Cost-effectiveness of antibiotic treatment strategies for community-acquired pneumonia: results from a cluster randomized cross-over trial

Abstract

Background: To determine the cost-effectiveness of strategies of preferred antibiotic treatment with beta-lactam/macrolide combination or fluoroquinolone monotherapy compared to beta-lactam monotherapy.

Methods: Costs and effects were estimated using data from a cluster-randomized cross-over trial of antibiotic treatment strategies, primarily from the reduced third payer perspective (i.e. hospital admission costs). Cost-minimization analysis (CMA) and cost-effectiveness analysis (CEA) were performed using linear mixed models. CMA results were expressed as difference in costs per patient. CEA results were expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per prevented death.

Results: A total of 2,283 patients were included. Crude average costs within 90 days from the reduced third payer perspective were €4,294, €4,392, and €4,002 per patient for the beta-lactam monotherapy, beta-lactam/macrolide combination, and fluoroquinolone monotherapy strategy, respectively. CMA results were €106 (95% CI €-697 to €754) for the beta-lactam/macrolide combination strategy and €-278 (95%CI €-991 to €396) for the fluoroquinolone monotherapy strategy, both compared to the beta-lactam monotherapy strategy. The ICER was not statistically significantly different between the strategies. Other perspectives yielded similar results.

Conclusions: There were no significant differences in cost-effectiveness of strategies of preferred antibiotic treatment of CAP on non-ICU wards with either beta-lactam monotherapy, beta-lactam/macrolide combination therapy, or fluoroquinolone monotherapy.

Trial registration: The trial was registered with ClinicalTrials.gov, number NCT01660204 , on May 2nd, 2012.

Keywords: Beta-lactam macrolide; Community acquired pneumonia; Cost-effectiveness; Fluoroquinolone.

Fig. 1

Mean costs per patient. a 90-day time horizon. b 30-day time horizon. Legend: Mean costs per patient for the three treatment strategies taking four different perspectives and applying a 90-day (a) and 30-day (b) time horizon. Point estimates and confidence intervals are generated using the 50^th, 2.5^th and 97.5^th percentiles of 2,000 bootstrapping samples. Exact numbers are given in Additional file 1: Table S3

Fig. 2

Cost-effectiveness plots from a reduced third payer perspective. a Beta-lactam/macrolide strategy vs. beta-lactam strategy-90-day time horizon. b Beta-lactam/macrolide strategy vs. beta-lactam strategy-30-day time horizon. c Fluoroquinolone monotherapy strategy vs. beta-lactam strategy-90-day time horizon. d Fluoroquinolone monotherapy strategy vs. beta-lactam strategy-30-day time horizon. Legend: Grey points represent incremental costs and incremental effects of 2,000 bootstrapping samples for the beta-lactam/macrolide combination strategy compared to the beta-lactam monotherapy strategy within 90 (a) and 30 (b) days of admission, and for the fluoroquinolone monotherapy strategy compared to the beta-lactam monotherapy strategy within 90 (c) and 30 (d) days of admission. The black points and curves represent the point estimates and the 95% confidence ellipses. Proportions in each quadrant indicate the proportion of bootstrap samples in that quadrant. Point estimates in the north-west quadrant are in favour of the beta-lactam monotherapy strategy; point estimates in the south-east quadrant are in favour of the other strategy. Exact point estimates and 95% confidence intervals for incremental costs and incremental effects are given in Additional file 1: Table S3