COMPARATIVE COST-EFFECTIVENESS STUDY OF ANTIBIOTIC THERAPIES IN PEDIATRIC LOWER RESPIRATORY TRACT INFECTIONS: IMPLICATIONS FOR RATIONAL DRUG USE

Abstract

Background: Lower respiratory tract infections (LRTIs) are a major cause of morbidity and mortality in children globally. Choosing empiric antibiotic treatment should reconcile clinical efficacy, risk for resistance and cost - particularly in resource-poor environments. In this study, the clinical efficacy and cost-effectiveness of three frequently prescribed oral antibiotic regimens for pediatric LRTIs were compared.

Methods: A prospective, pragmatic, multi-centre cost-effectiveness trial (June–November 2015) recruited children aged 2 months–12 years with non-severe community-acquired LRTI presenting to short-stay paediatric units or outpatient departments. Participants were assigned to one of three frequently administered oral antibiotic regimens per usual facility practice: (A) twice daily oral amoxicillin, (B) once daily oral azithromycin, or (C) once daily or twice daily oral cefixime. Primary outcome of effectiveness: clinical cure at day 7. Economic outcome: all-inclusive cost per cured patient (drug acquisition + hospitalization costs where relevant). Statistical analyses employed chi-square test and logistic regression. Incremental cost-effectiveness ratio (ICER) was calculated by comparing alternatives.

Results: 450 children were enrolled (n=150 per arm). Clinical cure at day 7: amoxicillin 90.0% (135/150), azithromycin 92.0% (138/150), cefixime 88.0% (132/150) (χ²=1.33, p=0.51). Mean total cost per arm (2015 INR): amoxicillin ₹37,500; azithromycin ₹42,000; cefixime ₹66,000. Cost per cured patient: amoxicillin ₹278, azithromycin ₹304, cefixime ₹500. Azithromycin compared to amoxicillin resulted in an additional 3 cures at an incremental cost of ₹4,500 (ICER = ₹1,500 per additional cure). No statistically significant differences in effectiveness were seen between arms after adjustment for age and baseline severity (adjusted OR for cure: azithromycin v amoxicillin 1.18; 95% CI 0.60–2.33).

Conclusions: For this 2015 six-month pragmatic trial, amoxicillin yielded the best cost per patient cured among the three regimens but with comparably good clinical efficacy to azithromycin and cefixime. Rational choice of antibiotics (with a preference for narrow-spectrum, low-cost drugs where needed) and stewardship interventions can optimize health gain per rupee and retard antimicrobial resistance.