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  • COLORADO: A Summary of Select Antimicrobial Resistance Data

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

    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
    • Surveillance is conducted in the five-county Denver metro with the most recent data available for 2008.  These data indicate that 526 cases of invasive MRSA infection were diagnosed in 2008, of which 20.5% were classified as community-associated.

    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.”4 
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.5
    • 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 Colorado, Streptococcus pneumoniae isolates were collected as part of the “Emerging Infections Program,” which is grant funded by CDC.  Colorado-specific data for the Denver metro area are comprised of information from Adams, Arapahoe, Douglas, Denver and Jefferson counties.6 
      • High–level resistance in Colorado increased from fiscal year 2006 to fiscal year 2007 for all tested antibiotics except TMP/sulfa, erythromycin and amoxicillin. However, high-level resistance to erythromycin remained above 15% of isolates.  Rates of high-level resistance to meropenem increased to above fiscal year 2001 levels.7
      • After a period of decreasing rates seen after the introduction of the pneumococcal conjugate vaccine, the resistance rates of S. pneumoniae to penicillin increased in fiscal year 2006 and continued to rise in fiscal year 2007.8
    • 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 Colorado over the past few years.  There were 5 in 2001, 10 in 2002, 15 in 2003, and 30 in 2004.9 
      • There were 2,888 hospital discharges in 2006 in Colorado 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 Colorado more than $10.1 million.10 
      • Colorado began active laboratory-based surveillance of C. diff. infections in the 5-county Denver metro area in 2009.  Preliminary data for January through May 2009 indicate:
        • 54 percent of the incident cases selected for further review were classified as community onset (specimen collected in an outpatient setting or within the first three calendar days of a health care facility admission).
        • Of these, 68 percent are considered to be community-associated, with no documented overnight stay in a healthcare facility in the twelve weeks prior to the date of initial specimen collection.

    Public health laboratory capacity:

    A key factor in Colorado’s ability to detect and monitor 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.   The Colorado public health laboratory maintains the targeted technical ability to detect and characterize emerging resistance patterns promptly in a range of pathogens. Yet, funding for this activity is insufficient to monitor all pathogens of interest on a year-round basis.

    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 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
    5 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
    6 Get Smart Colorado Provider Newsletter, Vol. 3, No. 2. Colorado Department of Public Health and Environment, Spring 2008.
    7 ibid
    8 ibid
    9 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown
    10 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Agency for Healthcare Research and Quality,, cited in a July 28, 2008 communication from CDC to Senator Sherrod Brown



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