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