title: Cost-effectiveness of micafungin as an alternative to fluconazole empiric treatment of suspected ICU-acquired candidemia among patients with sepsis: a model simulation.
abstract: BACKGROUND
  Recent epidemiologic literature indicates that candidal species resistant to azoles are becoming more prevalent in the face of increasing incidence of hospitalizations with candidemia. Echinocandins, a new class of antifungal agents, are effective against resistant candidal species. As delaying appropriate antifungal coverage leads to increased mortality, we evaluated the cost-effectiveness of 100 mg daily empiric micafungin (MIC) vs. 400 mg daily fluconazole (FLU) for suspected intensive care unit-acquired candidemia (ICU-AC) among septic patients.
  
  
  METHODS
  We designed a decision model with inputs from the literature in a hypothetical 1000-patient cohort with suspected ICU-AC treated empirically with either MIC or FLU or no treatment accompanied by a watchful waiting strategy. We examined the differences in the number of survivors, acquisition costs of antifungals, and lifetime costs among survivors in the cohort under each scenario, and calculated cost per quality adjusted life year (QALY). We conducted Monte Carlo simulations and sensitivity analyses to determine the stability of our estimates.
  
  
  RESULTS
  In the base case analysis, assuming ICU-AC attributable mortality of 0.40 and a 52% relative risk reduction in mortality with appropriate timely therapy, compared with FLU (total deaths 31), treatment with MIC (total deaths 27) would result in four fewer deaths at an incremental cost/death averted of $61,446. Similarly, in reference case, incremental cost-effectiveness of MIC over FLU was $34,734 (95% confidence interval $26,312 to $49,209) per QALY. The estimates were most sensitive to the QALY adjustment factor and the risk of candidemia among septic patients.
  
  
  CONCLUSIONS
  Given the increasing likelihood of azole resistance among candidal isolates, empiric treatment of ICU-AC with 100 mg daily MIC is a cost-effective alternative to FLU.
authors: School of Public Health and Health Sciences, University of Massachusetts, Arnold House, Amherst, MA 01003, USA. mzilberb@schoolph.umass.edu
authors: Marya D
authors: MD
authors: Zilberberg
authors: Smita
authors: S
authors: Kothari
authors: Andrew F
authors: AF
authors: Shorr
mesh_terms: D000935:Antifungal Agents / Q000191:economics* / Q000627:therapeutic use; D002177:Candidiasis / Q000188:drug therapy* / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D003428:Cross Infection / Q000188:drug therapy* / Q000453:epidemiology; D003663:Decision Trees; D016527:Drug Costs; D025141:Drug Resistance, Fungal; D054714:Echinocandins / Q000191:economics* / Q000627:therapeutic use; D015725:Fluconazole / Q000191:economics* / Q000627:therapeutic use; D016469:Fungemia / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000191:economics; D055666:Lipopeptides / Q000191:economics* / Q000627:therapeutic use; D000077551:Micafungin; D017059:Models, Econometric; D009010:Monte Carlo Method; D019057:Quality-Adjusted Life Years
chemical_list: D000935:Antifungal Agents; D054714:Echinocandins; D055666:Lipopeptides; D015725:Fluconazole; D000077551:Micafungin