A one health framework to estimate the cost of antimicrobial resistance

Morel, Chantal M.; Alm, Richard A.; Årdal, Christine; Bandera, Alessandra; Bruno, Giacomo M.; Carrara, Elena; Colombo, Giorgio L.; de Kraker, Marlieke E. A.; Essack, Sabiha; Frost, Isabel; Gonzalez-Zorn, Bruno; Goossens, Herman; Guardabassi, Luca; Harbarth, Stephan; Jørgensen, Peter S.; Kanj, Souha S.; Kostyanev, Tomislav; Laxminarayan, Ramanan; Leonard, Finola; Hara, Gabriel Levy; Mendelson, Marc; Mikulska, Malgorzata; Mutters, Nico T.; Outterson, Kevin; Baňo, Jesus Rodriguez; Tacconelli, Evelina; Scudeller, Luigia

doi:10.1186/s13756-020-00822-6

Table 5 Costs related to the patient colonised or infected with resistant pathogen in human health, necessary in a “One-Health” cost model

From: A one health framework to estimate the cost of antimicrobial resistance

Data element	Category of costs	Cost items
Direct costs	Costs of any treatment or prophylaxis of the patient borne by the health service (regardless of whether or not such costs are passed on to the payor/insurance company).^a	− Cost of antibiotics for treating infections − Higher antibiotic expenses for empirical therapy due to a change in guidelines in response to higher frequency of drug-resistant infections − Cost of drug administration (central lines, etc.) − Cost of nursing care − Cost of cohorting (including cost of leaving not unoccupied beds due to isolation of one patient restricting the use of the bed(s) in the same room) − Extended length of stay, whereby ICU and non-ICU days should be separated − Costs due to de-colonisation, if applicable, (e. g. mupirocin), re-testing, e.g. additional follow-up screening − Cost of non-standard surgical prophylaxis in colonised/infected patients, with more expensive drugs − Costs of infection prevention and control interventions as screening at hospital admission or before surgery
	Costs of long- term consequences of AMR infection	− Cost of additional laboratory tests or imaging to diagnose site of infection or foci of distant infectious metastatic foci − Cost of diagnosing and treating adverse events to 2nd, 3rd line etc. (Drugs used against MDROs infection need careful monitoring of toxicity and efficacy, thus more laboratory and radiological tests.) − Extra hospital admissions, or extra care for rehabilitation (e.g., respiratory, mobility, cognitive, neurological) and/or treatments required for disease sequelae directly linked to the drug-resistant infection, like recurrent infection, kidney failure, amputation, neurological sequelae, extra surgery
	Out-of-pocket expenditure borne by the patient for care	− Transport to and from the hospital (if the sole reason for the hospital admission was the infection) − Cost of funeral in cases of (attributable) death − Cost of (family/friend) care for the patient (e.g. hotel and meals to be near the hospital) due to excess length of stay of the patient related to the drug-resistant infection
	Surveillance and control activities^b	− Costs of enhanced surveillance − Cost of any screening that is triggered − Costs of isolation, cohorting or contact precautions to the health care system, including facility design and operational costs
	Training of health care professionals and information/communication	− Costs of pre-service, in-service and continuous professional education per relevant cadre of human healthcare professional − Cost of any related public health or information campaign
	Legal and insurance costs (patient)	− Additional insurance costs to cover problems associated specifically with resistance − Litigation costs, when suing hospitals for transmission of resistance infection
	Legal and insurance costs (hospital)	− Litigation costs, when sued by patients for transmission of resistance infection − Costs of implementing or regulating and enforcing national robust, representative comprehensive surveillance programmes at all levels of health care from primary to tertiary levels
Indirect costs	Indirect patients’ costs: Loss of productivity/earning/opportunity when seeking treatment for the resistant infection (or colonisation) or dying from the resistant infection	− Value of foregone workdays value of foregone workdays because of disease sequelae related to the drug-resistant infection foregone treatments that depend on effectiveness of prophylaxis, like surgical interventions such as hip or knee replacements or caesarian sections − Foregone leisure time (NB: difficult to quantify) − Loss of productivity/earnings by family &visitors attending patient − Loss of caretaker (family/friend) productivity – (workdays foregone) − Psychological impact (factored in as QALY) − Other costs related to different life style (e.g. amputation leading to prosthesis or wheel chair; home renovation works to adapt to disability; nursing care costs, if unable to perform activities)
	Indirect hospital costs	− Reduced patient turnover and decreased revenues (due to longer hospital duration or to isolation/cohorting, or to decision not to perform a non-essential procedure –e.g. cosmetic surgery - etc.) − Reduced capacity of hospital (due to longer hospital duration or to isolation/cohorting − reputational costs borne by the hospital: any loss in hospital income related to the level of resistant infection/colonisation Note that a reduction in visits to one hospital may simply lead to an increase in visits for another. As this study takes a societal perspective only overall net reduction should be considered. (Assumption that no visits to the hospital are superfluous so that a reduction in visits due to fear of contracting a resistant pathogen imposes negative utility.)
	Societal/government	− Financial burden on the government for disability benefits
	Research and development of new antibiotics	− Cost to develop and bring a replacement drug to market^c

^aIn sites where resistance is common and a greater percentage of fixed health care costs are spent managing it, the more the cost of overheads should be included in cost equations. Note that most colonization will not be treated with drugs, except cases like MRSA in patients awaiting surgery. However, colonization is likely to lead to more frequent visits, additional diagnostic tests, isolation of the patient, change in other contact precautions, etc.
^bThis work considers costs associated with phenotypic resistance in most cases. In the case of resistance surveillance, it considers genotypic resistance in that identification of resistance-carrying genes is assumed to impact on surveillance activities and screening in some cases
^cWhen an antibiotic is rendered ineffective due to resistance, in a sense it is retired from the tool kit (in the language of accounting: it is fully depreciated). In companies or governments, reserves would have been set aside to account for the eventual need to replace the key asset. If this replacement cycle is done well, there is no downtime (for antibiotics, downtime is harm to patients from lack of effective therapy). So even if the antibiotic replacement cycle worked perfectly (with no harm to patients) there still is a cost: the effort to bring a replacement drug successfully to market. There is significant social waste since drug developers require many years (up to 15) from the university laboratory to an approved drug: it is difficult to judge the epidemiological need 15–-20 years onward. There currently are many ongoing patent races, with some duplication of effort as well

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