A new ciprofloxacin stepdown program in the treatment of high-risk febrileneutropenia: A clinical and economic analysis

Study Objective. To determine treatment outcomes and economic impact of a c iprofloxacin stepdown program for high-risk febrile neutropenic adults from the hospital's perspective. Design. Unblinded, two-phase, single-center study. Setting. Adult leukemia and stem cell transplant unit. Patients. High-risk adults with febrile neutropenia. Intervention. Two conditions were analyzed: a multidisciplinary ciprofloxac in stepdown program involving a reduction in parenteral ciprofloxacin dose from 400 to 200 mg (i.v.-i.v.) and conversion to oral ciprofloxacin (i.v.-p .o.) when criteria were met; and no i.v.-i.v. stepdown program. Measurements and Main Results. Forty-six sequential treatment courses were compared with 42 treatment course from 6-month periods in preintervention ( P1) and postintervention (P2) phases. Assessed parameters were clinical and microbiologic outcomes, adverse drug reactions (ADRs), and direct medical resource use and costs (1998 $Canadian) for the episode of febrile neutrope nia. A decision analytic model was used to map probabilities and costs and to conduct sensitivity analyses. To supplement standard statistical testing , 1000 bootstrap samples were created, and the mean cost difference was cal culated between phases for each sample. Patient demographics, percentage i. v.-p.o. stepdown, and duration of therapy were similar between phases. Clin ical success (83% P1, 81% P2), microbiologic eradication (15% P1, 24% P2), and possible ADRs (6% P1, 9% P2) did not differ. Intravenous-to-intravenous dose stepdown occurred in 33% of P2 and no P1 treatment courses (p<0.001). Resource use and costs were similar between phases, although a reduction w as seen in the drug's mean total cost/day ($58 P1, $52 P2, p=0.04). There w as also a trend toward a decrease in mean total treatment costs ($4843 P1, $3493 P2, p=0.08). In 1000 bootstrap samples, 99.8% showed a cost advantage for P2. The model was robust to sensitivity analyses. Conclusion. This intervention influenced administration of ciprofloxacin wi thout apparent compromise of patient outcomes and resulted in a reduction i n total costs of treating febrile neutropenia.