Direct healthcare costs of selected diseases primarily or partially transmitted by water.

Despite US sanitation advancements, millions of waterborne disease cases occur annually, although the precise burden of disease is not well quantified. Estimating the direct healthcare cost of specific infections would be useful in prioritizing waterborne disease prevention activities. Hospitalization and outpatient visit costs per case and total US hospitalization costs for ten waterborne diseases were calculated using large healthcare claims and hospital discharge databases. The five primarily waterborne diseases in this analysis (giardiasis, cryptosporidiosis, Legionnaires' disease, otitis externa, and non-tuberculous mycobacterial infection) were responsible for over 40 000 hospitalizations at a cost of $970 million per year, including at least $430 million in hospitalization costs for Medicaid and Medicare patients. An additional 50 000 hospitalizations for campylobacteriosis, salmonellosis, shigellosis, haemolytic uraemic syndrome, and toxoplasmosis cost $860 million annually ($390 million in payments for Medicaid and Medicare patients), a portion of which can be assumed to be due to waterborne transmission.

Prospective, randomised study to compare empirical treatment versus targeted treatment on the basis of the urine antigen results in hospitalised patients with community-acquired pneumonia.

BACKGROUND: Recommendations for diagnostic testing in hospitalised patients with community-acquired pneumonia remain controversial. The aim of the present study was to evaluate the impact of a therapeutic strategy based on the microbiological results provided by urinary antigen tests for Streptococcus pneumoniae and Legionella pneumophila. METHODS: For a 2-year period, hospitalised patients with community-acquired pneumonia were randomly assigned to receive either empirical treatment, according to international guidelines, or targeted treatment, on the basis of the results from antigen tests. Outcome parameters, monetary costs and antibiotic exposure levels were compared. RESULTS: Out of 194 enrolled patients, 177 were available for randomisation; 89 were assigned to empirical treatment and 88 were assigned to targeted treatment. Targeted treatment was associated with a slightly higher overall cost (euro 1657.00 vs euro 1617.20, p=0.28), reduction in the incidence of adverse events (9% vs 18%, p=0.12) and lower exposure to broad-spectrum antimicrobials (154.4 vs 183.3 defined daily doses per 100 patient days). No statistically significant differences in other outcome parameters were observed. Oral antibiotic treatment was started according to the results of antigen tests in 25 patients assigned to targeted treatment; these patients showed a statistically significant higher risk of clinical relapse as compared with the remaining population (12% vs 3%, p=0.04). CONCLUSIONS: The routine implementation of urine antigen detection tests does not carry substantial outcome-related or economic benefits to hospitalised patients with community-acquired pneumonia. Narrowing the antibiotic treatment according to the urine antigen results may in fact be associated with a higher risk of clinical relapse.

[Active clinical surveillance for detection of Legionnaires' disease: implications for health care structures]. / Sorveglianza clinica attiva per la ricerca di polmoniti da Legionella: risultati e considerazioni per le strutture sanitarie.

In an university hospital of about 900 beds, a clinical surveillance was activated to detect cases of Legionnaires' disease in patients affected by community and/or nosocomial-acquired pneumonia. In the hospital Legionella spp was detected in the hot water distribution system and various disinfecting and control procedures were adopted to reduce contamination. Contemporary, the clinical surveillance began with the systematic detection of Legionella urinary antigen among recovered pneumonia, seroconversion as confirmation test and the collection of respiratory secretions or other biological materials to isolate the microorganism in patients positive to the urinary antigen. From September 2003 to May 2005, 486 pneumonia were followed, 98 of which considered of nosocomial origin. In total, 15 cases of community-acquired Legionnaires' disease were detected by the urinary test, whereas no cases of nosocomial origin were found. The characteristics of the detected cases are described in comparison with the other pneumonia and the surveillance cost was evaluated. The systematic clinical surveillance for Legionella infections is feasible with limit costs, allows to detect community-acquired cases otherwise unknown and to ascertain the absence/presence of nosocomial-acquired pneumonia, irrespective of the environment contamination.

Diagnostic, therapeutic and economic consequences of a positive urinary antigen test for Legionella spp. in patients admitted with community-acquired pneumonia: a 7-year retrospective evaluation.

AIMS: A positive urinary antigen test for Legionella spp. (Legionella urinary antigen test; LUAT) allows an early switch from empiric to targeted treatment (TT) in hospitalised, community-acquired pneumonia (CAP) patients. We aimed to evaluate the diagnostic, therapeutic and economic consequences of this frequently used test 7 years after its implementation. METHODS: We retrospectively evaluated LUATs performed between 2005 and 2011 in two teaching hospitals. All tests performed in hospitalised CAP patients were used in the economic evaluation and positive tests were included in the treatment evaluation. Data on patient characteristics, admission and outcome were retrieved from the patients' files. The number of days gained by making a rapid aetiological diagnosis, the number of days TT could be provided and their costs were calculated. RESULTS: Of 4485 LUATs, 2504 (56%) were performed for CAP including 55 (1%) positive tests (€1041/positive test). In 26 (60%) of the 43 included positive tests, LUAT was the only test showing Legionella spp. Subsequently, earlier TT was possible in the remaining cases during 209 cumulative admission days (€274/TT day). LUAT led to detection of Legionella spp. 13 days earlier per case (€203/day) as compared with culture/serology alone. CONCLUSIONS: Timely LUAT use in accordance with current guidelines allows early detection and treatment of CAP caused by Legionella spp. at considerable expense.

Use of surface water in drinking water production associated with municipal Legionnaires' disease incidence.

STUDY OBJECTIVES: Given an observed geographical variation in Legionnaires' disease incidence in The Netherlands, the aim of the study was to test the hypothesis that the type of drinking water production was an independent determinant of the incidence of Legionnaires' disease. DESIGN: For the 1987-2005 period, the incidence of Legionnaires' disease in The Netherlands and the price of water as a proxy for production type was studied at the municipal level. The data on the price of water were available at the municipal level. METHODS: For each of the 466 municipalities in The Netherlands a mean standardised incidence rate per 100,000 inhabitants over the 1987-2005 period was calculated, excluding patients with the most probable source of infection abroad or in hospital. Logistic regression was used to assess the relation of the price of water to the incidence rates. In order to control for diagnostic and inclusion bias, they were estimated using questionnaire data collected from all 62 medical microbiology laboratories in the country. MAIN RESULTS: The incidence of Legionnaires' disease varied between municipalities from 0.0 to 5.6 per 100,000 person-years. In univariate analysis high versus low water price was positively associated with a high municipal incidence rate (odds ratio (OR) 1.9; 95% CI 1.5-2.6). The association persisted (OR 5.1; 95% CI 3.2-8.0) after correction for diagnostic and inclusion bias. CONCLUSIONS: The price of water as a proxy for the type of water production was an independent risk factor for high municipal Legionnaires' disease incidence in The Netherlands. This can guide future prevention policies.