Assessment of Costs Associated with Hospital-Acquired Infections in a Private Tertiary Care Hospital in India

Surgical Site Infection in Laparoscopic Hysterectomy versus Abdominal Hysterectomy in Gynecological Disease(s): An Overview

Objective

Surgical site infection (SSI) is an unsettled complication seen in any surgery. The aim of this study is to assess the rate of postoperative SSIs between total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). Can the rate of SSI be reduced with the use of a laparoscopic mode of hysterectomy over abdominal?

Materials and Methods

It was a retrospective comparative study. The study was conducted in the obstetrics and gynecology department at a tertiary care center from June 2016 to March 2020. A total of 300 patients who underwent hysterectomy either via laparoscopic or abdominal route were included in the study. They were subdivided into two groups: a total of 167 underwent TLH (Group 1) and 133 had TAH (Group 2). The results were compared. It included the age and body mass index of the patient, indication of surgery, size of the uterus, intraoperative blood loss, postoperative SSIs, duration of hospital stay, and readmission rates.

Results

It was found a high rate of SSI in TAH (82.4% vs. 17.6%, P < 0.001, Cramer's V-0.18), the operative time taken (75 ± 25 min vs. 128 ± 52 min, P < 0.001), and the mean blood loss during TLH (110 ± 30 ml vs. 160 ± 116 ml, P < 0.001) was found significant for patients. The hospital stay after TLH was found to be significantly shorter (4 ± 2.47 days vs. 7 ± 2.43, P < 0.001).

Conclusion

TLH has improved the psychological, physical, and financial burden on the health care department. Thus, it has proved a preferred route over TAH.

Health care associated infections, antimicrobial resistance and outcomes in patients admitted to intensive care unit, India: A five-Year retrospective cohort study

Background

The present study was conducted to study the prevalence of HAIs in a newly established MICU, common microorganisms causing HAIs and their antibiotic-sensitivity profile, and antimicrobial utilization and mortality rate.

Methods

The present retrospective cohort study was carried out at AIIMS, Bhopal (2015-2019). The prevalence of HAIs was determined; sites of HAIs and common causative microorganisms were identified, and their antibiotic-sensitivity profiles were studied. The group of patients with HAIs was matched with a control group drawn from the pool of patients without HAIs; this matching was done with respect to age, gender, and clinical diagnosis. Antimicrobial utilization, Period of ICU stay, comorbidities and patient mortality rates in the two groups were analyzed. The clinical criteria by the CDC- National Nosocomial Infections Surveillance to diagnose HAIs.

Results

A total of 281 ICU patients' records were analyzed. The mean age was 47.21 ± 19.07 years. Of these 89 were found to have developed ICU-acquired HAIs (Prevalance:32%). Bloodstream infections (33%) and respiratory tract infections (30.68%), catheter-associated urinary tract infections (25.56%), and surgical site infections (6.76%) were the commonest. The most frequently isolated microorganism causing HAIs was K. pneumonia (18%), A. baumannii (14%) and E. coli (12%), 31% isolates of which were multidrug resistant. The average length of ICU stay was high in patients with HAIs (13.85 vs 8.2 days). The most common co-morbidity was type 2 diabetes mellitus (42.86%). Prolonged ICU stays [OR 1.13, (95% CI; 0.04-0.10)] and the presence of HAIs [OR 1.18(95%CI; (0.03-0.15)] were associated with an increased risk of mortality.

Conclusions

An increased prevalence of HAIs essentially bloodstream infections and respiratory infections with MDR organisms to antimicrobials in the watch group is highly considerable. Acquisition of HAIs with MDR organisms and increased length of hospital stay are considerable risk factors for increased mortality in ICU-admitted patients. Regular antimicrobial stewardship activities and revising existing hospital infection control policies accordingly may reduce HAIs.

The costs of surgical site infection after abdominal surgery in middle income countries: Key resource use In Wound Infection (KIWI) study

BACKGROUND

Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries.

METHODS

Centres from a randomised controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle (India, Mexico) and two lower-middle (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated versus contaminated-dirty), country and timing (inpatient versus outpatient).

FINDINGS

335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases was in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery.

CONCLUSION

SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.

Nanomaterial-Based Antimicrobial Coating for Biomedical Implants: New Age Solution for Biofilm-Associated Infections

Recently, the upsurge in hospital-acquired diseases has put global health at risk. Biomedical implants being the primary source of contamination, the development of biomedical implants with antimicrobial coatings has attracted the attention of a large group of researchers from around the globe. Bacteria develops biofilms on the surface of implants, making it challenging to eradicate them with the standard approach of administering antibiotics. A further issue of current concern is the fast resurgence of resistance to conventional antibiotics. As nanotechnology continues to advance, various types of nanomaterials have been created, including 2D nanoparticles and metal and metal oxide nanoparticles with antimicrobial properties. Researchers from all over the world are using these materials as a coating agent for biomedical implants to create an antimicrobial environment. This comprehensive and contemporary review summarizes various metals, metal oxide nanoparticles, 2D nanomaterials, and their composites that have been used or may be used in the future as an antimicrobial coating agent for biomedical implants, as well as their succinct mode of action to combat biofilm-associated infection and diseases.

Multidrug-resistant Acinetobacter baumannii infections: looming threat in the Indian clinical setting

INTRODUCTION

The recent increase in multidrug-resistant strains of A. baumannii has increased the incidences of ventilator-associated pneumoniae, catheter-associated urinary tract infections, and central line-associated blood stream infections, together increasing hospital stay, treatment cost, and mortality. Resistance genes blaOXA and blaNDM are dominant in India. Carbapenem-resistant A. baumannii (CRAB) International clone-2 (IC-2) are rising in India. High dependency on carbapenems and last-resort combination of tigecycline and polymyxins have aggravated outcomes. Despite nursing barriers, ward closure, environmental disinfections etc for detecting and controlling transmission, MDR isolates and CRAB nosocomial outbreaks continue. Treatment cost overruns by AMR adversely affect 80% of Indians without insurance cover.

AREA COVERED

This narrative review will cover epidemiology, resistance pattern, genetic diversity, device-related infection, cost, and mortality due to multidrug-resistant and CRAB in India. A comprehensive literature search in PubMed and Google Scholar using appropriate keywords at different time points yielded relevant articles.

EXPERT OPINION

It is challenging to enforce policies to control MDR A. baumannii in India. Government and hospitals should enforce stringent infection control measures, surveillance, and antimicrobial stewardship to prevent further spread and emergence of more virulent and resistant strains. Knowledge on antibiotic resistance mechanisms can help design novel antibiotics that can evade, resistance.

Financial impact of healthcare-associated infections on intensive care units estimated for fifty Brazilian university hospitals affiliated to the unified health system

BACKGROUND

Studies show that healthcare-associated infections (HAIs) represent a crucial issue in healthcare and can lead to substantial economic impacts in intensive care units (ICUs).

AIM

To estimate direct costs associated with the most significant HAIs in 50 teaching hospitals in Brazil, affiliated to the unified health system (Sistema Único de Saúde: SUS).

METHODS

A Monte Carlo simulation model was designed to estimate the direct costs of HAIs; first, epidemiologic and economic parameters were established for each HAI based on a cohort of 949 critical patients (800 without HAI and 149 with); second, simulation based on three Brazilian prevalence scenarios of HAIs in ICU patients (29.1%, 51.2%, and 61.6%) was used; and third, the annual direct costs of HAIs in 50 university hospitals were simulated.

FINDINGS

Patients with HAIs had 16 additional days in the ICU, along with an extra direct cost of US$13.892, compared to those without HAIs. In one hypothetical scenario without HAI, the direct annual cost of hospital care for 26,649 inpatients in adult ICUs of 50 hospitals was US$112,924,421. There was an increase of approximately US$56 million in a scenario with 29.1%, and an increase of US$147 million in a scenario with 61.6%. The impact on the direct cost became significant starting at a 10% prevalence of HAIs, where US$2,824,817 is added for each 1% increase in prevalence.

CONCLUSION

This analysis provides robust and updated estimates showing that HAI places a significant financial burden on the Brazilian healthcare system and contributes to a longer stay for inpatients.

The Socioeconomic Impact of Surgical Site Infections

Précis: Surgical site infections are an ever-increasing phenomenon worldwide due to different factors. This brief report aimeds to highlight at a glance, for both physicians and political and institutional leaders, the economic burden of surgical site infections.

Objectives: This brief report aimed to highlight the economic burden of surgical site infections (SSIs).

Methods: A narrative review focusing on this subject has been carried out.

Results: Surgical site infections are responsible for generating important costs. In 2017, a French cohort highlighted a mean cost of each SSI treatment to be around €1,814; the same year, the Centers for Disease Control and Prevention guidelines evaluated the mean cost caused by SSI treatment to be from $10,443 to $25,546 per SSI. This cost depends on many factors including the patient himself and the type of surgery.

Conclusions: Prevention of the risk of infection is, therefore, a profitable concept for surgery that must be integrated within all healthcare managements worldwide.

Incidence and impact of hospital-acquired complications in an internal medicine unit of a reference hospital in Cameroon: a prospective cohort study

BACKGROUND

Hospital-acquired complications (HACs) contribute to increased morbidity, mortality and hospital costs. However, their burden is often overlooked in resource-limited settings. We sought to determine the incidence, risk factors and effects of HACs on direct medical costs.

METHODS

This was a prospective cohort study conducted in the Internal Medicine inpatient ward of Douala General Hospital over 3 mo. Patients were examined daily from admission to discharge, transfer or death. Incidence of HACs was calculated and risk factors of HACs were determined using univariate and multivariate regression models.

RESULTS

The cumulative incidence rate of HACs in 230 participants was 29.2/1000 patient-days. The incidence rate of infectious and non-infectious complications was 8.4/1000 and 20.9/1000 patient-days, respectively. The most common HAC was constipation (8.3/1000 patient-days). The most common infection was urinary tract infection (3.7/1000 patient-days). HIV infection and length of stay >8 d were significantly associated with the occurrence of HACs. Deep vein thrombosis was associated with the highest direct medical cost.

CONCLUSION

The incidence of HACs is high in our setting and leads to increased length of hospital stays as well as greater direct medical costs. Thus, there is a need for effective preventive strategies.

Costs of healthcare-associated infections to the Brazilian public Unified Health System in a tertiary-care teaching hospital: a matched case-control study

BACKGROUND

Little is known about the economic burden of healthcare-associated infections (HAIs) in Brazil.

AIM

To analyse the costs of hospitalization by reimbursement from the Brazilian government, via the Brazilian Unified Health System (SUS) affiliation, and direct costs in the adult Intensive Care Unit (ICU).

METHODS

The matched-pairs case-control study (83 patients with HAIs and 83 without HAIs) was performed at a referral tertiary-care teaching hospital in Brazil in January 2018. In order to calculate the HAI costs from the perspective of the payer, the total cost for each hospitalization was obtained through the Hospital's Billing Sector. Direct costs were calculated annually for 949 critical patients during 2018.

FINDINGS

The reimbursement cost per hospitalization of patients with HAIs was 75% (US$2721) higher than patients without HAIs (US$1553). When a patient has an HAI, in addition to a longer length of stay (15 days), there was an extra increase (US$996) in the reimbursement cost per hospitalization. An HAI in the ICU was associated with a total direct cost eight times higher compared with patients who did not develop infections in this unit, US$11,776 × US$1329, respectively. The direct cost of hospitalization in the ICU without HAI was 56.5% less than the reimbursement (US$1329 × US$3052, respectively), whereas for the patient with an HAI, the direct cost was 111.5% above the reimbursement (US$11,776 × US$5569, respectively).

CONCLUSION

HAIs contribute to a longer stay and an eight-fold increase in direct costs. It is necessary to reinforce programmes that prevent HAIs in Brazilian hospitals.

Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden

BACKGROUND

Surgical site infection (SSI) is a worldwide problem which has morbidity, mortality and financial consequences. The incidence rate of SSI is high in Low- and Middle-Income countries (LMICs) compared to high income countries, and the costly surgical complication can raise the potential risk of financial catastrophe.

OBJECTIVE

The aim of the study is to critically appraise studies on the cost of SSI in a range of LMIC studies and compare these estimates with a reference standard of high income European studies who have explored similar SSI costs.

METHODS

A systematic review was undertaken using searches of two electronic databases, EMBASE and MEDLINE In-Process & Other Non-Indexed Citations, up to February 2019. Study characteristics, comparator group, methods and results were extracted by using a standard template.

RESULTS

Studies from 15 LMIC and 16 European countries were identified and reviewed in full. The additional cost of SSI range (presented in 2017 international dollars) was similar in the LMIC ($174-$29,610) and European countries ($21-$34,000). Huge study design heterogeneity was encountered across the two settings.

DISCUSSION

SSIs were revealed to have a significant cost burden in both LMICs and High Income Countries in Europe. The magnitude of the costs depends on the SSI definition used, severity of SSI, patient population, choice of comparator, hospital setting, and cost items included. Differences in study design affected the comparability across studies. There is need for multicentre studies with standardized data collection methods to capture relevant costs and consequences of the infection across income settings.

The Mutation of Conservative Asp268 Residue in the Peptidoglycan-Associated Domain of the OmpA Protein Affects Multiple Acinetobacter baumannii Virulence Characteristics

Acinetobacter baumannii is a nosocomial human pathogen of increasing concern due to its multidrug resistance profile. The outer membrane protein A (OmpA) is an abundant bacterial cell surface component involved in A. baumannii pathogenesis. It has been shown that the C-terminal domain of OmpA is located in the periplasm and non-covalently associates with the peptidoglycan layer via two conserved amino acids, thereby anchoring OmpA to the cell wall. Here, we investigated the role of one of the respective residues, D268 in OmpA of A. baumannii clinical strain Ab₁₆₉, on its virulence characteristics by complementing the ΔompA mutant with the plasmid-borne ompA_D268A allele. We show that while restoring the impaired biofilm formation of the ΔompA strain, the Ab₁₆₉ompA_D268A mutant tended to form bacterial filaments, indicating the abnormalities in cell division. Moreover, the Ab₁₆₉ OmpA D268-mediated association to peptidoglycan was required for the manifestation of twitching motility, desiccation resistance, serum-induced killing, adhesion to epithelial cells and virulence in a nematode infection model, although it was dispensable for the uptake of β-lactam antibiotics by outer membrane vesicles. Overall, the results of this study demonstrate that the OmpA C-terminal domain-mediated association to peptidoglycan is critical for a number of virulent properties displayed by A. baumannii outside and within the host.

Costs of hospital-acquired infection for patients hospitalized in intensive care unit of an Iranian referral hospital

Background: Hospital infections have affected millions of people around the world and are considered as one of the most important issues related to patient safety. Therefore, this study was conducted to estimate the extra costs caused by hospital-acquired infections in hospitals.

Methods: This retrospective cohort study was conducted in Tehran province, Iran, in 2017. Medical records of 235 patients hospitalized in one of Tehran hospitals were reviewed for the study. They were divided into case (90 patients) and control (145 patients) groups. Data were analyzed using SPSS and STATA software.

Results: Results revealed no significant relationship between age and gender with the incidence of nosocomial infection (p>0.05). However, the chance of nosocomial infection is most affected by length of hospital stay and costs paid by patients. Moreover, nosocomial infection increases the length of hospital stay up to 25 days. Our results revealed that the mean±SD hospital stay of infected and non-infected patients were 15.8±17.2 and 40.8±19.1 days, respectively. Furthermore, the total cost of patients without any hospital infection was 2451±3098 USD (83 674 480±105 765 500 Rials). On the other hand, the cost for infected patients was 3264±6078 USD (207 497 500±111 430 700 Rials).

Conclusion: Hospital-acquired infections can impose great costs on both patients and the health system. The results of this study indicated the importance of taking specific measures for infection control in hospitals.

Green synthesis of Kocuran-functionalized silver glyconanoparticles for use as antibiofilm coatings on silicone urethral catheters

Microbial infections due to biofilm formation on medical implants are serious complications arising after surgery which can be prevented by using antimicrobial coatings on biomaterial surfaces. We developed a simple, rapid and green chemistry approach for synthesis of silver glyconanoparticles (AgNPs) using Kocuran, an exopolysaccharide produced by Kocuria rosea strain BS-1. Kocuran-capped AgNPs exhibited a characteristic surface plasmon resonance (SPR) peak around 435 nm. They were mono-dispersed, spherical with an average particle size of 12 nm. XRD and SAED studies suggested that AgNPs were crystalline in nature. AgNPs had a zeta potential of -33.9 mV and were anionic charged. They showed colloidal stability at different pH (6 to 10), temperatures (30 °C to 100 °C), in NaCl, NaNO3 and BSA solutions. Kocuran-capped AgNPs exhibited effective antimicrobial activity against Staphylococcus aureus and Escherichia coli and cell death was mainly due to hydroxyl radical induction and depletion of NADH. They also inhibited the biofilm development by S. aureus and E. coli and confocal scanning laser microscopic images revealed the damage of intact cell architecture. In vitro evaluation of Kocuran-capped silver glyconanoparticles on human gingival fibroblasts demonstrated good cell proliferation as compared to commercial AgNPs suggesting that they are biocompatible and non-toxic in nature. This is a first report on Kocuran-functionalized AgNPs exhibiting potential antibacterial and antiadhesive properties for use as antimicrobial coatings against bacterial adhesion and biofilm formation on silicone urethral catheters.