1. 1 Economic and medical adverse effects of a national policy to control the spread of highly-resistant micro-organisms. G Birgand a, M Schwarzinger b, A Perozziello c, C Pelat b, L Armand- Lefevre, E Ruppé d, JC Buzzi c, A Andremont d, Y Yazdanpanah b, JC Lucet a a Infection control unit, Bichat-Claude Bernard Hospital, Paris, France b ATIP-Avenir, Inserm U738, Paris, France; c Medical Infomation Systems Program (PMSI), Bichat-Claude Bernard Hospital, Paris, France; d Bacteriology laboratory, Bichat-Claude Bernard Hospital, Paris, France

2. Disclosure statement Financial support: none Conflict of interest: – Pfizer: Travel grant for the ICAAC 2011 G. Birgand ECCMID Berlin 2013 2

3. 3 Introduction Epidemiological context G. Birgand GRECPE E.Faecium VR EARSS 2011 Kp Carba-R EARSS 2011 ECCMID Berlin 2013

4. 4 Introduction French National Recommandations Patients detected colonised with GRE or CPE: 1.Single room + contact precautions for carriers and contact patients along the entire hospital stay 2.Cohorting of carriers and contact patients in 2 different dedicated areas with dedicated staff 24/7 3.Interruption of transfers of carriers and contact patients + interruption of new admissions 4.Repeated rectal sampling of contact patients: D0, D7, D15 G. Birgand ECCMID Berlin 2013

5. 5 Introduction Potential consequences of guidelines Medical impact: ‒Unintended deleterious adverse effects for patients ? ‒Disruption for the ward ‒Delays in patient’s care and transfer Economical impact: ‒Lost income due to interruption of transfers and admissions (French daily incomes for 1 hospital day: € 300- 400 in medical units to € 1700 - 2000 in ICU) ‒Cost of lab techniques and contact precautions ‒Cost of additional staff for cohorting G. Birgand ECCMID Berlin 2013

6. 6 Objectives G. Birgand From 01/2009 to 06/2012 (3.5 years) in a 1000-bed University Hospital 6 Characteristics of hospital stays The additional hospital costs Patients colonised with GRE or CPE € Length of stay ECCMID Berlin 2013

7. Methods Study design G. Birgand 7 Outcomes: Length of hospital stay and overall hospital cost Retrospective data collection : Clinical, microbiological and hospital stay characteristics Estimated costs of inpatient care based on reimbursement rates of the DRG (national yearly survey, 2011) Statistical analysis: Univariate and multivariate ANOVA (SAS and Stata v10) Controls Patient never identified as colonized with GRE or CPE Cases Patient colonised or infected with GRE or CPE Matching criteria: gender, ward, period of hospitalisation (n-1), Age, diagnosis-related group (DRG)

8. 8 Methods Study population G. Birgand 107 surviving patients 26 cases colonised 81 Controls never identified 14 GRE12 CPE 1 1 186 10 vanA4 vanB 9 OXA-48 2 KPC 1 NDM-1 ECCMID Berlin 2013 37 Pts identified colonised during the study period: 4 death 7 still hospitalised

9. 9 G. Birgand Results Description of cases Characteristics GRE Pts n= 14 (%) CPE Pts n= 12 (%) n (%) N= 26 Patients from an episode with secondary cases8 (57)3 (25)11 (42) Time admission => positive culture, d (IQR)10 (7-20)13 (5-21)11 (7-20) In ICU at time of positive result3 (21)3 (25)6 (23) Infection with HDRB2 (14)1 (8)3 (12) Year of first HDRB identification 20092 (14)1 (8)3 (12) 20103 (21)2 (17)5 (19) 20115 (36)5 (42)10 (38) 2012 (6 months)4 (29)4 (33)8 (31)

10. Age, median (IQR)65 (57-77) 65 (56-77) 0.84 Female 11 (42) 33 (41) 0.89 Diagnosis-related group 1.00 Respiratory diseases 9 (35) 28 (35) Diabetes 3 (12) 8 (10) Vascular diseases 4 (15) 20 (24) Infectious diseases 3 (11) 9 (11) Others 7 (27) 16 (20) Charlson score, median (IQR) 6 (4-7) 4 (3-6) 0.1 Mc Cabe score 0.55 0 7 (27) 28 (36) 1 17 (65) 42 (53) 2 2 (8) 9 (11) Ward at the time of identification 0.73 ICU 5 (19) 15 (19) Medical unit 15 (58) 53 (65) Surgical unit 6 (23) 13 (16) Results Univariate analysis (1) G. Birgand Characteristics Cases N= 26 (%) Controls N= 81 (%) P 10

11. Median length of stay 28 (12-94) 11 (8-18) <0.01 Ward at hospital discharge 0,05 Intensive care unit 0 0 Surgical ward 9 (35) 27 (33) Medical ward 14 (54) 53 (65) Rehabilitation 3 (12) 1 (1) Destination at discharge Home 23 (88) 68 (84) 0.57 Transfer 3 (12) 13 (16) Health insurance beneficiaries 18 (69) 67 (83) 0.32 Mean cost of hospitalisation, € (sd) 15,830 (4,320) 8,919 (2,447) <0.01 Results Univariate analysis (2) G. Birgand Characteristics Cases N= 26 Controls N= 81 P 11

12. Results Multivariate analysis G. Birgand CharacteristicsColonised Patients Patients never identified as colonised Mean cost, € (95%CI)18,010 (14,561 – 21,469)11,029 (8,732 – 13,325) Final multivariate mixed models of ANOVA: CharacteristicsColonised Patients Patients never identified as colonised Mean length of stay, days (95%CI)43 (33 – 54)21 (14 – 27) Excess of length of stay = 22 days (12 - 34) Extra cost = 6,981€ (3,377 – 10,585) ECCMID Berlin 2013 12

13. 13 Discussion - Conclusion The impact of stringent measures to control HDRB on hospital stays characteristics was estimated to: – 22 days (12-34) of mean excess LOS per Pt – 6,981€ (3,377 – 10,585) of mean extra costs per Pt Strengths of this study: ‒Matching on patients comorbidity and DRG  Most costs are attributable to GRE or CPE Limits of this study: ‒Single center study ‒Costs based on DRG and not individual data. Perspectives: – Evaluation on a larger population at a multicenter level G. Birgand

14. 14 Thank you for your attention