Healthcare-associated infection: what the impact is and where the burden falls E. Tacconelli Dept. Infectious Diseases Catholic University, Rome, Italy
Road map Incidence Mortality Lenght of hospitalisation Costs Bloodstream infection CVC-BSI Pneumonia Prosthetic joint infection MSSA A.baumannii S/R P. aeruginosa S/R MRSA E. coli 3GR E. coli
Boyce, J hosp infect 2009
Which are the limits of mortality and costs analyses?
Limits of outcome analysis Antibiotic-resistant infections Study design (mainly retrospective, case-control, cohort) Erroneous selection of the control group, matching criteria Heterogeneous grouping of antimicrobial classes Lack of analysis of multiple resistance patterns Harris, CID, 2001, 2002 Kaye, ICHE, 2005; McGregor, J clin epidemiol, 2005; Tacconelli, ICHE, 2006; Tacconelli, Curr Op Infect Dis 2009
Limits of outcome analysis Antibiotic-resistant infections Limited controlling for confounding comorbidity context where data are gathered (outbreak or endemic) patients population infection versus colonisation length of hospitalization site of acquisition Cataldo & Tascconelli, Infect Dis Clin North Am, 2009
Patient costs Cost of adverse effects Cost of infrastructure Productivity costs Ecological cost Cost for laboratory Cost of the drug Cost of staff Cost for screening Cost of resistance Cost for isolation / cohorting Direct costs Productivity costs Intangibles Cost of infection Cost of litigation Cost of increased LOS Cost for infection control Hospital costs Cost of other nosocomial infection
Cost-effectiveness and infectious diseases (2005-2010 / top 10 journals) 95 studies, most of which were published in 2009 o HIV disease prevention (47%) and treatment (34%) o antimicrobial treatment (7%) o HAI (7%) MRSA screening MRSA bacteraemia Surgical site infections Clostridium difficile Antimicrobial stewardship team o A single study addressed costs attributable to antimicrobial-resistant infections in hospitals in the USA Paul, CMI 2010
Roberts, Clinical Infectious Diseases 2009; 49:1175 84
Roberts, Clinical Infectious Diseases 2009; 49:1175 84
Roberts, Clinical Infectious Diseases 2009; 49:1175 84
Cosgrove,CID 2003; Tacconelli, JHI 2006
Meta-analysis of mortality in patients with VRE BSI Diaz-Granados et al. CID 2005
Mortality associated with ESBL bacteraemia The study could not prove that the increased mortality is directly attributable to ESBL production, as almost all existing studies do not provide adjusted results Test for heterogeneity: p = 0.001 Schwaber, JAC, 2007
Annually in the EU, MRSA infections have been estimated to result in 1 million extra days of hospitalization and an attributable additional hospital cost of 380 million [ECDC & EMEA 2009]
MRSA & MSSA infections and mortality Koch, Eurosurveill 2010
MRSA & MSSA infections and LOS / Costs Koch, Eurosurveill 2010
MRSA: 4.8 x 100,000 individuals 9.1 0.3 7.3 5 4.6 5.3
MSSA: 13.9 x 100,000 individuals 4.6 27.8 20.9 15 8.8 10.3
G3CREC: 2.6 x 100,000 individuals 4.6 1 1 3.1 2 5.6
G3CSEC: 25.6 x 100,000 individuals 34.2 48.1 48.7 41.6 15.7 8.9
Excess deaths MSSA > MRSA (31/40 EU countries!!) 2
and the future is even worse.. de Kraker, PLoS Med 11 Oct 2011
ICU setting (20 EU countries): HA-pneumonia Laurent, Lancet Infect Dis, 2011
ICU setting (20 EU countries): BSI Laurent, Lancet Infect Dis, 2011
CVC-BSI / ICU Systematic review Tacconelli, J hosp infect, 2009
CVC BSI Costs Tacconelli, J hosp infect, 2009
PJI Incidence Hellmann, J Arthroplasty, Hellmann, 2009; J del Arthroplasty, Pozo, N Engl 2009 J Med, 2009
Etiological agents PJI Non tuberculous mycobacteria, Wang Intern Med 2011 Moran, J infect, 2007 Haemophilus parainfluenzae, Bailey J Infect 2011 Aspergillus, Yilmaz Scand J Infect Dis 2011 Group B streptococcus, Sendi J hosp infect 2011; Corvec, J Clin Microbiol 2011 S. Lugdunensi, Expert Rev Anti Infect Ther 2011
Prosthetic joint infection and Rheumatoid arthritis The higher risk of PJIs in patients with RA was statistically significant (HR 4.08, 95% CI 1.35 12.33), even after adjusting for previous infection in the index joint (HR 3.74, 95% CI 1.23 11.33). When restricting the analysis to infections diagnosed within the first year after surgery, 10 patients with RA (2.3% at 1 year) and 1 patient with OA developed an infection. Again, the excess risk for patients with RA was statistically significant (odds ratio 10.30, 95% CI 1.31 80.26). Bongartz, Arthritis & Rheumatism, 2008
Prosthetic joint infection and Rheumatoid arthritis Retrospective study of all consecutive total hip (THA) and total knee (TKA) arthroplasties. Multivariate logistic regression analysis: o use of biologic DMARDs [P = 0.0007, OR = 5.69; 95% CI 2.07-15.61] o longer RA duration (P = 0.0003, OR = 1.09; 95% CI 1.04-1.14) were the only significant risk factors for acute SSI infliximab P = 0.001, OR = 9.80, 95% CI 2.41-39.82 etanercept P = 0.0003, OR = 9.16, 95% CI 2.77-30.25 A history of PJI may be a contraindication for treatment with anti TNF Momohara, Mod Rehum 2011; Hirano Mod Rheumatol Oct 2011
annual adjusted diagnostic-related group cost: from $195 million to $283 million Lipsky, Infect Control Hosp Epidemiol, 2007; Hellmann, J Arthroplasty, 2009
MDR agents PJI «Collateral effects» of war Murphy, J Trauma 2011
Conclusions HAIs greatly increase mortality, lenght of hospitalisation and costs in ICU and non ICU patients Forecasts about changes in the coming years are worrisome The involvement of policy makers dealing with health as well as animal husbandry and pharmaceutical companies looks essential Civil society engagement will be fundamental to try to reverse the tide and the burden of antimicrobial resistance Patients should pretend doctors and health care systems take seriously the issue and push governement action
Are healthcare economics a factor behind European No significant relationship between the levels of GDP and MRSA proportions in the individual countries Significant relationship between IMR and MRSA proportion in the individual countries The degree of investment in healthcare systems would almost certainly play a critical role in determining the success or otherwise of MRSA control in the different European countries. MRSA rates? GDP: gross domestic product per capita IMR: infant mortality rate Borg, J hosp infect 2009