Infection Control & Hospital Epidemiology
Table 7. Clinical Management and Cost of Resistant and Susceptible BSIs, 2017 Organism
Treatment
Susceptible E. coli Resistant E. coli Susceptible KP Resistant KP
Susceptible PA Resistant PA
Susceptible Entero Resistant Entero Susceptible SA Resistant SA
Gentamicin or Ceftriaxone24 Meropenem23
Gentamicin or Ceftriaxone24 Meropenem23
Gentamicin or Ceftriaxone24 Meropenem23 Vancomycin24 Linezolid23
Flucloxacilin24 Vancomycin23
325
Dose; Duration
1×0.3 g; 3 d or 1×2g; 3 d 3×1 g; 14 d
1×0.3 g; 3 d or 1×2 g; 3 d 3×1 g; 14 d
1×0.5 g;3 d or 3×2 g; 3 d 3×1 g; 14 d
3×1–1.5 g; 3d 2×0.6 g; 14 d 4×2 g; 3 d 1×2 g; 21 d
Note. KP, K. pneumoniae; PA, P. aeruginosa; Entero, E. faecium; SA, S. aureus. aCosts of antibiotics were obtained from Queensland Department of Health, 2017 pricing agreement for hospital pharmacies. bCost of antibiotics used for resistant infection minus cost of antibiotics used for susceptible infections.
2000 4000 6000 8000 10000 12000 14000 16000
0
E. coli BSI KP BSI PA BSI PA RTI VRE BSI MRSA BSI MRSA RTI Resistant organisms
Fig. 2. Additional length of hospital stay (days) due to AMR infections in Australia, 2014. Note. AMR, antimicrobial resistant; BSI, bloodstream infection; RTI, respiratory tract infection; KP, K. pneumoniae; PA, P. aeruginosa; VRE, vancomycin-resistant E. fae- cium; MRSA, methicillin-resistant S. aureus.
Patients with BSIs caused by ceftriaxone-resistant E. coli stayed
in the hospital an average of 4.89 days (95% UI, 1.1–8.7) longer than patients with susceptible E. coli infections (Table 1).13 This additional LoS amounted to a total excess of 3,088 days (95% UI, 1,159–5,988) in 2014 (Fig. 2). The averageMRSApatient stayed in the hospital 2.54 days (95% UI, −3.2 to 8.3) longer than methicillin-susceptible S. aureus (MSSA) patients (Table 5),13 and we estimate that this resulted in an additional 2,899 hospital days per year (Fig. 2). However, we noted large variation around this point estimate. In our model, the greatest number of AMR- attributable deaths were among patients with an RTI caused by MRSA (155 deaths; 95% UI, 40–412) and P. aeruginosa (88 deaths; 95% UI, 9–196) (Fig. 3).
Economic burden
The cost of AMR in Australian hospitals is presented as the com- bined effect of incidence of infection, resistance rate, in-hospital antibiotic therapy, and additional LoS (Table 8). For total costs per infection (cost of treatment combined with extra hospital stay), VRE bacteremia was the most expensive infection and added an estimated AUD$10,682 per infection (95% UI, $3,500–$23,223) compared to a susceptible infection. We estimate that BSIs caused
Cost per Infection, AUDa $3.72
$259.98 $3.72
$259.98 $74.04
$202.72 $24.21
$1,646.40 $25.56
$112.98
Excess Cost of Treating Resistant Infection, AUDb
:::
$256.29 :::
$256.29 :::
$128.65 :::
$1,622.19 :::
$87.42
100 150 200 250 300 350 400 450 500 550 600
50 0
E. coli BSI KP BSI PA BSI PA RTI VRE BSI MRSA BSI MRSA RTI Resistant organisms
Fig. 3. Additional deaths due to AMR infections in Australia, 2014. Note. AMR, antimi- crobial resistant; BSI, bloodstream infection; RTI, respiratory tract infection; KP, K. pneumoniae; PA, P. aeruginosa; VRE, vancomycin-resistant E. faecium; MRSA, methicil- lin-resistant S. aureus.
by K. pneumoniae and E. coli cost an additional AUD$9,248 (95% UI, $3,597–$17,470) and AUD$9,200 (95% UI, $3,716–$17,381) per infection, respectively (Table 8). By combining the cost per infection with incidence density, the largest contributor was from ceftriaxone-resistant E. coli BSIs, which added an excess of AUD$5.8–11.2 million per year. These costs were similar to those for patients infected withMRSABSIs, where the Australian health- care system spent an additional AUD$5.5 million (95% UI, $339,633–$22.7 million per year) compared with MSSA patients.
Discussion
Australian hospitals are spending an additional AUD$5.8 million treating patients infected with 1 bacteria that is resistant to 1 anti- biotic (ie, ceftriaxone-resistant E. coli BSI), and this estimate could be as high as AUD$11.2 million per year. Without good-quality measurable indicators of the additional LoS and risk of death of patients, we cannot provide a more complete cost estimate and include other antimicrobial classes or sites of infection. In particu- lar, the lack of rigorous estimates of the additional burden of UTIs caused by E. coli, which are highly prevalent (7.85 per 1,000 patient days (95% UI, 7.7–7.9), precludes a more accurate estimate of the economic burden of resistant infections.
Extra length of hospiral stay (days)
Additional number of AMR-attributable deaths
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