Abstract
We performed a multicentre retrospective cohort study including 606,649 acute inpatient episodes at 10 European hospitals in 2010 and 2011 to estimate the impact of antimicrobial resistance on hospital mortality, excess length of stay (LOS) and cost. Bloodstream infections (BSI) caused by third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE), meticillin-susceptible (MSSA) and -resistant Staphylococcus aureus (MRSA) increased the daily risk of hospital death (adjusted hazard ratio (HR) = 1.80; 95% confidence interval (CI): 1.34–2.42, HR = 1.81; 95% CI: 1.49–2.20 and HR = 2.42; 95% CI: 1.66–3.51, respectively) and prolonged LOS (9.3 days; 95% CI: 9.2–9.4, 11.5 days; 95% CI: 11.5–11.6 and 13.3 days; 95% CI: 13.2–13.4, respectively). BSI with third-generation cephalosporin-susceptible Enterobacteriaceae (3GCSE) significantly increased LOS (5.9 days; 95% CI: 5.8–5.9) but not hazard of death (1.16; 95% CI: 0.98–1.36). 3GCRE significantly increased the hazard of death (1.63; 95% CI: 1.13–2.35), excess LOS (4.9 days; 95% CI: 1.1–8.7) and cost compared with susceptible strains, whereas meticillin resistance did not. The annual cost of 3GCRE BSI was higher than of MRSA BSI. While BSI with S. aureus had greater impact on mortality, excess LOS and cost than Enterobacteriaceae per infection, the impact of antimicrobial resistance was greater for Enterobacteriaceae.
Highlights
Antimicrobial resistance (AMR) represents a significant global threat [1,2]
While third-generation cephalosporin resistance significantly decreased the hazard of discharge alive among patients with bloodstream infections (BSI) due to Enterobacteriaceae, meticillin resistance showed only a trend in this direction among patients with BSI due to S. aureus
S. aureus BSI had a greater effect on mortality, length of stay (LOS) and cost than BSI due to Enterobacteriaceae
Summary
Antimicrobial resistance (AMR) represents a significant global threat [1,2]. Response to this threat requires coordinated international interventions likely to involve commitment of substantial resources [3]. Comprehensive data remain scarce; a recent World Health Organization (WHO) systematic review identified a “lack of properly designed and conducted economic studies comparing the resource use associated with resistant versus nonresistant pathogens” [1]. Studies to determine health outcomes of infections with community and hospital onset must adequately account for confounding, the timing of infection (time dependency) and simultaneous impact on risk of death and discharge (competing risks), and analyse a sample of sufficient size to produce precise estimates [4,5]. The major determinant of the economic burden of such infections from the hospital perspective is the number of bed-days they consume, it is challenging to produce an appropriate economic valuation of each marginal bed-day [6]
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