MAINE: A Summary of Select Antimicrobial Resistance Data
Antibiotic-resistant infections have become significant threats to citizens of MAINE:
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
- Maine CDC currently monitors only invasive MRSA infections. Health
care providers are encouraged to report cases of invasive MRSA or
suspected outbreaks of MRSA in any setting. During 2007, 6 cases of
invasive MRSA were reported. None of the cases were associated with an
outbreak and none of the cases were known to have had MRSA previously.4
- There were 47 cases of invasive MRSA in 2008.5
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 Maine over
the past few years. There were 9 in 2001, 20 in 2002, 28 in 2003, 81 in
2004, and 97 in 2005.8
- A total of 10 cases of antibiotic-resistant invasive pneumococcal
disease were reported in 2006. The 2006 rate of drug-resistant invasive
pneumococcal disease in Maine was 0.8 cases per 100,000 population.
This compares with rates of 0.6 in 2005 and 0.3 in 2004. While the
number of cases is low, the rate of growth of the disease is troubling.
All cases report resistance to penicillin, though most cases remain
susceptible to ceftriaxone and vancomycin.9
- There were 18 cases of antibiotic-resistant invasive pneumococcal disease in 2008 for a rate of 1.4 per 100,000.10
Public health laboratory capacity:
A key factor in Maine’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, Maine 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 Reportable Infectious Diseases in Maine, 2007 Summary, Maine Department of Health and Human Services
5 Personal communication with Dr. Dora Mills, State Epidemiologist for Maine, September 9, 2009.
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 Anne R. Sites, MPH, “Antibiotic-resistant Invasive
Streptococcus pneumoniae, 2006,” Infectious Disease Epidemiology Report,
10 Personal communication with Dr. Dora Mills, State Epidemiologist for Maine, September 9, 2009.