CONTROLLING HOSPITAL INFECTIONS
In Support of Maryland Senate Bill 535 and House Bill 966
Written testimony of Ramanan Laxminarayan
Fellow, Resources for the Future
Prepared for the Maryland Senate Finance Committee
March 9, 2006
Resources for the Future is home to a diverse community of scholars dedicated improving
environmental policy and natural resource management through social science research. RFF
provides objective and independent analysis and encourages scholars to express their individual
opinions, which may differ from those of other RFF scholars, officers, and directors.
March 9, 2006
Maryland Senate Finance Committee
11 Bladen Street
Annapolis, Maryland 21401-1991
Subject: Testimony of Ramanan Laxminarayan in respect of Maryland Senate Bill 535 and
House Bill 966
Dear Members of the Maryland Senate Finance Committee:
I am writing in support of the proposed legislation to require health care facilities in the State of
Maryland to implement the Society of Healthcare Epidemiology of America’s (SHEA)
guidelines to control hospital-acquired methicillin-resistant staphylococcus aureus (MRSA) and
vancomycin-resistant enterococcus (VRE). I have a PhD in Economics as well as a Masters
Degree in public health focusing on epidemiology, and have been studying antimicrobial
resistance for the last nine years, and I hope my testimony will be useful to the committee’s
deliberations.
My testimony is divided into four parts: First, I will show that this legislation addresses a
problem of great economic consequence, one that costs patients and hospitals in Maryland
substantially. Second, I will show that hospitals, both public and private, can benefit from
implementing better infection control measures. Third, I will explain why health care facilities
often do not recognize this benefit and follow SHEA guidelines on their own without regulatory
intervention. Lastly, I will conclude with a suggestion about the importance of enforcement –
adding “teeth” to this legislation will be beneficial if hospitalized citizens of Maryland are to be
made better off.
Although not a clinician, over the years that I have followed this topic closely and I have been
struck by the number of people interested in working in this area, not just because of academic
interest but because they have had someone in their family actually die of a hospital-acquired
drug resistant infection. This is happening more and more frequently, yet there is little attention
paid to this silent epidemic.
1616 P St. NW • Washington, DC 20036 • info@rff.org • http://www.rff.org • 202-328-5000 • fax 202-939-3460
DRUG RESISTANT INFECTIONS COST MORE
Infection control programs intended to control antibiotic resistant healthcare-associated
infections have been around for decades, however, it is common knowledge that implementation
of these programs has been highly variable across facilities. The Society for Healthcare
Epidemiology of America (SHEA), published a set of guidelines in 2003 (Muto, Carlene A.,
Jernigan, John A. et al. 2003) focused mainly on the spread of MRSA and VRE within the
hospital setting. The guidelines are based on clinical evidence that the vast majority of MRSA
and VRE infections are the result of transmission from patient to patient and not from de novo
mutations, and thus they suggest that stringent infection control practices are probably the most
important factor in limiting the spread of MRSA and VRE.
Numerous studies have documented the increased number and costs of nosocomial bloodstream
infections, stretching back into the 1970s and 1980s. Pittet and Wenzel (Pittet, D., Tarara, D. et
al. 1994; Pittet, D. and Wenzel, R. P. 1995) found that over the decade of the 1980s, the
incidence and risk-of-death from nosocomial bloodstream infections had risen markedly and that
a patient with a nosocomial bloodstream infection was 35% more likely to die. In addition, they
found that for patients who survived incurred excess charges of approximately $40,000 and extra
hospital costs of roughly $6,000 compared to those without such an infection. Haley (1986)
looked at all nosocomial infection costs and found that the average cost was about $1,800 per
infection with the maximum cost being almost $42,000 (see table 1).
Table 1. Costs attributable to nosocomial infection
Costs/Nosocomial infections ($)
Nosocomial Infection
Average
Maximum
Pneumonia
4,947
41,628
Septicaemia
3,061
9,027
Wound Infection
2,734
26,019
Urinary Tract Infection
593
8,280
All nosocomial infections
1,833
41,628
Source: RW Haley, Managing hospital infection control for cost-effectiveness, 1986, cited in Daschner 1989
It is important to recognize the significant economic costs that nosocomial infections impose on
both the hospital and the patient. The Office of Technology Assessment of Congress has
estimated that the minimal hospital cost associated with nosocomial infections caused by
antibiotic-resistant bacteria is over $1.3 billion per year (in 1992), but this estimate does not
include the increased cost to patients both monetarily and through indirect and long-term
morbidity and mortality consequences of resistant infections. With the majority of published
studies showing that mortality risk increases on the order of 1.3-2 times when a patient contracts
an antibiotic resistant infection within the hospital, this means that there are likely fairly
significant effects on indirect costs such as long-term lost productivity. It is also important to
understand that antibiotic resistance has an effect on many patients who have not and will not
1
become infected. These costs are the result of having to use stronger and more expensive drugs,
which besides costing more may have more dangerous side effects or may be more toxic or
possibly less effective then older or mainline drugs.
Even the direct cost of an antibiotic resistant infection is still significant. Cosgrove (Cosgrove,
Sara E., Qi, Youlin et al. 2005) found that a nosocomial MRSA bacteremia increases the length
of hospital stays, the charges per patient and the costs for the hospital significantly for each case.
They estimate that the excess cost of an MRSA bacteremia is $26,424 in patient charges and
$14,655 in excess hospitals costs (a total of $41,079 in excess charges) compared to a control
population. These were also compared to MSSA patients who averaged $19,212 in excess
patient charges and $10,655 in excess hospital costs (a total of $29,867). A study by McHugh
(McHugh, Carolyn Guertin and Riley, Lee W. 2004) who estimates total per patient costs (as
opposed to excess costs) for an MSSA infection of $9,699 versus $45,920 for an MRSA
infection.
Drug resistant surgical site infections are particularly responsible for increased morbidity and
mortality and cost hospitals more then $1.6 billion in extra charges each year (Martone, William
J. and Nichols, Ronald Lee 2001). Engemann (Engemann, John J., Carmeli, Yehuda et al. 2003)
studied MRSA in surgical site infections in a large cohort at the Duke medical center. MRSA in
a surgical wound was found to result in more then a 12-fold increase in mortality versus noninfected patients and more then a 3-fold increase versus patients infected with MSSA. They
estimate that an MRSA infection costs patients about $40,000 more then an MSSA infection and
about $84,000 more then an uninfected patient.
Vancomycin-resistant enterococci (VRE) is also associated with higher morbidity, mortality and
costs. Carmeli and Mozaffari (Carmeli, Yehuda, Eliopoulos, George et al. 2002) found that a
VRE infection led to longer hospital stays, a 2-fold increase in the rate of mortality, increased
odds that a patient would require major surgery or be placed in the ICU, and a 1.4-fold increase
in hospital costs, which over the length of the study translated to excess costs of $2,974,478 (233
patients at an excess cost of $12,766). In addition, the authors found that there was an increase
in the likelihood that a patient would end up being discharged to a long-term care facility,
meaning that the additional costs of a VRE infection are significantly understated in the study
and that they continue on for many patients. These estimates are lower then Stosor (Stosor,
Valentina, Peterson, Lance R. et al. 1998) who found VRE bacteremia was associated with
$27,190 in excess costs and Song and Perl (Song, Xiaoyan, Srinivasan, Arjun et al. 2003) who
found mean excess costs of VRE to be $81,208.
INVESTING IN INFECTION CONTROL CAN BE FINANCIALLY BENEFIAL TO THE
HOSPITAL
A program of intensive surveillance and interventions targeted at reducing the risk of hospitalacquired ventilator-associated pneumonia (VAP) was implemented at the University of
2
Massachusetts Medical Center from January 1997 through December 1998. The results were
dramatic reductions in VAP, 10.8/1000 ventilator days in the medical ICU and 17.2/1000
ventilator days in the surgical ICU, and cost savings of about $350,000, and this did not include
time saved by respiratory therapists. (Lai, Kwan Kew, Baker, Stephen P. et al. 2003)
In 1994 the University of Virginia hospital had a VRE outbreak, and in response implemented an
active surveillance program and contact isolation of colonized patients. The estimated costs of
cultures and resulting isolation were compared to a similar hospital that did not institute an active
surveillance program. The costs of the program, including time spent collecting samples,
additional length of hospital stays in isolation and laboratory fees, was estimated at $253,099
during the 2-year study, during which time only one primary VRE bacteremia occurred. (Muto,
Carlene A., Giannetta, Eve T. et al. 2002) This compares to 29 cases of VRE bacteremia in the
corresponding hospital with estimated costs for 28 avoided cases reported to be $761,320,
though this is based on an estimate of excess costs per case of VRE of $27,190 (Stosor,
Valentina, Peterson, Lance R. et al. 1998). Other estimates would put the cost avoided at
between $357,448 (Carmeli, Yehuda, Eliopoulos, George et al. 2002) and $2,273,824 (Song,
Xiaoyan, Srinivasan, Arjun et al. 2003).
One of the factors affecting the spread of MRSA is the lack of effective control measures at
many private hospitals, many of which avoid these measures partly due to their costs. In order to
estimate the cost savings for private hospitals, West (West, Timothy E., Guerry, Cile et al. 2006)
initiated a study at 2 private hospitals in Charleston, SC that implemented an active surveillance
program and a contact isolation protocol as recommended by the SHEA guidelines. Based on
prior rates of nosocomial infections, the new programs and protocols prevented an estimated 13
MRSA bacteremias and 9 SSIs for a costs savings of about $596,960 for the prevented
bacteremias ($45,920 per infection based on McHugh et al 2004) and $756,000 for the prevented
SSIs ($84,000 in excess costs per SSI, based on Engemann et al 2003). The cost of
implementing the program was estimated at $113,955 ($54,381 for surveillance, $59,573 for
contact isolation).
YET HOSPITALS DO NOT INVEST ENOUGH IN INFECTION CONTROL: WHY?
Hospital infection control is expensive and it becomes more difficult and less effective when
patients enter the hospital already carrying the resistant pathogens. Recent research on incentives
that hospitals face in controlling antibiotic-resistant bacteria suggests that a large spillover effect
between medical care facilities may be one factor that explains the lack of response (Smith,
Levin, & Laxminarayan, 2005). When a number of institutions share patients, then a person
colonized in one facility may be responsible for introducing or increasing the prevalence of
resistance in another facility. Since any single hospital (especially in the current era of costcutting and short term financial pressures) may ignore the benefits of their HIC programs outside
their own walls, hospitals may not benefit from decreasing the overall level of resistance in the
3
catchment population when those patients are admitted later to other hospitals. Instead, hospitals
may prefer to free ride on the infection control investments of other hospitals. This results in an
overall higher level of resistance. In particular, the level of hospital infection control that is in the
interests of any hospital to undertake depends on hospital infection control efforts of other
hospitals and in the absence of coordination, everyone is worse off.
A much better outcome can be achieved through regulation and the resulting coordination
between facilities. A good example is from the Siouxland experience. An epidemic of VRE in
the Siouxland Region of Iowa, Nebraska, and South Dakota was first detected in late 1996.
Within a short time, VRE had quickly spread to nearly half of the health-care facilities in the
region. In response, a VRE Task Force was constituted with representatives from acute and
long-term-care facilities and public-health departments in the region (Ostrowsky, 2001).
Following a comprehensive two-year intervention, (which included aggressive culturing of
patients to identify VRE-colonized patients, isolation of patients, improved antibiotic use, sterile
device measures, and improved healthcare worker hand hygiene) VRE was eliminated from all
acute-care facilities and significantly reduced in long-term-care facilities in the region. This
could not have worked without coordination and when hospitals are unwilling to coordinate on
their own, regulation can ensure that no single hospital free rides off the efforts of others.
HOW CAN WE ENSURE THAT HOSPITALS ACTUALLY COMPLY?
In my opinion, legislation that only requires hospitals to comply with SHEA guidelines and gets
them to report MRSA/VRE cases is not sufficient. Some degree of enforcement is required either
through periodical external surveillance cultures, withdrawal of approval for State Medicare
reimbursement or fines. Getting hospitals to report infections could work in other ways such as
encouraging them to cut back on their surveillance programs. This is similar to cities not
reporting crime rates reliably to the FBI since they are worried about the effect of this on their
economy and tourism. A well-designed implementation plan for this legislation should take
these factors into consideration.
Sincerely,
Ramanan Laxminarayan
Fellow
4
References
Carmeli, Y., G. Eliopoulos, et al. (2002). "Health and Economic Outcomes of VancomycinResistant Enterococci 10.1001/archinte.162.19.2223." Arch Intern Med 162(19): 22232228.
Cosgrove, S. E., K. S. Kaye, et al. (2002). "Health and Economic Outcomes of the Emergence of
Third-Generation Cephalosporin Resistance in Enterobacter Species
10.1001/archinte.162.2.185." Arch Intern Med 162(2): 185-190.
Cosgrove, S. E. and Y. Carmeli (2003). "The Impact of Antimicrobial Resistance on Health and
Economic Outcomes." Clinical Infectious Diseases 36: 1433-1437.
Cosgrove, S. E., Y. Qi, et al. (2005). "The Impact of Methicillin Resistance in Staphylococcus
aureus Bacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital
Charges." INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY 26: 166-174.
Daxboeck, F., T. Budic, et al. (2006). "Economic burden associated with multi-resistant Gramnegative organisms compared with that for methicillin-resistant Staphylococcus aureus in
a university teaching hospital." Journal of Hospital Infection 62(2): 214-218.
Drummond, M. F. and L. M. Davies (1991). "Evaluation of the costs and benefits of reducing
hospital infection." Journal of Hospital Infection 18(Supplement 1): 85-93.
Engemann, J. J., Y. Carmeli, et al. (2003). "Adverse Clinical and Economic Outcomes
Attributable to Methicillin Resistance among Patients with Staphylococcus aureus
Surgical Site Infection." Clinical Infectious Diseases 36: 592-598.
Graves, N. (2004). "Economics and Preventing Hospital-acquired Infection." Emerg Infect Dis
10(4).
Haley, R. W., D. H. Culver, et al. (1985). "The efficacy of infection surveillance and control
programs in preventing nosocomial infections in US hospitals." American Journal of
Epidemiology 121(2): 182-205.
Karchmer, T. B., L. J. Durbin, et al. (2002). "Cost-effectiveness of active surveillance cultures
and contact/droplet precautions for control of methicillin-resistant Staphylococcus
aureus." Journal of Hospital Infection 51(2): 126-132.
Lai, K. K., S. P. Baker, et al. (2003). "IMPACT OF A PROGRAM OF INTENSIVE
SURVEILLANCE AND INTERVENTIONS TARGETING VENTILATED PATIENTS
IN THE REDUCTION OF VENTILATOR-ASSOCIATED PNEUMONIA AND ITS
COST-EFFECTIVENESS." INFECTION CONTROL AND HOSPITAL
EPIDEMIOLOGY 24(11): 859-863.
Martone, W. J. and R. L. Nichols (2001). "Recognition, Prevention, Surveillance, and
Management of Surgical Site Infections: Introduction to the Problem and Symposium
Overview." Clinical Infectious Diseases 33: S67-S68.
McHugh, C. G. and L. W. Riley (2004). "Risk Factors and Costs Associated With MethicillinResistant Staphylococcus aureus Bloodstream Infections." Infect Control Hosp Epidemiol
25(5): 425-430.
Muto, C. A., E. T. Giannetta, et al. (2002). "COST-EFFECTIVENESS OF PERIRECTAL
SURVEILLANCE CULTURES FOR CONTROLLING VANCOMYCIN-RESISTANT
5
ENTEROCOCCUS." INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY
23(8): 429-435.
Muto, C. A., J. A. Jernigan, et al. (2003). "SHEA Guideline for Preventing Nosocomial
Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and
Enterococcus." INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY 24(5):
362-386.
Pittet, D., D. Tarara, et al. (1994). "Nosocomial bloodstream infection in critically ill patients.
Excess length of stay, extra costs, and attributable mortality 10.1001/jama.271.20.1598."
JAMA 271(20): 1598-1601.
Pittet, D. and R. P. Wenzel (1995). "Nosocomial bloodstream infections. Secular trends in rates,
mortality, and contribution to total hospital deaths 10.1001/archinte.155.11.1177." Arch
Intern Med 155(11): 1177-1184.
Rubinovitch, B. and D. Pittet (2001). "Screening for methicillin-resistant Staphylococcus aureus
in the endemic hospital: what have we learned?" Journal of Hospital Infection 47(1): 918.
Shaikh, Z. H. A., C. A. Osting, et al. (2002). "Effectiveness of a multifaceted infection control
policy in reducing vancomycin usage and vancomycin-resistant enterococci at a tertiary
care cancer centre." Journal of Hospital Infection 51(1): 52-58.
Slater, F. (2001). "Cost-Effective Infection Control Success Story: A Case Presentation." Emerg
Infect Dis 7(2).
Song, X., A. Srinivasan, et al. (2003). "Effect of Nosocomial Vancomycin-Resistant
Enterococcal Bacteremia on Mortality, Length of Stay, and Costs." Infect Control Hosp
Epidemiol 24(4): 251-256.
Stosor, V., L. R. Peterson, et al. (1998). "Enterococcus faecium Bacteremia: Does Vancomycin
Resistance Make a Difference? 10.1001/archinte.158.5.522." Arch Intern Med 158(5):
522-527.
West, T. E., C. Guerry, et al. (2006). "Effect of Targeted Surveillance for Control of MethicillinResistant Staphylococcus aureus in a Community Hospital System." INFECTION
CONTROL AND HOSPITAL EPIDEMIOLOGY 27(3): 233-238.
6