title: Cost-effectiveness of three strategies of managing tunnelled, cuffed haemodialysis catheters in clinically mild or asymptomatic bacteraemias.
abstract: BACKGROUND
  Immediate tunnelled, cuffed catheter (TCC) removal is the current standard of care when bacteraemia is associated with severe clinical symptoms. When minimal or no symptoms are present, the optimal strategy of TCC management is controversial. The following three strategies have been proposed: TCC 'salvage' (antibiotic administration without TCC removal), TCC exchange over a guidewire with antibiotics or immediate TCC removal with delayed reinsertion and antibiotics.
  
  
  METHODS
  We developed a decision-analytic model to assess the cost-effectiveness of each strategy for episodes of TCC-associated bacteraemia presenting with minimal symptoms, in a hypothetical cohort of haemodialysis patients followed for a 3 month period. Data regarding the probability of treatment failure due to recurrent infection for each strategy, secondary infectious complications and patient mortality were obtained from existing clinical trials and from the 1998 United States Renal Data System database. Costs were substituted with the current 2000 New York hospital charges.
  
  
  RESULTS
  Tunnelled, cuffed catheter exchange over a guidewire was associated with a reduction in net charges of $5241 and $750 when compared with TCC salvage and immediate TCC removal, respectively. The expected 3 month patient survival for TCC guidewire exchange and immediate TCC removal were similar (93%), whereas survival for TCC salvage was worse (89%). Tunnelled, cuffed catheter guidewire exchange remained the most cost-effective strategy when the probability of treatment failure with recurrent bacteraemia in 3 months was <25% for this strategy.
  
  
  CONCLUSIONS
  Tunnelled, cuffed catheter guidewire exchange is the most cost-effective strategy of catheter management when mild or no symptoms are present.
authors.affiliation: Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA. mokrzm@aol.com
authors.forename: Michele H
authors.initials: MH
authors.lastname: Mokrzycki
authors.forename: Abhay
authors.initials: A
authors.lastname: Singhal
mesh_terms: D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use*; D016470:Bacteremia / Q000628:therapy*; D002408:Catheters, Indwelling / Q000382:microbiology*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D020878:Device Removal / Q000191:economics; D004867:Equipment Design; D017048:Health Care Costs; D006801:Humans; D006435:Renal Dialysis / Q000295:instrumentation*; D012680:Sensitivity and Specificity
chemical_list: D000900:Anti-Bacterial Agents