Economic aspects of preventing health care-associated infections in the intensive care unit

Estimation of Additional Costs in Patients with Ventilator-Associated Pneumonia

Healthcare-associated infections (HAIs) present a global public health challenge, contributing to high morbidity and mortality and substantial economic burdens. Ventilator-associated pneumonia (VAP) ranks as the second most prevalent HAI in intensive care units (ICUs), emphasizing the need for economic analyses in this context. This retrospective cohort study, conducted at the General Hospital of Alicante from 2012 to 2019, aimed to assess additional costs related to VAP by comparing the extended length of stay for infected and non-infected ICU patients undergoing mechanical ventilation (MV) for more than 48 h. Employing propensity score association, 434 VAP patients were compared to an equal number without VAP. The findings indicate a significantly longer mechanical ventilation period for VAP patients (17.40 vs. 8.93 days, p < 0.001), resulting in an extra 13.56 days of stay and an additional cost of EUR 20,965.28 per VAP episode. The study estimated a total cost of EUR 12,348,965.28 for VAP during the study period, underscoring the economic impact of VAP. These findings underscore the urgent need for rigorous infection surveillance, prevention, and control measures to enhance healthcare quality and reduce overall expenditures.

Central line-associated bloodstream infections, multidrug-resistant bacteraemias and infection control interventions: a six-year time-series analysis in a tertiary-care hospital in Greece

BACKGROUND

Central line-associated bloodstream infections (CLABSI) are serious healthcare-associated infections with substantial morbidity and hospital costs.

AIM

To investigate the association between the incidence of CLABSI, the implementation of specific infection control measures, and the incidence of multidrug-resistant (MDR) bacteraemias in a tertiary-care hospital in Greece from 2013-2018.

METHODS

Analysis was applied for the following monthly calculated indices: 1.CLABSI rate, 2.use of hand hygiene disinfectants, 3.isolation rate of patients with MDR bacteria, 4.incidence of bacteraemias [total resistant Gram-negative: carbapenem-resistant (CR) Acinetobacter baumanii, Pseudomonas aeruginosa, Klebsiella pneumoniae and/or Gram-positive: meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci].

FINDINGS

Total bacteraemias from CR-Gram-negative pathogens statistically correlated with increased CLABSI rate in total Hospital Departments (IRR: 1.17, 95% CI: 1.05-1.31, p-value: 0.006) and Adults ICU (IRR: 1.37, 95%CI: 1.07-1.75, p-value: 0.013). In Adults ICU, every increase in the incidence of each resistant Gram-negative pathogen significantly correlated with decreased CLABSI rate (CR-A. baumanii: IRR: 0.59, 95%CI: 0.39-0.90, p-value=0.015; CR-K. pneumoniae: IRR: 0.48, 95%CI: 0.25-0.94, p-value=0.031; CR-P. aeruginosa: IRR: 0.54, 95%CI: 0.33-0.89, p-value=0.015). The use of hand disinfectants correlated with decreased CLABSI rate 1-3 months before the application of this intervention, in total Hospital Departments (IRR: 0.80, 95%CI: 0.69-0.93, p-value: 0.005), and for scrub disinfectants the current month in Adults ICU (IRR: 0.34, 95%CI: 0.11-1.03, p-value: 0.057). Isolation of patients with MDR pathogens was not associated with CLABSI incidence.

CONCLUSION

Hand hygiene was associated with a significant reduction of CLABSI incidence in our hospital. Time-series analysis is an important tool to evaluate infection control interventions.

Control of Gram-negative multi-drug resistant microorganisms in an Italian ICU: Rapid decline as a result of a multifaceted intervention, including conservative use of antibiotics

BACKGROUND

Gram-negative Multi-Drug-Resistant Organisms (GNMDROs) cause an increasing burden of disease in Intensive Care Units (ICUs). We deployed a multifaceted intervention to control selection and transmission of GNMDROs and to estimate at which rate GNMDROs would decline with our interventional bundle.

METHODS

Interventions implemented in 2015: in-ward Antimicrobial-Stewardship-Program for appropriate management of antimicrobial prescription; infection monitoring with nasal/rectal swabs and repeated procalcitonin assays; 24 h microbiological support (since 2016); prevention of catheter-related infections, VAPs and in-ward GNMDROs transmission; education of ICU personnel. In May 2017, epidemiological, clinical and microbiological data were collected and retrospectively analyzed. Rates of resistance in Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii, as well as percentages of resistance among all Gram-negative bacteria were compared during the study period.

RESULTS

Of 668 patients, at least one isolate was obtained from 399 patients. The proportions of patients with infection and with Gram-negative isolates were even across the 5 semesters (p = 0.8). For Klebsiella pneumoniae, the number of strains resistant to carbapenems fell from 94% to 6% (p < 0.001). Significant drops were also observed for Pseudomonas aeruginosa and Acinetobacter baumannii. Percentages of resistance for all Gram-negative isolates fell from 91% to 13% (p < 0.0001). The reduction in antibiotic prescription translated in a considerable reduction of pharmacy costs. Multivariate models confirmed that the hospitalization semester was the most relevant independent predictor of resistance among Gram-negative bacteria.

CONCLUSIONS

Our experience provides further evidence that a multi-faceted intervention, aimed to reduce selection and transmission of GNMDROs with efficient microbiological support, may yield remarkable results in a short time interval.

Hospital-acquired lower respiratory tract infections among high risk hospitalized patients in a tertiary care teaching hospital in China: An economic burden analysis

BACKGROUND

Data on the economic burden of hospital-acquired lower respiratory tract infection (LRTI) among high risk hospitalized patients are lacking in China. This study aims to fill this knowledge gap.

METHODS

We used a prospective matched cohort design, comparing patients with LRTIs and 1:1 matched patients without LRTIs. Study period was from January 2013 to December 2015 analyzing inpatients from high risk wards - intensive care unit (ICU), dialysis, hematology, etc. - in a tertiary hospital. Hospital information system and hospital infection surveillance system were applied to extract necessary information. The primary outcome was incidence of hospital-acquired LRTIs, and the secondary was economic burden outcomes, including incremental medical costs and prolonged length of stay (LOS). Wilcoxon's signed rank test was used to explore the differences in the economic burden.

RESULTS

Among 5990 hospital visitors over the period of time, 895 (14.94%) had hospital-acquired LRTIs. We analyzed 340 patients with LRTIs and 340 respective controls without infections. The median hospital costs for patients with ICU-acquired LRTIs were significantly higher than those without LRTIs in other wards ($12,301.17 vs. $4674.64, P<0.01). The average attributable cost per patient was $2853.93 ($6916.48 vs. $4062.55, P<0.01). Patients from hematology department had the longest LOS, at 15days (25days vs. 10 days, P<0.01). An LRTI led to an attributable increase in LOS by 8days on average (P<0.01). Western medicine, treatment and laboratory test were the dominant contributors to the growth in overall medical costs in hospital-acquired LRTIs.

CONCLUSIONS

Hospital-acquired LRTI imposed considerable economic burden on patients hospitalized in high risk wards in China. This study provides the first data for economic evaluation of LRTI, highlighting the urgent need to establish targeted preventive strategies to minimize the occurrence of this complication to reduce economic burden.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

Objective

To evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.

Design

This prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.

Setting

We conducted this study over a period of 16 months at a tertiary care referral medical center.

Participants

All patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.

Intervention and main outcome measures

Patient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.

Results

There were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.

Conclusions

Our results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses' chart for site inspection and alerts in all shifts are some measures planned at our center.

Improved method for the detection of catheter colonization and catheter-related bacteremia in newborns

Accurate diagnosis of catheter-related bloodstream infection (CRBSI) is mandatory for hospital infection control. Peripherally inserted central venous catheters (PICCs) are widely used in intensive care units, but studies about procedures for detection of colonization are scarce in neonates. We sequentially processed 372 PICCs by 2 methods, first by the standard roll-plate (RP) technique and then by rubbing catheters on a blood agar plate after being longitudinally split (LS). With both techniques, we detected 133 colonized PICCs. Ninety-four events of CRBSI were diagnosed. The sensitivity, specificity, positive predictive value, and negative predictive value for detection of CRBSI were 58.5%, 92.8%, 73.3%, and 86.9%, respectively, for RP technique and 96.8%, 88.5%, 74.0%, and 98.8%, respectively, for LS technique. The LS technique increased the proportion of detected CRBSI by 38.3%. Neonatal PICC tips should be cultured after cutting them open. This technique is simple and sensitive to detect catheter colonization and also to diagnose CRBSI.

The Necessity of Prerequisite Undergraduate Microbiology Courses for Pre-Allied Health Professionals

WA letter to the editor addressing recent concerns about the necessity of microbiology as a prerequisite for pre-nursing and pre-allied health programs.

Attributable costs of ventilator-associated lower respiratory tract infection (LRTI) acquired on intensive care units: a retrospectively matched cohort study

Background

Lower respiratory tract infections (LRTI) are the most common hospital-acquired infections on ICUs. They have not only an impact on each patient’s individual health but also result in a considerable financial burden for the healthcare system. Our aim was to determine the costs and the length of stay of patients with ICU-acquired LRTI.

Methods

We used a retrospectively matched cohort design, comparing patients with ICU-acquired LRTI and ICU patients without LRTI. LRTI was diagnosed using the definitions of the Centers for Disease Control and Prevention (CDC). Study period was from January to December 2010 analyzing patients from 10 different ICUs (medical, surgical, interdisciplinary). The device utilization ratio was defined as number of ventilator days divided by number of patient days and the device-associated LRTI rate was defined as number of ventilator associated LRTI divided by number of ventilator days. Patients were matched by age, sex, and prospectively obtained Simplified Acute Physiology Score II (SAPS II). The length of ICU stay of control patients needed to be at least as long as that of LRTI-patients before onset of LRTI. We used the Wilcoxon signed-rank test for continuous variables and the McNemar’s test for categorical variables.

Results

The analyzed ICUs had 40,772 patient days in the study period with a median ventilation utilization ratio of 56 (IQR 42–65). The median device-associated LRTI rate was 3.35 (IQR 0.96-5.36) per 1,000 ventilation days. We analyzed 49 patients with ICU-acquired LRTI and 49 respective controls without LRTI. The median hospital costs for LRTI patients were significantly higher than for patients without LRTI (45,041 € vs. 26,467 €; p < .001). The attributable costs per LRTI patient were 17,015 € (p < .001). Patients with ICU acquired LRTI stayed longer in the hospital than patients without (36 days vs. 24 days; p = 0.011). An LRTI lead to an attributable increase in length of stay by 9 days (p = 0.011).

Conclusions

ICU-acquired LRTI is associated with increased hospital costs and prolonged hospital stay. Hospital management should therefore implement control measurements to keep the incidence of ICU-acquired LRTI as low as possible.