1) The document discusses the economics of nosocomial infections and antimicrobial resistance. It outlines the high costs associated with nosocomial infections, including increased length of hospital stay, excess costs of treatment, and increased mortality. 2) Several studies are summarized that estimate the excess costs of various types of nosocomial infections, such as surgical site infections, bloodstream infections, pneumonias, and central line-associated infections. Across multiple countries and healthcare settings, the estimated excess costs per infection range from thousands to tens of thousands of dollars. 3) Nosocomial infections pose a significant economic burden to healthcare systems worldwide. Reducing their incidence could save hospitals substantial costs while improving patient outcomes.

1. Prof. Dr. Ata Nevzat Yalçın, MDProf. Dr. Ata Nevzat Yalçın, MD
Akdeniz University, Medicine FacultyAkdeniz University, Medicine Faculty
Dept. Infectious Dis. and ClinicalDept. Infectious Dis. and Clinical
MicrobiologyMicrobiology
Antalya-TURKEYAntalya-TURKEY
Economics of nosocomial
infections and
antimicrobial resistance

2. 2
Points of This TalkPoints of This Talk
 Incidence of NI and costIncidence of NI and cost
 Pharmacoeconomical analysisPharmacoeconomical analysis
 Excess costExcess cost
 Excess cost in NIExcess cost in NI
 Cost of antibioticsCost of antibiotics
 Extra length of stayExtra length of stay
 Extra mortalityExtra mortality
 Cost of antimicrobial resistanceCost of antimicrobial resistance

3. 3
• NosocomialNosocomial infections (infections (NNI) represent anI) represent an
important public health problem in developingimportant public health problem in developing
countries as in developed ones today as acountries as in developed ones today as a
major cause of high morbidity, mortality andmajor cause of high morbidity, mortality and
economic consequences in hospitalizedeconomic consequences in hospitalized
patients.patients.
Nosocomial infectionsNosocomial infections
Jarvis WR.Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-71996;17: 552-7

4. 4
Importance of NIsImportance of NIs
 The burden of Nosocomial infectionsThe burden of Nosocomial infections ((NIs) isNIs) is
substantial in developed countries, where it affectssubstantial in developed countries, where it affects
from 5% to 15% of hospitalized patients in regularfrom 5% to 15% of hospitalized patients in regular
wards, and as many as 50% or more of patients inwards, and as many as 50% or more of patients in
intensive care units (ICUs).intensive care units (ICUs).
 The incidence of NIs is between 25% and 40% inThe incidence of NIs is between 25% and 40% in
developing countries.developing countries.
 NIsNIs increase length of stay in hospital.increase length of stay in hospital.
 NIsNIs increase costs.increase costs.
 NIsNIs increase mortality.increase mortality.

5. 5
Nosocomial infectionsNosocomial infections
 GermanyGermany →→ 525.000-800.000 cases525.000-800.000 cases
~ 20.000- 40.000 deaths~ 20.000- 40.000 deaths
 UKUK →→ 500.000-1.000.000 cases500.000-1.000.000 cases
~ 5.000 deaths~ 5.000 deaths
 USAUSA →→ 2.220.000 cases2.220.000 cases
~ 115.000 deaths~ 115.000 deaths
 EUEU →→ 4.500.000 cases4.500.000 cases
~ 111.000 deaths~ 111.000 deaths

6. 7
Excess Cost of NosocomialExcess Cost of Nosocomial
InfectionsInfections
 NorwayNorway → →→ → 132 Million Dollars132 Million Dollars
 ScotlandScotland → →→ → 168 Million Pounds168 Million Pounds
 EnglandEngland → →→ → 1,7 Billion Dollars1,7 Billion Dollars
 FranceFrance → →→ → 3-5 Billion Franks3-5 Billion Franks
 USAUSA → →→ → 37-45 Billion Dollars37-45 Billion Dollars
 EUEU → →→ → 7 Billion Euros7 Billion Euros
 TurkeyTurkey → →→ → 1-1,5 Billion Dollars ???1-1,5 Billion Dollars ???
Andersen BM, et al.Andersen BM, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1998;19: 805-71998;19: 805-7
Astagneau P, et al.Astagneau P, et al. J Hosp InfectJ Hosp Infect 1999; 42 : 303-121999; 42 : 303-12
Plowman R, et al.Plowman R, et al. J Hosp InfectJ Hosp Infect 2001;47: 198-2072001;47: 198-207
Graves N.Graves N. Emerg Infect DisEmerg Infect Dis 2004;10: 561-62004;10: 561-6
ECDC Annual Report 2008: 16-38ECDC Annual Report 2008: 16-38
Dickema DJ, et al.Dickema DJ, et al. JAMAJAMA 2008;299:1190-22008;299:1190-2
Hassan M, et al.Hassan M, et al. Hospital TopicsHospital Topics 2010;88:82-92010;88:82-9
Zimlichman E, et al.Zimlichman E, et al. JAMAJAMA Intern MedIntern Med 20132013
Marchetti A. et al.Marchetti A. et al. J Med EconomicsJ Med Economics 2013:1-62013:1-6
Magill SS, et al.Magill SS, et al. NEJMNEJM,2014;370:1198-1208,2014;370:1198-1208

7. Zimlichman E, et al.Zimlichman E, et al. JAMA Intern MedJAMA Intern Med 2013; 173:2039-462013; 173:2039-46

8. 9
• Pneumonias → → 35,967Pneumonias → → 35,967
• Bloodstream inf. → → 30,655Bloodstream inf. → → 30,655
• Urinary tract inf. → → 8,225Urinary tract inf. → → 8,225
• Surgical site inf. → →13,088Surgical site inf. → →13,088
• Others → →12,085Others → →12,085
• TOTAL → →100,000TOTAL → →100,000
Nosocomial Infections andNosocomial Infections and
mortalitymortality
(US Department of Health and Human Services (DHHS-2009)(US Department of Health and Human Services (DHHS-2009)
Stone PW.Stone PW. Expert Rev Pharmacoecon Outcomes ResExpert Rev Pharmacoecon Outcomes Res 2009;9:417-222009;9:417-22

9. 10
Calculating costsCalculating costs
(Methodological subjects-1)(Methodological subjects-1)
 Study designStudy design
 Patient group (incidence,prevalence,epidemics)Patient group (incidence,prevalence,epidemics)
 Location (hospital, follow-up after discharge)Location (hospital, follow-up after discharge)
 Dimension of the study (hospital, country,Dimension of the study (hospital, country,
developing countries, pathogens, interventions)developing countries, pathogens, interventions)
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4

10. 11
Calculating costsCalculating costs
(Methodological subjects-2)(Methodological subjects-2)
 Extra cost and design of length of stayExtra cost and design of length of stay
 Costs (hospital charges, deaths, antibioticsCosts (hospital charges, deaths, antibiotics
utilisation, antibiotic resistance, environmentalutilisation, antibiotic resistance, environmental
damage)damage)
 Conclusion statistics (mean, median, percent, total)Conclusion statistics (mean, median, percent, total)
 Design of analysisDesign of analysis
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4

11. 12
Costs
1. Well described costs associated with
nosocomial infections
2. Poorly described costs associated with
nosocomial infections

12. 13
Well described costsWell described costs
associated with NIassociated with NI
 Drug (antibiotics) acquisitionDrug (antibiotics) acquisition

Increased hospital stayIncreased hospital stay
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4

13. 14
Poorly described costsPoorly described costs
associated with NIassociated with NI
 Control measures (isolation facilities,Control measures (isolation facilities,
commitees, policies)commitees, policies)
 Impaired hospital activity (ward closing, etc.)Impaired hospital activity (ward closing, etc.)
 Confidence, performance of staffConfidence, performance of staff
 LitigationLitigation
 Effects on communityEffects on community
 MorbidityMorbidity
 MortalityMortality
Wilcox MH, et al.Wilcox MH, et al. J Hosp InfectJ Hosp Infect 2000;45:81-42000;45:81-4

14. 15
Excess costs of NIExcess costs of NI
(Adults)-(US Dollars)(Adults)-(US Dollars)
Study Year Country Cost ($$))
Westwood JCN 1974 USA 1,650
Haley RW 1980 USA 1,018
Coello R 1993 England 1,759
Diaz Molina C 1993 Spain 1,909
Yalcin AN 1997 Turkey 1,582
Orrett FA 1998 Trinidad 1,910
Andersen BM 1998 Norway 2,200
Chen YY 2003 Taiwan 3,306
Roberts 2010 USA 1,581-6,824

15. 16
Excess costs of NIExcess costs of NI
(Pediatrics)-(US Dollars)(Pediatrics)-(US Dollars)
Study Year Country Cost ($$))
Leroyer A 1997 France 10,440
Navarette D 1999 Mexico 11,682
Mahieu LM 2001 Belgium 12,399
Yalcin AN.Yalcin AN. Indian J Med SciIndian J Med Sci 2003;57:450-62003;57:450-6

16. 17
Studies on excess costs inStudies on excess costs in
nosocomial infectionsnosocomial infections
 Surgical site infectionsSurgical site infections
 Bloodstream infectionsBloodstream infections
 Catheter-related bloodstream infectionsCatheter-related bloodstream infections
 PneumoniasPneumonias
 Ventilator-associated pneumoniasVentilator-associated pneumonias

17. 18
Surgical site infections
 Songklanagarind Hospital, Chiang Mai University,
Thailand,1998-2003
 140 matched pairs of case and control
 Procedures:Appendectomy, herniorrhaphy,
mastectomy, cholecystectomy, colostomy and
craniotomy
 Mean extra hospital charge………43,658 Baht
(95 % C.l;30,228-57,088 Baht ) (p(p<< 0.001)0.001)
 Mean excess postoperative stay…..21,3 days
(95 % C.l;16,6-26,0 days) (p(p<< 0.001)0.001)
Kasatpibal N, et al.Kasatpibal N, et al. J Med Assoc ThaiJ Med Assoc Thai 2005;88:1083-912005;88:1083-91

18. Surgical site infections
 Plymouth, England, April 2010-March
2012,
 282 operations
 Additional length of stay….10 days (7-13
days)
 Extra cost…5 239 Pounds (4622-6719)
 Total cost…..2 491 424 Pounds
Jenks PR, et al.Jenks PR, et al. J Hosp InfectJ Hosp Infect 2014;86:24-332014;86:24-33

19. Jenks PR, et al.Jenks PR, et al. J Hosp InfectJ Hosp Infect 2014;86:24-332014;86:24-33
Surgical site infections

20. 21
Nosocomial bloodstreamNosocomial bloodstream
infections (ICU)infections (ICU)
 Dr BL Kapur Memorial Hospital, New Delhi, India, 2006
 24 patients and 48 controls
 Excess hospitalization: 11,6 daysExcess hospitalization: 11,6 days (p(p<< 0.0001)0.0001)
 Mortality : 54 %Mortality : 54 % (p(p<< 0.0001)0.0001)
 Excess cost:Excess cost: $$14,818 (10,663 -18,974), (14,818 (10,663 -18,974), (pp<< 0.0001)0.0001)
Kothari A, et al.Kothari A, et al. J Hosp InfectJ Hosp Infect 2009;71:143-82009;71:143-8

21. Nosocomial bloodstreamNosocomial bloodstream
infections in elderlyinfections in elderly
Cases (n:830) Controls
(n:830)
Mortality 49.4 % 33.2 %
(p(p<< 0.001)0.001)
Excess length
of stay
29.2 days 20.2 days
(p(p<< 0.001)0.001)
Cost $ 102.276 $ 69.690 (p(p<< 0.001)0.001)
Kaye KS, et al. J Am Geriatr Soc 2014 ; 62 : 306-11

22. 23
Central catheter-relatedCentral catheter-related
bloodstream infectionsbloodstream infections
 Six ICU, Buenos Aires, Argentina, 1997-2002Six ICU, Buenos Aires, Argentina, 1997-2002
 142 patients, 142 controls142 patients, 142 controls
 Excess hospitalization: 11,9 daysExcess hospitalization: 11,9 days
 Excess mortality: 24,6 %Excess mortality: 24,6 %
 Excess cost:Excess cost: $$4,8884,888
 Excess antibiotics cost:Excess antibiotics cost: $$1,9131,913
Rosenthal VD, et al.Rosenthal VD, et al. Am J Infect ControlAm J Infect Control 2003;31:475-802003;31:475-80

23. 24
Central venous catheter-Central venous catheter-
associatedassociated
bloodstream infections (ICU)bloodstream infections (ICU) General Hospital, Specialties Intituto Mexicano delGeneral Hospital, Specialties Intituto Mexicano del
Seguro Social Hospital, Gabriel Mancera Hospital,Seguro Social Hospital, Gabriel Mancera Hospital,
Mexico City, Mexico, 2002-3Mexico City, Mexico, 2002-3
 55 patients, 55 controls55 patients, 55 controls
 Excess hospitalization: 6,1 daysExcess hospitalization: 6,1 days
 Excess mortality: 20%Excess mortality: 20%
 Excess cost (mean):Excess cost (mean): $$11,59111,591
 Excess antibiotics cost (mean):Excess antibiotics cost (mean): $$598598
Higuera F, et al.Higuera F, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2007;28:31-52007;28:31-5

24. 25
Nosocomial pneumoniasNosocomial pneumonias
 Six ICU, Buenos Aires, Argentina, 2001-2005Six ICU, Buenos Aires, Argentina, 2001-2005
 307 n. pneumonias, 307 controls307 n. pneumonias, 307 controls
 Excess cost → $ 2,255Excess cost → $ 2,255
 Excess antibiotic cost → $ 996Excess antibiotic cost → $ 996
 Extra length of stay → 8,95 daysExtra length of stay → 8,95 days
 Extra mortality → 30,3 %Extra mortality → 30,3 %
Rosenthal D, et al. Am JRosenthal D, et al. Am J Infect ControlInfect Control 2005;33:157-612005;33:157-61

25. 26
StudyStudy
(period)(period)
CountryCountry NumberNumber
VAP/VAP/
ControlControl
CostCost
VAPVAP
(($$))
CostCost
ControlControl
(($$))
pp
Hugonnet SHugonnet S
(1995-1997)(1995-1997)
SwitzerlandSwitzerland 97/9797/97 24 72724 727 17 43817 438 ‹‹ 0.0010.001
Warren DKWarren DK
(1998-1999)(1998-1999)
USAUSA 127/692127/692 70 56870 568 21 62021 620 ‹‹ 0.0010.001
Cocanour CSCocanour CS
(2002-2003)(2002-2003)
USAUSA 70/7070/70 82 19582 195 25 03725 037 ‹‹ 0.050.05
Karaoğlan HKaraoğlan H
(2004-2005)(2004-2005)
TurkeyTurkey
(Antalya)(Antalya)
81/8181/81 8 6028 602 2 6212 621 ‹‹ 0.00010.0001
Kollef MAKollef MA
(2008-2009)(2008-2009)
USA 2144/2144 133 371 74 729 ‹‹ 0.00010.0001
Ventilator-associated
pneumonias

26. 27
HA-Cl.difficile infections
 Retrospective, cohort studyRetrospective, cohort study
 New York State, 2007-8New York State, 2007-8
 4 853 000 HA-CDI cases4 853 000 HA-CDI cases
 29 000 deaths (USA)29 000 deaths (USA)
 Average cost per patient…$ 29 000Average cost per patient…$ 29 000
 Annual cost……$55 millionAnnual cost……$55 million
Lipp MJLipp MJ, et al., et al. J Gastroenterol HepatolJ Gastroenterol Hepatol 20201212;;2727:: 1733-71733-7

27. Resistant
microorganisms and cost
 Vienna, Austria, January-June 2002
Daxboeck F, et al. J Hosp Infect 2006; 614-8
MDRMDR-GNB-GNB
(n: 99)(n: 99)
MRSAMRSA
(n: 74)(n: 74)
pp
Length ofLength of
staystay
42 days42 days 37 days37 days 0.20.2
CostCost 18 11518 115 ££
(582-(582-
149 817)149 817)
6 6246 624 ££
(516-(516-
108 558)108 558)
0.010.01

28. A.baumannii -BSI
 Taipei,Taiwan, April 1996- August 2001
Lee NY, et al. Infect Control Hosp Epidemiol 2007;28:713-9
ResistantResistant--
A.baumanniiA.baumannii
((nn: 46): 46)
SensitiveSensitive
A.baumanniiA.baumannii
((nn: 46): 46)
pp
Length ofLength of
staystay
54.254.2 daysdays 34.134.1 daysdays 0.0060.006
CostCost $$ 9 3499 349 $$ 4 8654 865 0.0010.001

29. 30
StudyStudy YearYear NumberNumber
ResRes//
Suscept.Suscept.
ResistantResistant
(($$))
SusceptibleSusceptible
(($$))
pp
GasinkGasink
(Quinolone)(Quinolone)
20062006 320/527320/527 62 32562 325 48 73348 733 0.000.0088
EvansEvans
(Imipenem)(Imipenem)
20072007 47/7347/73 99 67299 672 69 50269 502 0.00.01515
EagyeEagye
(Meropenm)(Meropenm)
20092009 58/11558/115 100 700100 700 32 59432 594 ‹‹ 0.00.00101
LautenbachLautenbach
(Imipenem)(Imipenem)
20102010 2289/2532289/253 286 417286 417 189 274189 274 ‹‹ 0.0010.001
MoralesMorales
(MDR)(MDR)
2012 134/149 13 178 4 258 ‹‹ 0.0010.001
Cost: P.aeruginosa
Nathwani DNathwani D.. Antimicrob ResistanceAntimicrob Resistance Infect ControlInfect Control 2014;3:32-482014;3:32-48

30. Impact of antimicrobial
resistance on cost
Microorganism Attributable cost
CR-Non-fermenters $ 58 457 - 85 299
MDR A.baumannii $ 4484
ESBL(+)
Enterobacteriaceae
$ 1584 - 30 093
MRSA $ 1014 - 40 090
Giannoula S, et al.Giannoula S, et al. Expert Rev AntiExpert Rev Anti Infect TherInfect Ther 20120133;;1111::321-31321-31

31. Impact of antimicrobial
resistance on cost
Microorganism Excess cost
VRE $ 16 711 – 60 988
MDR A.baumannii $ 5336 – 126 856
ESBL(+)
Enterobacteriaceae
$ 3658 - 4892
MRSA $ 695 – 29 030
Gandra S, et al.Gandra S, et al. Clin Microbiol InfectClin Microbiol Infect 20120144;;2020::973-9973-9

32. 33
Costs of NI-USACosts of NI-USA (US(US $$))
Infection type Costs
(Mean)
Range
(Minimum-maximum)
CLA-Bloodstream
infections
$ 45,814 30,919-65,245
Ventilator-
associated
pneumonias
$ 40,144 36,286-44,220
Surgical site
infections
$ 20,785 18,902-22,667
Urinary tract
infections
$ 896 603-1,189
Zimlichman E, et al.Zimlichman E, et al. JAMA Intern MedJAMA Intern Med 2013; 173:2039-462013; 173:2039-46

33. 34
Attributable costs of NI (USAttributable costs of NI (US
$$))Infection type Attributable costs
(Mean)
Range
(Minimum-maximum)
Ventilator-
associated
pneumonias
22,875 9,986-54,503
CLA-Bloodstream
infections
18,432 3,592-34,410
Surgical site
infections
17,944 7,874-26,668
Urinary tract
infections
1,257 804-1,710
Yokoe DS, et al.Yokoe DS, et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 2008; 29 (Suppl. 1):S3-S112008; 29 (Suppl. 1):S3-S11

34. 35
Costs of NosocomialCosts of Nosocomial
infectionsinfections
HAIHAI ControlControl
 BedBed 464464 214214
 LaboratoryLaboratory 417417 249249
 AntibioticsAntibiotics 11901190 5454
 OthersOthers 209209 181181
 TOTALTOTAL $ 2280 $ 698$ 2280 $ 698
Yalcin AN, et al.Yalcin AN, et al. J ChemotherJ Chemother 1997; 9:411-41997; 9:411-4
(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)

35. 36
Distribution of costs in NIsDistribution of costs in NIs
Yalcin AN, et al.Yalcin AN, et al. J ChemotherJ Chemother 1997; 9: 411- 41997; 9: 411- 4
(Hacettepe University Hospital, Ankara, Turkey, 1995)(Hacettepe University Hospital, Ankara, Turkey, 1995)

36. 37
Distribution of cost (VAP)
($)
Costs Costs of VAP
Group ± SD (min-
max)
Costs of Control
Group ± SD (min-
max)
P
value
Bed 1193.7±679.8 (176-3140) 381.0±382.2 (154-3320) <0.0001
Antibiotics 837.1±472.9 (40-2140) 8.5±11.0 (0-40) <0.0001
Drugs and medical
materials
2305.0±1347.6 (330-
8143)
816.7±645.9 (125-4125) <0.0001
Laboratory 1647.0±1004.5 (248-
8068)
546.4±442.4 (34-2335) <0.0001
Radiology 269.9±222.1 (36-1683) 156.8±160.9 (16-806) <0.0001
Operation 628.2±1190.1 (0-7280) 302.4±535.3 (0-2523) <0.05
Intervention 1024.6±973.8 (135-7794) 254.3±271.7 (43-1579) <0.0001
Care 696.7±613.1 (72-3753) 155.4±192.8 (23-1524) <0.0001
Total 8602.7±5045.5 2621.9±2053.3 <0.0001
Karaoğlan H,Yalcin AN, et al.Karaoğlan H,Yalcin AN, et al. Infez MedInfez Med 2010;18:248-552010;18:248-55
(Akdeniz University Hospital, Antalya, Turkey, 2006-7)(Akdeniz University Hospital, Antalya, Turkey, 2006-7)

37. 38
Daily antibiotic cost inDaily antibiotic cost in
nosocomial infectionsnosocomial infections
 Urinary tract infectionsUrinary tract infections 96-203 FF96-203 FF
 PnemoniasPnemonias 108-219 FF108-219 FF
 Surgical site infectionsSurgical site infections 116-220 FF116-220 FF
 Bloodstream infectionsBloodstream infections 165-287 FF165-287 FF
Astagneau P, et al.Astagneau P, et al. J Hosp InfectJ Hosp Infect 1999;42:303-121999;42:303-12

38. 39
Daily antibiotic cost inDaily antibiotic cost in
nosocomial infectionsnosocomial infections
Yalçın AN, et al.Yalçın AN, et al. Turk J Hosp InfTurk J Hosp Inf 2002;6:41-52002;6:41-5
(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)

39. 40
Daily antibiotic cost inDaily antibiotic cost in
nosocomial infectionsnosocomial infections
 MS-KNSMS-KNS $ 44,9$ 44,9
 MSMS-S.aureus-S.aureus $$ 46,746,7
 E.coliE.coli $ 48,5$ 48,5
 EnterobacterEnterobacter spp.spp. $ 63,8$ 63,8
 MR-MR-S.aureusS.aureus $ 80,0$ 80,0
 P.aeruginosaP.aeruginosa $ 111,7$ 111,7
Yalçın AN, et al.Yalçın AN, et al. Turk J Hosp InfTurk J Hosp Inf 2002;6: 41-52002;6: 41-5
(Pamukkale University Hospital, Denizli, Turkey, 2001)(Pamukkale University Hospital, Denizli, Turkey, 2001)

40. 41
Daily antibiotic cost inDaily antibiotic cost in
nosocomial infectionsnosocomial infections
Inan D, et al.Inan D, et al. BMC Infect DisBMC Infect Dis 2005; 5 :1-52005; 5 :1-5
(Akdeniz University Hospital, Antalya, Turkey, 2004)(Akdeniz University Hospital, Antalya, Turkey, 2004)

41. 42
Costs of NIs with gramCosts of NIs with gram
negativenegative non-fermentativenon-fermentative
rodsrods
Aşık Z,Yalçın AN et al. (Aşık Z,Yalçın AN et al. (Thesis-2011-Akdeniz UniversityThesis-2011-Akdeniz University))
(Akdeniz University Hospital, Antalya, Turkey, 2011)(Akdeniz University Hospital, Antalya, Turkey, 2011)

42. 43
Excess length of stay inExcess length of stay in
nosocomial infectionsnosocomial infections
Study Year Country LOS (days)
Westwood JCN 1974 USA 22,0
Haley RW 1980 USA 13,4
French GL 1991 Hong Kong 23,4
Yalcin AN 1997 Turkey 20,3
Orrett FA 1998 Trinidad 33,5
Sanou J 1999 Burkina Faso 10,0
Roberts R 2010 USA 5,9-9,6
Askarian M 2003 Iran 6,2
Sanchez-V LD 2006 Mexico 10,0

43. 44
Excess length of stay inExcess length of stay in
nosocomial infectionsnosocomial infections
Infection type Excess length of stay (days)
Urinary tract infection 1-4
Surgical site infection 7-8,2
Bloodstream infection 7-21
Pneumonias 6,8-30
Jarvis WR.Jarvis WR. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol 1996;17: 552-71996;17: 552-7

44. 45
Excess length of stay in NIExcess length of stay in NI
(days)(days)
UTIUTI VAPVAP CR-BSICR-BSI
ArgentinaArgentina 7.97.9 8.78.7 9.39.3
BrasilBrasil 8.98.9 9.19.1 7.87.8
MexicoMexico 5.95.9 10.710.7 7.17.1
TurkeyTurkey 8.78.7 8.38.3 9.59.5
IndiaIndia 4.24.2 5.45.4 2.02.0
INICC Project (ICAAC-2005) posters :K-1916, K-1920, K-1922, K-1923, K-1924INICC Project (ICAAC-2005) posters :K-1916, K-1920, K-1922, K-1923, K-1924

45. Extra mortality inExtra mortality in
nosocomial infections (%)nosocomial infections (%)
Study Year Country Mortality rate
Spengler RF 1978 USA 32,1
French GL 1991 Hong Kong 7,4
Dinkel RH 1994 USA 4,1
Yalcin AN 1997 Turkey 16,7
Martin M 2001 Spain 21,3
Roberts 2010 USA 6,1

46. Mortality:Resistant and
susceptible P.aeruginosa
47Nathwani DNathwani D.. Antimicrob ResistanceAntimicrob Resistance Infect ControlInfect Control 2014;3:32-482014;3:32-48

47. Methodological limitations in
studies assessing disease
burden attributable to ARI
 Failure to adjust for hospital stay prior to
onset of infection
 Failure to adjust for severity of underlying
illness and comorbidities
 Failure to adjust for effective antibiotic
therapy
 Failure to consider exposure as time-
dependent
Gandra S, et al.Gandra S, et al. Clin Microbiol InfectClin Microbiol Infect 20120144;;2020::973-9973-9

48. Reasons for variability in
outcomes of antibiotic-
resistant infections
 Heterogeneity in study population
 Inadequate sample size
 Type of control group
 Causative pathogens
 Location of infection site
 Definitions of resistance
 Follow-up time
Gandra S, et al.Gandra S, et al. Clin Microbiol InfectClin Microbiol Infect 20120144;;2020::973-9973-9

49. 50
Economical analysis studiesEconomical analysis studies
in NIsin NIs
 Use of guidelines for authors and editors onUse of guidelines for authors and editors on
conducting an economic analysis,conducting an economic analysis,
 Continued development of more sophisticatedContinued development of more sophisticated
mathematical models,mathematical models,
 Training of infection control professionals inTraining of infection control professionals in
economic methods ……economic methods ……
Stone PW, et al.Stone PW, et al. Am J Infect ControlAm J Infect Control 2005; 33:501-92005; 33:501-9

51. Antimicrobial resistance (AMR)Antimicrobial resistance (AMR)
 Antimicrobial resistance (AMR) has
increasingly been recognised as a growing
global health threat, and the urgency of the
AMR situation is now well accepted by many
policy-makers, scientists, as well as by civil
society organisations, including patients’
advocacy groups.
 Despite growing awareness and concern,
inertia appears to persist in improving
stewardship of existing antimicrobials to
prevent a future with more resistant bacteria.
52Taylor J, et al. http://www.rand.org 11.

52. Antimicrobial resistance
 AMR is a challenge that requires a global
solution in a world where people, animals
and food are increasingly
interconnected.
 Common infections that are easily treated
could become life-threatening.
53
Taylor J, et al. http://www.rand.org 11. March. 2019

54. "If we fail to act, we are looking at an almost
unthinkable scenario where antibiotics no longer
work and we are cast back into the dark ages of
medicine“
David Cameron, former UK Prime Minister…2014

55. Antimicrobial resistanceAntimicrobial resistance
(AMR)(AMR)
Holmes AH, et al. Lancet 2016; 387:176-87

56. Antimicrobial resistance (AMR)Antimicrobial resistance (AMR)
(2014)(2014)
Taylor J, et al. http://www.rand.org/
23.November.2017

57. Antibiotics and naturalAntibiotics and natural
environmentenvironment
Wellington EMWellington EM, et al., et al. Lancet Infect DisLancet Infect Dis 20201313;; 1313:: 155-65155-65

58. Today: The impact ofToday: The impact of
antibacterial resistanceantibacterial resistance
(AMR)(AMR)
 Every year 700 000 patients die because
of AMR in the whole World.
 In European Union 25 000 patients die due
to AMR.
 The cost is about 1.5 billion Euros in EU.
 Extra length of stay is about 2.5 million
days.
ECDC, EMEA report 2009
Laxminarayan R, et al. Lancet 2016;388:218-

59. Tomorrow: The impact ofTomorrow: The impact of
antimicrobial resistanceantimicrobial resistance
(AMR)(AMR) In the year 2020; 2.5 million, in 2030; 5.9
million, and in 2050; 15 million patients will be
lost due AMR.
 If AMR reaches 100 %; in the year 2020
approximately 92.3 million people, in 2030, 200
million people and in 2050, approximately 11-
444 million people will die.
 Excess economic burden of AMR is estimated
over 100 trillion USD between now and 2050.
Taylor J, et al. http://www.rand.org/ 11.January.2019
Naylor NR, et al. Antimicrob Res Infect Control
Fitchett JP, et al. Lancet Infect Dis 2016; 16 : 388-389

60. Deaths due AMR (2050)Deaths due AMR (2050)

61. Antimicrobial resistanceAntimicrobial resistance

62. The impact of AMR in 2050The impact of AMR in 2050
Bassetti M, et al. Intensive Care Med 2017; 43
(10):1464-75

63. New antibioticsNew antibiotics
Boucher H W et al. Clin Infect Dis. 2013;152

64. MRSA:MRSA:
New antibioticsNew antibiotics
 Ceftaroline, Ceftobiprole
 Dalbavancin, Oritavancin
 Tedizolid
 Delafloxacin, Zabofloxacin
 Eravacycline, Omadacycline
 Lemafulin (Pleuromutilen group)
Bal M, et al. J Global Antibiotic Resistance 2017;
10:295-303

65. Multi-resistant gram negativeMulti-resistant gram negative
bacterial infections: Newbacterial infections: New
antibioticsantibiotics Ceftazidime+avibactam,Ceftolozane+tazobactam
 Ceftaroline+avibactam
 Imipenem/cilastatin+relebactam
 Meropenem+vaborbactam
 Aztreonam+avibactam
 Cefiderocol
 Plazomicin
 Eravacycline
 Murepavadin
Bassetti M, et al. Curr Opin Infect Dis 2018; 31:177-8

66. Future: New antimicrobialFuture: New antimicrobial
compoundscompounds
 Antimicrobial peptids
 Phage therapy
 Eligobiotics
 Phage endolysins
 Anti-virulance therapy
 Phytochemicals
 Metalloantibiotics
 Efflux pump inhibitors
 LPS inhibitors…..
Bassetti M, et al. Intensive Care Med 2017; 43
(10):1464-75

67. InterventionsInterventions (1)(1)
 A massive global public awareness
campaign
 Improve hygiene and prevent the spread
of infection
 Reduce unnecessary use of
antimicrobials in agriculture and their
dissemination into the environment
 Improve global surveillances of drug
resistance and antimicrobial
consumption in humans and animals
O’Neill J. Review on Antimicrobial Resistance. May.2016

68. InterventionsInterventions (2)(2)
 Promote new, rapid diagnostics to reduce
unnecessary use of antimicrobials
 Promote development and use of vaccines
and alternatives
 Improve the numbers, pay and recognition of
people working in infectious disease
 Establish global innovation fund for early
stage and non-commercial R&D
 Build a global coalition for real action - via the
G20 and the UN……
O’Neill J. Review on Antimicrobial Resistance. May.2016

70. 72
Thanks……..
anyalcin@yahoo.com
anyalcin@akdeniz.edu.tr

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