Background: Sepsis represents a significant cost and disease burden to the renal transplant recipient, adversely impacting both patient and graft survival. Sulfamethoxazole-trimethoprim (SMX-TMP) is a sulfonamide antibiotic used as primary prophylaxis against Pneumocyctis jiroveci Pneumonia (PCP) in patients receiving potent immunosuppression. Attributed to its relatively broad antimicrobial spectrum, we previously described a lower incidence of sepsis in patients receiving SMX-TMP compared to those no receiving SMX-TMP. We aimed to evaluate the costs associated with the use and non-use of SMX-TMP in renal transplant recipients.

Methods: We included renal transplant recipients who were transplanted between 1/2002 – 12/2010 at our center. Data were extracted from inpatient and outpatient electronic records. The primary outcome was the cost of sepsis in each group. The incidence of sepsis was determined using ICD-9 codes, followed by 100% verification of all cases through manual review. Drug costs were obtained from the 2012 Redbook, and cost of sepsis was determined from Lagu and colleagues to be $22,408. All costs were calculated in 2012 dollars.

Results: 1235 patients were included in the cost analysis, and those receiving SMX-TMP prophylaxis had a significantly lower rate of sepsis (13.6% vs. 4.2%, P <0.001). Patients receiving SMX-TMP remained on prophylaxis for a median of 2.6 years, and this duration was used for drug costs. The average cost per patient of sepsis and SMX-TMP prophylaxis was $1,265, while the average cost of no SMX-TMP prophylaxis was higher at $3,370. Sensitivity analysis demonstrated that SMX-TMP indefinite use is the dominant strategy across all variables for drug cost and costs of sepsis. A two-way sensitivity analysis demonstrates that the cost of SMX-TMP would have to exceed $2,227 ($2.34 per tablet) in order for the two strategies to be similar in cost.

Conclusions: Prophylaxis with SMX-TMP appears to be a simple means to reduce overall costs of care following kidney transplant.

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