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
• MSSA
• A.baumannii S/R
• P. aeruginosa S/R
• MRSA
• E. coli
• 3GR E. coli
• Bloodstream infection
• CVC-BSI
• Pneumonia
• Prosthetic joint infection
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
Hospital costs
Cost of increased LOS
Cost of other nosocomial infection
Cost of litigation
Cost of infection
Cost of the drug
Cost of staff
Cost of infrastructure
Cost of resistance
Cost for infection control
Cost for screening
Cost for isolation / cohorting
Cost for laboratory
Ecological cost Cost of adverse effects
Patient costs Productivity costs
Direct costs
Productivity costs
Intangibles
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
Schwaber, JAC, 2007
Test for heterogeneity: p = 0.001
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
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
4.6
7.3
9.1
5
5.3
0.3
MSSA: 13.9 x 100,000 individuals
8.8
20.9
4.6
15
10.3
27.8
G3CREC: 2.6 x 100,000 individuals
2
1
4.6
3.1
5.6
1
G3CSEC: 25.6 x 100,000 individuals
15.7
48.7
34.2
41.6
8.9
48.1
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
Tacconelli, J hosp infect, 2009
CVC-BSI / ICU Systematic review
CVC BSI Costs
Tacconelli, J hosp infect, 2009
PJI
Incidence
Hellmann, J Arthroplasty, 2009; del Pozo, N Engl J Med, 2009
Hellmann, J Arthroplasty, 2009
Moran, J infect, 2007 Non tuberculous mycobacteria, Wang Intern Med 2011
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
Etiological agents
PJI
Bongartz, Arthritis & Rheumatism, 2008
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).
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
Prosthetic joint infection and
Rheumatoid arthritis
Lipsky, Infect Control Hosp Epidemiol, 2007; Hellmann, J Arthroplasty, 2009
annual adjusted diagnostic-related group cost: from $195 million to $283 million
Murphy, J Trauma 2011
MDR agents
PJI
«Collateral effects» of war
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
MRSA rates?
• 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.
GDP: gross domestic product per capita IMR: infant mortality rate
Borg, J hosp infect 2009