title: Cost-Effectiveness Analysis of Multiplex PCR with Magnetic Resonance Detection versus Empiric or Blood Culture-Directed Therapy for Management of Suspected Candidemia.
abstract: Candida bloodstream infections (BSI) are associated with significant morbidity, mortality, and increased health care costs. Early treatment is essential, because delayed therapy detrimentally impacts clinical outcomes. The FDA recently approved the first culture-independent direct molecular detection method for Candida BSIs (T2Candida). The speed and sensitivity of this assay give it the potential to improve patient care, but the reagents and instrumentation are expensive. We used an analytic decision tree model to compare the cost-effectiveness of T2Candida-directed antifungal therapy (T2DT) to that of either empirical therapy (ET) or blood culture-directed therapy (BCDT). The costs included those of T2Candida testing, antifungal treatment, and hospital length of stay. The effectiveness measure was survival status at hospital discharge. T2DT was less costly and more effective than BCDT but was less costly and less effective than ET with an echinocandin (incremental cost-effectiveness ratio, $111,084 per additional survivor). One-way sensitivity analyses demonstrated that the cost-effectiveness of T2DT was highly dependent on Candida BSI prevalence and the cost of antifungal therapy and T2Candida test reagents. The use of T2DT reduced the number of unnecessarily treated patients by 98% relative to that with ET. Reduced drug exposure might lessen the possibility of drug-related adverse events and may also prevent the development of antifungal resistance or emergence of drug-resistant Candida species. The greatest benefit of T2Candida appears to be the ability to confidently withhold or stop empirical antifungal therapy in low-to-moderate-risk patients who are unlikely to benefit from treatment.
authors.affiliation: Institute for Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, Utah, USA.
authors.forename: Brandon
authors.initials: B
authors.lastname: Walker
authors.affiliation: Department of Pathology, University of Utah, Salt Lake City, Utah, USA margaret.powers-fletcher@aruplab.com kim.hanson@hsc.utah.edu.
authors.forename: Margaret V
authors.initials: MV
authors.lastname: Powers-Fletcher
authors.affiliation: Institute for Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, Utah, USA Department of Pathology, University of Utah, Salt Lake City, Utah, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Schmidt
authors.affiliation: Institute for Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, Utah, USA Department of Pathology, University of Utah, Salt Lake City, Utah, USA Department of Medicine, University of Utah, Salt Lake City, Utah, USA margaret.powers-fletcher@aruplab.com kim.hanson@hsc.utah.edu.
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Hanson
mesh_terms: D000935:Antifungal Agents / Q000494:pharmacology / Q000627:therapeutic use; D000071997:Blood Culture; D002175:Candida / Q000145:classification / Q000235:genetics*; D058387:Candidemia / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D019468:Disease Management; D006801:Humans; D008279:Magnetic Resonance Imaging; D015233:Models, Statistical; D060885:Multiplex Polymerase Chain Reaction; D012680:Sensitivity and Specificity; D013997:Time Factors
chemical_list: D000935:Antifungal Agents