Containing costs and containing bugs: are they mutually exclusive?

BACKGROUND The overall health care costs for managing patients with community-acquired pneumonia (CAP) in U.S. hospitals is burdensome. While pharmacy costs comprise only a minor proportion of these costs, hospital length of stay (LOS) is the greatest contributor. Infections due to antimicrobial-resistant pathogens are also associated with increased overall health care cost. Therefore, strategies that aim to minimize antimicrobial resistance and reduce hospital LOS may have the greatest impact in reducing overall health care costs in managing patients with CAP. OBJECTIVE To evaluate how antimicrobial resistance can impact health care costs associated with CAP and review strategies to minimize the risk of resistance development while promoting appropriate antimicrobial therapy (including optimized dosing) and decreasing hospital LOS. SUMMARY Antimicrobial resistance can increase the risk of clinical failure and result in higher overall health care costs. Further development of antimicrobial resistance during therapy should, therefore, be minimized. This can be achieved through optimized antimicrobial dosing strategies- using a higher dose of concentration-dependent agents or prolonged infusion of time-dependent agents - that increase the probability of attaining pharmacokinetic-pharmacodynamic targets for eradication of the pathogen and hence successful clinical outcomes. Decreasing LOS must be a priority when attempting to reduce hospital costs. Active intravenous-to-oral switch therapy has been shown to effectively reduce LOS. Appropriate short-course regimens may also offer the opportunity for effective treatment while reducing or eliminating unnecessary antimicrobial exposure that not only reduces the potential for drug-related adverse events, but may also minimize the selection of resistant organisms. CONCLUSION Clinical failure and antimicrobial resistance can significantly increase the cost of managing patients with CAP, primarily by increasing LOS. Therefore, strategies should be employed to minimize the risk of resistance development and reduce LOS. These include early appropriate therapy, optimized dosing based on pharmacodynamic principles, and efficient IV-to-PO switch therapy when appropriate.