Provider attitudes to the empiric treatment of asymptomatic contacts of gonorrhoea.

Background In the current era of antimicrobial stewardship, the availability of highly sensitive assays and faster turnaround times, the practice of empiric treatment of asymptomatic contacts of gonorrhoea needs review. The views of clinicians in a range of settings across Australia and clinic costs associated with a change of practice was examined. METHODS: An online anonymous survey for nurses and doctors working in public sexual health clinics and general practices in urban, regional and rural Australia was developed. Information on the relative importance of a range of factors influencing delivery of empiric treatment was collected. Participants were asked whether current guidelines should change. RESULTS: Surveys were distributed to 468 healthcare providers and 188 (40.2%) fully completed the survey. Most of the participants worked in public practice (84.9%) and 86 (43.2%) were doctors. Factors influencing provision of empiric treatment were: if the patient was unable to return (95.9%) or may not return (95.3%); risk of transmission to others (93.3%); likelihood of infection (88.6%); and patient request (82.9%). Respondents were evenly split as to whether current guidelines should change, with providers in private practice being less likely to support guideline change (P = 0.03). The model of empiric treatment of all asymptomatic sexual contacts was 34% more expensive than a model of testing and treatment of those with a positive result. CONCLUSION: Currently, the majority of clinicians provide empiric treatment for asymptomatic contacts in Australia. There was significant support for a change in guidelines with specific scenarios requiring individualised responses.

Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis.

OBJECTIVE: To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance. DESIGN: Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials. SETTING: 24 ICUs in the Netherlands. PARTICIPANTS: 12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232). INTERVENTIONS: SDD versus SOD. PRIMARY AND SECONDARY OUTCOME MEASURES: The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death. RESULTS: The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI -€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD. CONCLUSION: In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.

The cost of a disease targeted for elimination in Brazil: the case of schistosomiasis mansoni.

BACKGROUND: Schistosomiasis mansoni is a poverty-related parasitic infection that has a variety of clinical manifestations. We consider the disability and deaths caused by schistosomiasis unacceptable for a tool-ready disease. Its condition in Brazil warrants an analysis that will enable better understanding of the local health losses and contribute to the complex decision-making process. OBJECTIVE: This study estimates the cost of schistosomiasis in Brazil in 2015. METHODS: We conducted a cost of illness study of schistosomiasis mansoni in Brazil in 2015 based on a prevalence approach and from a societal perspective. The study included 26,499 schistosomiasis carriers, 397 hepatosplenic cases, 48 cases with the neurological form, 284 hospitalisations, and 11,368.26 years of life lost (YLL) of which 5,187 years are attributable to economically active age groups. RESULTS: The total cost of schistosomiasis mansoni in Brazil was estimated to be US$ 41,7million in 2015 with 94.61% of this being indirect costs. CONCLUSIONS: The economic burden of schistosomiasis mansoni in Brazil is high and results in the loss of productivity. Its persistence in Brazil is a challenge to public health and requires inter-sectorial interventions in areas such as indoor water supply, basic sanitation, and education.

[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.

[Diagnostics and Eradication Therapy for MRSA Carriers in the Outpatient Sector: an Analysis of the Reimbursement Situation in the Light of Current Reimbursement Changes]. / Diagnostik und ambulante Eradikationstherapie von Trägern mit MRSA in der vertragsärztlichen Versorgung ­ Eine Analyse der Erstattungssituation im Kontext aktueller Vergütungsveränderungen.

Infection with methicillin-resistant Staphylococcus aureus (MRSA) occurs in both the inpatient and outpatient sector. The reimbursement for diagnostic services and eradication therapy in the outpatient sector was regulated for the first time on 01.04.2012 and after a 2-year test period, has been adopted into the standard range of care services. The aim of this retrospective study was to give an overview of the current situation in services and reimbursement in Germany and describe MRSA patients and their treatment in the outpatient sector. Secondary data, namely reimbursement data of the National Association of Statutory Health Insurance Physicians (KBV) und the Physicians' Association (KV) Mecklenburg-West Pomerania for the period 01/04/2012-31/03/2014 were analyzed. Results show that on the federal level, MRSA services amounting to € 3,235,870.18 have been reimbursed and that diagnostic costs exceed treatment costs. In Germany, 5,627 doctors invoiced services related to MRSA; 51,56% of these were general practitioners and 21,25% specialists in internal medicine working in general practice. In the KV Mecklenburg-Western Pomerania, patients were elderly (average age 69,13), cost for services were on average 27,76 €, and 76,85% of the patients were treated within one quarter. On the whole, there were regional differences in the identification and eradication of MRSA in the outpatient setting. In order to provide an extended base for a more efficient resource allocation in the health care sector, in addition to analysis of MRSA eradication from the medical point of view, attention needs to be paid to patient flow between the out- and inpatient sectors, as well as economic aspects.

Cost savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial.

OBJECTIVE: To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients). DESIGN: Cost analysis using decision modeling. METHODS: We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature. RESULTS: In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions. CONCLUSIONS: A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.

Characteristics and costs of carbapenemase-producing enterobacteria carriers (2012/2013).

OBJECTIVES: We had for aim to determine the characteristics of carbapenemase-producing enterobacteria (CPE) carriers and to assess the economic impact of isolation measures leading to loss of activity (closed beds, prolonged hospital stays) and additional personnel hours. PATIENTS AND METHODS: We conducted a retrospective study for 2years (2012/2013), in a French general hospital, focusing on CPE carriers with clinical case description. The costs were estimated by comparing the activity of concerned units (excluding the ICU) during periods with CPE carriers or contacts, during the same periods of the year (n-1), plus additional hours and rectal swabs. RESULTS: Sixteen EPC carriers were identified: 10 men and 6 women, 65±10years of age. Seven patients acquired EPC in hospital during 2 outbreaks in 2012. Four patients presented with an infection (peritonitis, catheter infection, and 2 cases of obstructive pyelonephritis) with a favorable outcome. The median length of stay was 21days [4,150]. Six patients died, 1 death was indirectly due to CPE because of inappropriate empiric antibiotic therapy. A decrease in activity was observed compared to the previous year with an estimated 547,303€ loss. The 1779 additional hours cost 63,870€, and 716 screening samples cost 30,931€. The total additional cost was estimated at 642,104€ for the institution. CONCLUSIONS: Specialized teams for CPE carriers and isolation of contact patients, required to avoid/control epidemics, have an important additional cost. An appreciation of their support is needed, as well as participation of rehabilitation units.

Active surveillance for carbapenem-resistant Enterobacteriaceae using stool specimens submitted for testing for Clostridium difficile.

Active surveillance to identify asymptomatic carriers of carbapenem-resistant Enterobacteriaceae (CRE) is a recommended strategy for CRE control in healthcare facilities. Active surveillance using stool specimens tested for Clostridium difficile is a relatively low-cost strategy to detect CRE carriers. Further evaluation of this and other risk factor-based active surveillance strategies is warranted.

Economic risk analysis model for bovine viral diarrhea virus biosecurity in cow-calf herds.

A stochastic model was designed to calculate the cost-effectiveness of biosecurity strategies for bovine viral diarrhea virus (BVDV) in cow-calf herds. Possible sources of BVDV introduction considered were imported animals, including the calves of pregnant imports, and fenceline contact with infected herds, including stocker cattle raised in adjacent pastures. Spread of BVDV through the herd was modeled with a stochastic SIR model. Financial consequences of BVDV, including lost income, treatment costs, and the cost of biosecurity strategies, were calculated for 10 years, based on the risks of a herd with a user-defined import profile. Results indicate that importing pregnant animals and stockers increased the financial risk of BVDV. Strategic testing in combination with vaccination most decreased the risk of high-cost outbreaks in most herds. The choice of a biosecurity strategy was specific to the risks of a particular herd.

Pneumococcal transmission and disease in silico: a microsimulation model of the indirect effects of vaccination.

BACKGROUND: The degree and time frame of indirect effects of vaccination (serotype replacement and herd immunity) are key determinants in assessing the net effectiveness of vaccination with pneumococcal conjugate vaccines (PCV) in control of pneumococcal disease. Using modelling, we aimed to quantify these effects and their dependence on coverage of vaccination and the vaccine's efficacy against susceptibility to pneumococcal carriage. METHODS AND FINDINGS: We constructed an individual-based simulation model that explores the effects of large-scale PCV programmes and applied it in a developed country setting (Finland). A population structure with transmission of carriage taking place within relevant mixing groups (families, day care groups, schools and neighbourhoods) was considered in order to properly assess the dependency of herd immunity on coverage of vaccination and vaccine efficacy against carriage. Issues regarding potential serotype replacement were addressed by employing a novel competition structure between multiple pneumococcal serotypes. Model parameters were calibrated from pre-vaccination data about the age-specific carriage prevalence and serotype distribution. The model predicts that elimination of vaccine-type carriage and disease among those vaccinated and, due to a substantial herd effect, also among the general population takes place within 5-10 years since the onset of a PCV programme with high (90%) coverage of vaccination and moderate (50%) vaccine efficacy against acquisition of carriage. A near-complete replacement of vaccine-type carriage by non-vaccine-type carriage occurs within the same time frame. CONCLUSIONS: The changed patterns in pneumococcal carriage after PCV vaccination predicted by the model are unequivocal. The overall effect on disease incidence depends crucially on the magnitude of age- and serotype-specific case-to-carrier ratios of the remaining serotypes relative to those of the vaccine types. Thus the availability of reliable data on the incidence of both pneumococcal carriage and disease is essential in assessing the net effectiveness of PCV vaccination in a given epidemiological setting.

Burden of meticillin-resistant Staphylococcus aureus colonization and infection in London acute hospitals: retrospective on a voluntary surveillance programme.

Although meticillin-resistant Staphylococcus aureus (MRSA) is recognized as an important cause of hospital and community healthcare-associated morbidity, and colonization as a precursor to infection, few studies have attempted to assess the burden of both colonization and infection across acute healthcare providers within a defined health economy. This study describes the prevalence and incidence of MRSA colonization and infection in acute London hospital Trusts participating in a voluntary surveillance programme in 2000-2001. Hospital infection control staff completed a weekly return including details on incident and prevalent colonizations, bacteraemias and other significant infections due to MRSA. Incidence and prevalence rates were calculated for hospitals with sufficient participation across both years. Colonizations accounted for 79% of incident MRSA cases reported; 4% were bacteraemias, and 17% other significant infections. There was no change in incidence of colonization of hospital patients between 2000 and 2001. By contrast, there was an unexplained 49% increase in prevalence of colonizations over this period. For any given month, prevalent colonizations outnumbered incident colonizations at least twofold. This MRSA surveillance programme was unusual for prospective ascertainment of incident and prevalent cases of both colonization and infection within an English regional health economy. Consistent with other studies, the incidence and prevalence of colonization substantially exceeded infection. Given the small contribution of bacteraemias to the overall MRSA burden, and the surveillance, screening and control interventions of recent years, it may be appropriate to review the present reliance on bacteraemia surveillance.

Multistate modelling to estimate the excess length of stay associated with meticillin-resistant Staphylococcus aureus colonisation and infection in surgical patients.

Currently available evidence on the excess length of stay (LOS) associated with nosocomial infections is limited by methodology, including time-dependent bias. To determine the excess LOS associated with nosocomial meticillin-resistant Staphylococcus aureus (MRSA) infection and colonisation, 797 MRSA-colonised, 167 MRSA-infected and 13,640 MRSA-negative surgical patients were included in a multistate model. The occurrence of MRSA infection or colonisation was the time-dependent exposure, and discharge or death was the study endpoint. The excess LOS was extracted by computing the Aalen-Johansen estimator of the matrix of transition probabilities. Multivariate Cox regression analysis was used to assess the independent effect of MRSA on excess LOS. MRSA infection prolonged LOS by 14.5 [95% confidence interval (CI): 7.8, 21.3] days compared to uninfected patients, and by 5.9 (95% CI: 0.1, 11.7) days compared to patients only colonised by MRSA. The hazard of discharge was reduced by nosocomial MRSA infection both with respect to MRSA-free patients and MRSA carriers [adjusted hazard ratio (HR): 0.69; 95% CI: 0.59, 0.81; and HR: 0.79; 95% CI: 0.65, 0.95, respectively]. MRSA carriage alone did not decrease the hazard of discharge after adjustment for confounding (HR: 1.00; 95% CI: 0.93, 1.07). Multistate modelling is a promising statistical method to evaluate the health-economic impact of nosocomial antibiotic-resistant infections.

A simulation model to quantify the value of implementing whole-herd Bovine viral diarrhea virus testing strategies in beef cow-calf herds.

Although numerous diagnostic tests are available to identify cattle persistently infected (PI) with Bovine viral diarrhea virus (BVDV) in cow-calf herds, data are sparse when evaluating the economic viability of individual tests or diagnostic strategies. Multiple factors influence BVDV testing in determining if testing should be performed and which strategy to use. A stochastic model was constructed to estimate the value of implementing various whole-herd BVDV cow-calf testing protocols. Three common BVDV tests (immunohistochemistry, antigen-capture enzyme-linked immunosorbent assay, and polymerase chain reaction) performed on skin tissue were evaluated as single- or two-test strategies. The estimated testing value was calculated for each strategy at 3 herd sizes that reflect typical farm sizes in the United States (50, 100, and 500 cows) and 3 probabilities of BVDV-positive herd status (0.077, 0.19, 0.47) based upon the literature. The economic value of testing was the difference in estimated gross revenue between simulated cow-calf herds that either did or did not apply the specific testing strategy. Beneficial economic outcomes were more frequently observed when the probability of a herd being BVDV positive was 0.47. Although the relative value ranking of many testing strategies varied by each scenario, the two-test strategy composed of immunohistochemistry had the highest estimated value in all but one herd size-herd prevalence permutation. These data indicate that the estimated value of applying BVDV whole-herd testing strategies is influenced by the selected strategy, herd size, and the probability of herd BVDV-positive status; therefore, these factors should be considered when designing optimum testing strategies for cow-calf herds.

Ranking control options for tropical theileriosis in at-risk dairy cattle in Tunisia, using benefit-cost analysis.

An economic evaluation of various control programmes against Theileria annulata infection was conducted on a sample of 49 Tunisian dairy farms where clinical cases of tropical theileriosis had been recorded during the summer. Indicators of morbidity and the prevalence of infection, as well as production and demographic indicators (recorded in the present survey ortaken from secondary sources), were used to rank the potential costs and benefits of various control programmes for tropical theileriosis over a time horizon of 15 years. Three options were considered, i.e. vaccination with a local attenuated cell-line vaccine; partial barn upgrading, based on first roughcasting then smoothing all the walls of the animal premises (inner and outer surfaces); and applying acaricides to control the vector tick population on the cattle. The most important loss from this disease, representing between 22% and 38% of the overall losses, is the loss in milk yield from carriers of T. annulata. Upgrading barns produced the highest mean benefit-cost ratio (1.62 to 3.71), while the ratios for vaccination and acaricides ranged from 0.20 to 1.19 and 0.32 to 0.88, respectively. However, the benefit-cost ratio of vaccination increased (from 1.65 to 5.41), when the costs due to carrier state infection, which vaccination does not prevent, were ignored. Upgrading barns is a sustainable eradication policy against tropical theileriosis, based on a single investment, and is environmentally friendly. This control option should be encouraged by national Veterinary Authorities in regions where tropical theileriosis is transmitted by a domestic endophilic tick.

Candida infection and colonization among trauma patients.

BACKGROUND: Data on Candida infection among critically ill trauma patients are limited and not recently updated. Here we study the epidemiology and economic impact of Candida and examine potential risk factors for Candida infection in this population. METHODS: In this 5-year retrospective study, all severely injured patients with ≥4 days of intensive care unit stay were included, with the primary outcome being Candida infection. We identified 3 distinct patient groups: 1) The Candida infection, 2) The Candida colonization and 3) the Candida-free group. All comparisons between groups with p-values ≤0.2 from the univariate analysis were entered into stepwise logistic regression to identify independent risk factors for candidiasis. RESULTS: 374 patients were included. Upon comparisons between groups, candidiasis patients received significantly more blood transfusions (p=0.013), antibiotics (p=0.005), and total parenteral nutrition (TPN) (p=0.004), had a longer duration of mechanical ventilation (MV) (p=0.008) and underwent more laparotomy procedures than Candida free patients (56.5% versus 16.4%; p<0.001). Surgical complications (13% versus 1.4%; p=0.013), injury of the upper (13% versus 0.9%; p=0.007) and lower gastrointestinal tract (8.7% versus 0.9%; p=0.048), and bacterial wound or intra-abdominal infections (17.4% versus 1.9%; p=0.004) were also more common in candidiasis patients. Upon multivariate analysis, patients receiving TPN had 7-fold higher odds for developing candidiasis (Odds ratio [OR]: 7.2; 95% Confidence interval [CI]: 2.6-19.4; p=0.0001). Other predisposing factors included laparotomy (OR: 3.8, 95% CI: 1.5-9.9; p=0.0057) and female gender (OR: 5.7; 95% CI: 2.1-15.6; p=0.0007). Average total hospital charges were higher for patients with Candida infection compared to patients with Candida colonization or without a positive Candida culture. CONCLUSIONS: TPN, laparotomy, and female gender independently predict the development of candidiasis among trauma patients. Severely injured women requiring laparotomy and TPN therapy should be carefully managed for the possibility of increased risk for candidiasis.

Rapid screening of methicillin-resistant Staphylococcus aureus using PCR and chromogenic agar: a prospective study to evaluate costs and effects.

Pre-emptive isolation of suspected methicillin-resistant Staphylococcus aureus (MRSA) carriers is considered essential for controlling the spread of MRSA, but noncolonized patients will be isolated unnecessarily as a result of a delay in diagnosis of 3-5 days with conventional cultures. We determined costs per isolation day avoided, and incremental costs of rapid MRSA screening tests when added to conventional screening, but with decisions on isolation measures based on PCR results. A prospective multicentre study evaluating BD GeneOhm MRSA PCR (`IDI') (BD Diagnostics, San Diego, CA, USA), Xpert MRSA (`GeneXpert') (Cepheid, Sunnyvale, CA, USA) and chromogenic agar (MRSA-ID) (bioMérieux, Marcy-l'Etoile, France) was performed in 14 Dutch hospitals. Among 1764 patients at risk, MRSA prevalence was 3.3% (n=59). Duration of isolation was 19.7 and 16.1 h with IDI and GeneXpert, respectively, and would have been 30.0 and 76.2 h when based on chromogenic agar and conventional cultures, respectively. Negative predictive values (at a patient level) were 99.5%, 99.1% and 99.5% for IDI, GeneXpert and chromogenic agar, respectively. Numbers of isolation days were reduced by 60% and 47% with PCR-based and chromogenic agar-based screening, respectively. The cost per test was €56.22 for IDI, €69.62 for GeneXpert and €2.08 for chromogenic agar, and additional costs per extra isolation day were €26.34. Costs per isolation day avoided were €95.77 (IDI) and €125.43 (GeneXpert). PCR-based decision-making added €153.64 (IDI) and €193.84 (GeneXpert) per patient to overall costs and chromogenic testing would have saved €30.79 per patient. Rapid diagnostic testing safely reduces the number of unnecessary isolation days, but only chromogenic screening, and not PCR-based screening, can be considered as cost saving.

Clinical and economic impact of methicillin-resistant Staphylococcus aureus colonization or infection on neonates in intensive care units.

OBJECTIVE: The rising incidence and mortality of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in children has become a great concern. This study aimed to determine the clinical and economic impact of MRSA colonization or infection on infants and to measure excess mortality, length of stay, and hospital charges attributable to MRSA. DESIGN: This is a retrospective cohort study. SETTING AND PATIENTS: The study included infants admitted to a level III-IV neonatal intensive care unit from September 1, 2004, through March 31, 2008. METHODS: A time-dependent proportional hazard model was used to analyze the association between MRSA colonization or infection and mortality. The relationships between MRSA colonization or infection and length of stay and between MRSA colonization or infection and hospital charges were assessed using a matched cohort study design. RESULTS: Of 2,280 infants, 191 (8.4%) had MRSA colonization or infection. Of 132 MRSA isolates with antibiotic susceptibility results, 106 were resistant to clindamycin and/or trimethoprim-sulfamethoxazole, thus representing a noncommunity phenotype. The mortality rate was 17.8% for patients with MRSA colonization or infection and 11.5% for control subjects. Neither MRSA colonization (hazard ratio [HR], 0.9 [95% confidence interval {CI}, 0.5-1.5]; P > .05 ) nor infection (HR, 1.2 [95% CI, 0.7-1.9]; P > .05 ) was associated with increased mortality risk. Infection caused by MRSA strains that were resistant to clindamycin and/or trimethoprim-sulfamethoxazole increased the mortality risk by 40% (HR, 1.4 [95% CI, 0.9-2.2]; P > .05 ), compared with the mortality risk of control subjects, but the increase was not statistically significant. MRSA infection independently increased length of stay by 40 days (95% CI, 34.2-45.6; P < .001) and was associated with an extra charge of $164,301 (95% CI, $158,712-$169,889; P < .001). CONCLUSIONS: MRSA colonization or infection in infants is associated with significant morbidity and financial burden but is not independently associated with increased mortality.

Obtaining insurance after DNA diagnostics: a survey among hypertrophic cardiomyopathy mutation carriers.

Hypertrophic cardiomyopathy (HCM) is a common hereditary heart disease associated with increased mortality. Disclosure of DNA test results may have social implications such as low access to insurance. In The Netherlands, insurance companies are restricted in the use of genetic information of their clients by the Medical Examination Act. A cross-sectional survey was used to assess the frequency and type of problems encountered by HCM mutation carriers applying for insurance, and associations with carriers' characteristics. The response rate was 86% (228/264). A total of 66 carriers (29%) applied for insurance of whom 39 reported problems (59%) during an average follow-up of 3 years since the DNA test result. More problems were encountered by carriers with manifest disease (P<0.001) and carriers with symptoms of HCM (P=0.049). Carriers identified after predictive DNA testing less frequently experienced problems (P=0.002). Three carriers without manifest HCM reported problems (5% of applicants). Frequently reported problems were higher premium (72%), grant access to medical records (62%), and complete rejection (33%). In conclusion, HCM mutation carriers frequently encounter problems when applying for insurances, often in the case of manifest disease, but the risk assessment of insurance companies is largely justified. Still, 5% of carriers encounter potentially unjustified problems, indicating the necessity to monitor the application of the existing laws and regulations by insurance companies and to educate counselees on the implications of these laws and regulations.

Costs and benefits of the MRSA Search and Destroy policy in a Dutch hospital.

The objective of this study was to determine the costs and benefits of the MRSA Search and Destroy policy in a Dutch hospital during 2001 through 2006. Variable costs included costs for isolation, contact tracing, treatment of carriers and closure of wards. Fixed costs were the costs for the building of isolation rooms and the salary of one full-time infection control practitioner. To determine the benefits of the Search and Destroy policy, the transmission rate during the study period was calculated. Furthermore, the number of cases of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia prevented was estimated, as well as its associated prevented costs and patient lives. The costs of the MRSA policy were estimated to be euro 215,559 a year, which equals euro 5.54 per admission. The daily isolation costs for MRSA-suspected and -positive hospitalised patients were euro 95.59 and euro 436.62, respectively. Application of the Search and Destroy policy resulted in a transmission rate of 0.30 and was estimated to prevent 36 cases of MRSA bacteraemia per year, resulting in annual savings of euro 427,356 for the hospital and ten lives per year (95% confidence interval [CI] 8-14). In conclusion, application of the MRSA Search and Destroy policy in a hospital in a country with a low endemic MRSA incidence saves money and lives.