Abstract
BackgroundWidespread 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).AimAssess costs and effectiveness of AMR POCT strategies that optimise NG treatment and reduce ceftriaxone use.MethodsThe 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).ResultsAll 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).ConclusionsAMR 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.
Highlights
Antimicrobial resistance (AMR) has developed to every class of antibiotic used for treatment of the bacterial sexually transmitted infection (STI) Neisseria gonorrhoeae (NG) [1], with increasing reports of multidrugresistant strains [2]
Dual therapy with ceftriaxone and azithromycin is recommended in Europe [5], and was in the United Kingdom (UK) until 2019 [6] when it was replaced with 1 g ceftriaxone monotherapy due to the emergence of azithromycin resistance [7]
We compared standard care (SC) for NG treatment in the UK with five different AMR point-of-care tests (POCTs) strategies (Box, Supplementary Figure S1), where the AMR POCT was used as a reflex test to inform antibiotic selection irrespective of which test was used to diagnose NG initially
Summary
Antimicrobial resistance (AMR) has developed to every class of antibiotic used for treatment of the bacterial sexually transmitted infection (STI) Neisseria gonorrhoeae (NG) [1], with increasing reports of multidrugresistant strains [2]. Standard care with dual therapy of intramuscular ceftriaxone (500 mg) and oral azithromycin (1 g single dose). AMR pointof-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). 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
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