Abstract
Lower respiratory tract infections are an important cause for morbidity and mortality and associated with considerable costs and antibiotic consumption, especially in patients needing hospitalization. The aim of this thesis was to evaluate diagnostic and treatment strategies to decrease costs and control antibiotic use in hospitalized patients.
Early identification of patients
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with high risk a for a complicated course could prevent unnecessary ICU admissions, complications or deaths. However, current definitions of severe CAP do not seem suitable to guide pneumonia management. A new prediction rule based on routine clinical, biochemical and microbiological information was proposed to determine which patients are at risk for early clinical failure.
Results of rapid microbiological tests can help in tailoring therapy early in the course of treatment. An algorithm was developed to determine cost savings based on the results of rapid diagnostic testing. Application of this algorithm to a population of patients hospitalised with CAP showed that the use of Gram staining of sputum or urinary antigen testing to diagnose pneumococcal pneumonia will lead to only minimal cost-savings.
Cessation of empirically initiated antibiotic treatment may be justified if viruses are identified. Clinical and economical impact of early, rapid and sensitive identification of viral infection by means of novel Taq-man real-time PCR techniques was evaluated in a randomized trial. Diagnostic yield increased as compared to routine diagnostic procedures and viral infections were detected in over 20%, but its use was not associated with reductions in antibiotic use or costs. Hence, real-time PCR should not become part of the routine work-up for every patient, unless the cost-effectiveness can be improved. However, financial investment in rapid tests may outweigh the costs associated with future treatment of infections caused by resistant micro-organisms.
Putative beneficial effects of initial combination treatment with a b-lactam antibiotics plus a macrolides or monotherapy with fluoroquinolones are an increased patient survival as compared to with a b-lactam monotherapy; possible disadvantages are increases in antibiotic use and treatment costs. In a systematic review, unequivocal evidence of increased patient survival only mounted form studies with substantial patient prescription bias. Contrary, antibiotic use and treatment costs would increase with about 20%, increasing up to over 50% in patients with moderate CAP, whereas the adequacy of therapy hardly changes. Therefore, the current evidence for the use of combination therapy or treatment with fluoroquinolones in CAP is not strong enough to justify a place in routine clinical practice.
In theory, an early switch from intravenous to oral therapy reduces intravenous drug costs and allows an early discharge from hospital, but risks increase in treatment failures and treatment costs outside the hospital. In a study evaluating these factors, a early conversion to oral treatment significantly reduced length of hospital stay and overall costs as compared to a 7-day course of intravenous treatment. There were comparable clinical outcomes. Future steps towards more efficient management may include even shorter courses of antimicrobial treatment and implementation of early switch strategies in clinical practice.
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