Economic Burden
Although few estimates have been made of the economic impact of drug resistance in developing countries, there is some indication that this burden is substantial. Estimates for costs associated with the loss of antibiotic effectiveness in outpatient prescriptions in the United States range from US$378 million to as high as US$18.6 billion (Elbasha 1999). A report by the Office of Technology Assessment to the U.S. Congress estimated the annual cost associated with antibiotic resistance in hospitals (attributable to five classes of hospital-acquired infections from six antibiotic-resistant bacteria) to be at least US$1.3 billion in 1992 dollars (Office of Technology Assessment 1995). The U.S. Centers for Disease Control and Prevention (CDC) estimated that the cost of all hospital-acquired infections, including both antibiotic-resistant and antibiotic-susceptible strains, was US$4.5 billion.
Patients infected with resistant strains are more likely to be sicker, to be hospitalized for longer periods of time, and to die of the infection (Carmeli and others 2002). Both the duration of hospitalization and the attributable cost of treating methicillin-resistant Staphylococcus aureus were found to be nearly three time as large as those for a susceptible infection (Abramson and Sexton 1999). One problem with estimating the attributable morbidity and mortality that is caused by resistant pathogens is that patients who are infected with resistant strains are more likely to have been sicker in the first place. Therefore, the ability to appropriately control for the underlying severity of the illness that causes hospitalization is a concern.
Another important cost of resistance comes from the need to move to second-line treatments, which are often much more expensive than the first-line treatment that is no longer effective. For instance, treating the roughly 300 million cases of malaria with artemisinin-based combinations would involve an excess burden of roughly US$200 million each year in drug costs. Periodically changing first-line treatment may also involve costs of assessing alternate treatment regimens, retraining health care providers, and restocking health care facilities. Though all these impose a significant economic burden, especially in poorer countries, they may be an inevitable consequence of past drug use. A focus on the cost of resistance alone may be misleading, because it is potentially possible to eliminate drug resistance by not using any drugs. To appropriately assess the net benefits of drug use, one must include the cost of increased resistance and the benefits of antibiotic or antimalarial use in treating infections and preventing their spread to uninfected individuals.
