Cost-Effectiveness of Preferred Antibiotics for Community-Acquired Pneumonia

Updated 2/1/2017 at 12:30 PM EST.

Community-acquired pneumonia (CAP) is an expensive proposition.

In fact, according to a 2013 report by the Agency for Healthcare Research and Quality, CAP is the leading infectious cause of hospitalization and death in the US and results in more than $10 billion in medical expenditures annually. And, a 2012 study found that the infection accounts for €5 billion in annual in-hospital costs in Europe.

Now, research published online on January 10th by the journal BMC Infectious Diseases offers new insights into the cost-effectiveness of the most commonly used treatments for CAP, at least in Europe, and, unfortunately, there appears to be no clear “winner” from a financial perspective.

Indeed, the authors of the paper, from the Julius Center for Health Sciences and Primary Care at the University Medical Center in Utrecht, The Netherlands, where there are more than 30,000 CAP-related hospitalizations annually, assessed the cost-effectiveness of the “preferred” antibiotic regimens used to treat the infection, comparing beta-lactam/macrolide combination or fluoroquinolone monotherapy to beta-lactam monotherapy. They used data from a cluster-randomized crossover trial of the 3 regimens, based on hospital admission costs from the third-party payer perspective, performing cost-minimization analysis (CMA) and cost-effectiveness analysis (CEA) with “linear mixed models.” In their final analysis, CMA results were reported based on differences in costs per patient, while CEA results were reported as incremental cost-effectiveness ratios highlighting “additional costs per prevented death.”

“We determined actual health care utilization and multiplied this by estimated costs per procedure,” study co-author Douwe Postma, MD, PhD, Resident, Internal Medicine, Julius Center told Contagion. “Therefore, the cost estimates represent actual health care costs, not claimed costs. The cost totals might be different [in the US, or from country to country) because of differences in the system[s], but the differences in costs should be more or less comparable… given that most antibiotics cost more or less the same.”

Notably, the authors did not specify the agents used in treatment. Examples of beta-lactams used alone or in combination (with the macrolide clarithromycin) for the treatment of CAP include cefuroxime, amoxicillin, and clavulanic acid. The fluoroquinolones typically used to treat CAP include moxifloxacin, levofloxacin, and gemifloxacin. According to Dr. Postma, Dutch guidelines recommend beta-lactam monotherapy for CAP in hospitalized patients in non-ICU wards, while other international guidelines recommend antibiotic regimens covering atypical pathogens, such as respiratory fluoroquinolones or beta-lactam/macrolide combination therapy.

Earlier research by this same group of authors, he added, “challenged the different guideline recommendations by comparing them in a cluster-randomized crossover trial,” finding “no differences” in clinical outcomes.

In all, a total of 2,283 patients with CAP-related hospitalizations were included in the Dutch authors’ final analysis, with 656 having received beta-lactam monotherapy, 739 having received beta-lactam/macrolide, and 888 having received fluoroquinolone monotherapy. The median age of the study participants was roughly 71 years of age. Approximately 5% of the study participants residents in “elderly homes,” with such facilities being a common location for CAP outbreaks.

Average cost of treatment with beta-lactam monotherapy within 90 days was €4,294 ($4,608) per patient, compared to €4,392 ($4,713) for beta-lactam/macrolide combination, and €4,002 ($4,294) for fluoroquinolone monotherapy. The CMA over beta-lactam monotherapy findings were €106 ($114) for the beta-lactam/macrolide combination strategy compared to €-278 ($298) for fluoroquinolone monotherapy, with the positive number indicating a higher cost than that of the beta-lactam monotherapy approach. They also found that the “beta-lactam/macrolide strategy prevented fewer deaths than the beta-lactam strategy.”

Dr. Postma added, “As we found no differences in clinical outcomes [in our earlier study] and costs, we encourage clinicians to select the antibiotic treatment with the narrowest antibiotic spectrum, [which is] beta-lactam monotherapy. This regimen has the advantage of less antibiotic selective pressure, which should lead to less development and spread of antibiotic resistance. Naturally, this strategy might have to be adapted in regions with a different etiology of CAP, for example, [where there are] high incidences of pseudomonas or MRSA. In the Netherlands, to ensure the safety of beta-lactam monotherapy, we advise physicians to perform rapid diagnostic tests for Legionella pneumophila, as delayed treatment of this pathogen is associated with worse outcome.”

Editor's Note: This article was updated to include quotes from the author that were not published in the original version.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.