Background Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA. Methods This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used. Results Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, −4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group. Conclusions Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA. Clinical Trials Registration NCT01723150.
A cost-minimization analysis was conducted for Klebsiella pneumoniae liver abscess (KLA) patients enrolled in a randomized controlled trial which found oral ciprofloxacin to be non-inferior to intravenous (IV) ceftriaxone in terms of clinical outcomes. Healthcare service utilization and cost data were obtained from medical records and estimated from self-reported patient surveys in a non-inferiority trial of oral ciprofloxacin versus IV ceftriaxone administered to 152 hospitalized adults with KLA in Singapore between November 2013 and October 2017. Total costs were evaluated by category and payer, and compared between oral and IV antibiotic groups over the trial period of 12 weeks. Among the subset of 139 patients for whom cost data were collected, average total cost over 12 weeks was $16,378 (95% CI, $14,620–$18,136) for the oral ciprofloxacin group and $20,569 (95% CI, $18,296–$22,842) for the IV ceftriaxone group, largely driven by lower average outpatient costs, as the average number of outpatient visits was halved for the oral ciprofloxacin group. There were no other statistically significant differences, either in inpatient costs or in other informal healthcare costs. Oral ciprofloxacin is less costly than IV ceftriaxone in the treatment of Klebsiella liver abscess, largely driven by reduced outpatient service costs.Trial registration: ClinicalTrials.gov Identifier NCT01723150 (7/11/2012).
Background Cancer survivors may experience financial toxicity (FT) arising from diagnosis, treatµent, and potential employment loss. The prevalence of FT in the context of Singapore healthcare model is unknown. We investigate if higher out of pocket (OOP) expenditure correlates positively with FT, and if higher FT correlates with a worse quality of life (QoL). Methods In this pilot study, a cross-sectional survey was administered to survivors of nasopharyngeal or breast cancer, at National University Hospital Singapore. Patients’ FT and QOL were measured using the COmprehensive Score on financial Toxicity (COST) and Functional Assessment of Cancer Therapy: General (FACT-G). Two multivariate regression models estimated (i) the association between FT and a range of variables and (ii) FT and QOL. Results 63% of our cohort of 76 patients experienced mild-moderate FT. Overall, the mean COST and FACT-G scores are 18.0 (out of 44) and 68.3 (out of 108), respectively. There was a positive correlation between COST and FACT-G scores (r = 0.45). We did not find any significant association between OOP and FT. Predictors for FT included government-subsidized housing, lower education levels, hiring a formal caregiver, and the need for household members to take on extra employment. Conclusion Greater FT correlates with a decline in QoL. Lower socio-economic patients are at higher risk of FT. OOP was not directed related to FT, likely in view of the effective means-tested subsidies. Additional resources should be considered for this at-risk population. Based on our pilot study, our methodology to quantify FT and OOP can be scaled up to other cancer primaries.
AOR 0.39, 95CI 0.36-0.42, P<0.001), and rural (3.26% vs 6.87%, AOR 0.41, 95CI 0.34-0.50, P<0.001) counties. Conclusion: For men with prostate cancer managed with surgery, patients living farther from their treatment facility were 38-61% less likely to receive PORT relative to those living near the treatment facility, regardless of the presence of adverse pathologic features and county type. While the decision to use PORT depends on many patient-specific factors, these findings raise the possibility that the geographic availability of radiation treatment facilities influences the treatment decision. As alternative payment models in radiation oncology are being explored, attention should be given to supporting community-based radiation treatment centers to ensure accessibility of care for patients with prostate cancer.
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