Abstract
Excess length of stay (LOS) is an important outcome when assessing the burden of nosocomial infection, but it can be subject to survival bias. We aimed to estimate the change in LOS attributable to hospital-onset (HO) Escherichia coli/Klebsiella spp. bacteremia using multistate models to circumvent survival bias. We analyzed a cohort of all patients with HO E. coli/Klebsiella spp. bacteremia and matched uninfected control patients within the U.S. Veterans Health Administration System in 2003–2013. A multistate model was used to estimate the change in LOS as an effect of the intermediate state (HO-bacteremia). We stratified analyses by susceptibilities to fluoroquinolones (fluoroquinolone susceptible (FQ-S)/fluoroquinolone resistant (FQ-R)) and extended-spectrum cephalosporins (ESC susceptible (ESC-S)/ESC resistant (ESC-R)). Among the 5964 patients with HO bacteremia analyzed, 957 (16.9%) and 1638 (28.9%) patients had organisms resistant to FQ and ESC, respectively. Any HO E.coli/Klebsiella bacteremia was associated with excess LOS, and both FQ-R and ESC-R were associated with a longer LOS than susceptible strains, but the additional burdens attributable to resistance were small compared to HO bacteremia itself (FQ-S: 12.13 days vs. FQ-R: 12.94 days, difference: 0.81 days (95% CI: 0.56–1.05), p < 0.001 and ESC-S: 11.57 days vs. ESC-R: 16.56 days, difference: 4.99 days (95% CI: 4.75–5.24), p < 0.001). Accurate measurements of excess attributable LOS associated with resistance can help support the business case for infection control interventions.
Highlights
Healthcare-associated infection (HAI) is an important cause of increased mortality and morbidity in the United States (U.S.) with an estimated annual incidence of 1.7 million cases, with 99,000 deaths and an economic impact of approximately 6.5 billion U.S dollars [1]
E.coli/Klebsiella bacteremia was associated with excess length of stay (LOS), and both fluoroquinolone resistance (FQ-R) and extended-spectrum cephalosporin resistance (ESC-R) were associated with a longer LOS than susceptible strains, but the additional burdens attributable to resistance were small compared to HO bacteremia itself
When stratified by resistance profiles of case patients, both FQ-R and extended-spectrum cephalosporin (ESC)-R were associated with a longer LOS compared to susceptible strains
Summary
Healthcare-associated infection (HAI) is an important cause of increased mortality and morbidity in the United States (U.S.) with an estimated annual incidence of 1.7 million cases, with 99,000 deaths and an economic impact of approximately 6.5 billion U.S dollars [1]. The recent rise of antimicrobial resistance (AMR) is adding to the health and economic burden of HAIs. In 2019, the Centers for Disease Control and Prevention (CDC) estimated that infections with AMR affect at least 2.8 million people annually and cause at least 35,900 excessive deaths per Antibiotics 2020, 9, 96; doi:10.3390/antibiotics9020096 www.mdpi.com/journal/antibiotics. Studies assessing the mortality and non-mortality burden of AMR are needed because they will help us determine the most cost-effective target in infection control and antimicrobial stewardship, two major strategies to combat HAI and AMR
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