Carbapenem resistant-Enterobacteriaceae (CR-E) and Carbapenem-resistant Acinetobacter baumannii (CRAB) are urgent threats that cause severe healthcare-associated infections (HAIs), especially in critically ill and immunocompromised subjects, associated with significant morbidity, mortality, and increased healthcare costs. Acinetobacter baumannii with minor frequency put a noteworthy burden on hospitals. The annual cost of CR-E is higher than various acute and chronic diseases. Carbapenem-resistant Pseudomonas aeruginosa (CRPA) patients’ death risk is more than carbapenem sensitive Pseudomonas aeruginosa (CSPA). Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumonia, and Escherichia coli are included in WHO critical priority pathogens.

Resistant pathogens to carbapenems and correlated to clinical and economic burden. An estimated 700 thousand people die each year due to drug-resistant infections, more than 70% of mortality cases are due to difficulty in CR-E treatment, and CRAB increases total medical costs by 1.5 times more and puts a heavy financial burden on hospitals. If not taken seriously, more than 10 million deaths annually can occur by 2050, and a reduction to 3.8% in the annual gross domestic product (GDP) and an increase in vulnerability to poor people living in low- and middle-income countries (LMICs).

Research on resistant microbial infection to the hospital costs are quite rare to find in Indonesia. The research conducted at Dr. Soetomo General Hospital is an early study to estimate and explore the impact of the carbapenem-resistant and sensitive non-lactose fermenter and Enterobacteriaceae infections on costs.

The study started from January 2021 until August 2021. The data were extracted from the electronic medical record from March 2018 until February 2021. The study included 810 cases, and 270 (33.3%) were found carbapenem-resistant. There is no significant difference between the genders and age groups. The most common specimen were urine n = 567, 70% followed by blood n = 188, 23%, pleural fluid n = 22, 2.7% and CSF (cerebrospinal fluid) n = 15, 1.9%, and peritoneal n = 10, 1.2% and then few cases of others.

Both carbapenem-resistant and sensitive cases were categorized into two groups each, i.e., carbapenem-resistant EC + KP (CRE) and carbapenem-resistant PA + AB (CR-PA-AB). The average cost of patients treated with CRE is USD.1179.30 or around Rp. 17,159,000 and compared with the average cost in patients with CSE (Carbapene sensitive Enterobacteriaceae) infection of USD1061.20 or around Rp. 15,440,360. The difference is equal to Rp.1.718.640 rupiah was higher for each patient in the group of carbapenem-resistant bacteria. Though it is an insignificant difference, it still burdens the hospital budget.

However, CR-PA-AB infections are much higher compared to CS-PA-AB by USD 3026.24 versus USD 1299.28. This study showed that the hospital cost and expenditure of CR-PA-AB per patient were higher by $1726.96 or Rp. 25.127.268,-. The significant difference impacted the hospital treatment cost due to microbial resistance.

Apart from the medicine purchase and other supporting factors, the high cost was the longer length of stay (LoS) among the microbial resistance group for 15 days, compared to the 11 days in the sensitive group.

To handle the problem, the Health Minister Regulations no 8 of 2015 has been issued that requires all hospitals to jointly implement the PPRA (Antimicrobial Resistance Program) program, in particular, the target to increase the wise use of antibiotics. The regulation was coined from the joint research project of Universitas Airlangga Faculty of Medicine (FK) and the Dr. Soetomo General Hospital in 2000, a collaborative study with Dutch researchers, in particular Erasmus MC Rotterdam, Leiden University Medical Center (LUMC), Leiden and Radboud University Nijmegen Medical Centre, Nijmegen. This project is known as Antimicrobial resistance in Indonesia: Prevalence and Prevention or abbreviated as AMRIN.

In the future, the hospitals must obey in running the PRA program to improve patient management outcomes and the efficiency of infectious disease services in hospitals.

Authors: Prof. Kuntaman, Universitas Airlangga Faculty of Medicine (FK) and Universitas Airlangga Hospital (RSUA), Dr. Soetomo General Hospital Surabaya. Original article with Ph.D. candidate of FK UNAIR, Yasmeen Lashari, access published paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9137956/