COST-EFFECTIVE TREATMENT OF LOWER RESPIRATORY-TRACT INFECTIONS

Pneumonia is one of the most frequent causes of hospitalisation, accou nting for many deaths each year. Elderly patients, especially those in extended care facilities, are at particular risk for pneumonia and ha ve a higher mortality rate than younger patients. The cost of treating patients with lower respiratory tract infections (LRTIs) is staggerin g, especially for patients who require hospitalisation. Less extensive diagnostic testing may be utilised in the future to minimise the cost of LRTIs, although this in turn might compromise our knowledge of the pathogens involved and their resistance patterns. Currently, the prev alence of various pathogens is known, and varies on the basis of under lying risk factors such as age, structural or functional lung disease, mental status, immune system function and geographical region, Howeve r, resistance patterns of commonly implicated pathogens are ever-chang ing, For example, Streptococcus pneumoniae, which is the most frequent cause of community-acquired pneumonia, has become resistant to benzyl penicillin (penicillin G) in recent years. This is especially disturbi ng because cross-resistance with other classes of antibiotics frequent ly occurs. Many antibiotics have been used in the treatment of LRTIs. Cephalosporins are popular because of their broad spectrum of activity and excellent safety profiles. Penicillins have also been popular, al though resistant strains of S. pneumoniae now pose a serious threat. T he macrolides have recently enjoyed increased popularity because of th eir activity against atypical pathogens. Although the fluoroquinolones are second-line agents for community-acquired pneumonia, they have a place in the treatment of LRTIs encountered in the nursing home or hos pital setting, and even have activity against atypical bacteria. A var iety of innovative programmes have been developed in recent years to c ontrol the cost of treating LRTIs. Although limited formulary choices have been used in the hospital setting for years, and are now becoming popular in managed care, there is no proof that this mechanism saves money when looking at the overall picture. A rational approach is to c onduct a rigorous pharmacoeconomic evaluation of treatment options, th us identifying the therapies that provide the best value in each setti ng. Equally important are various programmes that encourage the cost-c onscious use of the antibiotics chosen. Some of the methods evaluated in the literature include: notifying prescribers of the true cost of t reatment alternatives, notifying prescribers whether or not third-part y coverage is available for the prescription, streamlining from combin ation therapy to a single agent, early switching from parenteral to or al therapy, initiating treatment with oral agents, administering paren teral antibiotics at home from the outset of therapy, and antibiotic s treamlining programmes that are partnered with infectious disease phys icians. For the most part, these programmes have not been rigorously e valuated. Newer, more innovative ways to provide cost-conscious treatm ent of LRTIs will undoubtedly be developed. The basic premise for thes e programmes should be rigorous, well-designed pharmacoeconomic evalua tions. Such studies will help ensure that all facets of therapy are ev aluated and should prevent choices being made simply on the basis of t he lowest acquisition cost.