Infection Control & Hospital Epidemiology
1013
Clinical outcome, healthcare cost and length of hospital stay among patients with bloodstream infections and acute leukemia in a cancer center in Eastern India
Chelsea Elizabeth Muennichow1,a, Gaurav Goel MD, DNB, MNAMS2, Arpita Bhattacharyya FRCP3, Reena Nair MD4,
Mammen Chandy MD, FRACP, FRCPA, FRCP4 and Sanjay Bhattacharya MD, DNB, FRCPath2 1Department of Molecular and Cell Biology, Neurobiology, University of California at Berkeley, Berkeley, California, 2Department of Microbiology, Tata Medical Center, Kolkata, India, 3Department of Pediatric Oncology, Tata Medical Center, Kolkata, India and 4Department of Clinical Hematology, Tata Medical Center, Kolkata, India
To the Editor—Acute leukemia is one of themost common forms of malignancy reported globally. Patients with acute leukemia acquire infections for many reasons related to disease, chemotherapy, immunosuppression, the use of vascular access devices, and mucosal barrier injury. Bloodstream infections (BSIs) are poten- tially the most serious infections in leukemic patients; they often lead to morbidity, hospitalization, and sometimes death. In a previous study, we reported the impact of BSI as a predictor of length of hospital stay (LOS) and cost of care in patients with cancer.1 In this study, conducted from April 2015 to March 2016, we investigated the effect of BSI on LOS, mortality rates, and healthcare cost among patients with acute leukemia. In total, 350 patients were analyzed during the study period: 234 acute lym- phoblastic leukemia (ALL) patients (median age, 8 years; range, 1.5–68.6 years; male:female ratio, 1.8:1) and 116 acute myeloblastic leukemia (AML) patients (median age: 32 years; range, 2.8–71.1 years; male:female ratio, 1:1). Among patients with gram-positive bacterial BSIs only 1 methicillin-resistant Staphylococcus aureus (MRSA) BSI was detected, and 5 methicillin-sensitive S. aureus BSIs were detected. Among gram-negative bacillary BSIs, carbapenem resistance varied from 22% to 81%. This resistance was greatest among Klebsiella spp, but it was also observed in Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. We detected 2 cases of colistin-resistant Klebsiella. Surveillance cultures from stool samples showed carba- penem resistance in gram-negative bacilli in 59% of patients, and surveillance cultures from throat swabs showed carbapenem resis- tance in gram negative bacilli in 18% of patients. Gram-negative bacterial BSIs were the most common, followed
by BSIs due to gram-positive cocci and Candida parapsilosis (Table 1). The median duration of hospital stay for patients with a BSI was highest for those with Candida BSIs (32 days) followed by those with gram-positive bacterial BSIs (25 days) and those with gram-negative bacterial BSIs (22 days). The intensive care unit (ICU) admission rate was highest for patients with gram-negative bacterial BSIs (23 of 69, 33.3%) followed by those with gram- positive bacterial BSIs (8 of 43, 18.6%). The ICU admission rate was least for Candida casesinthisstudy (0 or 2, 0%). The30-dayall-
Author for correspondence: Dr Sanjay Bhattacharya, MD, DNB, FRCPath, Tata Medical Center, 14 Major Arterial Road (E-W), Newtown, Kolkata 700160, India. E-mail:
drsanjay1970@hotmail.com a Tata Social Intern student.
Cite this article: Muennichow CE, et al. (2018). Clinical Outcome, Healthcare Cost
and Length of Hospital Stay Among Patients With Bloodstream Infections and Acute Leukemia in a Cancer Center in Eastern India. Infection Control & Hospital Epidemiology 2018, 39, 1013–1014. doi: 10.1017/ice.2018.118
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
cause mortality and BSI-related attributable mortality rate was highest for gram-negative bacterial BSI patients (20.3%). The clinical outcome data of the present study assume sig-
nificance in view of the high prevalence of multidrug-resistant (MDR) gram-negative bacterial infections in this setting.2,3 We have previously reported cases from our center of colistin- resistant Klebsiella among both pediatric and adult patients.4,5 In the period between 2014 and 2015, we reported 30-day all-cause mortality among patients with carbapenem-resistant E. coli (0%), Klebsiella pneumoniae (40%), P. aeruginosa (50%), and Acineto- bacter baumannii (60%).6 In the current study, the average cost for hospital stay was
highest for patients with Candida BSIs (US$12,232 [Rs. 795,134]), followed by those with gram-negative bacterial BSIs (US $4,945 [Rs. 321,433]). The average cost for hospital stay was lowest for those with gram-positive bacterial BSIs (US$4,163 [Rs. 270,607]). In our previous study, among all cancer patients (and not restricted to those with BSIs), we found that the overall mean LOS was 5.9 days, the average cost of care per admission was US $1,413 (Rs. 95,208), and the all-cause mortality rate was 5.7%.1 The comparison of healthcare outcome measures helps us to understand the efficacy of various clinical interventions, such as chemotherapy regimens and infection prevention and control measures, as well as the effect of infrastructure development or resource allocation. Data on these measures are far less commonly available from low- or middle-income countries than from developed economies, but they are important globally because of the migration of people for work, exigencies or medical tourism. A study from the United States showed that for patients with neutropenia plus infection, the mean hospitalization costs were $27,587, the LOS was 12.6 days, and the mortality rate was 19.4%.7 In a study from Mexico, the mean cost per hospital stay was US$2,246 among patients with ALL.8 An Indian study on patients undergoing cardiothoracic surgery, patients with hospital-acquired bacteremia experienced a significantly longer total hospital stay (mean, 22.9 days), longer ICU stay (mean, 11.3 days), a higher mortality rate (mean, 54%), and higher cost (mean, US$14,818) than similar patients without bacteremia.9 Healthcare service providers must take appropriate measures
to mitigate the negative effect of infections on clinical and health economic outcome measures. One of the key interventions to achieve a positive change is an awareness, education, and training program for care providers regarding matters related to infection epidemiology, diagnosis, and appropriate management. An Indian study from a tertiary-care teaching hospital reported that for every dollar spent on training, the return of investment was $236 in avoidance of healthcare-associated infections (HAIs).10
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