Cost-benefit analysis of extended antifungal prophylaxis in ventricular assist devices

This report defines the cost and benefit of extended antifungal prophylaxis in ventricular assist device (VAD) patients (pts). Extended antifungal pro phylaxis is defined as prophylaxis with fluconazole or nystatin that is giv en until pts are extubated and off antibiotics. These data are compared wit h that obtained from earlier VAD patients who only received antifungal drug s for documented fungal colonization or infection. Thirty-six patients had HeartMate (n = 15) or Thoratec (n = 21) VADs between 1989 and 1997. Culture s positive for fungus (n = 52 cultures) were obtained from 16 of 36 patient s (44% of patients). Forty-three fungal cultures were in the preprophylaxis and nine in the postprophylaxis era. There was one death attributable to f ungal sepsis in the preprophylaxis era and none in the postprophylaxis era. The total cost of antifungal drugs in the preprophylaxis era was $3,840 ov er 1,498 patient days (PD) (mean $2.56 per PD), versus $70,670 over 1,525 P D in the postprophylaxis era (mean $46.34 per PD). Extended antifungal prop hylaxis was not cost effective in VAD patients at this institution. However , short-term perioperative antifungal prophylaxis was not addressed by this study. We are now using short-term antifungal prophylaxis with fluconazole and nystatin in VAD patients because of the potential for serious morbidit y and mortality that is associated with fungal device infections. A future analysis will determine the usefulness of this change in strategy.