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  • ARIZONA: A Summary of Select Antimicrobial Resistance Data

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

    Drug-resistant Staphylococcus aureus:

    • Although primarily affecting ill people in hospitals, 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 
    • There were 1,432 cases of MRSA reported in Arizona in 2005, 1,336 in 2006 and 1,305 in 2007 and 1,411 in 2008.  From January to October 5, 2009, there have been 878 cases reported.4 

    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.”5
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.6 
    • 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:

    • In 2006, several isolates of a multidrug-resistant form of Klebsiella pneumoniae (MDR KP) were identified among hospitals in Maricopa County.  The isolates were sent to CDC for genetic analysis and a common mechanism of antibiotic resistance was identified – Klebsiella-producing carbapenemase (KPC).  Fourteen cases were identified in three hospitals for which medical records were readily available.  Cases were admitted from March 26 to September 7.7 
    • 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 death.  It is a common cause of antibiotic-associated diarrhea, accounting for 15-25% of all episodes.  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.  Elderly hospitalized patients are at especially high risk and mortality in these patients may exceed 10%.  The disease is very difficult to treat and recurs in at least 20% of cases, even when treated appropriately.
      • Deaths from C. diff. have increased steadily in Arizona over the past few years.  There were 16 in 2001, 28 in 2002, 50 in 2003, 74 in 2004, and 87 in 2005.8 
      • There were 6,226 hospital discharges in 2006 in Arizona that included C. diff. as a diagnosis, according to the Agency for Healthcare Research and Quality (AHRQ).  The cost per C. diff. patient in a hospital is estimated by CDC to be at least $3,500, making the annual healthcare cost for C. diff. in Arizona nearly $21.8 million.9 
    • On June 30, 2006, the Infection Control Practitioner (ICP) at a hospital in Maricopa County contacted the Arizona Department of Health Services to report eight patients with multidrug-resistant Pseudomonas aeruginosaP. aeruginosa is a gram-negative bacterium that can infect almost any part of the body including the skin and soft tissue, respiratory and urinary tracts, and the central nervous system.10 

    Public health laboratory capacity:

    A key factor in Arizona’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, Arizona lacks the targeted technical ability to detect and characterize emerging resistance patterns promptly in a range of pathogens, with the exception of vancomycin resistant Staphylococcus aureus. 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 Number of Reported Cases of Notifiable Diseases by Year for Arizona, 1997-2007, Office of Infectious Disease Services, Arizona Department of Health Services (note: MRSA was not reportable prior to 2004).
    5 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
    6 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
    7 Infectious Diseases Epidemiology Program 2006 Annual Report, Arizona Department of Health Services.
    8 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown
    9 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Agency for Healthcare Research and Quality, http://www.hcupnet.ahrq.gov/, cited in a July 28, 2008 communication from CDC to Senator Sherrod Brown
    10 Infectious Diseases Epidemiology Program 2006 Annual Report, Arizona Department of Health Services.

     

 

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