Healthcare resource use in hospitalized patients with carbapenem-resistant Gram-negative infections.

OBJECTIVES: Antimicrobial resistance (AMR) is a threat to global public health. Infections with resistant organisms are more challenging to treat, often delay patient recovery and can increase morbidity and mortality. Healthcare costs associated with treating patients with AMR organisms are poorly described. In particular, data for specific organisms, such as those harbouring carbapenem resistance, are lacking. METHODS: This was a retrospective, matched (1:1), single-centre, cohort study at a Central London hospital, comparing costs and resource use of 442 adult inpatients infected with either carbapenem-sensitive (CSO) or carbapenem-resistant organisms (CRO) over a two-year period. Resource use and micro-costing data were obtained from the hospital Patient, Education and Research Costing System (PERCS), and included both direct and indirect costs. RESULTS: Overall, the median healthcare-related cost of treating a patient with a CRO was more than double (£49,537 vs £19,299) that of treating a patient with a CSO. There were statistically significant increases in expenditure across 21 of 44 measured parameters including critical care costs, which accounted for the greatest proportion of overall costs in both groups. Infections were predominantly of the respiratory tract (41%) and caused by Pseudomonas aeruginosa (76%). CONCLUSIONS: Infection with CROs increases healthcare expenditure significantly. Many of the costs, including patient support, portering and catering, have been underappreciated in previous work. We additionally note that patients infected with CROs have longer hospital stays, and increased theatre operating times compared with patients infected with CSOs.

Efficacy and acceptability of rectal and perineal sampling for identifying gastrointestinal colonization with extended spectrum ß-lactamase Enterobacteriaceae.

OBJECTIVES: We evaluated 'pre-laboratory' factors associated with the detection of extended spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) colonization including anatomical site, and staff and patient factors. METHODS: All admissions to a large London hospital over 3 months were approached to provide rectal and perineal swabs, which were cultured for ESBL-E using chromogenic media. ESBL-E detection rates for patient- or staff-collected rectal or perineal swabs were compared using McNemar tests. Binary logistic regression was used to explore factors associated with patients declining to provide a rectal swab. The impact of simplifying the verbal study description to patients to improve the participation rate was evaluated. RESULTS: Carriage of ESBL-E was significantly higher in rectal swabs than perineal swabs (7.8% of 4006 versus 3.8% of 4006, p <0.001), whether collected by staff or patients; 31.9% of 869 patients did not provide a rectal swab before the change in study description compared with 7.6% of 3690 patients afterwards (p <0.001). In multivariable analysis, factors associated with patients declining to provide a rectal swab were younger age (OR 0.99, 95% CI 0.99-1.00), female gender (OR 1.26, 95% CI 1.04-1.52), transfers from other hospitals (OR 1.77, 95% CI 1.07-2.93) or an unknown admission route (OR 1.61, 95% CI 1.09-2.37), being admitted before the change in study description (OR 0.39, 95% CI 0.31-0.48), and the staff member who consented the patient (p <0.001); ethnicity was not a significant factor. CONCLUSIONS: Rectal swabs are recommended for the detection of ESBL-E colonization. Staff and patient factors influence whether patients participate in prevalence studies, which may skew their findings.

Multiplex molecular testing for management of infectious gastroenteritis in a hospital setting: a comparative diagnostic and clinical utility study.

Laboratory diagnosis and clinical management of inpatients with diarrhoea is complex and time consuming. Tests are often requested sequentially and undertaken in different laboratories. This causes prolonged unnecessary presumptive isolation of patients, because most cases are non-infectious. A molecular multiplex test (Luminex(®) Gastrointestinal Pathogen Panel (GPP)) was compared with conventional testing over 8 months to determine diagnostic accuracy, turnaround times, laboratory costs, use of isolation facilities and user acceptability. A total of 262 (12%) patients had a pathogen detected by conventional methods compared with 483 (22.1%) by GPP. Most additional cases were detected in patients developing symptoms in the first 4 days of admission. Additional cases were detected because of presumed improved diagnostic sensitivity but also because clinicians had not requested the correct pathogen. Turnaround time (41.8 h) was faster than bacterial culture (66.5 h) and parasite investigation (66.5 h) but slower than conventional testing for Clostridium difficile (17.3 h) and viruses (27 h). The test could allow simplified requesting by clinicians and a consolidated laboratory workflow, reducing the overall number of specimens received by the laboratory. A total of 154 isolation days were saved at an estimated cost of £30 800. Consumables and labour were estimated at £150 641 compared with £63 431 for conventional testing. Multiplex molecular testing using a panel of targets allowed enhanced detection and a consolidated laboratory workflow. This is likely to be of greater benefit to cases that present within the first 4 days of hospital admission.