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  • CONNECTICUT: A Summary of Select Antimicrobial Resistance Data

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

    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 estimates that 94,000 people have invasive MRSA and that it 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 

    With the spread of MRSA, vancomycin has been increasingly used to control these infections.  Vancomycin-intermediate S. aureus (VISA) is the first step toward developing complete resistance to vancomycin and was first recognized in Japan in 1996. Since that time, VISA infections have been recognized in several countries, including the United States, with 16 cases reported as of September 2006.  In 2004, the Connecticut Department of Public Health was notified of a case of VISA infection in a hospitalized Connecticut resident. This is the first confirmed VISA infection in a Connecticut resident and likely represents the tip of the iceberg.4  There have been three additional VISA cases since then in Connecticut (two in 2008 and one in 2009).

    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:

    • Clostridium difficile (C. diff) is a potentially serious infection 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.
    • In Connecticut, community onset C. diff was added to the list of diseases reportable to the state health department in 2006.  In 2006, 110 cases were identified among Connecticut residents, including 4 deaths.  In 2007, 128 cases were reported, with 5 deaths; and in 2008, 113 cases with 4 deaths.7 
    • During 2008, 494 cases of salmonellosis were reported to the Connecticut Department of Public Health.8   Salmonella species cause an estimated 1.4 million infections, 15,000 hospitalizations, and 400 deaths annually in the United States.  CDC conducts antimicrobial susceptibility testing on a variety of foodborne pathogens, including Salmonella species.  Fluoroquinolones (e.g., ciprofloxacin) and third generation cephalosporins (e.g., ceftriaxone) are commonly used to treat severe infections caused by Salmonella, but the bacteria are becoming increasingly resistant to these drugs.  National data demonstrate slowly increasing antimicrobial resistance in Salmonella.9  There have been outbreaks of Salmonella that are resistant to as many as five different antibiotic classes.

    Public health laboratory capacity:

    A key factor in Connecticut’s ability to detect, monitor and control antimicrobial resistance is its public health laboratory capacity. Approximately only half of state public health labs can provide some basic resistance testing.   There has been limited funding in the past for antibiotic resistance education programs and surveillance, and even this limited funding is on the decrease.  With adequate funding for staff, supplies and equipment, Connecticut could provide surveillance testing for antimicrobial resistance in community associated MRSA and Salmonella isolates. This data could be linked to ongoing DNA fingerprinting that identifies outbreaks and clusters of these pathogens to further characterize emerging resistance patterns.

    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 Connecticut Epidemiologist, Connecticut Department of Public Health, Vol. 27, No. 4, July 2007
    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 Personal communication, Dr. R. Nelson, Connecticut Department of Public Health.
    8 Disease Statistics by county, 2008; Connecticut Department of Health; accessed online at  September 4, 2009.
    9 Connecticut Epidemiologist, Connecticut Department of Public Health, Vol. 25, No. 3, June 2005


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