CDC Antibiotic Resistant Threats 2013 Report

7/29/2019 CDC Antibiotic Resistant Threats 2013 Report

1/114

ANTIBIOTIC RESISTANCE THREATSin the United States, 2013


2/114


3/114

TABLE OF CONTENTSForeword 5

Executive Summary 6

Section 1: The Threat of Antibiotic Resistance 11

Introduction 11

National Summary Data 13Cycle o Resistance Inographics 14

Minimum Estimates o Morbidity and Mortality rom Antibiotic-Resistant Inections 15

Limitations o Estimating the Burden o Disease Associated with Antibiotic-Resistant Bacteria 18

Assessment o Domestic Antibiotic-Resistant Threats 20

Running Out o Drugs to Treat Serious Gram-Negative Inections 22

People at Especially High Risk 24

Antibiotic Saety 25

Gaps in Knowledge o Antibiotic Resistance 27

Developing Resistance:Timeline o Key Antibiotic Resistance Events 28

Section 2: Fighting Back Against Antibiotic Resistance 31

Four Core Actions to Prevent Antibiotic Resistance 31

1 Preventing Inections, Preventing the Spread o Resistance 32

CDCs Work to Prevent Inections and Antibiotic Resistance in Healthcare Settings 32

CDCs Work to Prevent Antibiotic Resistance in the Community 34

CDCs Work to Prevent Antibiotic Resistance in Food 36

2 Tracking Resistance Patterns 39

3 Antibiotic Stewardship: Improving Prescribing, Improving Use 41

4 Developing New Antibiotics and Diagnostic Tests 44

Section 3: Current Antibiotic Resistance Threats in the United States, by Microorganism 49Microorganisms with a Threat Level o Urgent 50

Clostridium difcile 51

C a r b a p e n e m - r e s i s t a n t E n t e r o b a c t e r i a c e a e 53

Drug-resistant Neisseria gonorrhoeae 55Microorganisms with a Threat Level o Serious 58

Multidrug-resistantAcinetobacter 59

Drug-resistant Campylobacter 61

Fluconazole-resistant Candida (a ungus) 63

Extended spectrum -lactamase producing Enterobacteriaceae (ESBLs) 65

Vancomycin-resistantEnterococcus (VRE) 67

Multidrug-resistant Pseudomonas aeruginosa 69

Drug-resistant non-typhoidal Salmonella 71

Drug-resistant Salmonella Typhi 73

Drug-resistant Shigella 75

Methicillin-resistant Staphylococcus aureus (MRSA) 77

Drug-resistant Streptococcus pneumoniae 79Drug-resistant tuberculosis 81

Microorganisms with a Threat Level o Concerning 84

Vancomycin-resistantStaphylococcus aureus (VRSA) 85

Erythromycin-resistant Group A Streptococcus 87

Clindamycin-resistant Group B Streptococcus 89

Technical Appendix 93

Glossary 107

Acknowledgements 112
http://-/?-http://-/?-


4/1144ACINETOBACTER


5/1145

FOREWORDAntimicrobial resistance is one o our most serious health threats Inections rom resistant

bacteria are now too common, and some pathogens have even become resistant to

multiple types or classes o antibiotics (antimicrobials used to treat bacterial inections)The loss o eective antibiotics will undermine our ability to ght inectious diseases

and manage the inectious complications common in vulnerable patients undergoing

chemotherapy or cancer, dialysis or renal ailure, and surgery, especially organ

transplantation, or which the ability to treat secondary inections is crucial

When rst-line and then second-line antibiotic treatment options are limited by resistance

or are unavailable, healthcare providers are orced to use antibiotics that may be more toxic

to the patient and requently more expensive and less eective Even when alternative

treatments exist, research has shown that patients with resistant inections are oten

much more likely to die, and survivors have signicantly longer hospital stays, delayed

recuperation, and long-term disability Eorts to prevent such threats build on theoundation o proven public health strategies: immunization, inection control, protecting

the ood supply, antibiotic stewardship, and reducing person-to-person spread through

screening, treatment and education

Dr Tom Frieden, MD, MPH

Director, US Centers or Disease Control and Prevention

Meeting the Challenges o Drug-Resistant Diseases in Developing Countries

Committee on Foreign Aairs Subcommittee on Arica, Global Health, Human Rights,

and International Organizations

United States House o Representatives

April 23, 2013


6/1146

ANTIBIOTIC RESISTANCE THREATS INTHE UNITED STATES, 2013

Executive SummaryAntibiotic Resistance Threats in the United States, 2013 is a snapshot o the complex problem

o antibiotic resistance today and the potentially catastrophic consequences o inaction

The overriding purpose o this report is to increase awareness o the threat that antibiotic

resistance poses and to encourage immediate action to address the threat This document

can serve as a reerence or anyone looking or inormation about antibiotic resistance It is

specically designed to be accessible to many audiences For more technical inormation,

reerences and links are provided

This report covers bacteria causing severe human inections and the antibiotics used to

treat those inections In addition, Candida, a ungus that commonly causes serious illness,

especially among hospital patients, is included because it, too, is showing increasing

resistance to the drugs used or treatment When discussing the pathogens included in this

report, Candida will be included when reerencing bacteria or simplicity Also, inections

caused by the bacteria Clostridium difcile (C. difcile) are also included in this report

Although C. difcile inections are not yet signicantly resistant to the drugs used to treat

them, most are directly related to antibiotic use and thousands o Americans are aected

each year

Drug resistance related to viruses such as HIV and inuenza is not included, nor is drug

resistance among parasites such as those that cause malaria These are important

problems but are beyond the scope o this report The report consists o multiple one ortwo page summaries o cross-cutting and bacteria- specic antibiotic resistance topics

The rst section provides context and an overview o antibiotic resistance in the United

States In addition to giving a national assessment o the most dangerous antibiotic

resistance threats, it summarizes what is known about the burden o illness, level o

concern, and antibiotics let to deend against these inections This rst section also

includes some basic background inormation, such as act sheets about antibiotic saety

and the harmul impact that resistance can have on high-risk groups, including those with

chronic illnesses such as cancer

CDC estimates that in the United States, more than two million people are sickened every

year with antibiotic-resistant inections, with at least 23,000 dying as a result The estimatesare based on conservative assumptions and are likely minimum estimates They are the best

approximations that can be derived rom currently available data

Regarding level o concern, CDC has or the rst time prioritized bacteria in this report

into one o three categories: urgent, serious, and concerning


7/1147

Urgent Threats Clostridium difcile

Carbapenem-resistant Enterobacteriaceae (CRE)

Drug-resistant Neisseria gonorrhoeae

Serious Threats Multidrug-resistantAcinetobacter

Drug-resistant Campylobacter

Fluconazole-resistant Candida (a ungus)

Extended spectrum -lactamase producing Enterobacteriaceae (ESBLs)

Vancomycin-resistant Enterococcus (VRE)

Multidrug-resistant Pseudomonas aeruginosa

Drug-resistant Non-typhoidal Salmonella Drug-resistant Salmonella Typhi

Drug-resistant Shigella

Methicillin-resistant Staphylococcus aureus (MRSA)

Drug-resistant Streptococcus pneumoniae

Drug-resistant tuberculosis

Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA)

Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus

The second section describes what can be done to combat this growing threat, including

inormation on current CDC initiatives Four core actions that ght the spread o antibiotic

resistance are presented and explained, including 1) preventing inections rom occurring

and preventing resistant bacteria rom spreading, 2) tracking resistant bacteria, 3)

improving the use o antibiotics, and 4) promoting the development o new antibiotics and

new diagnostic tests or resistant bacteria

The third section provides summaries o each o the bacteria in this report These

summaries can aid in discussions about each bacteria, how to manage inections, andimplications or public health They also highlight the similarities and dierences among

the many dierent types o inections

This section also includes inormation about what groups such as states, communities,

doctors, nurses, patients, and CDC can do to combat antibiotic resistance Preventing

the spread o antibiotic resistance can only be achieved with widespread engagement,

especially among leaders in clinical medicine, healthcare leadership, agriculture, and public

health Although some people are at greater risk than others, no one can completely avoid


8/1148

the risk o antibiotic-resistant inections Only through concerted commitment and action

will the nation ever be able to succeed in reducing this threat

A reerence section provides technical inormation, a glossary, and additional resources

Any comments and suggestions that would improve the useulness o uture publications

are appreciated and should be sent to Director, Division o Healthcare Quality Promotion,National Center or Emerging and Zoonotic Inectious Diseases, Centers or Disease Control

and Prevention, 1600 Cliton Road, Mailstop A-07, Atlanta, Georgia, 30333 E-mail can also

be used: hip@cdcgov
mailto:[email protected]:[email protected]


9/1149


10/11410CAMPYLOBACTER


11/11411

THE THREAT OFANTIBIOTIC RESISTANCE

IntroductionAntibiotic resistance is a worldwide problem New orms o antibiotic resistance can

cross international boundaries and spread between continents with ease Many orms o

resistance spread with remarkable speed World health leaders have described antibiotic-

resistant microorganisms as nightmare bacteria that pose a catastrophic threat to people

in every country in the world

Each year in the United States, at least 2 million people acquire serious inections with

bacteria that are resistant to one or more o the antibiotics designed to treat those

inections At least 23,000 people die each year as a direct result o these antibiotic-resistant

inections Many more die rom other conditions that were complicated by an antibiotic-

resistant inection

In addition, almost 250,000 people each year require hospital care or Clostridium difcile

(C. difcile) inections In most o these inections, the use o antibiotics was a major

contributing actor leading to the illness At least 14,000 people die each year in the United

States rom C. difcile inections Many o these inections could have been prevented

Antibiotic-resistant inections add considerable and avoidable costs to the already

overburdened US healthcare system In most cases, antibiotic-resistant inections require

prolonged and/or costlier treatments, extend hospital stays, necessitate additional

doctor visits and healthcare use, and result in greater disability and death compared withinections that are easily treatable with antibiotics The total economic cost o antibiotic

resistance to the US economy has been difcult to calculate Estimates vary but have

ranged as high as $20 billion in excess direct healthcare costs, with additional costs to

society or lost productivity as high as $35 billion a year (2008 dollars)1

The use o antibiotics is the single most important actor leading to antibiotic resistance

around the world Antibiotics are among the most commonly prescribed drugs used

in human medicine However, up to 50% o all the antibiotics prescribed or people are

not needed or are not optimally eective as prescribed Antibiotics are also commonly

used in ood animals to prevent, control, and treat disease, and to promote the growth

o ood-producing animals The use o antibiotics or promoting growth is not necessary,

and the practice should be phased out Recent guidance rom the US Food and Drug

Administration (FDA) describes a pathway toward this goal2 It is difcult to directly

compare the amount o drugs used in ood animals with the amount used in humans, but

there is evidence that more antibiotics are used in ood production

1 http://wwwtutsedu/med/apua/consumers/personal_home_5_1451036133pd(accessed 8-5-2013); extrapolated rom

Roberts RR, Hota B, Ahmad I, et al Hospital and societal costs o antimicrobial-resistant inections in a Chicago teaching

hospital: implications or antibiotic stewardship Clin Inect Dis 2009 Oct 15;49(8):1175-84

2 http://wwwdagov/downloads/AnimalVeterinary/GuidanceComplianceEnorcement/GuidanceorIndustry/UCM299624

pd
http://www.tufts.edu/med/apua/consumers/personal_home_5_1451036133.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.tufts.edu/med/apua/consumers/personal_home_5_1451036133.pdf


12/11412

The other major actor in the growth o antibiotic resistance is spread o the resistant strains

o bacteria rom person to person, or rom the non-human sources in the environment,

including ood

There are our core actions that will help ght these deadly inections:

preventing inections and preventing the spread o resistance

tracking resistant bacteria

improving the use o todays antibiotics

promoting the development o new antibiotics and developing new diagnostic

tests or resistant bacteria

Bacteria will inevitably nd ways o resisting the antibiotics we develop, which is why

aggressive action is needed now to keep new resistance rom developing and to prevent

the resistance that already exists rom spreading


13/114

NATIONAL

SUMMARY DATA

Antibiotic-resistant infections can happen anywhere. Data show thatmost happen in the general community; however, most deaths relatedto antibiotic resistance happen in healthcare settings, such as hospitals

and nursing homes.

WHERE DO INFECTIONS HAPPEN?

CS239559

Estimated minimum number o illnesses anddeaths caused by antibiotic resistance*:

*bacteria and ungus included in this report

2,049,442

23,000

At least illnesses,

deaths

250,00014,000

At least illnesses,

deaths

Estimated minimum number o illnesses anddeath due to Clostridium difcile (C. difcile),a unique bacterial inection that, although

not signifcantly resistant to the drugs used totreat it, is directly related to antibiotic use andresistance:


14/114

Simply using antibiotics creates resistance. These drugs should only be used to treat infections.

Fertilizer or watercontaining animal fecesand drug-resistant bacteriais used on food crops.

Animals getantibiotics anddevelop resistantbacteria in their guts.

George getsantibiotics anddevelops resistantbacteria in his gut.

Drug-resistant bacteriain the animal feces canremain on crops and beeaten. These bacteriacan remain in thehuman gut.

Drug-resistantbacteria canremain on meatfrom animals.When not handledor cooked properly,the bacteria canspread to humans.

Healthcare Facility

Resistant bacteriaspread to otherpatients fromsurfaces within thehealthcare facility.

Resistant germs spreaddirectly to other patients orindirectly on unclean handsof healthcare providers.

George stays athome and in thegeneral community.Spreads resistantbacteria. George gets care at a

hospital, nursing home orother inpatient care facility

Vegetable Farm

Patientsgo home.

How Antibiotic Resistance Happens

Examples of How Antibiotic Resistance Spreads

4.Some bacteria give

their drug-resistance toother bacteria, causing

more problems.

3.The drug-resistant

bacteria are now allowed togrow and take over.

1.Lots of germs.

A few are drug resistant.

2.Antibiotics kill

bacteria causing the illness,as well as good bacteriaprotecting the body from

infection.

239559


15/11415

MinimumE

stimatesofMo

rbidityandMortalityfromA

nti

biotic-ResistantInfections*

An

tibiotic-

Res

istan

t

Microorgan

ism

In

ections

Inc

lude

d

inCase

/Dea

thEs

tima

tes

Inec

tion

sNo

tInc

lude

d

Es

tima

ted

Annua

lNum

ber

oCases

Es

tima

ted

Annua

lNum

ber

oDea

ths

Carbapenem-

res

istan

t

En

tero

bac

teriaceae

(CRE)

Healthca

re-associatedInfections

(HAIs)ca

usedbyKlebsiellaandE.coli

withons

etinhospitalizedpatients

Infectionsoccurringoutsideofacutecarehospitals(e

g,

nursing

homes)

Infectionsacquiredinacutecarehospitalsbutnotd

iagnoseduntil

afterdischarge

InfectionscausedbyEnterobacteriaceaeotherthan

Klebsiellaand

E.coli(e

g,

Enterobacterspp.)

9,3

00

610

Drug-res

istan

t

Neisseria

gonorrhoeae

(any

drug

)

Allinfect

ions

Notapplicable

246

,000

CDC Antibiotic Resistant Threats 2013 Report

Documents

Transcript of CDC Antibiotic Resistant Threats 2013 Report