Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017).

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) in intensive care unit (ICU) patients constitute a major therapeutic issue complicating the regular hospitalisation process and having influence on patients' condition, length of hospitalisation, mortality and therapy cost. METHODS: The study involved all patients treated > 48 h at ICU of the Medical University Teaching Hospital (Poland) from 1.01.2015 to 31.12.2017. The study showed the surveillance and prevention of DA-HAIs on International Nosocomial Infection Control Consortium (INICC) Surveillance Online System (ISOS) 3 online platform according to methodology of the INICC multidimensional approach (IMA). RESULTS: During study period 252 HAIs were found in 1353 (549F/804M) patients and 14,700 patient-days of hospitalisation. The crude infections rate and incidence density of DA-HAIs was 18.69% and 17.49 ± 2.56 /1000 patient-days. Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI) and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 12.63 ± 1.49, 1.83 ± 0.65 and 6.5 ± 1.2, respectively. VAP(137) constituted 54.4% of HAIs, whereas CA-UTI(91) 36%, CLA-BSI(24) 9.6%.The most common pathogens in VAP and CA-UTI was multidrug-resistant (MDR) Acinetobacter baumannii (57 and 31%), and methicillin-resistant Staphylococcus epidermidis (MRSE) in CLA-BSI (45%). MDR Gram negative bacteria (GNB) 159 were responsible for 63.09% of HAIs. The length of hospitalisation of patients with a single DA-HAI at ICU was 21(14-33) days, while without infections it was 6.0 (3-11) days; p = 0.0001. The mortality rates in the hospital-acquired infection group and no infection group were 26.1% vs 26.9%; p = 0.838; OR 0.9633;95% CI (0.6733-1.3782). Extra cost of therapy caused by one ICU acquired HAI was US$ 11,475/Euro 10,035. Hand hygiene standards compliance rate was 64.7%, while VAP, CLA-BSI bundles compliance ranges were 96.2-76.8 and 29-100, respectively. CONCLUSIONS: DA-HAIs was diagnosed at nearly 1/5 of patients. They were more frequent than in European Centre Disease Control report (except for CLA-BSI), more frequent than the USA CDC report, yet less frequent than in limited-resource countries (except for CA-UTI). They prolonged the hospitalisation period at ICU and generated substantial additional costs of treatment with no influence on mortality. The Acinetobacter baumannii MDR infections were the most problematic therapeutic issue. DA-HAIs preventive methods compliance rate needs improvement.

Trends and factors associated with antimicrobial resistance of Acinetobacter spp. invasive isolates in Europe: A country-level analysis.

OBJECTIVES: This study investigated trends and factors associated with antimicrobial resistance (AMR) in Acinetobacter spp. in Europe. METHODS: Using data from EARS-Net, population-weighted multilevel logistic regression models with random intercepts for each participating country were performed to assess trends in Acinetobacter AMR. Countries were divided into two groups (Northern versus Southern-Eastern) using a convenient US$35000 cut-off of the 2016 gross domestic product per capita (GDPPC). RESULTS: In most countries, there were no ascending or descending trends over time. The models showed a consistent higher prevalence of AMR to aminoglycosides, carbapenems and fluoroquinolones in countries with GDPPC US$35000 and

The difference in medical costs between carbapenem-resistant Acinetobacter baumannii and non-resistant groups: a case study from a hospital in Zhejiang province, China.

This retrospective study aims to compare differences in the medical costs between inpatients infected/colonised with carbapenem-resistant (CRAB) and carbapenem-susceptible (CSAB) Acinetobacter baumannii in a hospital in Zhejiang province, China. Because the patient population was large, we randomly selected 60% of all inpatients with clinical specimens between 2013 and 2015. We classified the A. baumannii cases as CRAB or CSAB based on antibiotic susceptibility testing. Univariate and multivariate analyses were used to identify factors associated with the total medical cost (TMC). Those included in the study totalled 2980 inpatients, 71.3% of whom had CRAB infection/colonisation. Differences in the TMC between the CRAB and CSAB groups were lower by multivariate analyses than the differences obtained by univariate analyses. Carbapenem resistance was significantly associated with an approximately 1.5-fold increase in the TMC after accounting for confounding factors. Our study highlights the heavy financial burden imposed by A. baumannii and carbapenem resistance on the Chinese healthcare system.

Carbapenemase-producing Acinetobacter baumannii: An outbreak report with special highlights on economic burden.

OBJECTIVE: We aimed to describe the management of a carbapenemase-producing Acinetobacter baumannii (CP-AB) outbreak using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. We also aimed to evaluate the cost of the outbreak and simulate costs if a dedicated unit to manage such outbreak had been set-up. METHODS: We performed a prospective epidemiological study. Multiple interventions were implemented including cohorting measures and limitation of admissions. Cost estimation was performed using administrative local data. RESULTS: Five patients were colonized with CP-AB and hospitalized in the neurosurgery ward. The index case was a patient who had been previously hospitalized in Portugal. Four secondary colonized patients were further observed within the unit. The strains of A. baumannii were shown to belong to the same clone and all of them produced an OXA-23 carbapenemase. The closure of the ward associated with the discharge of the five patients in a cohorting area of the Infectious Diseases Unit with dedicated staff put a stop to the outbreak. The estimated cost of this 17-week outbreak was $474,474. If patients had been managed in a dedicated unit - including specific area for cohorting of patients and dedicated staff - at the beginning of the outbreak, the estimated cost would have been $189,046. CONCLUSION: Controlling hospital outbreaks involving multidrug-resistant bacteria requires a rapid cohorting of patients. Using simulation, we highlighted cost gain when using a dedicated cohorting unit strategy for such an outbreak.

Costs and Mortality Associated With Multidrug-Resistant Healthcare-Associated Acinetobacter Infections.

BACKGROUND Our objective was to estimate the per-infection and cumulative mortality and cost burden of multidrug-resistant (MDR) Acinetobacter healthcare-associated infections (HAIs) in the United States using data from published studies. METHODS We identified studies that estimated the excess cost, length of stay (LOS), or mortality attributable to MDR Acinetobacter HAIs. We generated estimates of the cost per HAI using 3 methods: (1) overall cost estimates, (2) multiplying LOS estimates by a cost per inpatient-day ($4,350) from the payer perspective, and (3) multiplying LOS estimates by a cost per inpatient-day from the hospital ($2,030) perspective. We deflated our estimates for time-dependent bias using an adjustment factor derived from studies that estimated attributable LOS using both time-fixed methods and either multistate models (70.4% decrease) or matching patients with and without HAIs using the timing of infection (47.4% decrease). Finally, we used the incidence rate of MDR Acinetobacter HAIs to generate cumulative incidence, cost, and mortality associated with these infections. RESULTS Our estimates of the cost per infection were $129,917 (method 1), $72,025 (method 2), and $33,510 (method 3). The pooled relative risk of mortality was 4.51 (95% CI, 1.10-32.65), which yielded a mortality rate of 10.6% (95% CI, 2.5%-29.4%). With an incidence rate of 0.141 (95% CI, 0.136-0.161) per 1,000 patient-days at risk, we estimated an annual cumulative incidence of 12,524 (95% CI, 11,509-13,625) in the United States. CONCLUSION The estimates presented here are relevant to understanding the expenditures and lives that could be saved by preventing MDR Acinetobacter HAIs. Infect Control Hosp Epidemiol 2016;1-7.

Clinical importance and cost of bacteremia caused by nosocomial multi drug resistant acinetobacter baumannii.

BACKGROUND: A. baumannii is an important nosocomial pathogen associated with high mortality, morbidity and medical cost. AIM: The aim of this study was to investigate risk factors for MDR A. baumannii bacteremia and also evaluate cost of hospitalization of these patients. METHODS: Study was conducted in Ankara Atatürk Training and Research Hospital. Patients who were hospitalized in ICU and diagnosed for nosocomial blood stream infection (BSI) between January 2007 and December 2010 were checked retrospectively. Patients with nosocomial BSI caused by multidrug resistant A. baumannii were compared with the patients who had BSI caused by other Gram-negative microorganisms in terms of risk factors, mortality and medical costs. FINDINGS: In multivariate analysis previous use of carbapenem, quinolone and metronidazole, and SAPS II score were found as independent risk factors. In case group; immunosupression, SAPS II score, and hospital stay until infection were independently associated with mortality in multivariate analysis. CONCLUSION: Our results suggest that the occurrence of MDR A.baumannii bacteremia was related with the usage of the wide spectrum antibiotics, and mortality rates were increased in patients that high SAPS II scores, long term hospitalization. Infection control procedures and limited antibiotic usage are very important for prevent nosocomial infections.

Impact of carbapenem resistance on clinical and economic outcomes among patients with Acinetobacter baumannii infection in Colombia.

Acinetobacter baumannii is a major cause of healthcare-associated infection, often affecting critically ill patients. The purpose of the study was to examine the associations of carbapenem resistance with mortality, length of hospital stay and hospital costs among patients infected with A. baumannii in intensive-care units (ICUs) in Colombia. A prospective, multicentre cohort study was conducted among 165 patients with A. baumannii infection admitted to ICUs between April 2006 and April 2010. Patients with carbapenem-resistant A. baumannii had higher risk of 30-day mortality than patients with carbapenem-susceptible A. baumannii in the univariate analysis (unadjusted hazard ratio = 2.12; 95% CI 1.14-3.95; p 0.018). However, carbapenem resistance was not significantly associated with risk of mortality (adjusted hazard ratio = 1.45; 95% CI 0.74-2.87; p 0.28) after adjusting for APACHE II score and other confounding factors. We did not find a significant difference in length of stay in ICU after the onset of infection between the two groups in the multivariate analysis (adjusted mean = 13.1 days versus 10.5 days; p 0.14). The average total cost of hospitalization among patients with carbapenem-resistant A. baumannii was significantly higher than that among patients with carbapenem-susceptible A. baumannii in the multivariate analysis (adjusted cost; US$ 11 359 versus US$ 7049; p <0.001). Carbapenem resistance was not significantly associated with mortality, though we are unable to rule out an increased risk due to the limited sample size. Carbapenem resistance was associated with an additional cost of hospitalization.

Economic value of Acinetobacter baumannii screening in the intensive care unit.

Although Acinetobacter baumannii (A. baumannii) is an increasingly common nosocomial pathogen that can cause serious infections in the intensive care unit (ICU), most ICUs do not actively screen admissions for this pathogen. We developed an economic computer simulation model to determine the potential cost-consequences to the hospital of implementing routine A. baumannii screening of ICU admissions and isolating those patients who tested positive, comparing two screening methods, sponge and swab, with each other and no screening. Sensitivity analyses varied the colonization prevalence, percentage of colonized individuals who had active A. baumannii infections, A. baumannii reproductive rate (R), and contact isolation efficacy. Both screening methods were cost-effective for almost all scenarios tested, yielding cost-savings ranging from -$1 to -$1563. Sponge screening was not cost-saving when colonization prevalence was ≤1%, probability of infection ≤30%, R ≤ 0.25, and contact isolation efficacy ≤25%. Swab screening was not cost-saving under these same conditions when the probability of infection was ≤40%. Sponge screening tended to be more cost-saving than swab screening (additional savings ranged from $1 to $421). Routine A. baumannii screening of ICU patients may save costs for hospitals.

Epidemiology and impact of imipenem resistance in Acinetobacter baumannii.

BACKGROUND: Acinetobacter baumannii is an emerging gram-negative pathogen that can cause healthcare-acquired infections among patients. Treatment is complicated for cases of healthcare-acquired infection with A. baumannii resistant to imipenem. OBJECTIVE: To elucidate the risk factors for imipenem-resistant A. baumannii (IRAB) infection or colonization and to identify the effect of resistance on clinical and economic outcomes. METHODS: We analyzed data from 2 medical centers of the University of Pennsylvania. Longitudinal trends in the prevalence of IRAB clinical isolates were characterized during the period from 1989 through 2004. For A. baumannii isolates obtained from 2001 through 2006, a case-control study was conducted to investigate the association between prior carbapenem use and IRAB infection or colonization, and a cohort study was performed to identify the effect of IRAB infection or colonization on mortality, length of stay after culture, and hospital cost after culture. RESULTS: From 1989 through 2004, the annual prevalence of IRAB isolates ranged from 0% to 21%. During the period from 2001 through 2006, there were 386 unique patients with A. baumannii isolates, and 89 (23.1%) had IRAB isolates. Prior carbapenem use was independently associated with IRAB infection or colonization (adjusted odds ratio, 3.04 [95% confidence interval, 1.07-8.65]). There was a borderline significant association between IRAB infection or colonization and mortality, although this association was limited to isolates recovered from blood samples (adjusted odds ratio, 5.30 [95% confidence interval, 0.81-34.59]). Compared with patients with imipenem-susceptible A. baumannii infection or colonization, patients with IRAB infection or colonization had a longer hospital stay after culture (median, 21 vs 16 days; P = .07) and greater hospital charges after culture (mean, $334,516 vs $276,059; P = .03). After controlling for patient location in an intensive care unit, transfer from another facility, and length of hospital stay before culture, there was no longer an independent association between IRAB infection or colonization and higher cost after culture and length of stay after positive culture result. CONCLUSIONS: Many A. baumannii isolates exhibit imipenem resistance, which is strongly associated with prior use of carbapenems. Given the high mortality rate associated with A. baumannii infection or colonization, interventions to curb further emergence of cases of IRAB infection and strategies to optimize therapy are needed.

Epidemiologic, clinical, and economic evaluation of an outbreak of clonal multidrug-resistant Acinetobacter baumannii infection in a surgical intensive care unit.

OBJECTIVES: To determine risk factors for acquisition of multidrug-resistant (MDR) Acinetobacter baumannii infection during an outbreak, to describe the clinical manifestations of infection, and to ascertain the cost of infection. DESIGN: Case-control study. SETTING: Surgical intensive care unit in a 400-bed urban teaching hospital and level 1 trauma center. PATIENTS: Case patients received a diagnosis of infection due to A. baumannii isolates with a unique pattern of drug resistance (ie, susceptible to imipenem, variably susceptible to aminoglycosides, and resistant to all other antibiotics) between December 1, 2004, and August 31, 2005. Case patients were matched 1 : 1 with concurrently hospitalized control patients. Isolates' genetic relatedness was established by pulsed-field gel electrophoresis. RESULTS: Sixty-seven patients met the inclusion criteria. Case and control patients were similar with respect to age, duration of hospitalization, and Charlson comorbidity score. MDR A. baumannii infections included ventilator-associated pneumonia (in 56.7% of patients), bacteremia (in 25.4%), postoperative wound infections (in 25.4%), central venous catheter-associated infections (in 20.9%), and urinary tract infections (in 10.4%). Conditional multiple logistic regression was used to determine statistically significant risk factors on the basis of results from the bivariate analyses. The duration of hospitalization and healthcare charges were modeled by multiple linear regression. Significant risk factors included higher Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.1 per point increase; P=.06), duration of intubation (OR, 1.4 per day intubated; P<.01), exposure to bronchoscopy (OR, 22.7; P=.03), presence of chronic pulmonary disease (OR, 77.7; P=.02), receipt of fluconazole (OR, 73.3; P<.01), and receipt of levofloxacin (OR, 11.5; P=.02). Case patients had a mean of $60,913 in attributable excess patient charges and a mean of 13 excess hospital days. INTERVENTIONS: Infection control measures included the following: limitations on the performance of pulsatile lavage wound debridement, the removal of items with upholstered surfaces, and the implementation of contact isolation for patients with suspected MDR A. baumannii infection. CONCLUSIONS: This large outbreak of infection due to clonal MDR A. baumannii caused significant morbidity and expense. Aerosolization of MDR A. baumannii during pulsatile lavage debridement of infected wounds and during the management of respiratory secretions from colonized and infected patients may promote widespread environmental contamination. Multifaceted infection control interventions were associated with a decrease in the number of MDR A. baumannii isolates recovered from patients.

Clinical and economic impact of multidrug resistance in nosocomial Acinetobacter baumannii bacteremia.

OBJECTIVE: To investigate the impact of antimicrobial resistance on clinical and economic outcomes among hospitalized patients with multidrug-resistant (MDR) Acinetobacter baumannii bacteremia. DESIGN: A retrospective, matched-cohort study. SETTING: A tertiary care university teaching hospital. METHODS: A matched case-control (1 : 1) study was conducted to compare the differences in clinical and economic outcomes of patients with MDR A. baumannii bacteremia and patients with non-MDR A. baumannii bacteremia. Case patients were matched to control patients on the basis of sex, age, severity of underlying and acute illness, and length of hospital stay before onset of bacteremia. RESULTS: Forty-six (95.8%) of 48 cases with MDR A. baumannii bacteremia were eligible for the study and matched with appropriate controls. The sepsis-related mortality rate was 34.8% among cases and 13.0% among controls, for an attributable mortality rate of 21.8% (adjusted odds ratio, 4.1 [95% confidence interval, 1.1-15.7]; P=.036). After the onset of bacteremia, cases and controls had a significantly different length of hospital stay (54.2 vs 34.1 days; P=.006), hospitalization cost (US$9,349 vs US$4,865; P=.001), and antibiotic therapy cost (US$2,257 vs US$1,610; P=.014). Thus, bacteremia due to MDR A. baumannii resulted in 13.4 days of additional hospitalization and US$3,758 of additional costs, compared with bacteremia due to non-MDR A. baumannii. CONCLUSIONS: Patients with MDR A. baumannii bacteremia had a higher mortality rate and incurred greater medical costs than patients with non-MDR A. baumannii bacteremia.

Direct costs of multidrug-resistant Acinetobacter baumannii in the burn unit of a public teaching hospital.

We conducted a case-control study to determine the attributable direct costs of multidrug-resistant Acinetobacter baumannii (MDRAB) in the burn unit of a public teaching hospital. The mean total hospital cost of patients who acquired MDRAB was 98,575 dollars higher than that of control patients who had identical burn severity of illness indices ( P <.01). These data should help infection control practitioners and others determine the cost-effectiveness of specific interventions designed to control this emerging nosocomial pathogen.

Epidemiology, resistance, and outcomes of Acinetobacter baumannii bacteremia treated with imipenem-cilastatin or ampicillin-sulbactam.

STUDY OBJECTIVE: To evaluate epidemiology, resistance, and treatment outcomes of Acinetobacter baumannii bacteremia treated with imipenem-cilastatin or ampicillin-sulbactam for 72 hours or longer. DESIGN: Retrospective analysis. SETTING: University teaching hospital. PATIENTS: Forty-eight patients with A. baumannii bacteremia. INTERVENTION: Evaluation of susceptibility and clinical data from 48 patients treated with either ampicillin-sulbactam or imipenem-cilastatin from 1987-1999. MEASUREMENTS AND MAIN RESULTS: Comparing ampicillin-sulbactam and imipenem-cilastatin, there were no differences between days of bacteremia (4 vs 2 days, p=0.05), days to resolution of temperature or white blood cell count, success or failure during or at end of treatment, or intensive care unit total or antibiotic-related length of stay (13 vs 10 days, p=0.05). Patients treated with ampicillin-sulbactam had significantly decreased antibiotic treatment costs (1500 dollars vs 500 dollars, p=0.004). CONCLUSION: Ampicillin-sulbactam is at least as effective as imipenem-cilastatin based on clinical response at days 2, 7, and end of treatment and is a cost-effective alternative for treatment of A. baumannii infections.

Evaluation of Acinetobacter baumannii infection and colonization, and antimicrobial treatment patterns in an urban teaching hospital.

In 1990 there was a sudden increase in the incidence of colonization and infection due to Acinetobacter baumannii (AB) in our intensive care units (ICUs). The isolates were multiply resistant to beta-lactam and aminoglycoside antibiotics, but remained susceptible to imipenem, amikacin, and ampicillin-sulbactam. We examined the frequency of infection and colonization with AB and the effects of increased imipenem and amikacin therapy on Pseudomonas aeruginosa. We also used disease-matched controls to determine the clinical and financial impacts of treating colonization. All patients with at least one AB isolate from January-December 1992 were identified retrospectively and classified as infected or colonized based on published Centers for Disease Control criteria; the control group was selected from a computerized medical records data base matching primary diagnostic codes (102 patients both groups). The 102 patients yielded 140 isolates, 124 resistant AB and 16 sensitive AB. Thirty three patients were infected, 69 colonized. Mortality correlated with APACHE II scores. Patients acquired the organism approximately 2 weeks after admission; they had a mean ICU stay of 27.35 days, compared with 5.53 days for controls. Patients with positive AB cultures required significantly more use of ventilators than those with negative AB cultures. They also had significantly longer hospital stay, more bed transfers, greater duration and number of antibiotics, and higher hospital and pharmacy charges. Unnecessary treatment for colonization with either imipenem or amikacin resulted in a substantial decrease of P. aeruginosa susceptibility to each agent. The financial impact of treating colonization was significant and is a potential area for cost avoidance. Our results emphasize the need to extubate and move patients to non-ICU beds as soon as possible to decrease the risk of nosocomial infection. It also highlights the need to avoid treating colonization, thus avoiding unnecessary antibiotic therapy.