Diagnosis and Treatment of Pneumocystis carinii Pneumonia: Economic issuesand cost-effectiveness

Pneumocystis carinii pneumonia (PCP) has been one of the most common opport unistic infections since the beginning of the AIDS epidemic. It is associat ed with significant morbidity and mortality, and is costly. Because of conc ern over the high cost of health care for HIV-infected individuals, clinici ans and policy makers have been pressed to develop economically efficient a pproaches to the diagnosis and treatment of PCP, Substantial research, mainly in the form of cost-identification analyses, h as focused on assessing the costs of various diagnostic strategies for PCP. These studies have suggested that definitive diagnosis of PCP is generally preferable to empiric treatment, particularly using less invasive tests su ch as induced sputum, Cost-effectiveness analyses have found that the optim al diagnostic strategies are most dependent on the prevalence of PCP, the d iagnostic test performance, and the relative cost of sputum induction compa red to bronchoscopy with broncheoalveolar lavage (BAL), No studies have fou nd immediate BAL to be either less costly or more cost-effective than induc ed sputum followed by BAL if negative. Indirect tests like exercise induced oxygen desaturation (EOS) and arterial blood gas analysis, when used to st ratify patients into high or low probability categories of PCP, may allow f or more efficient triage to expensive BAL, While a variety of effective treatment options are now available for PCP, t rimethoprim-sulfamethoxazole (TMP-SMX) remains the first-line therapy becau se it is highly effective and least expensive. Cost-effectiveness analyses of second-line therapy for both mild to moderate and moderate to severe PCP have suggested that there are effective and cost-effective alternatives to pentamidine. Finally, intensive care unit (ICU) support for patients with AIDS-related PCP and severe respiratory failure has been shown to cost more per year of life saved than many commonly accepted clinical interventions, There will continue to be a need for reliable and accurate information on t he costs of AIDS related opportunistic infections such as PCP, Future resea rch should focus on the economic impact of PCP diagnosis and therapy in the outpatient setting, where the majority of such care now occurs.