- Email: [email protected]
Usage and cost of a nebulised pentamidine clinic in a large teaching hospital
Journal of Infection (2009) 58, 248e257
www.elsevierhealth.com/journals/jinf
LETTERS TO THE EDITOR Usage and cost of a nebulised pentamidine clinic in a large teaching hospital Nebulised pentamidine is a widely used prophylactic against Pneumocystis jirovecii pneumonia. Assessing the usage of this facility we noted that this service is now being accessed increasingly by other disciplines and generating a cost burden. A review of the service has allowed us to plan a more structured cost accountable facility. Pneumocystis jirovecii pneumonia is a life-threatening pulmonary and, occasionally, disseminated infection in patients with defects with cell-mediated immunity. Historically it has been one of the most common serious opportunistic respiratory infections in patients suffering from Acquired Immunodeficiency Syndrome (AIDS)1 necessitating widespread prophylaxis. The need for this has declined in the developed world since the introduction of highly active antiretroviral therapy (HAART).2 Increasing use of immunosuppressive drugs in transplantation and oncology means a large group of patients, who are immunosuppressed for other reasons, are also at significant risk of pneumocystis and benefit from prophylaxis.3 The most effective prophylaxis is a combination of trimethoprim and sulphamethoxazole (co-trimoxazole).4 As well as having the lowest rate of breakthrough infection, this treatment has the added benefit of protecting against infection by other microbes.5 Unfortunately a significant number of patients (particularly those with human immunodeficiency virus (HIV) infection) are intolerant of co-trimoxazole and require an alternative form of prophylaxis.6 One such treatment is nebulised pentamidine.7 We analysed the use of the pentamidine clinic within the hospital both to monitor how efficiently it was accessed,
Table 1
the patient population serviced and to establish appropriate funding lines. Addenbrooke’s Hospital is an 1100-bedded tertiary referral centre which has, since 2003, run a centralised clinic to provide nebulised pentamidine to patients who require pneumocystis prophylaxis but are intolerant of co-trimoxazole. The cost analysis was determined as follows: one 300 mg pentamidine nebule (£32.15), one 2.5 mg salbutamol nebule (£0.09), one nebuliser (£0.56), one pair of goggles (£1.20), one face mask (£1.93) and one length of elephant tubing (£1.39) were required per patient per clinic attendance. The ward had an additional band 5 nurse specifically for the clinic with an average hourly salary of £11.66 each clinic appointment expected lasted half an hour. Each patient had their own Venstream nebuliser (£23.45) which was replaced after 6 months of use (for the purposes of cost analysis this was assumed to be after 6 clinic attendances). Costs per patient were calculated by multiplying the costs per appointment by the number of appointments the patient had attended and then adding the cost for the nebulisers the patient had used. A total of 141 patients received nebulised pentamidine between January 2003 and July 2008. Between January 2003 and December 2007 115 people used the service, generating 598 appointments. Table 1 shows the number of patients (P) and the number of appointments (A) per referring team per year. The overall numbers attending from 2003 to 2008 and the departmental breakdown are shown in Figs. 1 and 2. Haematology patients on average had 6.65 clinic appointments, significantly more than ophthalmology, immunology, transplant and renal patients (P < 0.05). Infectious diseases (ID) patients had an average of 5.27 appointments (range 1e18 and standard
Number of patients (P) and number of appointments (A) per referring team per year. 2003
Referring team Infectious disease (ID) Haematology Renal Paediatric oncology Transplant Immunology Ophthalmology Total
P 6 16 3 7 0 0 1 33
2004 A 27 99 8 19 0 0 5 158
P 11 13 2 0 0 0 0 26
2005 A 62 60 7 0 0 0 0 129
P 18 11 1 2 0 0 0 32
2006 A 70 63 1 5 0 0 0 139
P 8 6 1 2 0 0 0 17
2007 A 27 18 1 5 0 0 0 51
P 11 9 9 0 4 1 0 34
A 30 46 31 0 11 3 0 121
Letters to the editor
249
Number of Patients per Team
Number of Appointments per Team Transplant, 11
Immunology, 1
Transplant, 4
Ophthalmology, 1
Immunology, 3 Ophthalmology, 5
Paeds onc, 29
Paeds onc, 10
Renal, 48 ID, 41
ID, 216
Renal, 15
Haematology, 286
Haematology, 43
Figure 1
Total number of patients and total number of appointments per team.
deviation 4.3). At the time of data collection, 16 of those patients who had previously used the pentamidine clinic had died. Clinical data was available for 127 patients. Table 2 shows the reasons given for the use of pentamidine instead of co-trimoxazole. Note that 42 patients (33%) did not have a reason documented for the need to use pentamidine instead of co-trimoxazole and a further 29 patients (23%) did not have a description of their intolerance. Sufficient data was available for 75 patients to evaluate time from referral to administration of first dose of pentamidine. The mean time before administration of 1st dose was 13 days (range 0e81 days and standard deviation of 13.2 days), with a median of 9 days. Complete data was available for clinic attendances in 2004, 2005 and 2007. This showed 34 missed appointments from a total of 71 clinics (each with 7 appointment slots). Table 3 shows the number of patients who failed to attend at least 1 appointment and number of appointments missed separated by team. Cost analysis was performed on the 115 people who attended clinic between 2003 and 2007. The total cost of the service during these years was £29867.00, excluding hospital infrastructure costs. Fig. 3 shows the cost per year and Fig. 4 shows the cost per team. The establishment of inhaled pentamidine as prophylaxis against pneumocystis has widened availability of effective preventive treatment to both patients with HIV
Number of appointments
8 6
ID
Transplant
Haematology
Immunol
Renal
Number of patients
Adverse reaction to co-trimoxazole Undefined allergy or intolerance Co-trimoxazole caused deranged liver function tests Co-trimoxazole caused rash Co-trimoxazole caused bone marrow suppression Co-trimoxazole caused pyrexia Trimethoprim caused angioedema Drug interaction with co-trimoxazole No reason documented Patient already has significant degree of myelosuppression Patient is recipient of bone marrow transplant Other
51 29 7 7 6 1 1 7 42 15 8 4
Ophthalmology
Referring team
Number of patients not attending 1 or more appointments (% of total)
Number of appointments missed (% of total)
Infectious diseases Haematology Renal Paediatric oncology Transplant Immunology Ophthalmology Total
10 6 2 1 1 0 0 20
21 9 2 1 1 0 0 34
Paeds onc
4 2 0
Reason for using pentamidine
Table 3 Number of patients who failed to attend and number of appointments missed, separated by team.
12 10
Table 2 Reasons given for use of pentamidine over co-trimoxazole.
Team
Figure 2 Average number of appointments per patient divided by team with 95% confidence intervals. Ophthalmology and Immunology had one patient each.
(50) (30) (10) (5) (5)
(62) (26) (6) (3) (3)
250
Letters to the editor
References
Cost of pentamidine clinic per year.
1. Wallace JM, Hansen NI, Lavange L, Glassroth J, Browdy BL, Rosen MJ, et al. Respiratory disease trends in the Pulmonary Complications of HIV Infection Study Cohort. Am J Respir Crit Care Med 1997;155:72e80. 2. Palella Jr FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338:853e60. 3. Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2004;17(4):770e82. 4. Ioannidis JPA, Cappelleri JC, Skolnik PR, Lau J, Sacks HS. A meta-analysis of the relative efficacy and toxicity of Pneumocystis carinii prophylactic regimens. Arch Intern Med 1996;156:177e88. 5. Hughes WT, Kuhn S, Chaudhary S, Feldman S, Verzosa M, Aur RJA, et al. Successful chemoprophylaxis for Pneumocystis carinii pneumonitis. N Engl J Med 1977;297:1419e26. 6. Masur H. Prevention and treatment of Pneumocystis carinii pneumonia. N Engl J Med 1992;327:1853e60. 7. Walzer PD, Perl DP, Krogstad DJ, Rawson PG, Schultz MG. Pneumocystis carinii pneumonia in the United States: epidemiologic, diagnostic, and clinical features. Ann Intern Med 1974;80:83e93. 8. Sands F, Kron M, Brown R. Pentamidine: a review. Rev Infect Dis 1985;7:625e34.
Cost of pentamidine clinic per referring team.
C. Ward D. O’Donovan A.M.L. Lever* Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK *Corresponding author. Tel: þ44 01223 330191; fax: þ44 01223 336846. E-mail address: [email protected] (A.M.L. Lever)
Figure 3
Figure 4
and those in other disciplines.7 Inhaled pentamidine is a convenient and usefully intermittent therapy, which the majority of individuals find acceptable.8 In our study we were concerned to identify a relatively large minority of individuals in whom the justification for pentamidine prophylaxis was not adequately documented or substantiated and this has led to a review of our procedures and a formalisation of our criteria for admission to the pentamidine clinic. The default rate on attendance for the clinic was worst in the HIV positive population and reflected the rather haphazard and chaotic lifestyles of some of these patients rather than any apparent difficulty in accessing the service for other reasons. The minimum cost of a single monthly appointment at the pentamidine clinic was £47.00, which compares with £2.81 for a one-month course of cotrimaxazole, 960 mg taken three times weekly. Thus pentamidine is an expensive alternative to the gold standard therapy. Highlighting this has been a trigger to initiating a review of reasons why patients are on pentamidine rather than alternative drugs. The identification of the proportions of patients coming from different disciplines has been of value in establishing payment pathways to support the service.
Acknowledgements The authors gratefully acknowledge support of the Cambridge University Hospitals NHS Foundation Trust Biomedical Research Centre.
22 January 2009 Available online 26 February 2009 ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2009.01.009
Simkania negevensis infection among Brazilian children hospitalized with community-acquired pneumonia
Dear Editor, Simkania negevensis is an obligate intracellular microbe, related to the chlamydiae.1 It has been found in domestic water supplies of infected children and this finding raises the possibility of transmission to children from the water of their homes.2 S. negevensis respiratory infections have been described from Europe, Japan and North America.3 In New York it was not a significant pathogen.4 We analyzed if S. negevensis acute infection occurred in Brazil. Children aged under five years hospitalized with community-acquired pneumonia (CAP) were enrolled in
www.elsevierhealth.com/journals/jinf
LETTERS TO THE EDITOR Usage and cost of a nebulised pentamidine clinic in a large teaching hospital Nebulised pentamidine is a widely used prophylactic against Pneumocystis jirovecii pneumonia. Assessing the usage of this facility we noted that this service is now being accessed increasingly by other disciplines and generating a cost burden. A review of the service has allowed us to plan a more structured cost accountable facility. Pneumocystis jirovecii pneumonia is a life-threatening pulmonary and, occasionally, disseminated infection in patients with defects with cell-mediated immunity. Historically it has been one of the most common serious opportunistic respiratory infections in patients suffering from Acquired Immunodeficiency Syndrome (AIDS)1 necessitating widespread prophylaxis. The need for this has declined in the developed world since the introduction of highly active antiretroviral therapy (HAART).2 Increasing use of immunosuppressive drugs in transplantation and oncology means a large group of patients, who are immunosuppressed for other reasons, are also at significant risk of pneumocystis and benefit from prophylaxis.3 The most effective prophylaxis is a combination of trimethoprim and sulphamethoxazole (co-trimoxazole).4 As well as having the lowest rate of breakthrough infection, this treatment has the added benefit of protecting against infection by other microbes.5 Unfortunately a significant number of patients (particularly those with human immunodeficiency virus (HIV) infection) are intolerant of co-trimoxazole and require an alternative form of prophylaxis.6 One such treatment is nebulised pentamidine.7 We analysed the use of the pentamidine clinic within the hospital both to monitor how efficiently it was accessed,
Table 1
the patient population serviced and to establish appropriate funding lines. Addenbrooke’s Hospital is an 1100-bedded tertiary referral centre which has, since 2003, run a centralised clinic to provide nebulised pentamidine to patients who require pneumocystis prophylaxis but are intolerant of co-trimoxazole. The cost analysis was determined as follows: one 300 mg pentamidine nebule (£32.15), one 2.5 mg salbutamol nebule (£0.09), one nebuliser (£0.56), one pair of goggles (£1.20), one face mask (£1.93) and one length of elephant tubing (£1.39) were required per patient per clinic attendance. The ward had an additional band 5 nurse specifically for the clinic with an average hourly salary of £11.66 each clinic appointment expected lasted half an hour. Each patient had their own Venstream nebuliser (£23.45) which was replaced after 6 months of use (for the purposes of cost analysis this was assumed to be after 6 clinic attendances). Costs per patient were calculated by multiplying the costs per appointment by the number of appointments the patient had attended and then adding the cost for the nebulisers the patient had used. A total of 141 patients received nebulised pentamidine between January 2003 and July 2008. Between January 2003 and December 2007 115 people used the service, generating 598 appointments. Table 1 shows the number of patients (P) and the number of appointments (A) per referring team per year. The overall numbers attending from 2003 to 2008 and the departmental breakdown are shown in Figs. 1 and 2. Haematology patients on average had 6.65 clinic appointments, significantly more than ophthalmology, immunology, transplant and renal patients (P < 0.05). Infectious diseases (ID) patients had an average of 5.27 appointments (range 1e18 and standard
Number of patients (P) and number of appointments (A) per referring team per year. 2003
Referring team Infectious disease (ID) Haematology Renal Paediatric oncology Transplant Immunology Ophthalmology Total
P 6 16 3 7 0 0 1 33
2004 A 27 99 8 19 0 0 5 158
P 11 13 2 0 0 0 0 26
2005 A 62 60 7 0 0 0 0 129
P 18 11 1 2 0 0 0 32
2006 A 70 63 1 5 0 0 0 139
P 8 6 1 2 0 0 0 17
2007 A 27 18 1 5 0 0 0 51
P 11 9 9 0 4 1 0 34
A 30 46 31 0 11 3 0 121
Letters to the editor
249
Number of Patients per Team
Number of Appointments per Team Transplant, 11
Immunology, 1
Transplant, 4
Ophthalmology, 1
Immunology, 3 Ophthalmology, 5
Paeds onc, 29
Paeds onc, 10
Renal, 48 ID, 41
ID, 216
Renal, 15
Haematology, 286
Haematology, 43
Figure 1
Total number of patients and total number of appointments per team.
deviation 4.3). At the time of data collection, 16 of those patients who had previously used the pentamidine clinic had died. Clinical data was available for 127 patients. Table 2 shows the reasons given for the use of pentamidine instead of co-trimoxazole. Note that 42 patients (33%) did not have a reason documented for the need to use pentamidine instead of co-trimoxazole and a further 29 patients (23%) did not have a description of their intolerance. Sufficient data was available for 75 patients to evaluate time from referral to administration of first dose of pentamidine. The mean time before administration of 1st dose was 13 days (range 0e81 days and standard deviation of 13.2 days), with a median of 9 days. Complete data was available for clinic attendances in 2004, 2005 and 2007. This showed 34 missed appointments from a total of 71 clinics (each with 7 appointment slots). Table 3 shows the number of patients who failed to attend at least 1 appointment and number of appointments missed separated by team. Cost analysis was performed on the 115 people who attended clinic between 2003 and 2007. The total cost of the service during these years was £29867.00, excluding hospital infrastructure costs. Fig. 3 shows the cost per year and Fig. 4 shows the cost per team. The establishment of inhaled pentamidine as prophylaxis against pneumocystis has widened availability of effective preventive treatment to both patients with HIV
Number of appointments
8 6
ID
Transplant
Haematology
Immunol
Renal
Number of patients
Adverse reaction to co-trimoxazole Undefined allergy or intolerance Co-trimoxazole caused deranged liver function tests Co-trimoxazole caused rash Co-trimoxazole caused bone marrow suppression Co-trimoxazole caused pyrexia Trimethoprim caused angioedema Drug interaction with co-trimoxazole No reason documented Patient already has significant degree of myelosuppression Patient is recipient of bone marrow transplant Other
51 29 7 7 6 1 1 7 42 15 8 4
Ophthalmology
Referring team
Number of patients not attending 1 or more appointments (% of total)
Number of appointments missed (% of total)
Infectious diseases Haematology Renal Paediatric oncology Transplant Immunology Ophthalmology Total
10 6 2 1 1 0 0 20
21 9 2 1 1 0 0 34
Paeds onc
4 2 0
Reason for using pentamidine
Table 3 Number of patients who failed to attend and number of appointments missed, separated by team.
12 10
Table 2 Reasons given for use of pentamidine over co-trimoxazole.
Team
Figure 2 Average number of appointments per patient divided by team with 95% confidence intervals. Ophthalmology and Immunology had one patient each.
(50) (30) (10) (5) (5)
(62) (26) (6) (3) (3)
250
Letters to the editor
References
Cost of pentamidine clinic per year.
1. Wallace JM, Hansen NI, Lavange L, Glassroth J, Browdy BL, Rosen MJ, et al. Respiratory disease trends in the Pulmonary Complications of HIV Infection Study Cohort. Am J Respir Crit Care Med 1997;155:72e80. 2. Palella Jr FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998;338:853e60. 3. Rodriguez M, Fishman JA. Prevention of infection due to Pneumocystis spp. in human immunodeficiency virus-negative immunocompromised patients. Clin Microbiol Rev 2004;17(4):770e82. 4. Ioannidis JPA, Cappelleri JC, Skolnik PR, Lau J, Sacks HS. A meta-analysis of the relative efficacy and toxicity of Pneumocystis carinii prophylactic regimens. Arch Intern Med 1996;156:177e88. 5. Hughes WT, Kuhn S, Chaudhary S, Feldman S, Verzosa M, Aur RJA, et al. Successful chemoprophylaxis for Pneumocystis carinii pneumonitis. N Engl J Med 1977;297:1419e26. 6. Masur H. Prevention and treatment of Pneumocystis carinii pneumonia. N Engl J Med 1992;327:1853e60. 7. Walzer PD, Perl DP, Krogstad DJ, Rawson PG, Schultz MG. Pneumocystis carinii pneumonia in the United States: epidemiologic, diagnostic, and clinical features. Ann Intern Med 1974;80:83e93. 8. Sands F, Kron M, Brown R. Pentamidine: a review. Rev Infect Dis 1985;7:625e34.
Cost of pentamidine clinic per referring team.
C. Ward D. O’Donovan A.M.L. Lever* Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK *Corresponding author. Tel: þ44 01223 330191; fax: þ44 01223 336846. E-mail address: [email protected] (A.M.L. Lever)
Figure 3
Figure 4
and those in other disciplines.7 Inhaled pentamidine is a convenient and usefully intermittent therapy, which the majority of individuals find acceptable.8 In our study we were concerned to identify a relatively large minority of individuals in whom the justification for pentamidine prophylaxis was not adequately documented or substantiated and this has led to a review of our procedures and a formalisation of our criteria for admission to the pentamidine clinic. The default rate on attendance for the clinic was worst in the HIV positive population and reflected the rather haphazard and chaotic lifestyles of some of these patients rather than any apparent difficulty in accessing the service for other reasons. The minimum cost of a single monthly appointment at the pentamidine clinic was £47.00, which compares with £2.81 for a one-month course of cotrimaxazole, 960 mg taken three times weekly. Thus pentamidine is an expensive alternative to the gold standard therapy. Highlighting this has been a trigger to initiating a review of reasons why patients are on pentamidine rather than alternative drugs. The identification of the proportions of patients coming from different disciplines has been of value in establishing payment pathways to support the service.
Acknowledgements The authors gratefully acknowledge support of the Cambridge University Hospitals NHS Foundation Trust Biomedical Research Centre.
22 January 2009 Available online 26 February 2009 ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2009.01.009
Simkania negevensis infection among Brazilian children hospitalized with community-acquired pneumonia
Dear Editor, Simkania negevensis is an obligate intracellular microbe, related to the chlamydiae.1 It has been found in domestic water supplies of infected children and this finding raises the possibility of transmission to children from the water of their homes.2 S. negevensis respiratory infections have been described from Europe, Japan and North America.3 In New York it was not a significant pathogen.4 We analyzed if S. negevensis acute infection occurred in Brazil. Children aged under five years hospitalized with community-acquired pneumonia (CAP) were enrolled in