Antibiotic-Resistant Infections Cost the U.S. Healthcare System in Excess of $20 Billion Annually

The Alliance for the Prudent Use of Antibiotics (APUA) and Cook County Hospital (currently John H. Stroger, Jr. Hospital of Cook County) announce the release of an eye-opening study on the economic impact of antibiotic overuse and antibiotic-resistant infections (ARIs) sponsored by an unrestricted educational grant from bioMerieux and the Centers for Disease Control and Prevention (CDC).

The authors conducted an exhaustive chart-by-chart review of 1,391 patients hospitalized in the year 2000, 188 of which had ARIs (13.5 percent). The medical costs attributed to these ARIs ranged from $18,588 to $29,069 per patient, while the duration of hospital stay was extended 6.4 - 12.7 days for affected patients. Additionally, the excess mortality attributed to ARIs alone was 6.5 percent -- a death rate two-fold higher than in patients without ARIs. The authors also estimated the societal costs incurred at this hospital as a result of the ARIs to be between $10.7 and $15 million, which is the cost that hits the families of those infected.

The study, "Hospital and Societal Costs of Antimicrobial Resistant Infections in a Chicago Teaching Hospital: Implications for Antibiotic Stewardship," analyzed the medical and human cost associated with ARIs. It was conducted at the Cook County (Stroger) Hospital of Chicago. Several studies have looked at the medical costs of these infections, but this is the first to look at the cost to families as well.

Antibiotic resistance is fueled by misuse and overuse of antibiotics. Bacteria become resistant to the very medicines developed to treat and cure the infection they cause. ARIs include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and a growing number of additional pathogens that are developing resistance to many common antibiotics.

The study was published in the Oct. 15 issue of Clinical Infectious Diseases, published by the Infectious Disease Society of America.

"The findings indicate that significant health and economic benefits could be realized through effective interventions to reduce antimicrobial-resistant and healthcare-associated infections," according to Dr. Rebecca Roberts, of the Department of Emergency Medicine, Cook County (Stroger) Hospital and the lead study author.

"At a time when our country is debating how to deliver better, more affordable care, this study demonstrates the enormous cost savings that could be realized, for both the healthcare system and to individuals and their families. These costs will only continue to increase if we don't amend our behavior and practice a more prudent usage of antibiotics," said Dr. Stuart Levy, professor of medicine at Tufts University School of Medicine, a senior author of the paper and co-founder and president of the APUA, which initiated the study in accord with its mission to "preserve the power of antibiotics".

"The results offer some good insight regarding just how much ARIs are costing the nation: not just in terms of dollars, but human life and suffering," said Levy. "As the enormous costs identified here are viewed on a national scale, it is clear that effectively addressing the issue of antimicrobial-resistant infection is an essential element for stemming the rising tide of healthcare costs in the United States."

"Further study is required, specifically to see how much we could save on a national level if we took some basic steps to halt the development of resistant infections and their spread within hospitals," Levy added.

Roberts explained, "If we apply the conservative costs seen in the Cook County (Stroger) Hospital study to all U.S. hospital admissions in the year 2000 and apply the same selection criteria used in that study nationwide, there would have been nearly 900,000 cases of ARIs in the year 2000." By applying the range of additional costs seen in the Cook County (Stroger) Hospital study of $18,588 to $29,069 to this enormous number of ARIs, we could conceivably avoid $16.6 billion on the low end and up to $26 billion in additional healthcare costs stemming from the treatment of these preventable infections: "Even a 20 percent reduction in these infections would save between $3.2 and $5.2 billion a year and between 5.7 and 11.3 million additional days in the hospital. Clearly, any discussion of healthcare reform must look at the cost of current clinical practice and the savings we could realize if we used antibiotics more prudently," noted Dr. Roberts. "Imagine if these hospital beds and healthcare resources were used instead for preventive care or for under-served patients," she added.

"Assuming 900,000 ARI cases in the year 2000, based on the conservative selection criteria used in our study, the total societal costs of ARIs to U.S. households in the year 2000 was approximately $35 billion," Roberts added. "This includes lost wages from extended hospital stays and from premature deaths."(1)

"Keep in mind these data were collected in 2000, and the rate of notifications of antibiotic resistant cases has more than doubled since then, so these figures should be viewed as very conservative; further work is ongoing to estimate the current burden at state and national levels," said Susan Foster, a co-author and health economist at APUA.

"Another mitigating factor that may also cause us to underestimate the true burden is the excellent clinical practice where the study actually occurred," said Levy. "To its credit, Cook County (Stroger) Hospital happens to have an enviably low rate of healthcare associated infections, including ARIs."

In discussions with the late Senator Edward M. Kennedy on the topic of drug resistance and healthcare, "I spoke frequently with Sen. Kennedy about the avoidable costs from the misuse of antibiotics," Levy said. "Without fail, the senator always concluded our discussions on the topic by telling me that we need to quantify the cost of treating antibiotic-resistant infections in order to make any real progress toward an appropriate policy for antibiotic stewardship. In a very real sense, this study grew from those talks with the late senator."

"This study is the first to quantify the alarming impact of antibiotic resistant infections on treatment costs and patient outcomes," said Herb Steward, general manager and executive vice president of bioMerieux North America, which funded this study. "It also highlights the vital role of simple, rapid and cost effective diagnostics in order to get the right information to clinicians as fast as possible so they can treat patients appropriately and use antibiotics prudently, while improving care and patient outcomes and reining in unnecessary costs."

"The societal financial impact of $15 million based on just over 188 cases of ARI is an alarming finding," said Dr. Robert A. Weinstein, interim chairman of the Department of Medicine at Cook County (Stroger) Hospital, and professor of medicine at Rush University Medical College, and a senior author and initiator of the project at Cook County (Stroger) Hospital. "Sustaining these kinds of costs is simply not tenable for individual families and for the economy at large. With healthcare reform and the focus on the direct cost of care, this study should remind us that every dollar spent to treat avoidable illness ripples throughout society and has an impact on individual, family, community, and corporate budgets across the nation."

The additional cost of patient care resulting from ARIs is not the only aspect of this study that has relevance to the ongoing debate over healthcare reform. "One topic that all parties seem to find agreement on is the need to bring healthcare information technology into the 21st century," said Weinstein. "We at Cook County (Stroger) Hospital have adopted an electronic medical records system, which made the review of literally thousands of pages of patient records and lab results infinitely easier. However, most hospitals in the U.S. still do not have EMR systems so this kind of review would be nearly impossible."

"Thanks to the leadership of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN), hospitals like ours have the tools and protocol to track ARIs," Weinstein added. "However, this is a voluntary program. Several states mandate that their hospitals comply with NHSN protocols, but most do not. Until we have a uniform standard for reporting and disclosure, we may never know the true cost of these avoidable infections."

Reference:

1. Prevention effectiveness: A guide to decision analysis and economic evaluation. 2nd edition. Editors: Haddix AC, Teutsch SM, Corso PS., New York: Oxford University Press 2003:345-57.

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