1. Introduction and Purpose
MRSA pneumonia: still a concern in Germany? A burden of disease analysis using big data from 69 hospitals W. Heinlein,1 D. Kuessner,2 J. Posthumus,2 K.F. Bodmann,3 and M. Wilke1
1inspiring-health GmbH, Munich, Germany; 2Basilea Pharmaceutica International Ltd, Basel, Switzerland; 3Clinic for Intensiv Care and Emergency Medicine and Clinical Infectiology, Werner-Forßmann-Hospital, Hospital Barnim GmbH, Eberswalde, Germany
Contact Information
Dr. med Michael Wilke
inspiring-health GmbH
Munich, Germany
Poster P0091
Session P005
Infection control for MRSA and VRE
Introduction and Purpose
Results
Results
The constant threat of antibiotic resistance is a topic with changing focus. Currently, extended-spectrum beta-lactamases (ESBLs) are seen as a major emerging threat in European hospitals and methicillin-resistant Staphylococcus aureus (MRSA) is perceived as being less of a concern or as a decreasing problem. Given this, the number of cases of pneumonia caused by ESBL-producing pathogens and/or MRSA in German hospitals was assessed.
Data were available for 106,269 patients with pneumonia. The information was obtained from 69 hospitals including 10 university clinics in Germany.
On average, patients were 66.8 years old, stayed in hospital for 13.4 days, and incurred treatment costs of 6,769€. An average of 12.6% of patients died during their hospital stay. Table 1 presents the patient demographics by origin of infection (CAP or HAP).
For most patients (89%), the causative pathogen was not coded. The rates of pathogen coding were low across both CAP and HAP (Figure 1 and Table 2).
The MRSA rate among Staphylococci is higher compared to the ESBL-positive pathogen rate among Enterobacteriaceae in both CAP and HAP (Figure 2A). The mortality rate was high for patients with MRSA and ESBL-positive pathogens (Figure 2B).
The distribution of pathogens in CAP and HAP differs with respect to infections caused by viruses. In both CAP and HAP 11% of patients had polymicrobial infection (Figure 3).
Of those patients with confirmed pathogens: ESBL was present in ̴2.0% of patients in both CAP and HAP; MRSA was present in 2.0% of patients with CAP and 3.1% of patients with HAP.
Figure 2: A. Rates of MRSA among Staphylococci and ESBL-positive pathogens among Enterobacteriaceae in pneumonia patients.* B. Mortality rates in pneumonia patients with MRSA and ESBL*
Table 1: Patient demographics A. B.
Methods
CAP
(N = 74,979)
HAP  
(N = 31,290)
Gender, n (%) Female
32,196 (42.9)
12,929 (41.3)
Age, years, mean (SD)
64.0 (26.4)
72.3 (15.6)
Underlying condition (top 5), n  (%)*
Diseases of the respiratory system
50,460 (67.3)
469 (1.5)
Diseases of the circulatory system
8,773 (11.7)
10,768 (34.4)
Neoplasms
6,643 (8.9)
4,392 (14.0)
Certain infectious and parasitic diseases
4,311 (5.7)
1,093 (3.5)
Diseases of the digestive system
525 (0.7)
4,477 (14.3)
Comorbidities, n  (%)†
COPD   
12,251 (16.3)
4,351 (13.9)
Renal impairment
19,564 (26.1)
11,731 (37.5)
Cancer
13,323 (17.8)
6,364 (20.3)
Diabetes
17,390 (23.2)
9,134 (29.2)
Immunosuppression
4,156 (5.5)
1,904 (6.1)
Chronic heart failure
20,515 (27.4)
11,057 (35.3)
Transplant 
891 (1.2)
338 (1.1)
DRG- Partition, n (%)
Medical
65,340 (87.1)
16,440 (52.5)
Surgical
6,751 (9.0)
11,261 (36.0)
Other (Interventional)
2,888 (3.9)
3,589 (11.5)
Length of stay, mean (SD) 
11.2 (10.1)
18.9 (15.8)
Cost per patient (€), mean (SD)
5,038 (7,272)
10,921 (14,249)
Demographic, clinical and economic data of 3,726,593 patients who had been hospitalised in 69 German hospitals between 2010 and 2014 formed the basis of the analysis. From this data set, patients with pneumonia (defined as pneumonia without ventilation longer than 48 hours during hospitalization and no aspiration pneumonia) and plausible cost data (>250€/day) were identified. Patients were classified as hospital-acquired pneumonia (HAP) based on specific ICD-10 GM code (U69.00!). Community-acquired pneumonia (CAP) was defined as all pneumonia which was not classified as HAP.
Descriptive analyses were conducted to describe the patients in terms of socio-demographics, clinical characteristics and economic parameters (length of stay and cost of hospital stay) by pathogen (methicillin-susceptible S. aureus [MSSA], MRSA, ESBL-producing pathogens, other multi-drug-resistant [MDR] pathogens, multiple-MDR pathogens; as coded using ICD-10 GM). Cases with pneumonia and without any ICD-10 code representing a pathogen were classified as “no pathogen reported”. Mortality refers to the in-hospital mortality.
*based on monomicrobial infections ; ̴11% are polymicrobial infections
Figure 3: Pathogen distribution in patients with A. CAP and B. HAP
Figure 1: Case selection and refinement A. B.
159,658 pneumonia cases
147,977 cases with plausible cost data
147,822 cases with correct cost and revenue data
3,726,593 cases at 69 hospitals ( )
106,269 cases of pneumonia WITHOUT ventilation* and aspiration
Case selection
*based on analysis of the coded ICD-10 diagnosis which was marked as “principal diagnosis (PDx)”. In Germany the PDx is defined as the “reason for admission”
† More than one comorbidity could occur in every patient
Case exclusion 1
Figure 1: Pathogen coding in pneumonia patients
Case exclusion 2
Case exclusion 3
Conclusions
Case selection: Cases with pneumonia – selected by IMR- Algorithm by inspring-health
Case exclusion 1: Cases without cost data or with implausible costs (<250 € / day) were excluded
Case exclusion 2: Cases without revenue (i.e., revenue not determinable) were excluded
Case exclusion 3: Cases with ventilation* and aspiration pneumonia were excluded
*ventilation longer than 48 h during hospitalization
This large data set from 69 hospitals in Germany reveals high mortality rates among pneumonia patients across all pathogens.
The incidence rate of ESBL-producing pathogens in this patient group was comparable to that of MRSA during this time period, as was the mortality. The results are in line with the paper by Basetti et al who raises concern that MRSA infections may be overlooked due to rising concerns over resistant Gram-negative bacteria.1
89% of the cases did not have pathogen information coded. Other sources report rates of up to 67% cases without pathogen information based on clinical studies.2 This is of great concern.
Table 2: Clinical outcomes of hospitalized pneumonia patients 
Disclosures
This study was sponsored by Basilea Pharmaceutica International Ltd (Basilea), Basel, Switzerland. W. Heinlein is employee and M. Wilke is employee and shareholder of inspiring-health GmbH, which was contracted by Basilea. Jan Posthumus and Daniel Kuessner are employees of Basilea and hold stock options with Basilea. W. K.F. Bodmann acted as a consultant to Basilea, and has received lecture honoraria from Basilea.
Presented at the 27th Annual European Congress of Clinical Microbiology and Infectious Diseases (ECCMID); Vienna, Austria; 22–25 April, 2017; poster number 5167
CAP
HAP
N (%)
Mortality (%)
Pneumonia patients (ALL)
74,979 (100)
8,625 (11.5)
31,290 (100)
4,720 (15.1)
No pathogen reported
65,514 (87.4)
7,863 (12.0)
28,247 (90.3)
4,247 (15.0)
With pathogen information
9,466 (12.6)
762 (8.0)
3,043 (9.7)
473 (15.5)
References
1Bassetti M, Righi E, Peghin M, Carnelutti A, Ansaldi F, Trucchi C, Alicino C, Tricarichi EM, Del Giacomo P, Tumbarello M. Is first-line antimicrobial therapy still adequate to treat MRSA in the ICU? A report from a highly endemic country. Crit Care Aug 27;20:246
2Welte, T.; Torres, A.; Nathwani, D.Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax 2012;67:71e79. doi: /thx