AN OPINION
SELECTING COST-EFFECTIVE ANTIMICROBIAL PROPHYLAXIS IN SURGERY: ARE WE GETTING WHAT WE PAY FOR? Albert C. Roach, Douglas S. Kernodle, and Allen B. Kaiser
ABSTRACf: The acquisition, administration, and infection-related expenses associated with the use of cefazolin or cefamandoleduring a prospective randomizedcomparison of antimicrobial prophylaxis in cardiac surgery were compared. Although the acquisition cost and administration charges related to the use of cefamandole were in excess of those incurred with cefazolin, differences in the charges associated with treating the wound infections that failed prophylaxis with each regimen made cefamandolethe more cost-effective prophylactic agent (mean total of $766 per cefazolin recipient vs. $315 per cefamandole recipient). Analysis of prophylactic antimicrobials should include the expenses associated with "prophylactic failures." The agent that is least expensivefor the pharmacy may not be the most cost-effectivechoice for the institution. DICP Ann Pharmacother 1990;24:183-5. ALTHOUGH CONTROLLED CLINICAL TRIALS have established the ability of perioperative prophylaxis with cephalosporins to reduce the incidence of wound infections associated with "clean" surgical procedures.r" the "best" agent for prophylavi- remains undetermined. The first-generation cephalosporins have become popular because of their excellent antistaphylococcal activity, the low incidence of significant toxicity associated with their use, and until recently, the lack of apparent benefit of more expensive altematives."? Because there are differences in both the acquisition costs and pharmacokinetic profiles of the firstgeneration agents that influence the charges associated with their use, attempts to reduce such charges have emphasized the value of using cefazolin for perioperative prophylaxis -its low unit-cost combined with relatively long half-life have made it an attractive choice." ALBERT C. ROACH, Phann.D., is the Assistant Director for Clinical Services, Department of Pharmacy, Saint Thomas Hospital. and an Adjunct Instructorof Medicine, Vanderbilt UniversitySchoolof Medicine;DOUGLAS S, KERNODLE, M.D., is an Assistant Professor of Medicine, Vanderbilt University School of Medicine; and ALLEN B. KAISER, M.D., is the Vice Chainnan, Clinical Affairs, andan Associate Professor of Medicine, Vanderbilt University School of Medicine. ReprInts: Albert C. Roach, Phann.D., Department of Phannacy, Saint Thomas Hospital, P.O. Box 380, Nashville, TN 37202. This paperwas presentedin part at an Exhibitors'Theater at the 22nd AnnualAmerican Society of Hospital Phannacists MidyearClinicalMeeting, Atlanta, GA, 01\ December 10,1987.
Traditionally, hospital pharmacists have focused on the cost of acquiring and administering antimicrobial prophylaxis with minimal consideration of the outcome of perioperative prophylaxis (i.e., the effect of the prophylactic regimen on the wound infection rate), Although cefazolin appears to be cost-effective on the basis of a comparison of the acquisition and administration costs of parenteral cephalosporins, the results of two clinical trials indicate that it may not be as effective in preventing postsurgical wound infections as cefamandolev" and cefuroxime. 9 Because postsurgical wound infections often require careful and costly management including surgical debridement, prolonged hospitalization, and an extended course of parenteral antimicrobials, a regimen resulting in fewer postsurgical infections may result in less money expended in the care of these complications, We independently designed a cardiothoracic prophylaxis trial to study the comparative efficacy of four prophylactic regimens, which included cefazolin (Kefzol, Eli Lilly; Ancef, Smith Kline & French Laboratories), cefazolin plus gentamicin, cefamandole (Mandol, Eli Lilly), and cefamandole plus gentamicin." Adult patients scheduled for elective median sternotomy procedures at Saint Thomas Hospital in Nashville, Tennessee, between November 1984 and January 1986 were eligible for participation. All antimicrobials were administered intravenously and were started at the induction of anesthesia. The cephalosporins were redosed intraoperatively and continued for 72 hours postoperatively. Gentamicin was administered as a single preoperative dose. During the study period, 1446 patients underwent median sternotomy procedures at Saint Thomas Hospital. Of these , 1057 (73 percent) were enrolled in the prospective study and, following exclusions, 1030 were suitable for evaluation. Sternal wound infections developed in II of 1030 (1.06 percent) patients who underwent median sternotomy procedures. Donor site infections developed in 6 of 963 (0.6 percent) patients who underwent harvest of a saphenous vein as part of their procedure. Among the four
DICP, The Annals of Pharmacotherapy
•
1990 February, Volume 24
•
183
prophylaxis groups, the only significant difference was the low rate of sternal wound infections among cefamandolel gentamicin recipients compared with cefazolinlgentamicin recipients (0 vs. 2.4 percent, respectively; p
SELECTING COST-EFFECTIVE ANTIMICROBIAL PROPHYLAXIS IN SURGERY: ARE WE GETTING WHAT WE PAY FOR? Albert C. Roach, Douglas S. Kernodle, and Allen B. Kaiser
ABSTRACf: The acquisition, administration, and infection-related expenses associated with the use of cefazolin or cefamandoleduring a prospective randomizedcomparison of antimicrobial prophylaxis in cardiac surgery were compared. Although the acquisition cost and administration charges related to the use of cefamandole were in excess of those incurred with cefazolin, differences in the charges associated with treating the wound infections that failed prophylaxis with each regimen made cefamandolethe more cost-effective prophylactic agent (mean total of $766 per cefazolin recipient vs. $315 per cefamandole recipient). Analysis of prophylactic antimicrobials should include the expenses associated with "prophylactic failures." The agent that is least expensivefor the pharmacy may not be the most cost-effectivechoice for the institution. DICP Ann Pharmacother 1990;24:183-5. ALTHOUGH CONTROLLED CLINICAL TRIALS have established the ability of perioperative prophylaxis with cephalosporins to reduce the incidence of wound infections associated with "clean" surgical procedures.r" the "best" agent for prophylavi- remains undetermined. The first-generation cephalosporins have become popular because of their excellent antistaphylococcal activity, the low incidence of significant toxicity associated with their use, and until recently, the lack of apparent benefit of more expensive altematives."? Because there are differences in both the acquisition costs and pharmacokinetic profiles of the firstgeneration agents that influence the charges associated with their use, attempts to reduce such charges have emphasized the value of using cefazolin for perioperative prophylaxis -its low unit-cost combined with relatively long half-life have made it an attractive choice." ALBERT C. ROACH, Phann.D., is the Assistant Director for Clinical Services, Department of Pharmacy, Saint Thomas Hospital. and an Adjunct Instructorof Medicine, Vanderbilt UniversitySchoolof Medicine;DOUGLAS S, KERNODLE, M.D., is an Assistant Professor of Medicine, Vanderbilt University School of Medicine; and ALLEN B. KAISER, M.D., is the Vice Chainnan, Clinical Affairs, andan Associate Professor of Medicine, Vanderbilt University School of Medicine. ReprInts: Albert C. Roach, Phann.D., Department of Phannacy, Saint Thomas Hospital, P.O. Box 380, Nashville, TN 37202. This paperwas presentedin part at an Exhibitors'Theater at the 22nd AnnualAmerican Society of Hospital Phannacists MidyearClinicalMeeting, Atlanta, GA, 01\ December 10,1987.
Traditionally, hospital pharmacists have focused on the cost of acquiring and administering antimicrobial prophylaxis with minimal consideration of the outcome of perioperative prophylaxis (i.e., the effect of the prophylactic regimen on the wound infection rate), Although cefazolin appears to be cost-effective on the basis of a comparison of the acquisition and administration costs of parenteral cephalosporins, the results of two clinical trials indicate that it may not be as effective in preventing postsurgical wound infections as cefamandolev" and cefuroxime. 9 Because postsurgical wound infections often require careful and costly management including surgical debridement, prolonged hospitalization, and an extended course of parenteral antimicrobials, a regimen resulting in fewer postsurgical infections may result in less money expended in the care of these complications, We independently designed a cardiothoracic prophylaxis trial to study the comparative efficacy of four prophylactic regimens, which included cefazolin (Kefzol, Eli Lilly; Ancef, Smith Kline & French Laboratories), cefazolin plus gentamicin, cefamandole (Mandol, Eli Lilly), and cefamandole plus gentamicin." Adult patients scheduled for elective median sternotomy procedures at Saint Thomas Hospital in Nashville, Tennessee, between November 1984 and January 1986 were eligible for participation. All antimicrobials were administered intravenously and were started at the induction of anesthesia. The cephalosporins were redosed intraoperatively and continued for 72 hours postoperatively. Gentamicin was administered as a single preoperative dose. During the study period, 1446 patients underwent median sternotomy procedures at Saint Thomas Hospital. Of these , 1057 (73 percent) were enrolled in the prospective study and, following exclusions, 1030 were suitable for evaluation. Sternal wound infections developed in II of 1030 (1.06 percent) patients who underwent median sternotomy procedures. Donor site infections developed in 6 of 963 (0.6 percent) patients who underwent harvest of a saphenous vein as part of their procedure. Among the four
DICP, The Annals of Pharmacotherapy
•
1990 February, Volume 24
•
183
prophylaxis groups, the only significant difference was the low rate of sternal wound infections among cefamandolel gentamicin recipients compared with cefazolinlgentamicin recipients (0 vs. 2.4 percent, respectively; p
