Skip to main content
SpringerLink
Log in

Cost-Effectiveness of Procalcitonin-Guided Antibiotic Therapy for Outpatient Management of Acute Respiratory Tract Infections in Adults

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

A Capsule Commentary to this article was published on 20 December 2013

ABSTRACT

BACKGROUND

Two clinical trials suggest that procalcitonin-guided antibiotic therapy can safely reduce antibiotic prescribing in outpatient management of acute respiratory tract infections (ARTIs) in adults. Yet, it remains unclear whether procalcitonin testing is cost-effective in this setting.

OBJECTIVE

To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults.

DESIGN

Cost-effectiveness model based on results from two published European clinical trials, with all parameters varied widely in sensitivity analyses.

PATIENTS

Two hypothetical cohorts were modeled in separate trial-based analyses: adults with ARTIs judged by their physicians to require antibiotics and all adults with ARTIs.

INTERVENTIONS

Procalcitonin-guided antibiotic therapy protocols versus usual care.

MAIN MEASURES

Costs and cost per antibiotic prescription safely avoided.

KEY RESULTS

We estimated the health care system willingness-to-pay threshold as $43 (range $0–$333) per antibiotic safely avoided, reflecting the estimated cost of antibiotic resistance per outpatient antibiotic prescribed. In the cohort including all adult ARTIs judged to require antibiotics by their physicians, procalcitonin cost $31 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored compared to usual care was 58.4 % in a probabilistic sensitivity analysis. In the analysis that included all adult ARTIs, procalcitonin cost $149 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored was 2.8 %.

CONCLUSIONS

Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults would be cost-effective when the costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their physicians to require antibiotics.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

REFERENCES

  1. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302(7):758–66.

    Article  PubMed  CAS  Google Scholar 

  2. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 1997;278(11):901–4.

    Article  PubMed  CAS  Google Scholar 

  3. Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis. 2001;33(5):757–62.

    Article  PubMed  CAS  Google Scholar 

  4. Huchon GJ, Gialdroni-Grassi G, Leophonte P, Manresa F, Shaberg T, Woodhead M. Initial antibiotic therapy for lower respiratory tract infection in the community: a European survey. Eur Respir J. 1996;9(8):1590–5.

    Article  PubMed  CAS  Google Scholar 

  5. Steinman MA, Landefield CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA. 2003;289(6):719–25.

    Article  PubMed  Google Scholar 

  6. Arroll B, Kenealy T. Antibiotics for the common cold and acute purulent rhinitis (review). Cochrane Database Syst Rev. 2010:CD000247.

  7. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis (review). Cochrane Database Syst Rev. 2012:CD000245.

  8. Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW, Mäkelä M. Antibiotics for acute maxillary sinusitis (review). Cochrane Database Syst Rev. 2011:CD000243.

  9. Goosens H, Ferech M, Stichele RB, Elseviers S. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365(9459):579–87.

    Article  Google Scholar 

  10. van de Sande-Bruinsma N, Grundman J, Verloo D, et al. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis. 2008;14(11):1722–30.

    Article  PubMed Central  PubMed  Google Scholar 

  11. The Interagency Task Force on Antimicrobial Resistance. A public health action plan to combat antimicrobial resistance: 2012 update. Available at: www.cdc.gov/drugresistance/actionplan/actionplan.html. Accessed October 10, 2013.

  12. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2009:CD003539.

  13. Goosens H, Guillemot D, Ferech M, et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol. 2006;62(5):373–9.

    Article  Google Scholar 

  14. van der Meer V, Neven AK, van den Broek PJ, Assendelft WJJ Diagnostic value of C reactive protein in infections of the lower respiratory tract: a systematic review. BMJ. 2005;331(757):26.

  15. Gonzales R, Aagaard EM, Camargo CA, et al. C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm. J Emerg Med. 2011;41(1):1–7.

    Article  PubMed  Google Scholar 

  16. Schuetz P, Chiappa V, Briel M, Greenwald JL. Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms. Arch Intern Med. 2011;171(15); 1322–31.

    Article  PubMed  Google Scholar 

  17. Briel M, Schuetz P, Mueller B, et al. Procalcitonin-guided antibiotic use vs a standard approach for acute respiratory tract infections in primary care. Arch Intern Med. 2008;168(18): 2000–7.

    Article  PubMed  Google Scholar 

  18. Burkhardt O, Ewig S, Haagen U, et al. Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection. Eur Respir J. 2010;36(3): 601–7.

    Article  PubMed  CAS  Google Scholar 

  19. Mainous AG, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population. Arch Fam Med. 1998;7(Jan/Feb):45–9.

    Article  PubMed  Google Scholar 

  20. Centers for Medicare & Medicaid Services. New Clinical Laboratory Fee Schedule Test Codes. Procalcitonin. Available at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2011-CLFS-New-Test-Codes.pdf. Accessed October 10, 2013.

  21. Gonzales R, Corbett KK, Wong S, et al. “Get Smart Colorado,” Impact of a mass media campaign to improve community antibiotic use. Med Care. 2008;46(6):597–605.

    Article  PubMed  Google Scholar 

  22. Oppong R, Billingsley K, Nuttall J, Hood K, Smith RD, Cost J. The impact of using different tariffs to value EQ-5D health state descriptions: an example from a study of acute cough/lower respiratory tract infections in seven countries. Eur J Health Econ. 2013;14(2):197–209.

    Article  PubMed  Google Scholar 

  23. Gold MR, Franks P, McCoy KI, Fryback DG. Toward consistency in cost-utility analysis: using national measures to create condition-specific values. Med Care. 1998;36(6):778–92.

    Article  PubMed  CAS  Google Scholar 

  24. Smith KJ, Wateska A, Nowalk MP, Raymund M, Lee BY, Zimmerman RK, Fine MJ. Cost-effectiveness of procalcitonin-guided antibiotic use in community acquired pneumonia. J Gen Intern Med. 2013;28(9):1157–64.

    Article  PubMed  Google Scholar 

  25. Bush K, Courvalin P, Dantas G, et al. Tackling antibiotic resistance. Nat Rev Microbiol. 2011; December(9):894–6.

  26. Phelps T. Bud/drug resistance: sometimes less is more. Med Care. 1989;27(2): 194–203.

    Article  PubMed  CAS  Google Scholar 

  27. Albrich WC, Dusemund F, Bucher B, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012;172(9):715–22.

    Article  PubMed  CAS  Google Scholar 

  28. Annual Salary, Physician – Internal Medicine. Available at www1.salary.com/Physician-Infectious-Disease-Salary.html. Accessed October 10, 2013.

  29. The Pew Charitable Trusts Health Initiative. Record-high antibiotic sales for meat and poultry production. Available at: www.pewhealth.org/other-resource/record-high-antibiotic-sales-for-meat-and-poultry-production-85899449119. Accessed October 10, 2013.

  30. Wise R, Hart T, Cars O, et al. Antimicrobial resistance is a major threat to public health. BMJ. 1998;September 5(317):609–10.

  31. Hersh AL, Shapiro DJ, Pavia AT, Shah S. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053–61.

    Article  PubMed  Google Scholar 

  32. Hersh AL, Shapiro DJ, Hicks LA. Antibiotic prescribing in ambulatory care in the United States: estimates from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (NAMCS/HAMCS). Abstract, 2012 IDWeek Conference.

Download references

Acknowledgements

This study was supported by the National Institute of Allergy and Infectious Diseases (Grant No. R01AI076256), the National Institute of Health (T32 Grant No. AG21885) and the Doris Duke Charitable Foundation. This study has not previously been presented in part or in full at any prior conference.

Conflict of Interest

Dr. Zimmerman and Dr. Nowalk have a research grant from Merck to study the HPV vaccine.

Author information

Authors and Affiliations

  1. University of Pittsburgh School of Medicine, M240 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA

    Constantinos I. Michaelidis BA

  2. Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Richard K. Zimmerman MD, MPH & Mary Patricia Nowalk PhD

  3. Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Michael J. Fine MD, MSc & Kenneth J. Smith MD, MS

  4. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Michael J. Fine MD, MSc

Authors
  1. Constantinos I. Michaelidis BA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Richard K. Zimmerman MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mary Patricia Nowalk PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael J. Fine MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kenneth J. Smith MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Constantinos I. Michaelidis BA.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Michaelidis, C.I., Zimmerman, R.K., Nowalk, M.P. et al. Cost-Effectiveness of Procalcitonin-Guided Antibiotic Therapy for Outpatient Management of Acute Respiratory Tract Infections in Adults. J GEN INTERN MED 29, 579–586 (2014). https://doi.org/10.1007/s11606-013-2679-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-013-2679-7

KEY WORDS

Search

Navigation