Background: The University of Maryland Greenebaum Cancer Center developed antifungal guidelines for suspected fungal infections in neutropenic patients that emphasized early intravenous to oral (IV-PO) conversion from either IV voriconazole or amphotericin B lipid complex (ABLC) to oral voriconazole. IV ABLC and, to a lesser extent, IV voriconazole were the initial empiric antifungals for patients unable to take PO (mucositis, nausea/vomiting, diarrhea). Patients were converted to PO voriconazole, which was dosed identically to IV voriconazole doses (6 mg/kg q12 hr for first 2 doses followed by 4 mg/kg q12 hr), when tolerating an oral diet. We reviewed the impact on costs and physician compliance with these guidelines. Method: This is a retrospective review of cost savings with IV antifungal to PO voriconazole conversion from 8/2003 to 4/2004 in 42 leukemia patients with 78 admissions. We compared these data to a historical control group of 1/2002 to 7/2002 treated with IV ABLC. We collected data on antifungal dosing and physician prescribing adherence to guidelines. Results: From 8/2003 to 4/2004, a total of $202,670 was spent on voriconazole. 85% (1702 of 2007) of the defined daily doses (DDD) were PO, costing $122,210. A total of 143 DDD of ABLC were given costing $25,968 for an overall total antifungal cost being $248,538. In the control period from 1/2002 to 7/2002, 1186 DDD of ABLC and 515 DDD of itraconazole were used with a total cost of $724,000. The IV-PO voriconazole switch strategy saved $475,462. 25% of PO voriconazole doses were greater than 300 mg bid. We observed a marked reduction in candidemia from 20 cases in 2002 to 0 in 2003. No culture-proven breakthrough fungal infections were seen with IV to PO voriconazole switch. Conclusions: An aggressive IV antifungal to oral voriconazole switch strategy in profoundly neutropenic leukemia patients has demonstrated considerable cost savings. No increases in treatment failures or breakthrough infections were seen. The tolerability of PO voriconazole enabled PO dosing identical to the IV formulation. There was a trend towards earlier initiation of voriconazole as first-line antifungal compared to ABLC.
Full conference title:
42nd Annual Meeting Infectious Diseases Society of America
- Infectious Diseases Society of America 42nd