The socio-economic impact of multidrug-resistant nosocomial infections: a qualitative study.

The burden of healthcare-associated infections (HCAIs) has traditionally been measured using clinical and economic outcomes. We conducted semi-structured interviews with 18 patients or their caregivers affected by HCAI caused by multidrug-resistant organisms to better understand the human impact of HCAI. Most patients had misconceptions about HCAI and antimicrobial resistance, leading to strong negative feelings towards HCAIs despite positive views of their healthcare providers. Communication issues across power imbalances need to be addressed to help deal with trauma of HCAIs. A holistic approach to HCAIs incorporating patient perspectives will likely help guide policymakers developing solutions to improve patient outcomes.

Impact and experiences of delayed discharge: A mixed-studies systematic review.

BACKGROUND: The impact of delayed discharge on patients, health-care staff and hospital costs has been incompletely characterized. AIM: To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients' outcomes and costs. METHODS: Four of the main biomedical databases were searched for the period 2000-2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included. RESULTS: Thirty-seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients' mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well-being. Extra bed-days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients. CONCLUSIONS: The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.

[Costs associated with multiresistant bacteria in neurorehabilitation]. / Mehrkosten durch multiresistente Erreger in der Neurorehabilitation.

BACKGROUND AND OBJECTIVES: The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB. MATERIALS AND METHODS: To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany. RESULTS: On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB. CONCLUSIONS: Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Antimicrobial consumption, costs and resistance patterns: a two year prospective study in a Romanian intensive care unit.

BACKGROUND: Due to the vulnerable nature of its patients, the wide use of invasive devices and broad-spectrum antimicrobials used, the intensive care unit (ICU) is often called the epicentre of infections. In the present study, we quantified the burden of hospital acquired pathology in a Romanian university hospital ICU, represented by antimicrobial agents consumption, costs and local resistance patterns, in order to identify multimodal interventional strategies. METHODS: Between 1st January 2012 and 31st December 2013, a prospective study was conducted in the largest ICU of Western Romania. The study group was divided into four sub-samples: patients who only received prophylactic antibiotherapy, those with community-acquired infections, patients who developed hospital acquired infections and patients with community acquired infections complicated by hospital-acquired infections. The statistical analysis was performed using the EpiInfo version 3.5.4 and SPSS version 20. RESULTS: A total of 1596 subjects were enrolled in the study and the recorded consumption of antimicrobial agents was 1172.40 DDD/ 1000 patient-days. The presence of hospital acquired infections doubled the length of stay (6.70 days for patients with community-acquired infections versus 16.06/14.08 days for those with hospital-acquired infections), the number of antimicrobial treatment days (5.47 in sub-sample II versus 11.18/12.13 in sub-samples III/IV) and they increased by 4 times compared to uninfected patients. The perioperative prophylactic antibiotic treatment had an average length duration of 2.78 while the empirical antimicrobial therapy was 3.96 days in sample II and 4.75/4.85 days for the patients with hospital-acquired infections. The incidence density of resistant strains was 8.27/1000 patient-days for methicilin resistant Staphylococcus aureus, 7.88 for extended spectrum ß-lactamase producing Klebsiella pneumoniae and 4.68/1000 patient-days for multidrug resistant Acinetobacter baumannii. CONCLUSIONS: Some of the most important circumstances collectively contributing to increasing the consumption of antimicrobials and high incidence densities of multidrug-resistant bacteria in the studied ICU, are represented by prolonged chemoprophylaxis and empirical treatment and also by not applying the definitive antimicrobial therapy, especially in patients with favourable evolution under empirical antibiotic treatment. The present data should represent convincing evidence for policy changes in the antibiotic therapy.

Pharmacotherapy for methicillin-resistant Staphylococcus aureus nosocomial pneumonia.

OBJECTIVE: To review the evidence for pharmacologic agents available in the treatment of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. DATA SOURCES: A search of PubMed (1975-July 2012) was conducted using a combination of the terms methicillin-resistant Staphylococcus aureus, pneumonia, nosocomial, vancomycin, linezolid, telavancin, ceftaroline, tigecycline, and quinupristin/dalfopristin. STUDY SELECTION AND DATA EXTRACTION: Randomized comparative clinical trials, meta-analyses, and review articles published in English were included. A manual review of the bibliographies of available literature was conducted and all relevant information was included. Observational and in vitro studies were incorporated as indicated. DATA SYNTHESIS: Pharmacotherapy for the treatment of nosocomial MRSA pneumonia is limited. Vancomycin has been the treatment of choice for several years. Linezolid has demonstrated similar efficacy to vancomycin in randomized clinical trials and recent data have suggested that it may be superior in some cases, although there are limitations to this conclusion. Telavancin has also demonstrated similar clinical efficacy to vancomycin; however, the drug is not commercially available in the US. Other agents with MRSA activity include ceftaroline, clindamycin, quinupristin/dalfopristin, and tigecycline, although the evidence for their use in nosocomial pneumonia is limited. CONCLUSIONS: Based on the currently available evidence and cost-effectiveness, vancomycin should continue to be the drug of choice for most patients with nosocomial MRSA pneumonia. Linezolid is a reasonable alternative for patients with treatment failure while receiving vancomycin, isolates with vancomycin minimum inhibitory concentrations over 2 µg/mL, allergic reactions, or vancomycin-induced nephrotoxicity.

Antimicrobial stewardship: bridging the gap between quality care and cost.

PURPOSE OF REVIEW: Antibiotic resistance continues to rise, whereas development of new agents to counter it has slowed. A heightened need exists to maintain the effectiveness of currently available agents. This review focuses on the need for better antimicrobial stewardship, expected benefits of well designed antimicrobial stewardship programs (ASPs), and provides suggestions for development of an effective ASP. RECENT FINDINGS: Healthcare-associated infections (HAIs) are a significant cause of poor treatment outcomes and elevated healthcare and societal costs worldwide. HAIs are often caused by antibiotic-resistant pathogens; overuse of antibiotics has been linked with antibiotic resistance. Benefits of improved antimicrobial stewardship include reduced emergence of antibiotic resistance, limitation of drug-related adverse events, minimization of other consequences of antibiotic use (e.g., superinfection), and reduction of societal and healthcare-related costs. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) provided guidelines for the development of institutional programs to enhance antimicrobial stewardship. Experiences at The Ohio State University Medical Center (OSUMC) reinforce this message, while providing specific examples of ways to optimize ASP development and implementation. The focus of an ASP should be on improving quality of care, reducing drug resistance, and cost savings. When implementing an ASP, it is important to identify those most likely to resist the ASP, understand their concerns, and develop easy-to-understand messages that address these concerns and highlight the benefits of the proposed changes. Antibiograms play a key role in identifying local and interdepartmental trends in antibiotic susceptibility or resistance. These data are important not only in devising best-treatment practices for the institution, but also in evaluating the impact of a recently implemented ASP. Other measures of the impact of an ASP should include patient outcomes and overall costs or savings. SUMMARY: Better antimicrobial stewardship is needed to limit the emergence of antibiotic resistance, prolong the effectiveness of currently available agents, improve patient outcomes, and reduce healthcare and societal costs associated with HAIs. Guidelines from the IDSA/SHEA and experiences at OSUMC provide examples of how best to develop an institutional ASP to accomplish these goals.

Hospital-acquired infections before and after healthcare reorganization in a tertiary university hospital in Norway.

BACKGROUND: To evaluate hospital-acquired infections (HAIs) in somatic (all admissions other than psychiatric) and psychiatric patients admitted to a tertiary university hospital in Oslo, before and after reorganization of the Norwegian healthcare system in 2002. METHODS: Point prevalence studies were conducted four times per annum and over the period from 1995 to 2007. RESULTS: A total of 57,360 patients were studied over the whole time period: 80.5% in somatic wards and 19.5% in psychiatric wards. The HAI rate was 6.9%, of which 8.1% were somatic and 1.9% psychiatric. 13.4% of operated patients had HAI, including 6.2% due to surgical wound infections. In somatic wards, 0.6-1% were re-admitted with HAI, 15.2-23% had infections and 18-23% used antibiotics. There was a reduction in HAI until 2002. From 2003 on, HAI increased (P = 0.010) in somatic wards (P = 0.002), in non-operated patients (P = 0.024) and in extra costs. In 2002, the Norwegian healthcare system was reorganized. This reorganization led to a 30% increase in somatic patients treated from 2003 to 2007 (P = 0.054), 27% increase in the total workload per work position (P = 0.024) and 23.5% decrease in internal service work. CONCLUSION: A declining trend of HAI was observed from 1995 to 2002 at the tertiary university hospital in Norway. In 2002, the Norwegian healthcare system was reorganized. From 2003 to 2007, HAI increased significantly as did the number of somatic patients and workload at our hospital.

In vitro inhibition of vancomycin-susceptible and vancomycin-resistant Enterococcus faecium and E. faecalis in the presence of citrus essential oils.

Glycopeptide-resistant Enterococcus (GRE) is an important healthcare-acquired infection (HCAI) which costs the healthcare service many millions of pounds worldwide. In this study, lemon (Citrus limon), sweet orange (Citrus sinensis) or bergamot (Citrus bergamia) essential oils (EO) and their vapours, alone and in combination, are tested for their antimicrobial activity against vancomycin-resistant and vancomycin-sensitive strains of E. faecium and E. faecalis. A blend of 1:1 (v/v) orange and bergamot EO was the most effective of the oils and/or blends tested with a minimum inhibitory concentration (MIC), at 25 degrees C and pH 5.5, of 0.25-0.5% (v/v) and a minimum inhibitory dose (MID) of 50 mg/L, at 50 degrees C at pH 7.5, when viable counts reduced by 5.5-10 log10 colony forming units (cfu)/mL, suggesting that this blend of citrus oils is effective under a range of conditions for inhibiting the growth and survival of E. faecalis, E. faecium and VRE.

Cost-effectiveness of rotavirus vaccination: exploring caregiver(s) and "no medical care'' disease impact in Belgium.

AIM: To estimate the cost-effectiveness of universal childhood rotavirus vaccination in Belgium, taking into account the impact of caregiver burden and the burden of sick children for whom no medical care is sought ("no medical care'' ). METHODS: A cohort of newborns is modeled in relation to costs and health outcomes for rotavirus disease, distinguishing episodes leading to consultations, hospitalizations, and deaths from no medical care episodes. Fully funded universal vaccination is compared with no vaccination as well as with the current situation in Belgium, whereby the 2-dose Rotarix or the 3-dose RotaTeq vaccine can be bought at market prices, which are partially reimbursed. RESULTS: Compared with no vaccination, fully funded universal rotavirus vaccination would cost 51,030 per quality-adjusted life year (QALY) gained with Rotarix and 65,767 with RotaTeq (for society, 7572 and 30,227 per QALY, respectively). However, there is considerable uncertainty due to some analytical choices: the proportion of simulations with an acceptable incremental cost-effectiveness ratio (given a willingness to pay 50,000 for an additional QALY), increases from 2%/0.6% (Rotarix/RotaTeq) to 86%/59% when considering no medical care, and including 2 caregivers to estimate QALY loss instead of zero. Uncertainty is greater still under the societal than under the health care payer perspective. CONCLUSION: For the Belgian health care payer, at current vaccine prices, universal childhood rotavirus vaccination is unlikely to be judged cost-effective versus no vaccination but would be a more efficient and equitable choice than continuing with current practice.

Gram-negative antibiotic resistance: there is a price to pay.

Resistance rates are increasing among several problematic Gram-negative pathogens that are often responsible for serious nosocomial infections, including Acinetobacter spp., Pseudomonas aeruginosa, and (because of their production of extended-spectrum beta-lactamase) Enterobacteriaceae. The presence of multiresistant strains of these organisms has been associated with prolonged hospital stays, higher health care costs, and increased mortality, particularly when initial antibiotic therapy does not provide coverage of the causative pathogen. Conversely, with high rates of appropriate initial antibiotic therapy, infections caused by multiresistant Gram-negative pathogens do not negatively influence patient outcomes or costs. Taken together, these observations underscore the importance of a 'hit hard and hit fast' approach to treating serious nosocomial infections, particularly when it is suspected that multiresistant pathogens are responsible. They also point to the need for a multidisciplinary effort to combat resistance, which should include improved antimicrobial stewardship, increased resources for infection control, and development of new antimicrobial agents with activity against multiresistant Gram-negative pathogens.

[The Dutch MRSA policy should be retained]. / Het Nederlandse MRSA-beleid is succesvol.

The Dutch methicillin-resistant Staphylococcus aureus (MRSA) 'search and destroy' policy is effective. MRSA should be banned from hospitals: MRSA infections are associated with increased mortality and costs. In addition, widespread use of vancomycin for treating MRSA infections encourages the spread and development of vancomycin-resistant micro-organisms.

Costs associated with hospital-acquired bacteraemia in a Belgian hospital.

Studies from around the world have shown that hospital-acquired infections increase the costs of medical care due to prolongation of hospital stay, and increased morbidity and mortality. The aim of this study was to determine the extra costs associated with hospital-acquired bacteraemias in a Belgian hospital in 2001 using administrative databases and, in particular, coded discharge data. The incidence was 6.6 per 10000 patient days. Patients with a hospital-acquired bacteraemia experienced a significantly longer stay (average 21.1 days, P<0.001), a significantly higher mortality (average 32.2%, P<0.01), and cost significantly more (average 12853 euro, P<0.001) than similar patients without bacteraemia. At present, the Belgian healthcare system covers most extra costs; however, in the future, these outcomes of hospital-acquired bacteraemia will not be funded and prevention will be a major concern for hospital management.

Reduction in broad-spectrum antimicrobial use associated with no improvement in hospital antibiogram.

OBJECTIVE: To evaluate the effect of an antimicrobial management programme on broad-spectrum antimicrobial use and antimicrobial susceptibilities of common nosocomial pathogens at a tertiary-care teaching hospital. METHODS: Review of hospital charts of patients who had been prescribed broad-spectrum antimicrobials 48 h earlier. Recommendations to streamline or discontinue antimicrobials were made based on results of available microbiology data, radiography studies, as well as the working diagnosis at the time of review. The charts were reviewed again on the following day to assess acceptance or rejection of the recommendations. Antimicrobial use, measured as defined daily dose per 1000 patient days (DDD/1000 PD), was determined before and after the antimicrobial management programme was started and was assessed as the mean quarterly use in the six quarters preceding implementation of the programme compared to the most recent six quarters that the programme has been in existence. Antibiotic susceptibilities were obtained from the clinical microbiology laboratory. RESULTS: Compared to the six quarters before the programme, broad-spectrum antibiotic use decreased by 28% (693 DDD/1000 PD to 502 DDD/1000 PD, P = 0.003). Total antifungal agent use decreased by a similar amount, i.e. 28% (144 DDD/1000 PD to 103 DDD/1000 PD, P = 0.02). Total antimicrobial use decreased by 27% (1461 DDD/1000 PD to 1069 DDD/1000 PD, P = 0.0007). Susceptibilities of common nosocomial Gram-negative organisms to commonly prescribed antibiotics did not change significantly over the 3 years of the programme. The rate of methicillin-resistant Staphylococcus aureus increased significantly in the non-intensive care areas of the hospital (P = 0.02) and decreased significantly in the intensive care areas of the hospital (P = 0.009) over the 4 year period from 2000 to 2003. CONCLUSION: Implementation of an antibiotic management programme resulted in substantial reductions in both broad-spectrum and total antimicrobial consumption without having a significant impact on antibiotic susceptibilities of common Gram-negative microorganisms within the institution. The changes in MRSA rate in the non-ICU and ICU settings may reflect infection control measures that were in place during the study period.

Endemic nosocomial infections and misuse of antibiotics in a maternity hospital in Saudi Arabia.

Patients admitted during a 6-month period to a maternity hospital in Saudi Arabia were studied for nosocomial infections and misuse of antibiotics. Patient history and diagnosis on admission and subsequent clinical and laboratory data were analysed. Infection developing from 72 h after admission was considered nosocomial. Therapeutic and prophylactic data as recorded on the patients' charts were assessed for possible misuse of antibiotics. Of 3439 patients, 136 (4.0%) developed nosocomial infection: 2.0%, 8.9% and 37.7% in obstetric, gynaecologic and nursery patients, respectively. Infections among adults were mostly found in the urinary (44.4%) and lower genital (33.3%) tracts. Among newborns, over 70% of cases were eye and ear (29.8%), skin (26.2%) and blood (19.0%) infections. Gram-negative bacteria caused 65.7% of the infections. Over 90% of the bacterial isolates were multidrug-resistant. About 24% of patients received single or multiple antibiotics; 57.2% were misused. The minimal hospital cost estimate for both nosocomial infections and misused antibiotics was US $318,705. The findings of this study, the first of its type in this region, should prompt improved infection control measures as well as educational and antibiotic restriction interventions.

Clinical and economic evaluation of subsequent infection following intravenous ciprofloxacin or imipenem therapy in hospitalized patients with severe pneumonia.

A recent multicentre clinical study evaluated the safety and efficacy of i.v. ciprofloxacin therapy compared with imipenem-cilastatin in hospitalized patients with severe pneumonia. Monotherapy with i.v. ciprofloxacin was at least equivalent to imipenem in terms of bacteriological eradication and clinical response. In a single-centre, retrospective, post-therapy evaluation of persistent and subsequent infection, the incidence of gram-negative infections and associated costs were compared. The main elements of the economic analysis included costs of additional antimicrobial therapy and hospitalization. Thirty-two patients were randomized into the study, of whom 27 were efficacy-valid. The 13 patients randomized into the ciprofloxacin group were not significantly different from the 14 patients in the imipenem group in terms of clinical parameters. Clinical cure occurred in ten of 13 patients (77%) in the ciprofloxacin group and in seven of 14 (50%) in the imipenem group. Bacteriological eradication was achieved in 11 of 13 (85%) ciprofloxacin-treated and eight of 14 (57%) imipenem-treated patients. Five of 13 (38%) patients in the ciprofloxacin group and nine of 14 (64%) in the imipenem group experienced persistent or subsequent infection requiring post-treatment antimicrobials. In these five ciprofloxacin patients, three had cultures with gram-positive organisms only and two had cultures with both gram-positive and gram-negative organisms. In the nine imipenem-treated patients requiring post-study antimicrobials, all had gram-negative bacteria and three also had gram-positive organisms. The incidence of subsequent gram-negative infection in the two groups (15% vs 64%) was significantly different (P < 0.05). Pseudomonas aeruginosa was isolated from seven patients in the imipenem group but only one in the ciprofloxacin group (P < 0.05). Subsequent costs for post-therapy antimicrobials and hospital stay while receiving study and post-study drug therapy were evaluated; the cost per patient cure was US$29,000 for ciprofloxacin and US$76,000 for imipenem. Initial treatment of severe pneumonia with ciprofloxacin resulted in significantly less subsequent gram-negative infection and was associated with substantially lower curative costs.