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ABSTRACT: To determine if appropriate timing of vancomycin prophylaxis in patients undergoing cardiovascular surgery results in an economic benefit by assessing the differences in total duration of hospitalization and hospital costs based on infusion start time in relation to first surgical incision.
Prospective, observational study.
Tertiary care medical center.
A total of 1666 patients undergoing coronary artery bypass graft (CABG) and/or valve replacement surgery who received prophylactic vancomycin.
Appropriateness of vancomycin prophylaxis timing, based on national guidelines defining appropriate timing as start time of infusion ranging from 16-120 minutes before surgery start time, was prospectively monitored. The timing of vancomycin administration was grouped as follows: 0-15 minutes (11 patients), 16-60 minutes (156), 61-120 minutes (772), or more than 120 minutes (727) before incision. Antibiotic timing was appropriate in 928 patients and inappropriate in 738 patients. Length of hospital stay and total hospital costs were compared based on appropriateness of therapy by using multivariate linear regression and validated with a Heckman two-stage model. Median numbers of hospitalization and intensive care unit days were significantly fewer in patients given appropriate prophylaxis at an appropriate time (9 and 2 days, respectively) compared with inappropriate time (10 and 3 days, respectively, p<0.001 for both analyses). Hospital costs were significantly lower in patients who had appropriate timing of antibiotic prophylaxis (median $25,321, interquartile range [IQR] $19,429-35,471) compared with inappropriate timing (median $29,475, IQR $21,507-46,488, p<0.001). Multivariate linear regression and a Heckman two-stage model confirmed that appropriate antibiotic prophylaxis timing was associated with decreased hospitalization duration and hospital costs.
In patients undergoing CABG or valve replacement surgery, the administration of vancomycin 16-120 minutes before incision significantly reduced patient hospitalization duration and total hospital costs.
Pharmacotherapy 07/2008; 28(6):699-706. · 2.90 Impact Factor
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ABSTRACT: High-dose fluconazole is an alternative for patients with candidemia caused by Candida glabrata or other Candida species with decreased fluconazole susceptibility. However, empiric high-dose fluconazole is not currently recommended and may result in higher drug costs and toxicity.
To determine the cost-effectiveness of using empiric high-dose fluconazole in intensive care unit (ICU) with suspected invasive candidiasis.
Decision analytic model.
ICU patients with suspected invasive candidiasis.
Lifetime.
Societal.
Low-dose fluconazole (loading dose of 800 mg followed by 400 mg daily) vs. high-dose fluconazole (loading dose of 1600 mg followed by 800 mg daily). Generic fluconazole costs were used for the analysis.
Incremental life expectancy and incremental cost per discounted life year (DLY) saved. RESULT OF BASE-CASE ANALYSIS: Based on current national levels of fluconazole resistance and ability to correctly identify patients with candidemia, high-dose fluconazole was the more effective but more expensive treatment strategy. Empiric high-dose fluconazole therapy decreased the mortality rate by 0.15% compared to low-dose strategy with a cost-effectiveness rate of $55,526 per DLY saved.
Empirical high-dose fluconazole was an acceptable treatment strategy (using $100,000 per DLY saved as threshold) unless the physical age of an ICU survivor was 66 years or older. Empirical high-dose fluconazole was an acceptable treatment strategy using $50,000 per DLY saved with minor changes in parameters estimates.
The estimates of our model may not be applicable to all ICU patients. Other hospitals with differences in fluconazole resistance, prevalence of invasive candidiasis, or duration of fluconazole therapy may produce different results.
These results suggest that empiric high-dose fluconazole therapy should reduce the mortality associated with invasive candidiasis at an acceptable cost.
Current Medical Research and Opinion 06/2007; 23(5):1057-65. · 2.38 Impact Factor
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ABSTRACT: Increased incidence of methicillin-resistant Staphylococcus species has required some hospitals to choose vancomycin for surgical prophylaxis. Guidelines for appropriate timing of vancomycin prophylaxis state that the infusion should begin within 120 min before the first surgical incision. However, no studies have investigated the proper timing of vancomycin prophylaxis in relationship to surgical site infections (SSI). The objective of the present study was to assess the effect of vancomycin prophylaxis timing in relation to the first surgical incision on the incidence of SSI.
We prospectively monitored vancomycin prophylaxis timing and incidence of SSI in 2048 patients undergoing coronary bypass graft or valve replacement surgery. The timing of vancomycin was categorized into five groups based on the relation between the start of the infusion and the surgical cut time. Study hypotheses were tested using logistic analysis and further validated using a Heckman two-stage model.
The incidence of SSI were lowest in the 176 patients given vancomycin between 16 and 60 min before the surgical incision (3.4%) compared with 15 patients given vancomycin between 0 and 15 min [26.7%; relative risk (RR): 7.8; 95% CI: 2.5-24.7], 888 patients given vancomycin between 61 and 120 min (7.7%; RR: 2.2; 95% CI: 0.99-5.09), 700 patients given vancomycin between 121 and 180 min (6.9%; RR: 2.0; 95% CI: 0.87-4.62) or 269 patients given vancomycin >180 min (7.8%; RR: 2.3; 95% CI: 0.94-5.56) (P = 0.0119 by chi(2) analysis). Stepwise logistic regression analysis and a Heckman two-stage model confirmed that vancomycin administration between 16 and 60 min before the first surgical incision was associated with the lowest incidence of SSI.
Vancomycin administration within 16-60 min before the first surgical incision reduced the risk of SSI in cardiac surgery patients.
Journal of Antimicrobial Chemotherapy 10/2006; 58(3):645-50. · 5.07 Impact Factor
