Managing hospitalized patients with bacterial infections: the price-to-pay upon site of infection.

INTRODUCTION: Infections impose a significant burden on healthcare costs worldwide. We aimed to explore antibiotic- and hospital-related costs of infections needing admission in a tertiary university hospital in Greece. METHODS: We performed a prospective cohort study in the medical care unit of a tertiary university hospital in Greece, for the period May 2016 to May 2018. Patients admitted with respiratory, urinary, gastrointestinal tract, skin, soft tissue and bone infections or primary bacteremia were included in this study. Costs of hospitalization and unit cost of antibiotic regimen were retrieved from a database for Greek hospitals containing data for each International Classification of Diseases (ICD-10) code and the national formulary respectively, and manually calculated for each patient. RESULTS: Antibiotic costs represent approximately 14-40% of total hospital-related costs depending on infection studied. Skin, soft tissue and bone infections and primary bacteremia led hospital- and antibiotic-related costs, with median costs of €6370 (interquartile range (IQR) 3330.90-11 503.90), €2519.90 (IQR 431.50-8371.10), €4418.10 (IQR 2335-8281.90) and €1394.30 (IQR 519.12-6459.90), respectively. Antibiotic- and hospital-related costs significantly differs with site of infection (p<0.0001). Length of stay is strongly correlated with antibiotic- and hospital-related costs, while site of infection is moderately related to antibiotic cost (eta value 0.445), and hospital-related cost (eta value 0.387). CONCLUSION: Healthcare-related costs vary substantially depending on site of infection. Information about real-life costs can drive best decisions and help to reduce healthcare expenditures.

Tocilizumab improves 28-day survival in hospitalized patients with severe COVID-19: an open label, prospective study.

BACKGROUND: Data on the safety and efficacy profile of tocilizumab in patients with severe COVID-19 needs to be enriched. METHODS: In this open label, prospective study, we evaluated clinical outcomes in consecutive patients with COVID-19 and PaO2/FiO2 < 200 receiving tocilizumab plus usual care versus usual care alone. Tocilizumab was administered at the time point that PaO2/FiO2 < 200 was observed. The primary outcome was 28-day mortality. Secondary outcomes included time to discharge, change in PaO2/FiO2 at day 5 and change in WHO progression scale at day 10. FINDINGS: Overall, 114 patients were included in the analysis (tocilizumab plus usual care: 56, usual care: 58). Allocation to usual care was associated with significant increase in 28-day mortality compared to tocilizumab plus usual care [Cox proportional-hazards model: HR: 3.34, (95% CI: 1.21-9.30), (p = 0.02)]. There was not a statistically significant difference with regards to hospital discharge over the 28 day period for patients receiving tocilizumab compared to usual care [11.0 days (95% CI: 9.0 to 16.0) vs 14.0 days (95% CI: 10.0-24.0), HR: 1.32 (95% CI: 0.84-2.08), p = 0.21]. ΔPaO2/FiO2 at day 5 was significantly higher in the tocilizumab group compared to the usual care group [42.0 (95% CI: 23.0-84.7) vs 15.8 (95% CI: - 19.4-50.3), p = 0.03]. ΔWHO scale at day 10 was significantly lower in the tocilizumab group compared to the usual care group (-0.5 ± 2.1 vs 0.6 ± 2.6, p = 0.005). CONCLUSION: Administration of tocilizumab, at the time point that PaO2/FiO2 < 200 was observed, improved survival and other clinical outcomes in hospitalized patients with severe COVID-19 irrespective of systemic inflammatory markers levels.

Patterns, price and predictors of successful empiric antibiotic therapy in a real-world setting.

WHAT IS KNOWN AND OBJECTIVE: Prompt and appropriate empiric antibiotic therapy (EAT) remains the cornerstone of successful outcomes, while the majority of blood cultures do not identify pathogen. We aimed to report patterns of EAT and its impact on outcomes and associated medical costs, while exploring predictors of its success in a real-world setting. METHODS: We retrospectively utilized the prospective registry of the medical unit of a tertiary university hospital, including patients admitted with diagnosis of infection between 1st May 2016 and 1st May 2018. Costs of hospitalization and unit of antibiotic regimen were retrieved from a database regarding Greek hospitals containing hospitalization-cost data for each ICD-10 code and the national formulary, respectively. RESULTS: A total of 489 patients were included in this study. Mean age was 61.3 years, 53% were males, while intra-abdominal infections predominated (55%). The most commonly administered EAT included quinolones (48%), followed by piperacillin/tazobactam (18%), or other regimens alone or in combination. EAT was successful in 67% and failed in 33% of cases. Fourteen patients died of the infection before EAT was switched, while among 55 patients that EAT had to be modified, mortality was 22%. Presence of urinary tract infection and use of quinolones, least predicted for failure of EAT [OR:0.15 (0.07-0.35), p < 0.0001, OR:0.53 (0.32-0.90), p = 0.019, respectively], in contrast to presence of sepsis [OR:3.11 (1.79-5.40), p < 0.0001]. Patients with failure had longer length of stay [7(5-11) versus 4 (3-6) days], higher antibiotic [201.9 (97.8-471.8) vs 104.6 (60.2-187.7) euros] and hospitalization costs [1409.3 (945.4-2311.6) vs 759.4 (516.5-1036.5) euros] (p < 0.0001). DISCUSSION: We observed significantly increased antibiotic-related, healthcare-related costs and length of stay in patients with failure of EAT. Moreover, in our cohort, absence of sepsis, presence of urinary tract infection and use of quinolones better predicted for success of EAT. WHAT IS NEW AND CONCLUSIONS: Appropriate selection of EAT is crucial to ensure better outcomes and minimize costs.

Escherichia coli Endocarditis Presenting With Septic Shock in an Immunocompetent Female Patient.

Escherichia coli (E. coli) is a rare cause of infective endocarditis, despite being a common cause of bacteremia. E. coli endocarditis affects most frequently immunocompromised elderly women, especially those with diabetes mellitus. We present a case of a 78-year-old female immunocompetent patient, presenting with septic shock and multiple organ dysfunction syndrome. E. coli was isolated in all sets of blood cultures and in urine culture and a contrast-enhanced abdominal computed tomography (CT) scan revealed spleen and left kidney infracts. Transthoracic echocardiography revealed a large (> 15 mm) mobile mass on the atrial side of the posterior mitral valve leaflet. The patient was initially treated with intravenous ceftriaxone and ciprofloxacin for 2 weeks with successful clinical response and clearance of bacteremia, was then subjected to valve replacement (with isolation of E. coli from replaced valve cultures) and continued antibiotic therapy for additional 4 weeks postoperatively. E. coli has emerged in recent years as an important cause of bacteremia, especially in the elderly. In selected patients, as those with persistent Gram-negative bacteremia or severe sepsis/septic shock, echocardiography is of paramount importance for the diagnosis of Gram-negative endocarditis and should be included in our diagnostic algorithm of patient's evaluation.