Skin infections due to Panton-Valentine leukocidin (PVL)-producing S. aureus-Cost effectiveness of outpatient treatment

Abstract

Introduction: Skin and soft tissue infections (SSTI) caused by Panton-Valentine leukocidin (PVL)-producing strains of Staphylococcus aureus (PVL-SA) are associated with recurrent skin abscesses. Secondary prevention, in conjunction with primary treatment of the infection, focuses on topical decolonization. Topical decolonization is a standard procedure in cases of recurrent PVL-SA skin infections and is recommended in international guidelines. However, this outpatient treatment is often not fully reimbursed by health insurance providers, which may interfere with successful PVL-SA decolonization.

Aim: Our goal was to estimate the cost effectiveness of outpatient decolonization of patients with recurrent PVL-SA skin infections. We calculated the average cost of treatment for PVL-SA per outpatient decolonization procedure as well as per in-hospital stay.

Methods: The study was conducted between 2014 and 2018 at a German tertiary care university hospital. The cohort analyzed was obtained from the hospital's microbiology laboratory database. Data on medical costs, DRG-based diagnoses, and ICD-10 patient data was obtained from the hospital's financial controlling department. We calculated the average cost of treatment for patients admitted for treatment of PVL-SA induced skin infections. The cost of outpatient treatment is based on the German regulations of drug prices for prescription drugs.

Results: We analyzed a total of n = 466 swabs from n = 411 patients with recurrent skin infections suspected of carrying PVL-SA. PVL-SA was detected in 61.3% of all patients included in the study. Of those isolates, 80.6% were methicillin-susceptible, 19.4% methicillin-resistant. 89.8% of all patients were treated as outpatients. In 73.0% of inpatients colonized with PVL-SA the main diagnosis was SSTI. The median length of stay was 5.5 days for inpatients colonized with PVL-SA whose main diagnosis SSTI; the average cost was €2,283. The estimated costs per decolonization procedure in outpatients ranged from €50-€110, depending on the products used.

Conclusion: Our data shows that outpatient decolonization offers a highly cost-effective secondary prevention strategy, which may prevent costly inpatient treatments. Therefore, health insurance companies should consider providing coverage of outpatient treatment of recurrent PVL-SA skin and soft tissue infections.

Fig 1. Overview data.

PVL, Panton-Valentine leukocidin. SA, Staphylococcus aureus. DRG, Diagnosis Related Groups. ICD, International Classification of Diseases (Medical classification code for systematizing diagnoses).

Fig 2. Overview recruitment pathogen perspective.

PVL-SA isolated, stratified by methicillin-resistance (MRSA) and methicillin-susceptibility (MSSA). PVL, Panton-Valentine leukocidin. SA, Staphylococcus aureus.

Fig 3. PVL-SA examination sites and associated detection rate.

PVL-SA-positive, Panton-Valentine leukocidin Staphylococcus aureus positive. PVL-SA-negative, Panton-Valentine leukocidin Staphylococcus aureus negative. Pharyngeal, nasopharyngeal swab either combined or alone.

Fig 4. Overview recruitment patient perspective.

MRSA, methicillin-resistant Staphylococcus aureus. MSSA, methicillin-susceptible Staphylococcus aureus. PVL, Panton-Valentine leukocidin. DRG, diagnosis related groups.