International Journal of Clinical Pharmacy

, Volume 40, Issue 5, pp 1051–1058 | Cite as

Cost-effectiveness analysis of low versus high dose colistin in the treatment of multi-drug resistant pneumonia in Saudi Arabia

  • Abdul Karim Suleman CaraEmail author
  • Syed Tabish Razi Zaidi
  • Fatima Suleman
Research Article


Background Gram negative pathogens are increasingly resistant to commonly used first line antibiotics and colistin is in most cases the only medicine available. There is very limited information available comparing the effectiveness and costs of low versus high dose colistin with studies showing efficacy with both doses and with variable levels of adverse effects. The absence of a definite dosing strategy makes a model to compare low dose and high dose colistin invaluable in making decisions regarding the appropriate use of colistin. Objective This study was designed to evaluate the cost effectiveness of low versus high dose colistin in the treatment of Pneumonia caused by colistin-only sensitive gram negative bacteria from the perspective of a tertiary care hospital in Saudi Arabia. Setting 300-bed tertiary care hospital in Saudi Arabia. Method A retrospective review was conducted to compare the costs and outcomes of treatment of pneumonia with low versus high dose colistin. The model followed an average patient from initiation of treatment until clinical cure or failure. Main outcome measures The main outcomes were cure, nephrotoxicity, total direct costs per episode, cost per additional cure and cost per nephrotoxicity avoided. Results There was no significant difference between high and low dose colistin with regards to clinical cure (30% vs. 21%; p = 0.292). Significantly more patients experienced nephrotoxicity with high versus low dose colistin (30% vs. 8%; p = 0.004). With low dose colistin the incremental costs per nephrotoxicity avoided was SAR—3056.28. One-way sensitivity analyses did not change the overall results. Conclusion Low dose was not inferior to high dose colistin in terms of clinical cure and had a lower incidence of nephrotoxicity resulting in significant cost avoidance.


Colistin Cost effectiveness Efficacy Gram negative Multi drug resistant Pneumonia Saudi Arabia 



We thank Ms. Analyn Crisostomo (B.Pharm) for collecting data on some study variables and Ms. Iman Moustafa (M.Pharm) for assistance with layout and proof reading.



Conflicts of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Focaccia R, Gomes Da Conceicao OJ. Pneumonia hospitalar. Rev Bras Med. 1994;51(SPEC. ISS.):95–8.Google Scholar
  2. 2.
    Nair GB, Niederman MS. Nosocomial pneumonia. Lessons learned. Crit Care Clin. 2013;29(3):521–46.CrossRefGoogle Scholar
  3. 3.
    Aly M, Balkhy HH. The prevalence of antimicrobial resistance in clinical isolates from Gulf Corporation Council countries. Antimicrob Resist Infect Control. 2012;1(1):26.CrossRefGoogle Scholar
  4. 4.
    Tao L, Hu B, Rosenthal VD, Gao X, He L. Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis. 2011;15(11):e774.CrossRefGoogle Scholar
  5. 5.
    Navoa-Ng JA, Berba R, Galapia YA, Rosenthal VD, Villanueva VD, Tolentino MCV, et al. Device-associated infections rates in adult, pediatric, and neonatal intensive care units of hospitals in the Philippines: International Nosocomial Infection Control Consortium (INICC) findings. Am J Infect Control. 2011;39(7):548–54.CrossRefGoogle Scholar
  6. 6.
    Scott II RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. CDC; 2009.Google Scholar
  7. 7.
    Kalin G, Alp E, Coskun R, Demiraslan H, Gündogan K, Doganay M. Use of high-dose IV and aerosolized colistin for the treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia: do we really need this treatment? J Infect Chemother. 2012;18(6):872–7.CrossRefGoogle Scholar
  8. 8.
    Zaidi STR, Al Omran S, Al Aithan ASM, Al Sultan M. Efficacy and safety of low-dose colistin in the treatment for infections caused by multidrug-resistant gram-negative bacteria. J Clin Pharm Ther. 2014;39(3):272–6.CrossRefGoogle Scholar
  9. 9.
    Pintado V, San Miguel LG, Grill F, Mejía B, Cobo J, Fortún J, et al. Intravenous colistin sulphomethate sodium for therapy of infections due to multidrug-resistant gram-negative bacteria. J Infect. 2008;56(3):185–90.CrossRefGoogle Scholar
  10. 10.
    Montero M, Horcajada JP, Sorlí L, Alvarez-Lerma F, Grau S, Riu M, et al. Effectiveness and safety of colistin for the treatment of multidrug-resistant Pseudomonas aeruginosa infections. Infection. 2009;37(5):461–5.CrossRefGoogle Scholar
  11. 11.
    Yilmaz GR, Baştuǧ AT, But A, Yildiz S, Yetkin MA, Kanyilmaz D, et al. Clinical and microbiological efficacy and toxicity of colistin in patients infected with multidrug-resistant gram-negative pathogens. J Infect Chemother. 2013;19(1):57–62.CrossRefGoogle Scholar
  12. 12.
    Dubrovskaya Y, Chen T-Y, Scipione MR, Esaian D, Phillips MS, Papadopoulos J, et al. Risk factors for treatment failure of polymyxin B monotherapy for carbapenem-resistant Klebsiella pneumoniae infections. Antimicrob Agents Chemother. 2013;57(11):5394–7.CrossRefGoogle Scholar
  13. 13.
    Doshi NM, Mount KL, Murphy CV. Nephrotoxicity associated with intravenous colistin in critically ill patients. Pharmacotherapy. 2011;31(12):1257–64.CrossRefGoogle Scholar
  14. 14.
    Falagas ME, Fragoulis KN, Kasiakou SK, Sermaidis GJ, Michalopoulos A. Nephrotoxicity of intravenous colistin: a prospective evaluation. Int J Antimicrob Agents. 2005;26(6):504–7.CrossRefGoogle Scholar
  15. 15.
    Gauthier TP, Wolowich WR, Reddy A, Cano E, Abbo L, Smith LB. Incidence and predictors of nephrotoxicity associated with intravenous colistin in overweight and obese patients. Antimicrob Agents Chemother. 2012;56(5):2392–6.CrossRefGoogle Scholar
  16. 16.
    Pogue JM, Lee J, Marchaim D, Yee V, Zhao JJ, Chopra T, et al. Incidence of and risk factors for colistin-associated nephrotoxicity in a large academic health system. Clin Infect Dis. 2011;53(9):879–84.CrossRefGoogle Scholar
  17. 17.
    Chan JD, Graves JA, Dellit TH. Antimicrobial treatment and clinical outcomes of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia. J Intensive Care Med. 2010;25(6):343–8.CrossRefGoogle Scholar
  18. 18.
    Magiorakos A, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2011;18:268–81.CrossRefGoogle Scholar
  19. 19.
    Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1–138.CrossRefGoogle Scholar
  20. 20.
    Bounthavong M, Hsu DI, Okamoto MP. Cost-effectiveness analysis of linezolid vs. vancomycin in treating methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections using a decision analytic model. Int J Clin Pract. 2009;63(3):376–86.CrossRefGoogle Scholar
  21. 21.
    De Cock E, Krueger WA, Sorensen S, Baker T, Hardewig J, Duttagupta S, et al. Cost-effectiveness of linezolid vs vancomycin in suspected methicillin-resistant staphylococcus aureus nosocomial pneumonia in Germany. Infection. 2009;37(2):123–32.CrossRefGoogle Scholar
  22. 22.
    Michalopoulos AS, Falagas ME. Colistin: recent data on pharmacodynamics properties and clinical efficacy in critically ill patients. Ann Intensive Care. 2011;1(1):30.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Abdul Karim Suleman Cara
    • 1
    Email author
  • Syed Tabish Razi Zaidi
    • 2
  • Fatima Suleman
    • 3
  1. 1.King Abdulaziz HospitalMinistry of National Guard-Health AffairsAl-HasaSaudi Arabia
  2. 2.School of HealthcareUniversity of LeedsLeedsUnited Kingdom
  3. 3.School of Health SciencesUniversity of KwaZulu-NatalDurbanSouth Africa

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