Walker Brandon, Powers-Fletcher Margaret V, Schmidt Robert L, Hanson Kimberly E
Institute for Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, Utah, USA.
Department of Pathology, University of Utah, Salt Lake City, Utah, USA
J Clin Microbiol. 2016 Mar;54(3):718-26. doi: 10.1128/JCM.02971-15. Epub 2016 Jan 6.
Candida bloodstream infections (BSI) are associated with significant morbidity, mortality, and increased health care costs. Early treatment is essential, because delayed therapy detrimentally impacts clinical outcomes. The FDA recently approved the first culture-independent direct molecular detection method for Candida BSIs (T2Candida). The speed and sensitivity of this assay give it the potential to improve patient care, but the reagents and instrumentation are expensive. We used an analytic decision tree model to compare the cost-effectiveness of T2Candida-directed antifungal therapy (T2DT) to that of either empirical therapy (ET) or blood culture-directed therapy (BCDT). The costs included those of T2Candida testing, antifungal treatment, and hospital length of stay. The effectiveness measure was survival status at hospital discharge. T2DT was less costly and more effective than BCDT but was less costly and less effective than ET with an echinocandin (incremental cost-effectiveness ratio, $111,084 per additional survivor). One-way sensitivity analyses demonstrated that the cost-effectiveness of T2DT was highly dependent on Candida BSI prevalence and the cost of antifungal therapy and T2Candida test reagents. The use of T2DT reduced the number of unnecessarily treated patients by 98% relative to that with ET. Reduced drug exposure might lessen the possibility of drug-related adverse events and may also prevent the development of antifungal resistance or emergence of drug-resistant Candida species. The greatest benefit of T2Candida appears to be the ability to confidently withhold or stop empirical antifungal therapy in low-to-moderate-risk patients who are unlikely to benefit from treatment.
念珠菌血流感染（BSI）与严重的发病率、死亡率及医疗费用增加相关。早期治疗至关重要，因为延迟治疗会对临床结局产生不利影响。美国食品药品监督管理局（FDA）最近批准了首个用于念珠菌BSI的非培养直接分子检测方法（T2念珠菌检测法）。该检测方法的速度和灵敏度使其有潜力改善患者护理，但试剂和仪器成本高昂。我们使用分析决策树模型比较了T2念珠菌导向的抗真菌治疗（T2DT）与经验性治疗（ET）或血培养导向治疗（BCDT）的成本效益。成本包括T2念珠菌检测、抗真菌治疗及住院时间的费用。有效性指标为出院时的生存状态。T2DT比BCDT成本更低且更有效，但比使用棘白菌素的ET成本更低且效果更差（增量成本效益比为每多一名幸存者111,084美元）。单向敏感性分析表明，T2DT的成本效益高度依赖于念珠菌BSI的患病率、抗真菌治疗成本及T2念珠菌检测试剂成本。与ET相比使用T2DT可使不必要治疗的患者数量减少98%。减少药物暴露可能会降低药物相关不良事件的可能性，还可能预防抗真菌耐药性的产生或耐药念珠菌物种的出现。T2念珠菌检测法的最大益处似乎在于能够有信心地对不太可能从治疗中获益的低至中度风险患者停止或不给予经验性抗真菌治疗。
