# Impact of Antimicrobial-Resistant Bacterial Pneumonia on In-Hospital Mortality and Length of Hospital Stay: A Retrospective Cohort Study in Spain

## TL;DR

This study shows that bacterial pneumonia caused by antibiotic-resistant bacteria leads to higher death rates and longer hospital stays in Spain.

## Contribution

The study provides new evidence on the clinical and economic burden of antimicrobial resistance in bacterial pneumonia using a large national dataset.

## Key findings

- Antimicrobial-resistant pneumonia was linked to a 47% higher risk of in-hospital mortality.
- Patients with resistant infections had hospital stays 1.46 times longer than those without.
- Common resistant pathogens included Staphylococcus aureus and Gram-negative bacilli.

## Abstract

Objectives: Antimicrobial resistance is a major global health threat. This study aimed to assess the impact of antimicrobial-resistant bacterial pneumonia on in-hospital mortality and length of hospital stay in Spain using a large, nationally representative cohort. Methods: A retrospective cohort study that used data from Spain’s Registry of Specialized Health Care Activity (RAE-CMBD) between 2017 and 2022. Hospitalized adults with bacterial pneumonia were included. Hospitalization episodes with bacterial antimicrobial resistance, defined according to ICD-10-CM codes for antimicrobial resistance (Z16.1, Z16.2), were analyzed versus hospitalization episodes without these codes. Multivariate logistic regression models, adjusted for potential confounders (e.g., age, comorbidity, intensive care unit admission) and sensitivity analyses (Poisson regression and propensity score matching test), were performed. Results: Of the 116,901 eligible hospitalizations, 6017 (5.15%) involved antimicrobial-resistant bacteria. Patients with antimicrobial-resistant bacterial pneumonia were older (median 75 vs. 72 years), had greater comorbidity (Elixhauser–van Walraven index: 8 vs. 5), and were more frequently admitted to the intensive care unit (22% vs. 14%). Crude in-hospital mortality was higher in the antimicrobial resistance group (18.46% vs. 10.05%, p < 0.0001), with an adjusted odds ratio of 1.47 (95% confidence interval, 1.36–1.58), p < 0.0001. Length of hospital stay was prolonged in antimicrobial resistance patients (median 14 vs. 8 days; adjusted incident rate ratio of 1.46; 95% confidence interval of 1.41 to 1.50). The most prevalent antimicrobial resistant pathogens were Staphylococcus aureus and Gram-negative bacilli (Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli). Conclusions: Antimicrobial resistance is associated with longer hospital stays and an up to 50% higher risk of mortality. Despite the implementation of control policies in place over the past decade, policymakers must strengthen AMR surveillance and ensure adequate resource allocation. Clinicians, in turn, must reinforce antimicrobial stewardship and incorporate rapid diagnostic tools to minimize the impact of antimicrobial resistance on patient outcomes.