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  • HAWAII: A Summary of Select Antimicrobial Resistance Data

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

    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 
    • In a Hawaii study, a total of 41,250 S. aureus isolates were identified from combined inpatient and outpatient settings from 2000 to 2002. After removal of duplicate data, 31,482 isolates remained in the analysis; 23,550 were from outpatients, and 7,932 were from hospital inpatients. A total of 8,206 (26%) of all isolates included in the analyses were MRSA.4 
    • Whereas high rates of MRSA in inpatient settings have been described previously, data in Hawaii highlight an issue of more recent concern, i.e., increasing MRSA infections occurring in the outpatient setting.  Previous studies have established that skin and soft tissue infections are the most common sources of community-associated MRSA.  In this study, approximately 25% of all S. aureus infections from pediatric outpatients were MRSA, with 95% of these isolated from wounds.  These data suggest that MRSA is an important cause of wound infections in children in Hawaii.5 

    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.”6 
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.7 
    • 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 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. 
      • The first deaths from C. diff. in Hawaii have recently occurred, with 1 in 2001.  The second occurred in 2002 and there were 2 in 2003, 3 in 2004, and 4 in 2005.8 
      • There were 554 hospital discharges in 2006 in Hawaii 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 Hawaii nearly $2 million.9 

    Public health laboratory capacity:

    A key factor in Hawaii’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, Hawaii 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 Fenfang Li,et al. “Methicillin-resistant Staphylococcus aureus, Hawaii, 2000–2002,” Emerging Infectious Diseases, August 2005, Available from http://www.cdc.gov/ncidod/EID/vol11no08/05-0164.htm
    5 ibid
    6 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
    7 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
    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

 

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