Inappropriate antibiotic prescriptions attributable to dengue infection represent an economic burden in Singapore, driving up costs on the healthcare and societal levels, according to new research.
Between 2015 and 2024, the cumulative economic burden associated with antibiotic prescriptions given to patients with laboratory-confirmed dengue in the absence of bacterial complications (eg, hospital-acquired infections) was SGD 16.13 million from the societal perspective. [Pharmacoecon Open 2026;doi:10.1007/s41669-026-00680-9]
Direct medical costs accounted for the largest share of total cost at SGD 14.32 million, driven mostly by prolonged hospital stays (SGD 10.11 million), followed by adverse drug event management (SGD 3.26 million) and antibiotic acquisition (SGD 0.95 million). Direct non-medical costs totalled SGD 1 million and accounted for informal caregiving time associated with adverse drug reactions, while indirect costs due to productivity losses amounted to SGD 0.81 million.
From the healthcare system perspective, the cumulative economic burden was SGD 14.32 million, which included direct medical costs borne by healthcare providers and excluded direct non-medical costs and productivity losses.
“These findings indicate that the healthcare system bears most of the financial burden, while the societal perspective captures the additional consequences for patients and caregivers,” said principal investigator Dr Peter Ong from the National University of Singapore and colleagues.
Diagnostic uncertainty
During the 10-year observation period, 6,866 of the 7,055 total antibiotic prescriptions attributable to laboratory-confirmed dengue cases reported were deemed inappropriate, and 79.6 percent of these inappropriate prescriptions occurred in ambulatory care.
Ong and colleagues identified diagnostic uncertainty as a key driver of inappropriate antibiotic exposure in dengue care.
“Although dengue is a viral illness for which antibiotics are not indicated, empirical antibiotic prescribing frequently occurs during the initial febrile phase due to overlapping clinical features with bacterial infections and delays in laboratory confirmation,” they pointed out.
One way to address diagnostic uncertainty and reduce unnecessary antibiotic exposure is to use point-of-care tests such as the NS1 antigen test recommended by Singapore’s Ministry of Health at the initial patient encounter, according to Ong and colleagues.
The investigators also highlighted the potential of behavioural interventions that target prescribing decisions among clinicians. Social norm feedback nudges, particularly those aimed at high prescribers or benchmarking against peers, and public- and clinician-facing education campaigns have been shown to be effective internationally, they said.
Reducing the unnecessary antibiotic prescriptions is especially important because beyond its direct cost implications it can accelerate the development and spread of antimicrobial resistance, as Ong and colleagues pointed out. “This can result in treatment-resistant infections that are more difficult and costly to manage, with broader implications for public health and healthcare systems,” they noted.
“Future research should prioritize the collection of updated, age-stratified data on dengue management, antibiotic prescribing and hospital-acquired infections, as well as dynamic modelling approaches that incorporate longer-term antimicrobial resistance outcomes,” they said.
For the study, Ong and colleagues used national surveillance data and prescribing rates-informed model inputs. They constructed a decision tree model to determine costs associated with 142,525 laboratory-confirmed dengue cases reported in Singapore between 2015 and 2024.