Nosocomial infections are public health threats with often grave human costs. Because implementing screening and best outbreak response practices is costly for health care organizations, allocating resources for interventions requires consensus among stakeholders with a plurality of perspectives about how to weigh prospective interventions' risks and benefits. Economic analysis can facilitate decision making but is relatively new in nosocomial infection prevention and control. This article describes features of and reasons for economic analysis in this specific area and focuses on emerging challenges in antimicrobial stewardship.To claim one AMA PRA Category 1 Credit TM for the CME activity associated with this article, you must do the following: (1) read this article in its entirety, (2) answer at least 80 percent of the quiz questions correctly, and (3) complete an evaluation. The quiz, evaluation, and form for claiming AMA PRA Category 1 Credit TM are available through the AMA Ed Hub TM .
The red secTion 359 What's Hot in the red journal t h i s m o n t hColonization With Toxinogenic C. difficile upon Hospital admission, and risk of Infection: a Systematic review and Meta-analysis Clostridium difficile continues to be a major scourge of hospitalized patients. This meta-analysis used 19 studies incorporating more than 8,700 patients. The pooled prevalence of colonization with C. difficile was 8.1%, with an increasing trend over time, and was slightly higher at 10% in North American studies. Patients who became colonized upon hospital admission were much more likely to develop C. difficile infections, at a rate almost six times greater than in those who were not colonized. The absolute risk for C. difficile infection in colonized patients was 21%, much greater than in non-colonized patients. The risk for colonization was determined largely by prior hospitalization, not prior antibiotic or proton pump inhibitor use or even prior C. difficile infection. The authors conclude that patients who are carriers of toxigenic C. difficile are at substantially increased risk of C. difficile infection. These results may have implications for hospital management of this quite severe iatrogenic illness. See page 381 risk Factors on the development of new-onset Gastroesophageal reflux Symptoms. a Population-Based Prospective Cohort Study: The HunT StudyThis study assessed risk factors for recent-onset gastroesophageal reflux symptoms. It is based on a prospective adult population in Norway, with a 61% response rate, encompassing more than 29,000 individuals. Five hundred individuals who had no reflux at the beginning had severe reflux symptoms at follow-up. Increasing age was positively associated, but, interestingly, male gender and high education were negatively associated, with new-onset gastroesophageal reflux disease (GERD) symptoms. Body mass index gain was important, even if the patients were thin at the beginning, and any history of smoking was associated with reflux symptoms. The combination of tobacco smoking cessation with weight gain was also associated with reflux. The authors conclude that, surprisingly, female sex was associated with an increase in GERD symptoms, as were increasing age, lower education, gain in body mass index, and having ever been a smoker. In particular, the observation that tobacco smoking cessation associated with weight gain was associated with reflux symptoms suggests that prospective intervention may be worth considering in patients who stop smoking. See page 393
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ImportanceStaphylococcus aureus bacteremia is associated with a significant burden of mortality, morbidity, and health care costs. Infectious disease consultation may be associated with reduced mortality and bacteremia recurrence rates.ObjectiveTo evaluate the cost-effectiveness of infectious disease consultation for Staphylococcus aureus bacteremia.Design, Setting, and ParticipantsIn this economic evaluation, a decision-analytic model was constructed comparing infectious disease consult with no consult. The population was adult hospital inpatients with Staphylococcus aureus bacteremia diagnosed with at least 1 positive blood culture. Cost-effectiveness was calculated as deaths averted and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Costs and outcomes were calculated for a time horizon of 6 months. The analysis was performed from a societal perspective and included studies that had been published by January 2022.InterventionsPatients received or did not receive formal bedside consultation after positive blood cultures for Staphylococcus aureus bacteremia.Main Outcomes and MeasuresThe main outcomes were incremental difference in effectiveness (survival probabilities), incremental difference in cost (US dollars) and incremental cost-effectiveness ratios (US dollars/deaths averted).ResultsThis model included 1708 patients who received consultation and 1273 patients who did not. In the base-case analysis, the cost associated with the infectious disease consult strategy was $54 137.4 and the associated probability of survival was 0.77. For the no consult strategy, the cost was $57 051.2, and the probability of survival was 0.72. The incremental difference in cost between strategies was $2913.8, and the incremental difference in effectiveness was 0.05. Overall, consultation was associated with estimated savings of $55 613.4/death averted (incremental cost-effectiveness ratio, −$55613.4/death averted). In the probabilistic analysis, at a willingness-to-pay threshold of $50 000, infectious disease consult was cost-effective compared with no consult in 54% of 10 000 simulations. In cost-effectiveness acceptability curves, the consult strategy was cost-effective in 58% to 73%) of simulations compared with no consult for a willingness-to-pay threshold ranging from $0 to $150 000.Conclusions and RelevanceThese findings suggest that infectious disease consultation may be a cost-effective strategy for management of Staphylococcus aureus bacteremia and that it is associated with health care cost-savings.
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