The Cost of Resistance

Antibiotic resistance has devastating economic and social costs. In 2009, the Alliance for the Prudent Use of Antibiotics (APUA), in conjunction with a Chicago teaching hospital, conducted a study of the medical and societal costs attributable to antimicrobial-resistant infections (ARI) and the implications of antibiotic stewardship. In its Clinical Infectious Diseases report by Roberts et al. the medical costs for ARI treatment, including those associated with duration of hospital stay, comorbidities, ICU, surgery, and mortality ranged from $18,588 to $29,069 per patient. The team extrapolated that $10.7 to $15.0 million in societal costs can be attributed to antibiotic resistance. In a press release from October 19, 2009 Dr. Roberts is quoted: “Assuming 900,000 ARI cases in the year 2000, based on the conservative selection criteria used in our study, the total societal costs of ARIs to U.S. households in the year 2000 was approximately $35 billion. This includes lost wages from extended hospital stays and from premature deaths.”  Regarding the report, President and co-founder of APUA, and Tufts University professor Dr. Stuart Levy said, “The results offer some good insight regarding just how much ARIs are costing the nation: not just in terms of dollars, but human life and suffering. As the enormous costs identified here are viewed on a national scale, it is clear that effectively addressing the issue of antimicrobial-resistant infection is an essential element for stemming the rising tide of healthcare costs in the United States."

As of September 2013, the CDC has continued to cite APUA’s assessment, stating that “antibiotic resistance adds $20 billion in excess direct health care costs, with additional costs to society for lost productivity as high as $35 billion per year.” In its original 2013 Report, the CDC states the following about estimating total costs:

“This report does not provide a specific estimate for the financial cost of antibiotic-resistant infections. Although a variety of studies have attempted to estimate costs in limited settings, such as a single hospital or group of hospitals, the methods used are quite variable. Similarly, careful work has been done to estimate costs for specific pathogens, such as Streptococcus pneumoniae and MRSA.  However, no consensus methodology currently exists for making such monetary estimates for many of the other pathogens listed in this report.  For this reason, this report references non-CDC estimates in the introduction, but does not attempt to estimate the overall financial burden of antibiotic resistance to the United States."

Additional studies and examples examining the economic and societal costs of antibiotic resistance include:

  • Betsey McCaughy, health policy expert and chairman of Reduce Infection Deaths(RID), estimates $30.5 billion for total hospital-acquired infection costs (2014).
  • Lloyd-Smith et al. analyze the costs of vancomycin-resistant enterococci in Canadian hospitals and estimates $17,949 Canadian dollars per ARI-patient (2013).
  • Dr. Richard Shannon, University of Pennsylvania School of Medicine, estimates $5 billion of additional health care costs can be avoided by eliminating hospital-acquired infections (2011). His presentation can be found here.
  • Dr. J.A. O’Brien et al. summarize the costs of Clostridium difficile (C. diff) infections in Massachusetts hospitals to be $3.2 billion per year (2007).
  • Dr. S. Cosgrove et al. state that patients with ARI cost $6,000-$30,000 more than patients with infections due to antimicrobial-susceptible organisms (2006).

Bioterrorism & Stockpiling Antibiotics

Risks of Stockpiling Antibiotics to Counter Bioterrorism
The problem: Many U.S. citizens, concerned about the current anthrax scare, are calling physicians to demand antibiotics 'just in case'. This is called stockpiling and it has its risks…

Why does stockpiling antibiotics occur?
Both the government and individual patients can stockpile antibiotics. The government stockpiles, or stores, antibiotics to care for its citizens, and to be ready to respond to an actual bioterrorist event. As the US Secretary of Health and Human Services has said on a number of occasions, the government has stockpiled medicines, including antibiotics, supplies, and other necessities at strategic places around the nation to respond to a bioterrorist event.

Individual patients, on the other hand, stockpile antibiotics by obtaining and storing them ahead of time, "just in case" they need them. In the case of the current anthrax scare, ciprofloxacin, a member of the fluoroquinolone family commonly call Cipro, is the antibiotic being stockpiled. The rest of my remarks refer to the risks of stockpiling antibiotics by individual patients.

Are there disadvantages to stockpiling antibiotics?
Yes, there are disadvantages. The consumer receives drugs without specific instructions and they might not know when to take them. What are the unique symptoms of anthrax and which ones could be the symptoms of some other disease? Without specific instructions, patients are likely to take the drug for a common illness, cold, or cough, which is not anthrax. Thus, stockpiling ciprofloxacin could lead to widespread misuse of this important antibiotic prior to any bioterrorist event. This can create the perfect scenario for the emergence of bacterial resistance to the drug in both harmless bacteria, which is less of a concern, and harmful bacteria, which cause pneumonias, urinary tract infections, peritonitis, septicemias, sexually transmitted diseases, and so on.

Is there any safe way to stockpile antibiotics?
Consumers should not use stockpiled antibiotics unless there is an official public health alert stating that we ARE having a bioterrorism event and that the organism is in fact one that can be treated with this drug. There are bacteria for which ciprofloxacin does not work. If the antibiotics are just stockpiled and used only after an alert, then I am less worried. However, this puts the responsibility on the consumer to refrain from popping these pills. Many consumers are known to ask for antibiotics in the event of a cold, for which they do not work. What's to keep the consumer from using an antibiotic they already have?!

What is the appropriate antibiotic for anthrax now?
At the moment, because we do not know to which drugs the anthrax bacterium is susceptible, the most appropriate drug to use for anthrax is ciprofloxacin, a broad spectrum antibiotic, although penicillin and tetracyclines may also work. Ciprofloxacin-resistant anthrax has not yet been reported. However, some anthrax bacteria have become resistant to penicillin and anthrax could certainly learn to become resistant to ciprofloxacin.

What is the danger in widespread misuse of ciprofloxacin before a terrorist event?
The real danger is that we will lose the efficacy of this drug very rapidly as homes across America begin to use it. Widespread use of ciprofloxacin will kill a great number of bacteria that are susceptible to ciprofloxacin. The bacteria that are not killed will be those that evolve resistance to ciprofloxacin. These ciprofloxacin-resistant bacteria can then flourish unchecked by this important antibiotic. Currently, many bacteria that cause severe human illnesses are already resistant to other antibiotics; the drug of choice is often from the fluoroquinolone family, of which ciprofloxacin is a member. If the U.S. and the rest of the world begin using ciprofloxacin indiscriminately, then the bacterial world is going to consist of increasing numbers of resistant mutants and not susceptible ones. Consequently, widespread misuse of ciprofloxacin means that when we want to use a fluoroquinolone to treat a severe septic event (infection) or pneumonia that is resistant to all the other antibiotics, the fluoroquinolone may no longer be effective.

Are there consequences for an individual who takes ciprofloxacin unnecessarily?
As you use ciprofloxacin, susceptible bacteria in your intestinal tract and on your skin are killed, leaving behind resistant bacteria. If you deplete enough susceptible bacteria, you create unoccupied, fertile regions available to be colonized by a truly dangerous organism. This new infectious organism could be resistant to ciprofloxacin because you have been using it. People can and do die of bacterial infections because an effective antibiotic cannot be found.

Whose responsibility is it to ensure the appropriate use of antibiotics?
The physician and patient share responsibility. It is a misuse of the physician's abilities to prescribe a drug for a patient without understanding clearly how the patient intends to use the drug. It is irresponsible for patients to demand antibiotics against their doctors' advice or to use critical drugs haphazardly. This behavior directly contributes to the growing problem of antibiotic resistance for the patient and the entire community.

How can a physician resist a patient's demand for an antibiotic?
A physician should begin by refusing to prescribe the antibiotic and providing the reasons why. Educating the patient on the risks of antibiotic misuse is essential. If the physician does prescribe the antibiotic, it is very important to stress to the patient the need to refrain from taking it for any reason until receiving a government bioterrorism alert. I urge third party payers and pharmacists not to dispense ciprofloxacin or other antibiotics without a specific indication for its use.

Could the overuse of fluoroquinolones due to fear of bioterrorism really lead to resistance in bacteria?
There are convincing examples of how, within a relatively short time period, the use of fluoroquinolones led to the emergence of important resistant disease-causing agents. This is the reason that the CDC and medical societies are warning against the inappropriate use of Cipro. One example from Minnesota is a group of Campylobacter strains of diarrhea-producing bacteria that came from chickens that were given fluoroquinolones. Another example comes from China, where 60% of the E. coli causing urinary tract infections, septicemias and other life threatening diseases are resistant to the fluoroquinolones. This happened because of the ease and quantity of fluoroquinolone use in China. Very recently, through the GAARD project (a collaborative effort sponsored by APUA), two global surveillance groups, SENTRY and the Alexander Project, have detected the first signs of fluoroquinolone resistance in Haemophilus influenzae, a respiratory tract infectious agent.