INDIANA: A Summary of Select Antimicrobial Resistance Data
Antibiotic-resistant infections have become significant threats to citizens of INDIANA:
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 the past several years, MRSA has emerged into the community, where its incidence has greatly increased. In Indiana, most CA-MRSA cases originate in correctional facilities and competitive sports teams in high schools and colleges. In January 2003, the Indiana Department of Health was notified of two wrestlers on a high school team who had MRSA skin infections diagnosed.4
- Beginning January 1, 2008, all laboratories in Indiana are required to submit laboratory reports indicating evidence of skin or invasive infections due to MRSA to the Indiana State Department of Health (ISDH). Laboratory reporting of positive MRSA results will allow ISDH to gain information about the burden of MRSA infections in Indiana. This was prompted by increased awareness and concern of MRSA infections in October 2006 stemming from a Journal of the American Medical Association article and reported deaths in three children nationwide due to MRSA infection.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.
- Deaths from C. diff. have increased steadily in Indiana over the past few years. There were 15 in 2001, 35 in 2002, 49 in 2003, 75 in 2004, and 145 in 2005.8
- Of the 106 culture positive cases of tuberculosis reported in Indiana during 2007, drug susceptibility testing showed a total of 13 persons were resistant to one, or more, of the four standard first line medications. A total of nine persons were resistant to at least Isoniazid; eight of these were resistant to Isoniazid only; one person was resistant to Isoniazid and Ethambutol. Three persons were resistant to Pyrazinamide. There was one case that was Multi-drug resistant (MDR-TB). MDR TB is defined as resistance to both Isoniazid and Rifampin. MDR-TB is of particular public health concern since these two drugs are the most effective agents. If the organism is resistant to them, less effective and more expensive second-line drugs must be added, and the treatment period is extended from the usual 6 to 9 months to 18 to 24 months.9
- Drug-Resistant Streptococcus pneumoniae (DRSP) has increased substantially over the past 15 years. DRSP varies regionally and has been reported to be over 30 percent in some areas of the U.S. In Indiana, testing of isolates has shown about 28 percent resistance to penicillin, 34 percent resistance to Erythromycin, and 26 percent resistance to Trimethoprim/Sulfamethoxazole.10
Public health laboratory capacity:
A key factor in Indiana’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, Indiana 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 “MRSA Lives Among Us”, Indiana Epidemiology Newsletter, September 2007
5 “MRSA Laboratory Results Now Reportable,” Indiana Epidemiology Newsletter, January 2008
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 Indiana Tuberculosis Annual Summary 2007, Indiana State Department of Health
10 2005 Indiana Report of Infectious Diseases, Indiana State Department of Health