October 19, 2010
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Coccidioidomycosis burden in southwestern US may be greater than previously thought

Tsang CA. Emerg Infect Dis. 2010;16. [Epub ahead of print]

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Nearly half of patients with coccidioidomycosis in an Arizona cohort visited an ED and incurred a total cost of treatment that was higher than previously estimated, according to study results.

Researchers from the Arizona Department of Health Services said the Council of State and Territorial Epidemiologists case definition for coccidioidomycosis requires laboratory and clinical criteria, but that Arizona uses only laboratory criteria. The current study assessed the validity of the Arizona approach and characterized the burden of the infection in the state.

Health officials conducted a population-based investigation and conducted a telephone interview of every tenth coccidioidomycosis case patient from a cohort of 5,664 patients reported between January 2007 and February 2008. There were 493 patients interviewed.

The interview included questions about the signs and symptoms of coccidioidomycosis, health care-seeking behavior, medical treatment information and the effects of the disease on the daily lives of patients. For patients younger than 18 years, a parent or guardian answered the questions or was present for the interview.

Defining symptoms included fever, cough, sore throat, chills, dyspnea, chest pain, hemoptysis, headache, rash, stiff neck, myalgias or arthralgia.

Awareness of disease

An average of 11 days (interquartile range [IQR] 2–31 days) was required to seek health care after onset of symptoms, and the time from seeking health care to diagnosis was 23 days (IQR 6–74 days).

Individuals aware of coccidioidomycosis before seeking treatment received earlier diagnoses than individuals who were not aware of the disease (median 20 days [IQR 6–56 days] vs. 25 days [IQR 7–144 days]; P=.04) and to request testing for Coccidioides spp. (95% CI, 1.0–3.2), according to the results.

Clinical case definition criteria were met by 95% of patients interviewed. Three percent reported no symptoms and 2% had only one symptom.

Symptoms included fatigue (84%), cough (67%), dyspnea (59%) and fever (54%). Symptoms lasted 120 days overall, 42 days for patients who had recovered at the time of interview and 157 days for those who had not recovered at the time of interview.

Three-quarters of patients reported that the illness affected performance of usual daily activities at some point.

Effect on system

An average of two visits to a health care provider was required before testing occurred, and 26% of patients visited a health care provider more than 10 times.

Forty-six percent of patients reported at least one visit to an ED, and 23% initially sought care in an ED. Overnight hospital stays were reported by 41% of interviewees; the average hospital stay was 6 days (range 0–306 days, IQR 4–10 days).

A primary diagnosis of coccidioidomycosis occurred in 1,093 hospital visits, accounting for $59 million in hospital charges and a median of $33,000 per coccidioidomycosis-related visit. The 1,735 visits with a primary or secondary diagnosis of coccidioidomycosis incurred a cost of $86 million with a median charge of $30,000 per visit, which is higher than previous estimates, according to the researchers.

Antifungals were prescribed to 61% of patients, and antibacterials were prescribed to 60% of patients.

“These findings suggest that eliminating clinical criteria from the coccidioidomycosis case definition allows for simpler surveillance methods and requires fewer resources yet still accurately estimates prevalence and incidence of the disease in endemic regions,” the researchers wrote. They noted that education campaigns could decrease delays to diagnosis, which would, in turn, aid antimicrobial stewardship and relieve patient anxiety.