Cost-effectiveness analysis of implementing an antimicrobial stewardship program in critical care units

Figures & data

Table 1. Costs, infection rate, and mortality considered in the model.

	No intervention	AS program	References
Short-term
Daily treatment cost (€)	34.94	19.99	Kaki et al.^14
Cost per CDI infection (€)	3,901	3,901	Asensio et al.^38
CDI infection rate (%)	12.70	6.60	Feazel et al.^15
Annual healthcare specialist salary (€)	0	44,500	Generalitat Valenciana^39
Annual cost per all AS personnel (€)	0	133,500	Generalitat Valenciana^39
% Infection rate (IC95%)
Sepsis	10.0 (4.8–18.4)	10.0 (4.8–18.4)	Bouza et al.^16
Community acquired pneumonia	25.0 (16.2–36.9)	25.0 (16.2–36.9)	Azkárate et al.^17
Cather-related bacteremia	2.03 (1.2–2.9)	2.03 (1.2–2.9)	GTEIS-SEMICYUC^19
VAP	3.00 (1.9–4.1)	3.00 (1.9–4.1)	GTEIS-SEMICYUC^19
Urinary-tract infection	2.81 (1.8–3.8)	2.81 (1.8–3.8)	GTEIS-SEMICYUC^19
CDI	0.89 (0.71–1.09)	0.48 (0.35–0.63)	Bouza et al.^16
Long-term
Cost per MDRB infection (€)	5,500	5,500	Cosgrove^22
% MDRB infection (IC95%)	40.0 (28.0–54.0)	32.0 (21.0–45.0)	Ma et al.^20; López-Pueyo et al.^21
% Additional MDRB mortality rate	40.0	40.0	Cosgrove^22
% MDRB reduction due to AS program	20.0	0.0–40.0	Karanika et al.^37; Bantar et al.^40

AS: Antimicrobial stewardship; CDI: Clostridium difficile infection; VAP: Ventilator Associated Pneumonia; MDRB: Multi-drug resistant bacteria.

Figure 1. Short-term decision model.

Table 2. Probability values and fixed applied during probabilistic sensitivity analysis.

Name	Data distribution	Point estimate of probability	Initial value considered	Range	Probability estimates references
Ventilator Associated Pneumonia	beta	0.030		0.024–0.036	Levy et al.^18
Bacteremia	beta	0.028		0.022–0.034	Levy et al.^18
Urinary-tract infection	beta	0.020		0.016–0.024	Levy et al.^18
MDRB Nosocomial infection rate	beta	0.400		0.320–0.480	Ma et al.^20
MDRB reduction due AS program	beta	0.200		0–0.400	Karanika et al.^37; Bantar et al.^40
Additional mortality due to MDRB infection	beta	0.400		0.320–0.480	Cosgrove^22
MDRB infection additional cost (€)	uniform		5,500	4,400–6,600	López-Pueyo et al.^21
Short-term AS benefit (€)	uniform		99,434	69,603–129,264	Short-term analysis
Annual antimicrobial spending reduction (Second and third year)	uniform	0,1*Antimicrobial spending reduction during the previous year			*

MDRB: Multi-drug resistant bacteria; AS: Antimicrobial stewardship.

Figure 2. Results of short-term univariate analysis. Each horizontal line represents how the variation of the variables affects the final result obtained in the model (–€71,738). The variations considered were 20% for the reason of admission in the critical care unit (Sepsis and NAC) and in the incidence of nosocomial infection, 50% for the reduction in the incidence of CDI, 30% for the reduction of the average cost of antimicrobial treatment, and 10% for the number of patients admitted in the critical care unit.

Figure 3. Long-term multivariate analysis results (Cost per LYG).

Figure 4. Long-term multivariate analysis results (Cost per resistance avoided).

Figure 5. Predicted proportion of cost-effective antimicrobial stewardship (AS) services at incremental willingness to pay per LYG. Incremental cost-effectiveness of implementing an AS was calculated and compared with standard to compute an ICER.

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