Costs and length of stay associated with antimicrobial resistance in acute kidney injury patients with bloodstream infection.

INTRODUCTION: Antimicrobial resistance negatively impacts on prognosis. Intensive care unit (ICU) patients, and particularly those with acute kidney injury (AKI), are at high risk for developing nosocomial bloodstream infections (BSI) due to multi-drug-resistant strains. Economic implications in terms of costs and length of stay (LOS) attributable to antimicrobial resistance are underevaluated. This study aimed to assess whether microbial susceptibility patterns affect costs and LOS in a well-defined cohort of ICU patients with AKI undergoing renal replacement therapy (RRT) who developed nosocomial BSI. METHODS: Historical study (1995-2004) enrolling all adult RRT-dependent ICU patients with AKI and nosocomial BSI. Costs were considered as invoiced in the Belgian reimbursement system, and LOS was used as a surrogate marker for hospital resource allocation. RESULTS: Of the 1330 patients with AKI undergoing RRT, 92 had microbiologic evidence of nosocomial BSI (57/92, 62% due to a multi-drug-resistant microorganism). Main patient characteristics were equal in both groups. As compared to patients with antimicro-4 bial-susceptible BSI, patients with antimicrobial-resistant BSI were more likely to acquire Gram-positive infection (72.6% vs 25.5%, P<0.001). No differences were found neither in LOS (ICU before BSI, ICU, hospital before BSI, hospital, hospital after BSI, and time on RRT; all P>0.05) or hospital costs (all P>0.05) when comparing patients with antimicrobial-resistant vs antimicrobial-susceptible BSI. However, although not statistically significant, patients with BSI caused by resistant Gram-negative-, Candida-, or anaerobic bacteria incurred substantial higher costs than those without. CONCLUSION: In a cohort of ICU patients with AKI and nosocomial BSI undergoing RRT, patients with antimicrobial-resistant vs antimicrobial-susceptible Gram-positive BSI did not have longer hospital stays, or higher hospital costs. Patients with resistant "other" (i.e. Gram-negative, Candida, or anaerobic) BSI were found to have a distinct trend towards increased resources use as compared to patients with susceptible "other" BSI, respectively.

Leukocyte CD14 and CD45 expression during hemodialysis: polysulfone versus cuprophane.

The expression of CD14 on monocytes and CD45 on monocytes and granulocytes was evaluated during hemodialysis by flow cytometric analysis in the 'resting state' and after in vitro stimulation with phorbol myristate acetate (PMA). A comparison of complement activating cuprophane (CU) versus less complement activating polysulfone (PS) was undertaken. 'Resting state' CD45 expression on granulocytes increased markedly during CU dialysis compared to time 0, whereas this rise was only moderate with PS (CU vs. PS, p < 0.01). When considering the increase in expression upon PMA stimulation, a lower value was obtained during CU dialysis for both CD14 (monocytes at 60 and 240 min) and for CD45 (monocytes and granulocytes at 15 min). In conclusion, granulocytes in the 'resting state' expressed more CD45 on their cell membranes during CU dialysis, whereas CD14 and CD45 upregulation after ex vivo addition of PMA was blunted during CU dialysis.