New Delhi: Managing life-threatening bloodstream infections caused by superbugs (bacteria that have become resistant to antibiotics) is over 54 percent costlier compared to treating infections that respond to antibiotics, a first-of-its-kind analysis assessing the impact of antimicrobial resistance on cost of therapies in hospitals across India has shown.
Antimicrobial resistance is a condition in which pathogenic bacteria no longer respond to antibiotics.
The study, conducted by 13 organisations including the Indian Council of Medical Research (ICMR), found that in government hospitals, the direct median total cost (cost incurred on treating infections) for management of bloodstream infections triggered by antimicrobial-resistant bacteria was US$199 (Rs 89,377 as per 2021 exchange rate) as opposed to US$109 (Rs 55,229) for infections that respond to antibiotics.
The research, titled ‘Incremental cost of treating antimicrobial-resistant infections among hospitalised patients in India: a cohort study’, was published in the peer-reviewed British Medical Journal (BMJ) last month. The project saw the participation of institutions like the National AIDS Research Institute (NARI), Pune; Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry; Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh; Apollo Hospital, Chennai; PD Hinduja Hospital, Mumbai; and Mahatma Gandhi Institute of Medical Sciences, Sevagram.
It found that compared to treatment of infections that respond to antibiotics, the incremental cost of treating bloodstream infections acquired in community and hospital settings and that do not respond to antibiotics was 53.9 percent in case of Enterobacteriaceae, 43.8 percent in case of Acinetobacter and 49.7 percent in case of Staphylococcus in government hospitals.
The cost was driven, the study revealed, mainly by increased length of hospital stay and purchase of expensive medicines.
It is estimated that India reports nearly 1.1 crore cases of bloodstream infections annually, which often lead to fatal sepsis, while nearly 30 lakh people die due to the condition every year.
Sepsis refers to blood poisoning in which the body has an extreme reaction to infection.
Focus on fatal pathogens
Enterobacteriaceae, Acinetobacter and Staphylococcus are families of gram-negative bacteria—pathogens that are particularly difficult to treat and a major public health challenge in the Indian context. Also, most of them no longer respond to even last resort antibiotics and hence, are responsible for high mortalities in infected patients.
Many bacteria belonging to these families have been categorised as high priority pathogens by the World Health Organization (WHO) and cause life-threatening hospital-acquired pneumonia, bloodstream infections, intra-abdominal infections and complicated urinary tract infections (UTIs), among others.
Dr Raman Gangakhedkar, former chief epidemiologist at ICMR who is also associated with the study, pointed out some key findings.
“There was a dramatic increase in cost in treating critical and antibiotic-resistant pathogens in government hospitals. The financial burden created by these infections affects the family budget leading to financial indebtedness and the pattern of these pathogens commonly seen in government, private and trust hospitals was different,” he told ThePrint.
In a country like India, where out-of-pocket healthcare expenditure (OOPE) is considerably high, the findings have a significant lesson for policymakers and hospital administrations on why antimicrobial resistance should be given top priority, he added.
In India, about 70 percent of household health expenditure is out of pocket, the study underlines, citing the 15th Finance Commission report released in 2020.
Findings of the Global Research on Antimicrobial Resistance (GRAM) Project, released in September, showed that between 3 and 10.4 lakh people died in India in 2019 due to bacterial antimicrobial resistance. The report also said that 29.9 lakh people died in the country either directly from or due to conditions triggered by sepsis, and whose management has become difficult due to antimicrobial resistance.
Estimating antimicrobial resistance-related financial burden
The cohort study published last month was conducted between 2018 and 2021 in eight hospitals, including government, private and trust-run hospitals, which are part of the ICMR’s Antimicrobial Resistance Surveillance Network (AMRSN).
Patients analysed in the project included those infected with K. pneumoniae, E. coli, P. aeruginosa, A. baumannii, Enterococcus faecium, S. aureus and Salmonella typhi.
The analysis had a retrospective component, which calculated the direct cost of treating resistant and susceptible bloodstream infections caused by WHO-designated priority pathogens. Susceptible bloodstream infections were those which responded to antibiotics.
The prospective component estimated indirect cost and financial coping strategies for the treatment of antimicrobial resistance. In the retrospective component, 1723 records were included, while in the prospective component, 170 patients were recruited.
The researchers found that pharmaceutical cost was the major contributor to incremental cost in government (61.5 percent) and private hospitals (27.1 percent). In the prospective component, 46.5 percent of patients resorted to borrowing money for hospitalisation expenses and the per day median total cost for resistant and susceptible infections was estimated to be US$65 and US$35, respectively.
The per day median total cost for management of drug-resistant infection was US$13 (Rs 825), whereas for susceptible infections, it was US$9 (Rs 716) in government hospitals.
The median total management cost for drug-resistant infections in private hospitals was observed to be US$3382 (Rs 2,12,067) as opposed to US$215 (Rs 92,898) in trust-run hospitals which are not profit driven.
Also, the proportion of deaths among patients infected with drug-resistant pathogens in trust-run hospitals was 48.4 percent, followed by 40.9 percent in government facilities and 24.2 percent in private ones.
For hospitalisation cases that were analysed prospectively, the median total cost of treating drug resistant infection was US$1238 versus US$827 for drug-susceptible infections, marking a difference of over 33 percent.
The per day median total cost for drug-resistant and drug-susceptible infections, on the other hand, stood at $65 (Rs 20,384) and $35 (Rs 10,353), respectively, and the costs of pharmaceuticals and consumables were major components of the total cost.
The incremental cost of treating a resistant Enterobacteriaceae infection was 72.4 percent.
Pathogen-directed infection control measures
The analysis of financial coping strategies also revealed that 46.5 percent of patients analysed in the prospective component resorted to borrowing money to cover the cost of treatment, and 33.1 percent of families reported withdrawal of savings to meet hospitalisation expenses.
Additional activities reported by the families were cutting down food consumption and making additional family members work.
The proportion of families who had to sell or mortgage their assets was 11.4 percent for drug-resistant infections and 9.8 percent for susceptible infections.
“The current study concluded that the presence of any critical or high priority pathogens led to an increase in the direct and indirect medical costs,” the authors noted in the paper.
They also underlined that direct and indirect medical expenses as a result of infections caused by antimicrobial resistance affected the family as a whole.
“All the priority strategies identified in the national action plan for prevention of AMR should be implemented with utmost rigour to prevent AMR and reduce treatment cost. Considering pathogen-wise incremental costs at all sites, prioritisation of pathogen-directed infection control measures is essential,” the paper said.
(Edited by Radifah Kabir)