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  • ALASKA: A Summary of Select Antimicrobial Resistance Data

    Antibiotic-resistant infections have become significant threats to citizens of ALASKA: 

    Drug-resistant Staphylococcus aureus:

    • Methicillin-resistant Staphylococcus aureus (MRSA), a drug-resistant bacteria, are infecting a growing number of people in the community and outside hospitals, including healthy athletes and children.  A recent study in the Journal of the American Medical Association demonstrates that MRSA alone infects more than 94,000 people and kills nearly 19,000 annually in the United States – more deaths than those caused by emphysema, HIV/AIDS, Parkinson’s disease, and homicide.2 
    • Hospitalizations for or complicated by MRSA cost nearly double that for non-MRSA stays – 14,000 for MRSA stays compared with $7,600 for non-MRSA stays.  The average length of stay in the hospital for a patient with MRSA infection was more than double that for non-MRSA stays – 10.0 days versus 4.6 days.3 
    • A recent study looking at MRSA-associated hospitalizations among American Indians and Alaska Natives (AI/ANs) using Indian Health Service (IHS) healthcare from 1996-2005 found that MRSA-associated hospitalization rates increased for all IHS regions; however, the increase was greatest in Alaska (3.4 to 98.2 per 100,000).4 A recent similar study performed in Alaska found similar results.5 
    • A large outbreak of skin infections began in southwestern Alaska in May 1999. The majority of S. aureus skin infections were caused by MRSA.  In August 2000, healthcare providers at a hospital in southwestern Alaska reported an increase in skin infections caused by MRSA in patients with no history of hospital exposure.  MRSA infections in hospital settings are well-described, but reports of community-onset MRSA infections are increasing.6 

    Drug-resistant “gram negative” bacterial infections:

    • Serious and life-threatening infections due to antibiotic resistant “gram negative” bacteria are on the rise across the United States.  Gram negative bacteria primarily are differentiated from gram positive bacteria, like MRSA, by a cell wall that is particularly adept at preventing antibiotics from entering the bacteria.  These infections, primarily acquired in hospitals and long term care settings, are extremely difficult to treat and cause significant numbers of illnesses and deaths.  Bacteria in this group include:  Escherichia coli (E. coli), Klebsiella pneumonia, Pseudomonas aeruginosa, and Acinetobacter.
    • In March 2009, CDC published guidelines for detection and control of E. coli and Klebsiella species with increasing resistance to a subclass of antibacterial drugs known as carbapenems.  Carbapenems are among the most potent antibiotics currently available and are often considered the “last line of defense” in the treatment of antibiotic resistant bacteria.  Studies have shown that the mortality rate from infections caused by carbapenem resistant Klebsiella species is roughly 40%.  CDC described this problem as “another in a series of worrisome public health developments regarding antimicrobial resistance among gram-negative bacteria [that] underscores the immediate need for aggressive detection and control strategies.”7 
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.8 
    • Of critical importance, there are few to no approved antibacterial drugs currently available to treat many gram negative bacterial infections and few to no new drugs in the pipeline; drug discovery in this area is extremely difficult due to challenges in overcoming the gram negative bacteria’s cell wall.

    Other Antimicrobial Resistance Issues:

    • The incidence of Streptococcus pneumoniae resistant to penicillin and other commonly used antibiotics has been increasing.  Pneumococcal isolates have recently been recovered in Alaska that are either moderately or fully resistant to penicillin. A nasopharyngeal carriage study of 185 children 6 years of age living in the Yukon Kuskokwim Delta found that 50% carried S. pneumoniae and that 29% of the isolates recovered were moderately resistant to penicillin.  Among 27 penicillin resistant isolates, 20 (74%) were also resistant to erythromycin and trimethoprim/sulfamethoxazole.  The arrival of pneumococcal strains fully resistant to penicillin and to third generation cephalosporins is of concern because of the widespread empiric use of these antibiotics.9 
    • Clostridium difficile (C. diff) is spawning infections in hospitals in the U.S. and abroad that can lead to severe diarrhea, ruptured colons, perforated bowels, kidney failure, blood poisoning and even death.  CDC estimates there are 500,000 cases of C. diff infection annually in the U.S., contributing to between 15,000 and 30,000 deaths.  The disease is very difficult to treat and recurs in at least 20% of cases, even when treated appropriately.  The first deaths from C. diff in Alaska have been reported.  There were two deaths in 2003, one in 2004 and two in 2005.10  Among Alaska Natives, a high proportion of Helicobacter pylori (H. pylori) strains have been found to be resistant to antibiotics both in urban and in rural settings.  44 percent of isolates collected from 1999 through 2003 were found to be resistant to metronidazole and 31% to clarithromycin.11  Additional studies in Alaska determined that a person’s previous use of antibiotics is significantly associated with subsequent isolation of antimicrobial resistant strains.12  

    Public health laboratory capacity:

    A key factor in Alaska’s ability to detect, monitor and control antimicrobial resistance is its public health laboratory capacity.  Across the nation, increasing cases of antimicrobial resistance are currently swamping the ability of each state's public health laboratory to keep pace.  There has been limited funding in the past for antibiotic resistance education programs and surveillance, and even this limited funding is on the decrease.  Approximately only half of state public health labs can provide some basic resistance testing.  Like many states, Alaska lacks the targeted technical ability to detect and characterize emerging resistance patterns promptly in a range of pathogens.  Therefore, such resistant organisms continue to spread unrecognized and unimpeded throughout the state.

    1 Dr. Fred Tenover, quoted in “The Bacteria Fight Back” Science, July 18, 2008.
    2 R. Monina Klevens et al. “Invasive Methicillin-resistant Staphylococcus aureus Infections in the United States,” JAMA, October 17, 2007: 1763-1771.
    3 Elixhauser, A. and Steiner, C. Infections with Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #35. July 2007. Agency for Healthcare Research and Quality.
    4 Byrd K, Bruce MG, et al. Methicillin-resistant Staphylococcus aureus-associated hospitalizations among the American Indian and Alaska Native population. CID 2009 49(7)
    5 State of Alaska Epidemiology Bulletin, Jan 26, 2009
    6 State of Alaska Epidemiology Bulletin, Sept. 5, 2003
    7 CDC MMWR “Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities” March 20, 2009 / Vol. 58 / No. 10
    8 K. F. Anderson, et al.; Evaluation of Methods To Identify the Klebsiella pneumoniae Carbapenemase in Enterobacteriaceae; Journal of Clinical Microbiology, August 2007, p. 2723-2725, Vol. 45, No. 8
    9 State of Alaska Epidemiology Bulletin, September 7, 1994
    10 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown.
    11 Bruce MG et al. Helicobacter 2006.
    12 Carothers JJ et al. CID 2007, and McMahon BJ et al. Annals Int Med 2003






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