Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine (2022) / Chapter Skim
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3 The Health and Economic Burden of Resistance
3 The Health and Economic Burden of Resistance
Pages 73-116
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From page 73... ...
Gradual improvements in surveillance of both antimicrobial use and resistance patterns, a topic discussed in more detail in the next chapter, could facilitate better understanding of the true burden of resistant infections in the future.
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.1 This analysis indicated there are 2.8 million resistant infections every year in the United States, causing 35,900 deaths; Clostridioides difficile (C. 1 The CDC report's technical appendix thoroughly explains the methods used to estimate the burden of the 21 resistant pathogens included (CDC, 2019)
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. Nevertheless, there is no consensus methodology to estimate the economic burden of resistant infections.
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The direct costs of treating six, common multidrug-resistant pathogens was $4.6 billion a year, C difficile another billion, and drug-resistant gonorrhea another $133.4 million (CDC, 2019; Nelson et al., 2021)
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0 5 10 15 20 25 30 35 40 45 %50 FIGURE 3-1 Trends in antimicrobial resistance across OECD countries, 2005 to 2014.
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. By 2050, the OECD model suggests resistant infections will have caused 2.4 million deaths in the same countries (plus Canada, Mexico, and Australia)
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AMR mortality rate per 100,000 persons Average number of AMR deaths per year Mortality rate per 100,000 persons Number of AMR deaths per year FIGURE 3-2 Projected average annual number of deaths from resistant infections and mortality rate per 100,000, 2015 to 2050. NOTE: AMR = antimicrobial resistance.
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DALYs per 100,000 people 80 FIGURE 3-3 Projected average annual burden of antimicrobial resistance expressed in disability-adjusted life years (DALYs)
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From page 81... ...
OECD research has also made valuable contributions to understanding the economic consequences of resistant infections. Based on their calculations of morbidity and mortality associated with resistant infections, the report estimated that resistance costs the health system of the 33 countries studied about $3.5 billion a year (adjusted for purchasing power parity)
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From page 82... ...
. The pathogens causing HIV, malaria, and tuberculosis are not usually central to the discussion of antimicrobial resistance.
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A lack of data from low- and middle-income countries, where the burden of resistant infection is undoubtedly greatest, is a reason to support these countries in routine surveillance for, and prevalence surveys of, resistant infections (Islam et al., 2019)
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. The cost of health services could be perhaps the most directly affected by antimicrobial resistance, given that resistant infections cost more to treat.
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. Through its effects on health costs, trade, and livestock production, the World Bank models indicate that antimicrobial resistance could push between 8 and 28 million people into extreme poverty by 2050 (The World Bank, 2017)
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SOURCE: The World Bank, 2017. Increase in number of people living under $1.90/day 30 2.1 Figure 3-5 (purchasing power parity)
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Even in the United States, with its sophisticated laboratory infrastructure, there are challenges in reporting resistant isolates through the regional and national Antibiotic Resistance Laboratory Network, a problem discussed more in Chapter 5. Regardless of the capacity of the national surveillance systems, there are also challenges in measuring mortality and morbidity from resistant infections.
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From page 88... ...
Scientists from the ECDC recently published one such analysis of the health outcomes of resistant infections. Drawing on data from the Euro pean Antimcrobial Resistance Surveillance Network and health outcome models for specific types of infection (e.g., bloodstream infection, surgical site infection)
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From page 89... ...
The consequences of resistance associated with other common infections, though sometimes more serious, are less amenable to modeling. Drug-resistant infections in the bone and brain, for example, are serious because it is difficult to achieve clinically meaningful concentrations of antimicrobial medicines in these tissues (Nau et al., 1998, 2010; Thabit et al., 2019)
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Morgan, Ramanan Laxminarayan, Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: A literature review and modelling study, 1429-1437, Copyright (2015) , with permission from Elsevier.
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Estimates of how health problems affect the workforce are often of particular interest to policy makers. Most health problems, resistant infections included, hurt the workforce in two ways: the lost productivity among patients suffering from resistant infections and, in some cases, the lost productivity of the workers looking after them (Tillotson and Zinner, 2017)
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. The quality of what is published is also lower, a recent systematic review concluded, and held back by a "lack of rigorous, transparent mod elling studies which appropriately present or incorporate uncertainty" (Naylor et al., 2018)
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. In a systematic review on the economic burden of resistant infections, Wozniak and colleagues (2019)
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NOTE: BSI = bloodstream infection; CR = carbapenem-resistant; GN = gramnegative; hVISA = heterogeneous vancomycin-intermediate Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant Enterococci. SOURCE: Naylor et al., 2018.
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From page 95... ...
. After reviewing over 1,000 abstracts the researchers concluded that, while economic valuations of the excess costs associated with resistant infections are sorely needed, especially in lowand middle-income countries, currently the only rigorous and unbiased research available is on health care–associated bloodstream infections with resistant Enterobacterales and MRSA (Wozniak et al., 2019)
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96 TABLE 3-5 Adjusted Attributable Cost by Pathogen for Community and Hospital Onset Infections Invasivea Noninvasivea Pathogen Estimate 95% Confidence Interval Estimate 95% Confidence Interval Community Onset MRSA $19,749 $17,414 $22,084 $596 –$162 $1,355 VRE $17,490 $8,475 $26,505 $7,590 $4,796 $10,384 ESBL $7,352 $3,903 $10,802 $3,914 $1,880 $5,948 CRE $8,354 –$1,191 $17,899 $5,154 $908 $9,400 CR Acinetobacter $62,396 $20,370 $104,422 $29,265 $11,412 $47,119 MDR Pseudomonas $13,442 –$5,257 $32,140 $11,882 $5,987 $17,776 Hospital Onset MRSA $30,998 $25,272 $36,724 $9,588 $7,088 $12,087 VRE $37,893 $31,598 $44,188 $6,835 $3,630 $10,039 ESBL $33,637 $20,074 $47,200 $16,240 $11,316 $21,163 CRE $54,614 $26,992 $82,236 $16,606 $8,684 $24,529 CR Acinetobacter $74,306 $20,377 $128,235 $30,590 $12,784 $48,396 MDR Pseudomonas $66,934 $32,943 $100,925 $50,810 $41,062 $60,558 NOTE: CI = confidence interval; CR = carbapenem-resistant; CRE = carbapenem-resistant Enterobacterales; ESBL = extended-spectrum beta-lactamase; ICU = intensive care unit; MDR = multidrug-resistant; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant Enterococci.
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. The incurred costs to society from resistant infections is an important point to capture in economic analysis of antimicrobial resistance, partly because of the negative externalities, or the harm associated with antimicrobial use not incurred to the patients or prescriber (Broughton, 2017)
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Antimicrobial Use and Productivity Research from Denmark, Sweden, and the United States indicates that in modern production systems, when implemented against a background of good hygiene, feeding practices, and selective breeding, the gains in productivity from using antimicrobial growth promoters is minimal (Laxminarayan et al., 2015)
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Some encouraging evidence indicates that, at least in China, government and public concern about antimicrobial growth promoters is leading to increased restrictions on antimicrobial growth promoters and improvements to infection control measures (Luo et al., 2020; Ryan, 2019; Schoenmakers, 2020)
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Resistant infections in animals are less well studied than those in humans. In dairy cattle, for example, Staphylococcus aureus causes considerable clinical mastitis, though MRSA and beta-lactam resistance are uncommon (Patel et al., 2021)
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. In both livestock and companion animals there is concern that resistant infections may be increasing, but it is difficult to say precisely; there are no accepted, standardized definitions of multidrug resistance, extensive drug resistance, and pandrug resistance in veterinary medicine (Sweeney et al., 2018)
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Resistance can emerge in any number of microbial pathogens, and resistant infections can present in different ways (e.g., pneumonia, skin infection, urinary tract infection)
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. Attention to such questions in study design, drawing on the research guidelines presented in Box 3-1 could help avoid some of the methodological problems studies on the burden of antimicrobialresistant infections often face.
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Rather, across disciplines researchers, government officials, and private industry could all give better attention to capturing the costs associated with resistant infections. The Global Antimicrobial Resistance Platform for ONE-Burden Estimates, an international research network, recently released a One Health framework for estimating the costs of resistance (Morel et al., 2020)
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. The Global Research on Antimicrobial Resistance Project The Global Burden of Disease, Injuries, and Risk Factors program on antimicrobial resistance (the Global Research on Antimicrobial Resistance project)
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. As Table 3-6 shows, even the estimates of the health consequences of resistant infections vary so widely, including variability in the way they are reported, that it is difficult to identify trends in the literature.
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This is not a direct analytic question, and the economic fallout of resistance is not easily reduced to a number. The burden of any one resistant pathogen depends on context; the same resistant infections can have drastically different consequences in humans or animals, if acquired in a hospital or outside of it, in a high-income country or a low-income one.
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2017. Potential economic burden of carbapenem-resistant enterobacteriaceae (CRE)
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2013. Antibiotic resistance threats in the United States.
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2019. No time to wait: Securing the future from drug-resistant infections.
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2015. The economic costs of withdrawing antimicrobial growth promoters from the livestock sector.
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https://www.oecd.org/agriculture/topics/antimicrobial-resistance-and-agriculture (accessed June 25, 2021)
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2016b. Tackling drug-resistant infections globally: Final report and recommendations.
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2015. Potential bur den of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophy laxis in the USA: A literature review and modelling study.
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2016. By 2050, drug-resistant infections could cause global economic damage on par with 2008 financial crisis.
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