Cost–utility analysis of antimicrobial stewardship programme at a tertiary teaching hospital in Ethiopia

OBJECTIVE: Antimicrobial stewardship (AMS) significantly reduces inappropriate antibiotic use and improves patient outcomes. In low-resource settings, AMS implementation may require concurrent strengthening of clinical microbiology capacity therefore additional investments. We assessed the cost-effectiveness of implementing AMS at Tikur Anbessa Specialised Hospital (TASH), a tertiary care hospital in Ethiopia. DESIGN: We developed a Markov cohort model to assess the cost–utility of pharmacist-led AMS with concurrent strengthening of laboratory capacity compared with usual care from a ‘restricted societal’ perspective. We used a lifetime time horizon and discounted health outcomes and cost at 3% annually. Data were extracted from a prospective study of bloodstream infections among patients hospitalised at TASH, supplemented by published literature. We assessed parameter uncertainty using deterministic and probabilistic sensitivity analyses. SETTING: Tertiary care hospital in Ethiopia, with 800 beds and serves over half a million patients per year. POPULATION: Cohort of adults and children inpatient population aged 19.8 years at baseline. INTERVENTION: Laboratory-supported pharmacist-led AMS compared with usual care. Usual care is defined as empirical initiation of antibiotic therapy in the absence of strong laboratory and AMS. OUTCOME MEASURES: Expected life-years, quality-adjusted life-years (QALYs), costs (US$2018) and incremental cost-effectiveness ratio. RESULTS: Laboratory-supported AMS strategy dominated usual care, that is, AMS was associated with an expected incremental gain of 38.8 QALYs at lower expected cost (incremental cost savings:US$82 370) per 1000 patients compared with usual care. Findings were sensitive to medication cost, infection-associated mortality and AMS-associated mortality reduction. Probabilistic sensitivity analysis demonstrated that AMS programme was likely to be cost-effective at 100% of the simulation compared with usual care at 1%–51% of gross domestic product/capita. CONCLUSION: Our study indicates that laboratory-supported pharmacist-led AMS can result in improved health outcomes and substantial healthcare cost savings, demonstrating its economic advantage in a tertiary care hospital despite greater upfront investments in a low-resource setting.