Antimicrobial resistance point-of-care testing for gonorrhoea treatment regimens: cost-effectiveness and impact on ceftriaxone use of five hypothetical strategies compared with standard care in England sexual health clinics

Background Widespread ceftriaxone antimicrobial resistance (AMR) threatens Neisseria gonorrhoeae (NG) treatment, with few alternatives available. AMR point-of-care tests (AMR POCT) may enable alternative treatments, including abandoned regimens, sparing ceftriaxone use. We assessed cost-effectiveness of five hypothetical AMR POCT strategies: A-C included a second antibiotic alongside ceftriaxone; and D and E consisted of a single antibiotic alternative, compared with standard care (SC: ceftriaxone and azithromycin). Aim Assess costs and effectiveness of AMR POCT strategies that optimise NG treatment and reduce ceftriaxone use. Methods The five AMR POCT treatment strategies were compared using a decision tree model simulating 38,870 NG-diagnosed England sexual health clinic (SHC) attendees; A micro-costing approach, representing cost to the SHC (for 2015/16), was employed. Primary outcomes were: total costs; percentage of patients given optimal treatment (regimens curing NG, without AMR); percentage of patients given non-ceftriaxone optimal treatment; cost-effectiveness (cost per optimal treatment gained). Results All strategies cost more than SC. Strategy B (azithromycin and ciprofloxacin (azithromycin preferred); dual therapy) avoided most suboptimal treatments (n = 48) but cost most to implement (GBP 4,093,844 (EUR 5,474,656)). Strategy D (azithromycin AMR POCT; monotherapy) was most cost-effective for both cost per optimal treatments gained (GBP 414.67 (EUR 554.53)) and per ceftriaxone-sparing treatment (GBP 11.29 (EUR 15.09)) but with treatment failures (n = 34) and suboptimal treatments (n = 706). Conclusions AMR POCT may enable improved antibiotic stewardship, but require net health system investment. A small reduction in test cost would enable monotherapy AMR POCT strategies to be cost-saving.

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Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population

Sexually Transmitted Infections ◽

10.1136/sextrans-2019-054129 ◽

2020 ◽

Vol 96 (6) ◽

pp. 464-468 ◽

Cited By ~ 3

Author(s):

Rachel Pitt ◽

Magnus Unemo ◽

Pam Sonnenberg ◽

Sarah Alexander ◽

Simon Beddows ◽

...

Keyword(s):

Antimicrobial Resistance ◽

General Population ◽

Sexual Health ◽

Treatment Guidelines ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Sample Survey ◽

23S Rrna ◽

Health Clinic ◽

Rrna Gene

BackgroundMycoplasma genitalium is a common sexually transmitted infection. Treatment guidelines focus on those with symptoms and sexual contacts, generally with regimens including doxycycline and/or azithromycin as first-line and moxifloxacin as second-line treatment. We investigated the prevalence of antimicrobial resistance (AMR)-conferring mutations in M. genitalium among the sexually-active British general population.MethodsThe third national survey of sexual attitudes and lifestyles (Natsal-3) is a probability sample survey of 15 162 men and women aged 16–74 years in Britain conducted during 2010–12. Urine test results for M. genitalium were available for 4507 participants aged 16–44 years reporting >1 lifetime sexual partner. In this study, we sequenced regions of the 23S rRNA and parC genes to detect known genotypic determinants for resistance to macrolides and fluoroquinolones respectively.Results94% (66/70) of specimens were re-confirmed as M. genitalium positive, with successful sequencing in 85% (56/66) for 23S rRNA and 92% (61/66) for parC genes. Mutations in 23S rRNA gene (position A2058/A2059) were detected in 16.1% (95%CI: 8.6% to 27.8%) and in parC (encoding ParC D87N/D87Y) in 3.3% (0.9%–11.2%). Macrolide resistance was more likely in participants reporting STI diagnoses (past 5 years) (44.4% (18.9%–73.3%) vs 10.6% (4.6%–22.6%); p=0.029) or sexual health clinic attendance (past year) (43.8% (23.1%–66.8%) vs 5.0% (1.4%–16.5%); p=0.001). All 11 participants with AMR-conferring mutations had attended sexual health clinics (past 5 years), but none reported recent symptoms.ConclusionsThis study highlights challenges in M. genitalium management and control. Macrolide resistance was present in one in six specimens from the general population in 2010–2012, but no participants with AMR M. genitalium reported symptoms. Given anticipated increases in diagnostic testing, new strategies including novel antimicrobials, AMR-guided therapy, and surveillance of AMR and treatment failure are recommended.

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Assessing the clinical impact and resource use of a 30-minute chlamydia and gonorrhoea point-of-care test at three sexual health services

Therapeutic Advances in Infectious Disease ◽

10.1177/20499361211061645 ◽

2021 ◽

Vol 8 ◽

pp. 204993612110616

Author(s):

Susie Huntington ◽

Georgie Weston ◽

Elisabeth Adams

Keyword(s):

Health Services ◽

Sexual Health ◽

Resource Use ◽

Standard Care ◽

Point Of Care ◽

Structured Interviews ◽

Process Data ◽

Point Of Care Test ◽

Clinical Benefits ◽

Patient Groups

Objectives: To assess clinical metrics and resource use of a 30-minute point-of-care test (POCT) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) compared to laboratory-based testing. Methods: Three English sexual health services (SHSs) were recruited as part of a study. Existing processes for CT/NG testing and treatment were assessed, and adaptions to incorporate the CT/NG POCT were developed during semi-structured interviews. Staff time and consumables data were collected by clinic staff prior to and following introduction of the POCT. Results: SHSs selected patient groups for whom the CT/NG POCT would be used. Testing and treatment process data were collected for 225 patients (n = 118 POC; n = 107 standard). The percentage of patients receiving unnecessary CT treatment was 5% (5/95) and 13% (12/93) for POC and standard care respectively. The average CT/NG pathway cost varied and was on average £61.55 for POC and £50.88 for standard care. For the two SHSs where the POCT was used during a patient’s visit, for standard and POC respectively, the average time to CT treatment was 10.0 and 0.0 days and to NG treatment, 0.3 and 0.0 days. Conclusion: Use of a 30-minute POCT at three SHSs yielded clinical benefits by reducing time to treatment and unnecessary CT treatment.

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Mycoplasma genitalium Antimicrobial Resistance in Community and Sexual Health Clinic Patients, Auckland, New Zealand

Emerging Infectious Diseases ◽

10.3201/eid2602.190533 ◽

2020 ◽

Vol 26 (2) ◽

pp. 332-335

Author(s):

Anna Vesty ◽

Gary McAuliffe ◽

Sally Roberts ◽

Gillian Henderson ◽

Indira Basu

Keyword(s):

New Zealand ◽

Antimicrobial Resistance ◽

Sexual Health ◽

Mycoplasma Genitalium ◽

Health Clinic

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Infliximab for the treatment of acute exacerbations of ulcerative colitis

Health Technology Assessment ◽

10.3310/hta14suppl1-02 ◽

2010 ◽

Vol 14 (Suppl 1) ◽

pp. 9-15

Author(s):

S Bryan ◽

L Andronis ◽

C Hyde ◽

M Connock ◽

A Fry-Smith ◽

...

Keyword(s):

Ulcerative Colitis ◽

Cost Effectiveness ◽

Initial Treatment ◽

Standard Care ◽

Sensitivity Analyses ◽

Base Case ◽

Active Ulcerative Colitis ◽

Tree Model ◽

Single Technology Appraisal ◽

Acute Exacerbations

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of infliximab for the treatment of acute exacerbations of ulcerative colitis, in accordance with the licensed indication, based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The submitted clinical evidence included four randomised controlled trials (RCTs), two comparing infliximab with placebo in patients not responsive to initial treatment with intravenous corticosteroids and one comparing ciclosporin with placebo. A fourth RCT compared ciclosporin with intravenous corticosteroids as the initial treatment after hospitalisation. The manufacturer’s submission concluded that infliximab provides clinical benefit to patients with acute severe, steroid-refractory ulcerative colitis and is well tolerated; it also provides additional clinical benefits over ciclosporin, particularly avoidance of colectomy. A decision tree model was built to compare infliximab with strategies involving ciclosporin, standard care and surgery. After correcting a small number of errors in the model, the revised base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with standard care was £20,000. However, sensitivity analyses revealed considerable uncertainty emanating from the weight of the patient, the timeframe considered and, most importantly, the colectomy rates used. When a more appropriate mix of trials were included in the estimation of colectomy rates, the ICER for infliximab rose to £48,000. The guidance issued by NICE on 31 October 2008 states that infliximab is recommended as an option for the treatment of acute exacerbations of severely active ulcerative colitis only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient; for people who do not meet this criterion, infliximab should only be used for the treatment of acute exacerbations of severely active ulcerative colitis in clinical trials.

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O15.3 Cost-effectiveness of antimicrobial resistance point-of-care testing for optimising the treatment of gonorrhoea

10.1136/sextrans-2017-053264.86 ◽

2017 ◽

Author(s):

Emma Harding-Esch ◽

Susie E Huntington ◽

Mike Harvey ◽

Claire E Broad ◽

Elisabeth J Adams ◽

...

Keyword(s):

Cost Effectiveness ◽

Antimicrobial Resistance ◽

Point Of Care ◽

Point Of Care Testing

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Cost-Effectiveness of Competing Treatment Strategies for Clostridium difficile Infection: A Systematic Review

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.303 ◽

2018 ◽

Vol 39 (4) ◽

pp. 412-424 ◽

Cited By ~ 15

Author(s):

Phuc Le ◽

Van T. Nghiem ◽

Patricia Dolan Mullen ◽

Abhishek Deshpande

Keyword(s):

Systematic Review ◽

Cost Effectiveness ◽

Clostridium Difficile ◽

Fecal Microbiota Transplantation ◽

Treatment Strategies ◽

Cost Effective ◽

Influential Factors ◽

Effective Therapy ◽

Tree Model ◽

Study Results

BACKGROUNDClostridium difficile infection (CDI) presents a substantial economic burden and is associated with significant morbidity. While multiple treatment strategies have been evaluated, a cost-effective management strategy remains unclear.OBJECTIVEWe conducted a systematic review to assess cost-effectiveness analyses of CDI treatment and to summarize key issues for clinicians and policy makers to consider.METHODSWe searched PubMed and 5 other databases from inception to August 2016. These searches were not limited by study design or language of publication. Two reviewers independently screened the literature, abstracted data, and assessed methodological quality using the Drummond and Jefferson checklist. We extracted data on study characteristics, type of CDI, treatment characteristics, and model structure and inputs.RESULTSWe included 14 studies, and 13 of these were from high-income countries. More than 90% of these studies were deemed moderate-to-high or high quality. Overall, 6 studies used a decision-tree model and 7 studies used a Markov model. Cost of therapy, time horizon, treatment cure rates, and recurrence rates were common influential factors in the study results. For initial CDI, fidaxomicin was a more cost-effective therapy than metronidazole or vancomycin in 2 of 3 studies. For severe initial CDI, 2 of 3 studies found fidaxomicin to be the most cost-effective therapy. For recurrent CDI, fidaxomicin was cost-effective in 3 of 5 studies, while fecal microbiota transplantation (FMT) by colonoscopy was consistently cost-effective in 4 of 4 studies.CONCLUSIONSThe cost-effectiveness of fidaxomicin compared with other pharmacologic therapies was not definitive for either initial or recurrent CDI. Despite its high cost, FMT by colonoscopy may be a cost-effective therapy for recurrent CDI. A consensus on model design and assumptions are necessary for future comparison of CDI treatment.Infect Control Hosp Epidemiol 2018;39:412–424

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Detection of Neisseria gonorrhoeae and Chlamydia trachomatis from pooled rectal, pharyngeal and urine specimens in men who have sex with men

Sexually Transmitted Infections ◽

10.1136/sextrans-2017-053303 ◽

2017 ◽

Vol 94 (4) ◽

pp. 293-297 ◽

Cited By ~ 20

Author(s):

David John Speers ◽

I-Ly Joanna Chua ◽

Justin Manuel ◽

Lewis Marshall

Keyword(s):

Nucleic Acid ◽

Chlamydia Trachomatis ◽

Neisseria Gonorrhoeae ◽

Sexual Health ◽

Point Of Care ◽

Standard Of Care ◽

Urine Samples ◽

Health Clinic ◽

Sex With Men ◽

The Cost

ObjectivesScreening of men who have sex with men (MSM) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) requires sampling from anorectal and pharyngeal sites in addition to urogenital sampling. Due to the cost of testing multiple anatomical sites individually testing of pooled specimens has potential merit. The Cepheid GeneXpert CT/NG assay (GeneXpert), which also has potential for point-of-care nucleic acid testing in the sexual health clinic, has not been assessed for pooled specimen testing.MethodsWe prospectively compared GeneXpert testing of pooled pharyngeal and rectal swabs with urine samples to standard of care testing of individual specimens from 107 participants using the Roche cobas 4800 CT/NG assay (cobas) for CT and NG in high-risk MSM attending an inner city sexual health clinic.ResultsWe found testing of pooled pharyngeal, rectal and urine samples by the GeneXpert to have 100% agreement for NG and 94% overall agreement for CT when compared with individual specimen testing by cobas. For CT testing, 14 cases were detected for both tests, 4for cobas only, 2 for GeneXpert only and 89 participants were negative for both tests.ConclusionsPooled specimen CT and NG testing by the GeneXpert was accurate when compared with single specimen testing and has potential for screening MSM for CT and NG. The role of pooled specimen testing with the GeneXpert as a point-of-care nucleic acid test in MSM requires further investigation.

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