title: Institutional experience with voriconazole compared with liposomal amphotericin B as empiric therapy for febrile neutropenia.
abstract: OBJECTIVE
  To assess the effectiveness, safety, and cost of empiric treatment of febrile neutropenia before and after implementing an algorithm in which voriconazole was substituted for liposomal amphotericin B (L-AmB).
  
  
  METHODS
  Retrospective cohort analysis.
  
  
  METHODS
  An 850-bed tertiary care hospital, which is also a referral site for patients with acute leukemia.
  
  
  METHODS
  Fifty-five adult patients who started empiric antifungal therapy for febrile neutropenia between January 1, 2002, and December 31, 2003, encompassing 58 treatment episodes (defined as a hospitalization during which empiric antifungal therapy was administered).
  
  
  RESULTS
  Medical charts, including patients' pharmacy and laboratory data, were reviewed. Twenty-six and 32 episodes of L-AmB and voriconazole use, respectively, were identified. No significant differences between the L-AmB and voriconazole groups were noted at baseline. Rates of fever resolution (54% vs 59%, p=0.791) and breakthrough invasive fungal infections (11% vs 12%, p>0.999) were similar for the L-AmB and voriconazole episodes. Premature drug discontinuation due to the prescriber's perceived lack of efficacy occurred most frequently in the voriconazole group (25% vs 8%, p=0.160). Survival was significantly higher in the voriconazole than in the L-AmB group (100% vs 77%, p=0.006). Adverse effects that were significantly more common in the L-AmB group than in the voriconazole group were elevated serum creatinine levels (27% vs 3%, p=0.017) and electrolyte disturbances (19% vs 0%, p=0.014). Adverse effects reported more frequently in the voriconazole group than in the L-AmB group were visual disturbances (9% vs 0%, p=0.245) and elevated hepatic enzyme levels (9% vs 8%, p>0.999). Mean drug expenditures/episode for initial empiric antifungal therapy were lower for voriconazole than for L-AmB ($1593 vs $4144, or $153 vs $380/day).
  
  
  CONCLUSIONS
  Our institution's algorithm incorporating voriconazole into the empiric management of febrile neutropenia was associated with effectiveness outcomes comparable to those observed with L-AmB as well as a lower frequency of adverse effects and overall expenditures for antifungal drugs.
authors.affiliation: Department of Clinical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Nadine
authors.initials: N
authors.lastname: Shehab
authors.forename: Daryl D
authors.initials: DD
authors.lastname: DePestel
authors.forename: Emily R
authors.initials: ER
authors.lastname: Mackler
authors.forename: Curtis D
authors.initials: CD
authors.lastname: Collins
authors.forename: Kathleen
authors.initials: K
authors.lastname: Welch
authors.forename: Harry P
authors.initials: HP
authors.lastname: Erba
mesh_terms: D000666:Amphotericin B / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D000935:Antifungal Agents / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D005260:Female; D005334:Fever / Q000188:drug therapy / Q000191:economics; D017048:Health Care Costs; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009503:Neutropenia / Q000188:drug therapy* / Q000191:economics; D011743:Pyrimidines / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D016896:Treatment Outcome; D014230:Triazoles / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D011743:Pyrimidines; D014230:Triazoles; C068538:liposomal amphotericin B; D000666:Amphotericin B; D065819:Voriconazole