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PLoS One. 2019 Sep 10;14(9):e0221944. doi: 10.1371/journal.pone.0221944. eCollection 2019.

The health and cost burden of antibiotic resistant and susceptible Escherichia coli bacteraemia in the English hospital setting: A national retrospective cohort study.

Author information

National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, England.
Modelling and Economics Unit, National Infection Service, Public Health England, London, England.
Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
Healthcare Associated Infection and Antimicrobial Resistance Department, Public Health England, London, England.
Department of Infectious Disease Epidemiology, Imperial College London, England.
Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America.
The Health Foundation, London, England.



Antibiotic resistance poses a threat to public health and healthcare systems. Escherichia coli causes more bacteraemia episodes in England than any other bacterial species. This study aimed to estimate the burden of E. coli bacteraemia and associated antibiotic resistance in the secondary care setting.


This was a retrospective cohort study, with E. coli bacteraemia as the main exposure of interest. Adult hospital in-patients, admitted to acute NHS hospitals between July 2011 and June 2012 were included. English national surveillance and administrative datasets were utilised. Cox proportional hazard, subdistribution hazard and multistate models were constructed to estimate rate of discharge, rate of in-hospital death and excess length of stay, with a unit bed day cost applied to the latter to estimate cost burden from the healthcare system perspective.


14,042 E. coli bacteraemia and 8,919,284 non-infected inpatient observations were included. E. coli bacteraemia was associated with an increased rate of in-hospital death across all models, with an adjusted subdistribution hazard ratio of 5.88 (95% CI: 5.62-6.15). Resistance was not found to be associated with in-hospital mortality once adjusting for patient and hospital covariates. However, resistance was found to be associated with an increased excess length of stay. This was especially true for third generation cephalosporin (1.58 days excess length of stay, 95% CI: 0.84-2.31) and piperacillin/tazobactam resistance (1.23 days (95% CI: 0.50-1.95)). The annual cost of E. coli bacteraemia was estimated to be £14,346,400 (2012 £), with third-generation cephalosporin resistance associated with excess costs per infection of £420 (95% CI: 220-630).


E. coli bacteraemia places a statistically significant burden on patient health and the hospital sector in England. Resistance to front-line antibiotics increases length of stay; increasing the cost burden of such infections in the secondary care setting.

Conflict of interest statement

The authors have declared that no competing interests exist.

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