Elimination of Aerosol Ribavirin Use in Immunocompromised Patients with Metapneumovirus and Parainfluenza Virus Infections

Abstract

BackgroundAdministration of ribavirin by aerosol (AR) is often used in attempted treatment of respiratory virus infections in severely immunocompromised patients and was the standard of care at Stanford Health Care (SHC) in the management of metapneumovirus (MPV), parainfluenza virus (PIV), as well as respiratory syncytial virus infections, in hematopoietic stem cell (HCT) and lung transplant (LT) recipients.MethodsA literature review by the transplant ID team in November 2014 failed to provide evidence of benefit of AR for treatment of MPV and PIV infections and, also taking into account its extraordinary cost, it was decided by the transplant ID group that AR should not be used for these infections. Meetings with HCT and LT MDs, however, failed to achieve their concurrence. All evidence was posted online for easy access. An independent expert panel of HCT and pulmonary MDs was asked to review the evidence and they concurred with the conclusion of ID. A meeting was held with all stakeholders together with the P&T committee at which all opinions were heard. All were invited to a subsequent P&T meeting at which it was decided to ban the use of AR for MPV and PIV infections, although oral ribavirin was allowed. The decision was confirmed by the SHC Medical Executive Committee and implemented Dec 2015 after removal of the option from the EHR orders and creation of an escalation pathway for appeals.ResultsAR DOT for MPV and PIV infections decreased from 119 (23 patients) in the previous 12 months to 2 (2 patients) in the subsequent 12 months. The drug acquisition cost was reduced from $2,777,222 to $46,676 – a recurring annual saving of $2,730,546. Additional savings accrued from reduced hospital days, freeing of airborne isolation rooms, reduced housekeeping costs, and reduced exposure of women of childbearing age to the potential teratogenic effects of ribavirin. There were no observable adverse effects from the restriction of AR use.ConclusionCareful examination of clinical practice together with relentless efforts in changing prescriber behavior can result in elimination of ineffective therapy with large associated cost savings and without adverse clinical effects.Disclosures All authors: No reported disclosures.