided biopsy of a lung cavity with focal RSA uptake, which turned to be positive for aspergillosis. Conclusion: SPECT/CT with 99mTc-EDDA-HYNIC-TOC or 111In-DTPA-octreotide seems to be a good alternative to 67Ga citrate imaging for the evaluation of patients with systemic granulomatous disease.</p></div

Airborne transmission of invasive fusariosis in patients with hematologic malignancies

<div><p>From 2006 to 2013, an increasing incidence of fusariosis was observed in the hematologic patients of our University Hospital. We suspected of an environmental source, and the indoor hospital air was investigated as a potential source of the fungemia. Air samplings were performed in the hematology and bone marrow transplant (BMT) wards using an air sampler with pre-defined air volumes. To study the molecular relationship among environmental and clinical isolates, 18 <i>Fusarium</i> spp. recovered from blood cultures were included in the study. DNA sequencing of a partial portion of <i>TEF1α</i> gene was performed for molecular identification. Molecular typing was carried out by multi-locus sequence typing (MLST) using a four-gene scheme: <i>TEF1α</i>, rDNA, <i>RPB1</i> and <i>RPB2</i>. One hundred four isolates were recovered from the air of the hematology (n = 76) and the BMT (n = 28) wards. <i>Fusarium</i> isolates from the air were from five species complexes: <i>Fusarium fujikuroi</i> (FFSC, n = 56), <i>Fusarium incarnatum-equiseti</i> (FIESC, n = 24), <i>Fusarium solani</i> (FSSC, n = 13), <i>Fusarium chlamydosporum</i> (FCSC, n = 10), and <i>Fusarium oxysporum</i> (FOSC, n = 1). Fifteen <i>Fusarium</i> isolates recovered from blood belonged to FSSC, and three to FFSC. MLST identified the same sequence type (ST) in clinical and environmental isolates. ST1 was found in 5 isolates from blood and in 7 from the air, both identified as FSSC (<i>Fusarium petroliphilum</i>). STn1 was found in one isolate from blood and in one from the air, both identified as FFSC (<i>Fusarium napiforme</i>). <i>F</i>. <i>napiforme</i> was isolated from the air of the hospital room of the patient with fungemia due to <i>F</i>. <i>napiforme</i>. These findings suggested a possible clonal origin of the <i>Fusarium</i> spp. recovered from air and bloodcultures. In conclusion, our study found a diversity of <i>Fusarium</i> species in the air of our hospital, and a possible role of the air as source of systemic fusariosis in our immunocompromised patients.</p></div

Primers used for sequencing of clinical and environmental <i>Fusarium</i> isolates.

<p>Primers used for sequencing of clinical and environmental <i>Fusarium</i> isolates.</p

Molecular identification of <i>Fusarium</i> species isolated from hospital air samplings.

<p>(A) and (B) shows <i>TEF1α</i> DNA sequencing classification in species complex and species, respectively. The number of isolates is shown above each bar. FCSC: <i>F</i>. <i>chlamydosporum</i> species complex; FFSC: <i>F</i>. <i>fujikuroi</i> species complex; FIESC: <i>F</i>. <i>incarnatum-equiseti</i> species complex; FOSC: <i>F</i>. <i>oxysporum</i> species complex; FSSC: <i>F</i>. <i>solani</i> species complex.</p

Sequence types (ST) determined by sequencing of portions of the genes <i>TEF1α</i>, rDNA, <i>RPB1</i> and <i>RPB2</i> for <i>Fusarium</i> species isolated from air and blood.

<p>The number of samples with each ST is shown above the bar. FSSC: <i>F</i>. <i>solani</i> species complex. FFSC: <i>F</i>. <i>fujikuroi</i> species complex. ST: sequence type.</p