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Cost analysis of ertapenem therapy for urinary tract infections and assessment of its suitability for outpatient parenteral antibiotic therapy programme in Turkey/Uriner Sistem Enfeksiyonlarinda Ertapenem Tedavisinin Maliyet Analizi ve Turkiye'de Ayaktan Paranteral Antibiyotik Tedavi Programinda Degerlendirilmesi.

Running Head: Cost analysis of ertapenem therapy

Abstract

Introduction: The primary aim of this study was to evaluate whether there was a difference between Outpatient paranteral antibiotic therapy (OPAT) and inpatient parenteral antibiotic therapy (IPAT) costs of ertapenem for urinary tract infections (UTI's) due to extended-spectrum beta-lactamase (ESBL) producing gram negative bacilli, and to discuss suitability of ertapenem for OPAT programme of Turkey for the near future.

Materials and Methods: A total of 53 patients hospitalized with the diagnosis of UTI and treated with ertapenem were retrospectively evaluated. The cost of ertapenem treatment as IPAT was actual costs retrieved from the hospital records. The estimated cost of the same antibiotic for the same patients as an OPAT programme was then calculated and the costs were compared.

Results: The cost difference between IPAT and OPAT was [??] 12.305 ([euro] 5783). OPAT programme would provide an estimated 20% reduction in treatment costs. The estimated number of bed days earned if the patients had received the treatment as OPAT was calculated to be 583 days, which constitutes about 5% of the total number of hospitalization days.

Conclusion: Applying ertapenem therapy through OPAT programme for UTIs caused by ESBL-producing gramnegative bacilli will decrease the financial burden of health expenses and the number of inpatient bed days in Turkey.

Keywords: Ertapenem, ESBLs, urinary tract infection, cost analysis, OPAT.

Ozet:

Giris: Bu calismanin ana amaci genislemis spektrumlu beta laktamaz (GSBL) ureten gram negatif basillere bagli gelisen uriner sistem enfeksiyonlarinda (USE) ertapenemin ayaktan paranteral antibiyotik tedavisi (APAT) ve hastanede yatan hasta paranteral antibiyotik tedavisi (YPAT) olarak uygulanmasi arasindaki maliyet farkinin degerlendirilmesi ve yakin gelecekte Turkiye'de ertapenemin APAT programina alinmasinin uygunlugunun tartisilmasidir.

Materyal ve metot: Uriner sistem enfeksiyonu tanisi ile hastanede yatirilan ve ertapenem tedavisi alan 53 hasta retrospektif olarak degerlendirildi. Ertapenem tedavi maliyeti, YPAT olarak hastane kayitlarindan gerceklesen maliyetten hesaplandi. Ayni antibiyotigin ayni hastalarda APAT programi seklinde uygulanimi ile olusan tahmini maliyet hesaplandi ve maliyetler karsilastirildi.

Bulgular: YPAT ve APAT arasindaki maliyet farki 12.305 [??] (5783 [euro]) olarak hesaplandi. APAT programi tedavi maliyetlerinde yaklasik %20 azalma saglayacaktir. Eger hastalar tedavilerini APAT olarak almis olsalardi tahmini kazanilacak yatak gun sayisi 583 gun olarak hesaplandi. Bu da toplam hospitalizasyon gununun %5'ini olusturmaktaydi.

Sonuc: Turkiyede ertapenem tedavisinin APAT programi sekinde uygulanmasi saglik harcalamalarinda finansal yuku ve hasta yatak gun sayisini azaltacaktir.

Anahtar sozcukler: Ertapenem, GSBL, uriner sistem enfeksiyonu, tedavi maliyeti, APAT

1.Introduction

In recent years urinary tract infections (UTIs) due to extended-spectrum beta-lactamase (ESBL)-producing bacteria show an increased incidence both among out-patients and hospitalized group of patients in our country as well as around the world. ESBL-producing bacteria show increasing levels of resistance to aminoglycosides and quinolones as well as most beta-lactam antibiotics. Because of the ESBL-producing bacterial infections, patients' hospitalization, morbidity and mortality rates increase and this condition causes an increasing cost of treatment and socio-economic losses. Carbapenem antibiotics seem to be the only treatment option in at least some part of the patients ([1,2]).

Decision for the appropriate antibiotherapy should be made according to isolated organism, results of the antibiotic susceptibility test and the potential pharmacokinetic, pharmacodynamic features of the drug. . Outpatient paranteral antibiotic therapy (OPAT) is generally used to refer to the provision of parenteral antimicrobial therapy in at least 2 doses on different days without intervening hospitalization ([3]) OPAT practice will decrease the staffing and maintenance services compared to hospitalization. Consequently, this will allow vacancy of beds for other patients who need hospitalization ([4]). Among carbapenem antibiotics, ertapenem is a good alternative with its pharmacokinetic features and bactericidal activity. Additionally, it can be applied daily as a single intramuscular, subcutaneous, or intravenous injection and therefore it is suitable for OPAT ([5-7]). Various studies in different countries show that OPAT is efficient, reliable and cost-effective ([8-11]). However ertapenem is not approved for OPAT programme in Turkey yet.

The primary aim of this study was to evaluate whether there is a difference between OPAT and inpatient parenteral antibiotic therapy (IPAT) costs of ertapenem for UTI's due to ESBL-producing gram negative bacilli, and to discuss suitability of ertapenem for OPAT programme of Turkey for the near future.

2. Materials and Methods

This study was conducted in a tertiary training and research hospital between July 2008 and August 2010. Files of hospitalized patients with the diagnosis of UTI in the Department of the Infectious Diseases and Clinical Microbiology were retrospectively reviewed. Diagnosis of UTI was defined acording to; positive culture of ESBL-producing isolates ([greater than or equal to] 105 cfu/mL) and presence of one of the followings ; fever (>38), UTI symptoms (dysuria, pollakiuria, urinary urgency, urinary incontinence, abdominal pain, suprapubic tenderness, etc) -2]. The demographic characteristics, clinical findings, risk factors for UTI and the duration of treatment were analysed. Adult patients (over 17 years old), symptomatic and who were unresponsive and /or couldn't use prior fosfomycin, nitrofurontain and/or other antibiotic treatments were included in the study. Patients with clinical and/or radiological evidence of upper UTI and sepsis were excluded . Sepsis was defined by using the final report of the 2001 International Sepsis Definitions Conference ([12]) .. Patients were not stratified according to whether the infection was community acquired or nosocomial. The isolates were identified by conventional methods, and antibiotic susceptibility tests were performed by Kirby Bauer disc diffusion method according to Clinical and Laboratory Standards Institute (CLSI) standards. ESBL production was tested by double disk diffusion method ([13])

The cost of ertapenem treatment as IPAT was retrieved from the actual hospital records. The estimated cost of the OPAT was calculated with following assumptions: 1- Same duration of antibiotic treatment given as IPAT; and 2-Same antibiotic treatment used as IPAT given to the same patient. Then the actual IPAT cost was compared to estimated OPAT cost. Total actual hospitalization cost was retrieved from the hospital registration system in a breakdown format. Using the total cost, calculations were made to include only the cost components attributed to the treatment of UTI. Following cost compenents were taken into consideration in order to calculate the cost of IPAT; bed fees, escort fees: intravenous access, intravenous injection, intravenous cannula, isotonic solution, ertapenem (1gram per day) and, urine analysis (UA) charges. For the cost calculation of the OPAT; it was assumed that actual costs of the following cost compenents had to be included: ertapenem 1 gram vial, intramuscular injection (for which the cost is the same with intravenous injection) and UA fees. The difference between the two costs was then calculated. Costs of tests in common both for out - and inpatients such as hemogram, erythrocyte sedimentation rate, C-reactive protein (CRP), urea, creatinine, UA, urine culture, and urinary tract ultrasound examinations were excluded from the calculation for cost analysis. Similarly, laboratory examinations, consultations and treatments for other comorbid diseases during hospitalization were also excluded. Inpatient bed days gained were calculated using the total number of the patients in our clinic and the inpatient bed days during the study period.

2.1. Cost Analysis Method

The activity based cost analysis method was used in this study. All of the cost calculations were based on actual costs retrieved from the hospital records of financial unit. The costs were calculated from Social Security Institute perspective. In this study cost figures were converted to a hard currency in order to eliminate inflationary impacts and to show the present value of the costs. All of the calculations were made using the prices in Turkish liras ([??]) in 2008-2010 and the exchange rate of Central Bank of Turkey was used for converting [??] to Euros ([euro]). The average exchange rate for [??] to [euro] was 0.47 for the given period (Central Bank of Turkey foreign currency exchange rates archive: Web site: http://www.tcmb.gov.tr/wps/wem/connect/TCMB+TR/TCMB+TR/Main+Menu/istatistikler/Doviz+Kurlari/Gosterge+Niteligindeki+Merkez+Bankasi+Kurlarii, Access date: 12.10.2014). All costs were presented with mean values and standard deviations.

Ethical declaration

This study has got an ethics committee approval from the Ethics Committee of Izmir Katip Celebi University Ataturk Training and Research Hospital.

3. Results

Clinic data:

Fifty- three patients were included in the study. Most (n = 36, 67.9%) were females. Mean age was 55.1 [+ or -] 19.0 (age range: 20-86) years. The most common symptoms were dysuria (85%), pollakiuria (25%) and urinary urgency (19%). Frequency of urinary incontinence and abdominal pain were < 10%. Fever was not detected in any of the patients. Risk factors for urinary tract infection were uro-genital interventions and pathologies (transurethral prostate surgery, bladder cancer surgery, urolithiasis operation, benign prostatic hypertrophy, ureterocele, etc.) in 38% and diabetes mellitus in 32% of the patients. Diabetes mellitus was more frequent in female and uro - genital interventions and diseases were more frequent in male patients. No risk factor was found in 21% of patients (Figure 1). Only 9% of patients had a history of recurrent UTIs Laboratory test results were as follows: mean erythrocyte sedimentation rate (ESR) 42.5 [+ or -] 33.8 (range 6 - 123) mm / h; CRP 5.4 [+ or -] 31.3 (range 0.06 - 56) mg / dL; and white blood cell count mean 7284.1 [+ or -] 2367.6 (range 3060-12 000) cells / [mm.sup.3]. Escherichia coli was the most common bacteria (92%) isolated from urinary cultures. Other isolates were Klebsiella pneumoniae (4%), Citrobacter freundii (2%) and Enterobacter cloacae (2%). Although all of the isolates were susceptible to imipenem and ertapenem, rates of resistance to other antibiotics were as follows: piperacillin / tazobactam 11%, gentamycin 59%, trimethoprim- sulfamethoxazole 84%, ciprofloxacin 97% and ampicillin / sulbactam 100%. During the study period, nitrofurantoin and fosfomycin were not included in the antibiotic susceptibility test.

Duration of ertapenem treatment ranged from 5 to 18 days (mean: 10.7 [+ or -] 2.5). No serious side effect leading to drug discontinuation was observed during ertapenem treatment. Clinical improvement and microbiological eradication was achieved at the end of the treatment in all patients.

Cost analysis:

The total inpatient cost for 53 patients was [??] 74.084 ([euro] 34819); calculated cost of IPAT was [??] 62.447 ([euro] 29350) The difference (?? 11.637 ([euro] 5469)) was due to comorbid disorders, additional examinations, or treatment consultation fees. The total estimated cost of OPAT (if the patients were to receive the same agent as OPAT) was found to be [??] 50.142 ([euro] 23566) The cost difference between IPAT and OPAT was [??] 12.305 ([euro] 5783) and it was 20% less than IPAT cost. Treatment costs for IPAT and OPAT by age and gender per patient were shown in Table 1. The number of patients in productive ages (ages 20-65) was almost twice the number of patients older than 65 years. Detailed cost components for IPAT and OPAT for per patient were presented in Table 2. During the study period, 1,089 patients were hospitalized for 11,124 days in the clinic where this study was conducted. The estimated number of bed days earned if the patients had received the treatment as OPAT was calculated to be 583 days, which constitutes about 5% of the total number of hospitalization days.

4. Discussion

This study showed that, implementation of ertapenem therapy as an OPAT protocol for UTIs caused by ESBL-producing bacteria would decrease the financial burden of health expenses in our country.

In different parts of the world, as well as in Turkey, a significant increase has been observed in the burden of both complicated and non-complicated community or hospital acquired urinary infections due to ESBL-producing E. coli strains. Treatment of these patients is becoming more complicated and expensive ([14-18]).

In a recent study, which examined risk factors for ESBL- production in uropathogenic E.coli isolated from community-acquired UTIs from four different geographical regions, it was observed that the production of ESBL was at alarming rates, especially in patients with complicated UTIs (17.4%). The main risk factors were more than three UTI episodes in the preceding year, usage of beta-lactam antibiotics in the preceding 3 months, and prostatic disease ([19]) In the study carried out in a tertiary training hospital in Switzerland, the analysis of UTI risk factors occurring due to community acquired ESBL-producing E.coli were: older age, female gender, diabetes mellitus, recurrent UTI, invasive urological procedures, and prior use of antibiotics such as aminopenicillins, cephalosporins or fluoroquinolones ([14]). In our study, uro-genital interventions or diseases and diabetes mellitus were found as the most important risk factors. Failing to detect any risk factors in 21% of patients might be due to not being able to get a detailed history about the prior use of antibiotics.

Rates of antibiotic resistance and ESBL production increased in recent years both in Turkey and all over the world. This causes difficulties in treating patients with UTIs. More patients need hospitalization. Treatments are getting more complicated. Morbidity and mortality rates and treatment costs have increased. In a study from our country, which compared community- onset healthcare-associated and hospital-acquired UTIs caused by ESBL-producing E.coli no resistance was found to carbapenems or fosfomycin. Sensitivities to nitrofurantoin, amikacin, trimethoprim sulfamethoxazole and quinolons were 97.6%, 89%, 29.4% and 17.9%, respectively. In both groups similar rates of antibiotic resistance was found ([20]). In our study, rate of sensitivity to carbapenem was similar but the rates of sensitivity to other antibiotics were much lower.

In a study in which clinical and microbiological outcomes of ertapenem in OPAT for complicated UTIs was investigated; microbiological and clinical cure rates were 67% and 92% retrospectively. In this study, it was demostrated that ertapenem is a good alternative to broader-spectrum carbapenems for the treatment of complicated UTIs. As well as being safe and effective, it has adventages of having a narrower spectrum and once daily dosing ([21]). In an other study, clinical efficacy of ertapenem for recurrent cystitis caused by ESBL-producing E. coli in female outpatients was retrospectively reviewed and ertapenem treatment was found to be effective and well-tolerated ([22]).

In our study, clinical and microbiological cure was sustained in all of the patients with ertapenem therapy and no side effect was observed. This showed that ertapenem therapy is efficient and safe for OPAT and it was estimated that use of ertapenem therapy for OPAT would increase patients satisfaction.

Today, indications of OPAT programs which are successfully used, differ among countries ([23,24]). In a study which analyzed the cost of application of OPAT in adult patients in a tertiary training hospital in Canada between 1995 and 1998, different parenteral antibiotics were administered for different types of infections: bone and joint, skin and soft tissue, endocarditis and others. This study showed that OPAT programme provided an economically attractive alternative to continued hospitalization for selected adult patients with infections that require parenteral antimicrobial treatment. Also from the hospital perspective, the cost of therapy through the OPAT programme was approximately 13% of the cost estimated if the patient were to continue to be managed in hospital settings ([23]).

In another study from UK, clinical efficacy and cost-effectiveness of OPAT in 334 episodes (skin and soft tissue infections, cardiovascular infections, central nervous system infections, genito-urinary infections..etc) between 200b and 2008 was evaluated. They found that OPAT cost was 41% of equivalent inpatient cost for an Infectious Diseases Unit and over the 2 year period the total number of bed days saved through OPAT activity was 4034. As a result they concluded that OPAT was safe and clinically effective, with low rates of complications / readmissions and high levels of patient satisfaction, and also OPAT was found to be cost-effective when compared with equivalent inpatient care ([24]). In these two studies OPAT programme was found more cost- effective than our study. This can be attributed to longer duration of OPAT needed for the treatment of infections such as bone and joint infections, endocarditis, skin and soft tissue infections, central nevous system infections (mean duration: 23 days) in these studies. Another reason might be differences among countries regarding health care expenditures for inpatients. In another retrospective study of patients treated for UTIs caused by ESBL-producing organisms through the OPAT programme over a 4 year period, 24 OPAT episodes involving 11 patients were reviewed. Six patients had an underlying urological abnormality and all patients were treated with parenteral ertapenem. There were no adverse effects related to ertapenem requiring cessation of a course earlier than planned. The mean duration of the OPAT episodes was 9.9 days and a total of 238 inpatient bed days were avoided. As a result they concluded that ertapenem administration through OPAT may help to decrease the costs associated with ESBL infections by reducing the number of inpatient bed days ([8]).

In our study, all patients were treated with ertapenem and the mean duration of treatment was 10.7 [+ or -] 2.5 days and there were no serious side effects during the treatment. At the end of the treatment, clinical improvement and microbiological eradication was achieved in all patients, and ertapenem therapy was found to be safe and effective. It was predicted that if ertapenem therapy had been applied as OPAT programme, there would have been an estimated 20% savings of the existent inpatient cost. During this 2 year period the total number of bed days that would have been saved through OPAT activity was 583(%5 of total number of bed days). Most of the patients were in economically productive age groups and the changes in opportunity costs due to missed work days were not included in our study, hence the difference in costs between two treatment options might be underestimated.

Limitations:

The finding of this study should be evaluated within its limitations. This is a retrospective study. Limited number of patients were evaluated in this study. This study shows data from a tertiary training hospital from Turkey so it demonstrates only local data which can limit generalisibility of the findings. Patients were not stratified according to whether the infection was community acquired or nosocomial During the study period nitrofurantoin and fosfomycin couldn't be included in the antibiotic susceptibility test.

Opportunity costs were not evaluated in this study so the actual cost differences might be higher than our estimates. Multicenter studies about cost analysis of ertapenem therapy for UTIs and assesment of its suitability for OPAT programme are needed for our country.

5. Conclusion:

In conclusion, the widespread and rapid dissemination of ESBL-producing microorganisms seems to be an emerging issue worldwide as well as Turkey. Consequently, treatment of these infections is becoming more difficult, which is causing high treatment costs as well as growing financial burden on health services. In our country, due to the increasing incidence of UTIs caused by ESBL-producing bacteria, applying ertapenem treatment with OPAT programmes for this indication will decrease the financial burden of expenditures for the treatment of these infections. Also this programme might reduce the number of inpatient bed days required for successful treatment and increase patient satisfaction. Use of ertapenem in an OPAT programme is not available in our country. This is the first study in Turkey analysing the cost of ertapenem used in an OPAT programme.

6. Acknowledgements

Special thanks to Cicek Kopraman for the contribution to this study through analyzing the cost calculations (Deputy Managing Director of a leading dairy company operating in Turkey; Bachelor's Degree in Business Administration).

Funding

This study was undertaken as part of our routine clinical activity and did not receive additional funding.

Transparency declarations

Conflicts of interest: None to declare.

ethic: This study has got an ethics committee approval from the Ethics Committee of Izmir Katip Celebi University

Ataturk Training and Research Hospital.

informed: The consent form is not needed for this submission.

Medical practices: Bahar Ormen, Nesrin Turker, Zerrin Kara , Nurbanu Sezak

Concept: Bahar Ormen; Nesrin Turker

Design: Bahar Ormen, Nesrin Turker, Figen Kaptan

Data collection or processing: Zerrin Kara, Nurbanu Sezak

Analysis or interpretation: Melih Kaan Sozmen

Literature search: Nurbanu Sezak, Tuna Demirdal, Zerrin Kara

Writing: Bahar Ormen, Nesrin Turker, Figen Kaptan,Tuna Demirdal

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(2.) Yapar N. Urinary tract infections. In: Yuce A, Cakir N, (ed). In: Hospital Infectionsi. 2nd ed. Izmir: Guven printing 2009: 277- 86.

(3)- Tice AD, Rehm SJ, Dalovisio JR, Bradley JS, Martinelli LP, Graham DR, Gainer RB, Kunkel MJ, Yancey RW, Williams DN. Practice Guidelines for OPAT CID 2004; 38: 1651-72.

(4.) Hizel K. Special Strategies in Antimicrobial Therapy: OPAT, Sequential Therapy. ANKEM Journal. 2007; 21: 133-7.

(5.) Forestier E, Gros S, Peynaud D, Levast M, Boisseau D, Ferry-Blanco C, Labe A, Lecomte C, Rogeaux O. Ertapenem administered intravenously or subcutaneously for urinary tract infections caused by ESBL-producing enterobacteriacea. Med Mal Infect. 2012; 42: 440-3.

(6.) Legua P, Lema J, Moll J, Jiang Q, Woods G, Friedland I. Safety and local tolerability of intramuscularly administered ertapenem diluted in lidocaine: a prospective, randomized, double - blind study versus intramuscular ceftriaxone. Clin Ther. 2002; 24: 434-44.

(7.) Parakh A, Krishnamurthy S, Bhattacharya M. Ertapenem. Kathamandu Unv Med J. 2009; 7(28): 454-60.

(8.) Bazaz R, Chapman AL, Winstanley TG. Ertapenem administered as outpatient parenteral antibiotic therapy for urinary tract infections caused by extended-spectrum beta-lactamase-producing Gram-negative organisms. J Antimicrob Chemother. 2010; 65: 1510-3.

(9.) Kolbin AS, Sidorenko SV, Zagorodnikova KA, Musatov VB, Iakovlev AA. Clinical and economic expedience of ertapenem therapy of complicated urinary tract infection. Antibiot Khimioter. 2011; 56: 35-42.

(10.) Qureshi ZA, Syed A, Doi Y. Safety and efficacy of long-term outpatient ertapenem therapy. Antimicrobial Agents and Chemotherapy. 2014; 58: 3437-40.

(11.) Seaton RA, Barr DA. Outpatient paranteral antibiotic therapy: principles and practice. Eur J Intern Med. 2013; 24: 617-23.

(12.) Levy ML, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2001 SCCM / ESICM / ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive care Med. 2003; 29: 530-8.

(13.) Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing, Vol. 25, No.1. Fifteenth Informational Supplement M100-S15. Wayne, PA: Clinical and Laboratory Standards Institute; 2005; 98-101.

(14.) Meier S, Weber R, Zbinden R, Ruef C, Hasse B. Extended-spectrum [beta]-lactamase-producing Gram-negative pathogens in community-acquired urinary tract infections: an increasing challenge for antimicrobial therapy. Infection. 2011; 39: 333-40.

(15.) Qi C, Pilla V, Yu JH, Reed K. Changing prevalence of Escherichia coli with CTX-M-type extended-spectrum beta-lactamases in outpatient urinary E. coli between 2003 and 2008. Diagn Microbiol Infect Dis. 2010; 67: 87-91.

(16.) Hoban DJ, Nicolle LE, Hawser S, Bouchillon S, Badal R. Antimicrobial susceptibility of global inpatient urinary tract isolates of Escherichia coli: results from the Study for Monitoring Antimicrobial Resistance Trends (SMART) program: 2009-2010. Diagn Microbiol Infect Dis. 2011; 70: 507-11.

(17.) Hsueh PR, Hoban DJ, Carmeli Y, Chen SY, Desikan S, Alejandria M, Ko WC, Binh TQ. Consensus review of the epidemiology and appropriate antimicrobial therapy of complicated urinary tract infections in Asia-Pacific region. J Infect. 2011; 63: 114-23.

(18.) Tasbakan MI, Pullukcu H, Sipahi OR, YamazhanT, Arda B, Ulusoy S. A pooled analysis of the resistance patterns of Escherichia coli strains isolated from urine cultures in Turkey: a comparison of the periods 1997-2001 and 2002-2007. Turk J Med Sci. 2011; 41: 557-64.

(19.) Azap OK, Arslan H, Serefhanoglu K, Colakoglu S, Erdogan H, Timurkaynak F,Senger S S. Risk factors for extended-spectrum [beta]-lactamase positivity in uropathogenic Escherichia coli isolated from community-acquired urinary tract infections. Clin Microbiol Infect. 2010; 16: 147-51.

(20.) Saltoglu N, Karali R, Yemisen M, Ozaras R, Balkan II, Mete B, Tabak F, Mert A, Hondur N, Ozturk R. Comparision of community-onset healthcare-associated and hospital-acquired urinary infections caused by extended-spectrum beta-lactamase-producing Escherichia coli and antimicrobial activities. Int J Clin Pract. 2015; 69: 766-70.

(21.) Trad MA, Zhong LH, Llorin RM, Tan SY, Chan M, Archuleta S, Sulanman Z, Tam VH, Lye DC, Fisher DA. Ertapenem in outpatient parenteral antimicrobial therapy for complicated urinary tract infections. J Chemother. 2017; 29: 25-9.

(22.) Song S, Kim C, Lim D. Clincal efficacy of ertapenem for recurrent cystitis caused by multidrug-resistant extended-spectrum ??-lactamase-producing Escherichia coli in female outpatients. Korean J Urol. 2014;55: 270-5.

(23.) Wai AO, Frighetto L, Marra CA, Chan E, Jewesson PJ. Cost analysis of an adult outpatient parenteral antibiotic therapy (OPAT) programme. A Canadian teaching hospital and Ministry of Health perspective. Pharmacoeconomics. 2000; 18: 451-7.

(24.) Chapman AL, Dixon S, Andrews D, Lillie PJ, Bazaz R, Patchett JD. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J Antimicrob Chemother. 2009; 64: 1316-24.

Bahar ORMEN (1), Nesrin TURKER (1), Nurbanu SEZAK (1), Zerrin KARA (2), Figen KAPTAN (1), Tuna DEMIRDAL (1), Melih Kaan SOZMEN (3)

(1) Izmir Katip Celebi University Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey

(2) Izmir Odemis State Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey

(3) Izmir Katip Celebi University Department of Public Health, Izmir, Turkey

Corresponding author: Bahar ORMEN MD, Izmir Katip Celebi Universtiy Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology. Basin Sitesi /Karabaglar/ Izmir/Turkey

Telephone number: +90 535 8828672

Fax number: +90 232 2431530

e-mail: bormen2002@yahoo.com

Gelis: 22-Feb-2017

Accept (28-Aug-2017)

A poster version of this study was presented at the IDWeek 8-12 october 2014 in Philadelphia,PA,USA.
Table 1. Distribution of treatment costs for IPAT and OPAT by age and
gender per patient

Variables                                 Male
                                          Age groups
                                          20-65

Number of patient                     11
Average treatment days                10.6 [+ or -] 2.4
Total cost of treatment ([??])      1636.9 [+ or -] 551.8
Cost of IPAT ([??])                 1289.6 [+ or -] 331.4
Calculated cost of OPAT ([??])      1049.8 [+ or -] 315.6
Cost difference IPAT vs OPAT([??])   239.8 [+ or -] 92.8
Cost difference IPAT vs OPAT (%)      19 [+ or -] 1

Variables                               Male
                                        Age groups
                                        > 65

Number of patient                      6
Average treatment days                12.1 [+ or -] 3.8
Total cost of treatment ([??])      1680.3 [+ or -] 630.7
Cost of IPAT ([??])                 1272.6 [+ or -] 252.3
Calculated cost of OPAT ([??])       989.5 [+ or -] 227.9
Cost difference IPAT vs OPAT([??])   283.1 [+ or -] 102.7
Cost difference IPAT vs OPAT (%)      22 [+ or -] 1

Variables                               Male
                                        Age groups
                                        Total

Number of patient                     17
Average treatment days                11.2 [+ or -] 2.1
Total cost of treatment ([??])      1652.2 [+ or -] 561.3
Cost of IPAT ([??])                 1283.6 [+ or -] 297.6
Calculated cost of OPAT ([??])      1028.5 [+ or -] 281.7
Cost difference IPAT vs OPAT([??])   255.1 [+ or -] 95.5
Cost difference IPAT vs OPAT (%)      20.5 [+ or -] 1

Variables                              Female
                                       Age groups
                                       20-65

Number of patient                     24
Average treatment days                10.5 [+ or -] 2.2
Total cost of treatment ([??])      1174.4 [+ or -] 306.8
Cost of IPAT ([??])                 1056.2 [+ or -] 280.5
Calculated cost of OPAT ([??])       842.9 [+ or -] 282.5
Cost difference IPAT vs OPAT([??])   213.3 [+ or -] 44.9
Cost difference IPAT vs OPAT (%)      21 [+ or -] 1

Variables                             Female
                                      Age groups
                                      > 65

Number of patient                     12
Average treatment days                10.5 [+ or -] 2.5
Total cost of treatment ([??])      1483.8 [+ or -] 449.4
Cost of IPAT ([??])                 1273.2 [+ or -] 363.6
Calculated cost of OPAT ([??])      1035.7 [+ or -] 341.3
Cost difference IPAT vs OPAT([??])   237.5 [+ or -] 80.5
Cost difference IPAT vs OPAT (%)      19 [+ or -] 1

Variables                              Female
                                       Age groups
                                       Total

Number of patient                     36
Average treatment days                10.5 [+ or -] 2.3
Total cost of treatment ([??])      1277.5 [+ or -] 383
Cost of IPAT ([??])                 1128.5 [+ or -] 322.5
Calculated cost of OPAT ([??])       907.1 [+ or -] 312.3
Cost difference IPAT vs OPAT([??])   221.3 [+ or -] 59.1
Cost difference IPAT vs OPAT (%)      21 [+ or -] 1

Variables                                Grand
                                         Total


Number of patient                     53
Average treatment days                10.7 [+ or -] 2.5
Total cost of treatment ([??])      1397.7 [+ or -] 476.7
Cost of IPAT ([??])                 1178.2 [+ or -] 320.3
Calculated cost of OPAT ([??])       946.1 [+ or -] 305.5
Cost difference IPAT vs OPAT([??])   232.2 [+ or -] 73.6
Cost difference IPAT vs OPAT (%)      20 [+ or -] 1

Table 2. Cost components of IPAT and OPAT (per patient)

                           IPAT Treatment            OPAT Treatment
Features                   Cost ([??])               Cost ([??])

Cost Components
Bed fees                    189.0 [+ or -] 66.6      0
Escort fees                   5.2 [+ or -] 21.8      0
Intravenous access           14.5 [+ or -] 3.9       0
Intravenous cannula           1.5 [+ or -] 0.4       0
Isotonic solution            22.0 [+ or -] 5.6       0
Intravenous/Intramuscular
injection                    24.0 [+ or -] 6.1      24.0 [+ or -] 6.1
Urine analysis (UA)           1.5 [+ or -] 0.5       1.5 [+ or -] 0.5
Ertapenem                   920.6 [+ or -] 299.6   920.6 [+ or -] 299.6
Total Treatment Cost
(??, per patient)          1178.2 [+ or -] 320.3   946.1 [+ or -] 305.5

                             Cost Difference
Features                     (IPAT-OPAT)
                             ([??])

Cost Components
Bed fees                     189.0 [+ or -] 66.6
Escort fees                    5.2 [+ or -] 21.8
Intravenous access            14.5 [+ or -] 3.9
Intravenous cannula            1.5 [+ or -] 0.4
Isotonic solution             22.0 [+ or -] 5.6
Intravenous/Intramuscular
injection                      0
Urine analysis (UA)            0
Ertapenem                      0
Total Treatment Cost
([??], per patient)          232.2 [+ or -] 73.6
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Title Annotation:mjima-2017-0007-research
Author:Ormen, Bahar; Turker, Nesrin; Sezak, Nurbanu; Kara, Zerrin; Kaptan, Figen; Demirdal, Tuna; Sozmen, M
Publication:Mediterranean Journal of Infection, Microbes and Antimicrobials
Article Type:Report
Geographic Code:7TURK
Date:Jan 1, 2017
Words:4816
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