Abstract
BackgroundDiagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, particularly in developing countries. Highly sensitive diagnostic methods are costly, while less expensive methods often lack sensitivity or specificity. Cost-effectiveness comparisons of the various diagnostic options have not been presented.Methods and FindingsWe compared cost-effectiveness, as measured by cost per life-years gained and proportion of patients successfully diagnosed and treated, of 33 PCP diagnostic options, involving combinations of specimen collection methods [oral washes, induced and expectorated sputum, and bronchoalveolar lavage (BAL)] and laboratory diagnostic procedures [various staining procedures or polymerase chain reactions (PCR)], or clinical diagnosis with chest x-ray alone. Our analyses were conducted from the perspective of the government payer among ambulatory, HIV-infected patients with symptoms of pneumonia presenting to HIV clinics and hospitals in South Africa. Costing data were obtained from the National Institutes of Communicable Diseases in South Africa. At 50% disease prevalence, diagnostic procedures involving expectorated sputum with any PCR method, or induced sputum with nested or real-time PCR, were all highly cost-effective, successfully treating 77–90% of patients at $26–51 per life-year gained. Procedures using BAL specimens were significantly more expensive without added benefit, successfully treating 68–90% of patients at costs of $189–232 per life-year gained. A relatively cost-effective diagnostic procedure that did not require PCR was Toluidine Blue O staining of induced sputum ($25 per life-year gained, successfully treating 68% of patients). Diagnosis using chest x-rays alone resulted in successful treatment of 77% of patients, though cost-effectiveness was reduced ($109 per life-year gained) compared with several molecular diagnostic options.ConclusionsFor diagnosis of PCP, use of PCR technologies, when combined with less-invasive patient specimens such as expectorated or induced sputum, represent more cost-effective options than any diagnostic procedure using BAL, or chest x-ray alone.
Highlights
Pneumocystis jirovecii causes a fungal pneumonia (PCP) affecting HIV-infected and other immunocompromised persons worldwide [1]
Highly active anti-retroviral therapy (HAART) and Pneumocystis jirovecii pneumonia (PCP) prophylaxis, usually with cotrimoxazole (CTX), have reduced the burden of PCP among AIDS patients in developed countries [2,3,4,5], PCP remains an important cause of HIV-related morbidity and mortality throughout much of the developing world [1]
Estimates of sensitivity and specificity of diagnostic procedures used in the model are shown in Table 1 and are based on reports from the literature [29,30,31,36, 38,39,40,44,47,48,49,50,52,54,55,57,59,60,61,62,63,64,65,66,67, 68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84], or estimated by the authors
Summary
Pneumocystis jirovecii causes a fungal pneumonia (PCP) affecting HIV-infected and other immunocompromised persons worldwide [1]. The prevalence of PCP among HIV-infected African children with pneumonia ranges from 10 to 49% [6,7,8,9,10], with mortality as high as 80% [11]. Among African adults, in whom the disease is often misdiagnosed as smear-negative TB [12,13,14], increases in PCP diagnoses have been noted during the past 15 years [15,16,17,18,19,20]. In Southeast Asia, PCP prevalence among HIV-infected children and adults with pneumonia has been reported to be as high as 66% [21,22,23]. Mortality from PCP among HIV-uninfected patients can be as high as 40% [1]. Diagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, in developing countries. Cost-effectiveness comparisons of the various diagnostic options have not been presented
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