• Vol. 41 No. 5, 189–193
  • 15 May 2012

The Excess Financial Burden of Multidrug Resistance in Severe Gram-negative Infections in Singaporean Hospitals



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Introduction: Multidrug-resistant (MDR) Gram-negative healthcare-associated infections are prevalent in Singaporean hospitals. An accurate assessment of the socioeconomic impact of these infections is necessary in order to facilitate appropriate resource allocation, and to judge the cost-effectiveness of targeted interventions.

Materials and Methods: A retrospective cohort study involving inpatients with healthcare-associated Gram-negative bacteraemia at 2 large Singaporean hospitals was conducted to determine the hospitalisation costs attributed to multidrug resistance, and to elucidate factors affecting the financial impact of these infections. Data were obtained from hospital administrative, clinical and financial records, and analysed using a multivariate linear regression model.

Results: There were 525 survivors of healthcare-associated Gram-negative bacteraemia in the study cohort, with 224 MDR cases. MDR bacteraemia, concomitant skin and soft tissue infection, higher APACHE II score, ICU stay, and appropriate definitive antibiotic therapy were independently associated with higher total hospitalisation costs, whereas higher Charlson comorbidity index and concomitant urinary tract infection were associated with lower costs. The excess hospitalisation costs attributed to MDR infection was $8638.58. In the study cohort, on average, 62.3% of the excess cost attributed to MDR infection was paid for by government subvention.

Conclusion: Multidrug resistance in healthcare-associated Gram-negative bacteraemia is associated with higher financial costs—a significant proportion of which are subsidised by public funding in the form of governmental subvention. More active interventions aimed at controlling antimicrobial resistance are warranted, and the results of our study also provide possible benchmarks against which the cost-effectiveness of such interventions can be assessed.

Healthcare-associated infections (HAIs) are a burden on healthcare systems in both developed as well as developing nations, resulting in prolonged hospitalisation, poor outcomes and increased hospitalisation costs. Between 5% and 15% of acute-care inpatients develop an infection during their admission, and critically ill patients nursed in intensive care units (ICUs) are 5 to 10 times more likely to acquire a HAI than those in general wards. Gram-negative bacilli (GNB) collectively cause the majority of HAIs, and have been associated with progressively increasing rates of resistance, including multidrug resistance. In Singapore, a hospital-based surveillance program showed that 21.7% and 27.4% of Escherichia coli and Klebsiella pneumoniae blood isolates were resistant to third-generation cephalosporins, whereas 12.8% and 50.0% of blood Pseudomonas aeruginosa and Acinetobacter spp. isolates respectively were resistant to the carbapenems.

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