The health and cost burden of antibiotic resistant and susceptible Escherichia coli bacteraemia in the English hospital setting: A national retrospective cohort study

Abstract

IntroductionAntibiotic resistance poses a threat to public health and healthcare systems. Escherichia coli causes more bacteraemia episodes in England than any other bacterial species. This study aimed to estimate the burden of E. coli bacteraemia and associated antibiotic resistance in the secondary care setting.Materials and methodsThis was a retrospective cohort study, with E. coli bacteraemia as the main exposure of interest. Adult hospital in-patients, admitted to acute NHS hospitals between July 2011 and June 2012 were included. English national surveillance and administrative datasets were utilised. Cox proportional hazard, subdistribution hazard and multistate models were constructed to estimate rate of discharge, rate of in-hospital death and excess length of stay, with a unit bed day cost applied to the latter to estimate cost burden from the healthcare system perspective.Results14,042 E. coli bacteraemia and 8,919,284 non-infected inpatient observations were included. E. coli bacteraemia was associated with an increased rate of in-hospital death across all models, with an adjusted subdistribution hazard ratio of 5.88 (95% CI: 5.62–6.15). Resistance was not found to be associated with in-hospital mortality once adjusting for patient and hospital covariates. However, resistance was found to be associated with an increased excess length of stay. This was especially true for third generation cephalosporin (1.58 days excess length of stay, 95% CI: 0.84–2.31) and piperacillin/tazobactam resistance (1.23 days (95% CI: 0.50–1.95)). The annual cost of E. coli bacteraemia was estimated to be £14,346,400 (2012 £), with third-generation cephalosporin resistance associated with excess costs per infection of £420 (95% CI: 220–630).ConclusionsE. coli bacteraemia places a statistically significant burden on patient health and the hospital sector in England. Resistance to front-line antibiotics increases length of stay; increasing the cost burden of such infections in the secondary care setting.

Excess Length of Acute Inpatient Stay Attributable to Acquisition of Hospital-Onset Gram-Negative Bloodstream Infection with and without Antibiotic Resistance: A Multistate Model Analysis

“…As with previous studies addressing the burden of bloodstream infections caused by ESBL-producing or ESC-R Enterobacteriaceae [11][12][13], ESC-R was associated with about five days excess LOS compared with ESC-susceptible strains in our study. There are several possible explanations for the increased LOS caused by ESC-R Enterobacteriaceae.…”

“…Our results were comparable with previous studies from Europe, which addressed the burden of antimicrobial resistance and suggest similar impacts of HAI and AMR despite differences in healthcare systems between the United States and European nations. The recent study conducted in the United Kingdom demonstrated that the excess length of stay in patients with E. coli bacteremia was 3.87 days (95% CI: 3.69-4.04 days) compared to non-infected control patients, and there were 1.58 days (95% CI: 0.84-2.31 days) of additional excess LOS caused by third-generation cephalosporin resistance [13]. In contrast to third-generation cephalosporin resistance, ciprofloxacin resistance did not significantly prolong LOS (0.46 days, 95% CI: -0.11-1.03 days).…”

“…These studies found that either ESBL-positive or third-generation cephalosporin resistance were associated with 1.6-9.4 days excess LOS compared with ESBL-negative or third-generation cephalosporin-susceptible strains. One retrospective study by Naylor et al also found that ciprofloxacin resistance was not associated with excess LOS [13]. However, it was unclear whether these results from Europe were generalizable to the United States, where the healthcare delivery system is substantially different.…”

“…Multistate models have been increasingly used to describe attributable LOS due to drug-resistant organisms in several European studies to account for competing outcomes and time-dependent biases [11][12][13]. These studies found that either ESBL-positive or third-generation cephalosporin resistance were associated with 1.6-9.4 days excess LOS compared with ESBL-negative or third-generation cephalosporin-susceptible strains.…”

Combating Antimicrobial Resistance in Singapore: A Qualitative Study Exploring the Policy Context, Challenges, Facilitators, and Proposed Strategies

“…For example, Naylor et al used a national mandatory surveillance database in England to quantify the cost and mortality burden of Escherichia coli bacteremia, as well as the influence different resistances have on them. Such findings will be useful for understanding the health and economic impact of future trends in resistance, and for prioritization of funding and strategies to tackle the problem [33]. In addition, future research could focus on exploring further how the current Singapore National Strategic Action Plan is being implemented; exploring in more detail the social, political, behavioral and cultural components affecting AMR; and analyzing at greater length what type of AMR awareness campaigns could be developed to reach the community and engage civil society organizations.…”