Dr. Erkan Hassan

Monthly Writings

Evaluations and reviews of the latest in the field.

Antimicrobial Resistance Poses Global Health Threat

Summary

  • Congress has resourced the CDC to prevent and stop the spread of resistant infections within inpatient and outpatient settings.

  • There is both a clinical and economic value to Antibiotic Stewardship Programs

  • Overall incidence rate of colonization or infections should be added as a metric to programs.

Background

It is estimated that by the year 2050, antimicrobial resistance will cause up to 10 million deaths, at a healthcare cost of up to one trillion U.S. dollars. Contributors to antimicrobial resistance include: overuse; misuse; under use or abuse of antibiotics.

Antimicrobial Stewardship Programs (ASPs) were developed to address inappropriate use and resistance development. The goals of ASPs are to promote judicious antibiotic use to improve patient outcomes and safety while simultaneously reducing the incidence of resistance and healthcare costs.

Approached to Antibiotic Stewardship Programs
The CDC has established 7 Core Elements for an ASP which consists of:

  • Leadership Commitment: Dedicating necessary human, financial and information technology Resources

  • Accountability: Appointing a single leader responsible for the programs outcomes

  • Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic usage

  • Action: Implement at least 1 recommended action for the ASP

  • Tracking: Monitoring antibiotic prescribing and resistance patterns and reporting to clinicians and key stakeholders

  • Education: Educating clinicians about resistance and optimal prescribing

The ASP is a substantial undertaking, therefore, it should also have a substantial impact. Recently, Nathwani et al conducted a systematic review to assess the current clinical and economic impact of ASPs published between the years 2000-2017. A total of 146 studies met inclusion criteria with 74% being from North America and Europe.

Economic Outcomes

Operating Costs (total direct costs to treat infection)
22 studies

  • 69% decreased annual costs

  • 31% increased annual costs

Antimicrobial Expenses
87 studies

  • 80 (92%) decreased antibiotic costs (0.06-80.1%)

  • Average decrease in costs was 35.6%

LOS Costs
3 studies

  • Decreased from $18,305 - $1.95 million

Overall Cost Savings
54 studies

  • Average annual cost savings = $435,000 Per Year (range $9,110 - $2.06 million)

  • $732 per patient (range 42.50 - $2,640)

Clinical Outcomes

Antimicrobial Resistance
18 studies

  • 11 (61%) statistically significantly changed resistance patters following ASP (some resistance increased)

Patient Length of Stay (LOS)
68 studies

  • 57 (85%) no change or decreased LOS (range 0-22 D)

  • 10 (15%) increased LOS (1-5 D)

  • Statistically significant change was decrease of 3.24 days

Mortality Rate
57 studies

  • 42 (77%) no change or decreased all cause mortality

  • (0-18.1%) Statistically significant changes: 10.5% decrease in all cause; 11.3% decrease in infection related mortality.

Readmission Rate (28 or 30 day)
21 studies

  • 13 studies decreased or no change (0-12%)

  • 8 studies increased


Limitations of these studies

  • Heterogeneous of studies: size of hospital & patient population studied

  • Geographic distribution (mainly North America & Europe)

  • Wide range in years studies conducted

  • Majority of studies did not report start up or implementation costs

Conclusion

  • ASP can offset or reduce costs while improving certain patient outcomes

  • Overall increase in ASP cost can be offset by total cost savings for the hospital

  • LOS can be influenced by factors other than antimicrobial use

  • ASP provides beneficial effects on hospital LOS, resistance patterns and infection incidence





References: 1. Nathwani D, Varghese D, Stephens J, et al. Value of hospital antimicrobial stewardship programs (ASP): a systematic review. Antimicrobial Resistance and Infection Control 2019;8:35





Norel Hassan