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  • MINNESOTA: A Summary of Select Antimicrobial Resistance Data

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

    Drug-resistant Staphylococcus aureus:

    • A recent study that included hospitalized patients in Minnesota, found that invasive methicillin-resistant S. aureus (MRSA) infections occur in more than 94,000 people and kill nearly 19,000 each year in the United States – more deaths than those caused by emphysema, HIV/AIDS, Parkinson’s disease, and homicide.2 
    • A study at the Minneapolis Veteran’s Affairs Medical Center found that the median cost for hospitalization was twice as much for patients with MRSA, compared to patients with methicillin-susceptible S. aureus (MSSA).3  
    • MRSA infections are increasing at an astounding rate in previously healthy people.  In 2000, Minnesota Department of Health (MDH) initiated active surveillance for community-associated MRSA at 12 sentinel hospitals; infections increased from 131 cases (12% of all MRSA infections reported) in 2000 to 1,502 cases (41% of total MRSA infections reported) in 2006.4  

    Drug-Resistant Neisseria meningitidis:

    • Meningococcus (Neisseria meningitidis) causes meningitis, bloodstream infections and other serious infections; approximately 10% of invasive infections are fatal, and up to 15% of survivors have long-term clinical consequences.  Ciprofloxacin is commonly used as a preventative antibiotic for household contacts of invasive meningococcal cases.  Ciprofloxacin-resistant meningococcal strains have now been detected in Minnesota. Resistance was also found in North Dakota and in California.5  
    • One of the alternative antibiotics used as a preventative is rifampin.  Two strains with rifampin- resistance have been found in Minnesota.6 

    Drug-Resistant Gonorrhea:

    • Because of increasing resistance, ciprofloxacin, can no longer be used to treat gonorrhea.  In 2007, 9% of 361 gonococcal isolates tested in Minnesota were resistant to ciprofloxacin, and an additional 2% had reduced susceptibility to azithromycin, a different type of antibiotic.7 

    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.”8 
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.9   
    • 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:

    • Tuberculosis; in 2006, a case of extremely-drug resistant tuberculosis, occurred in Minnesota.10Carbapenam-resistant Enterobacteriaceae (CRE); over a dozen cases of CRE have been detected in Minnesota during the first seven months of 2009, the year the MDH Public Health Laboratory began testing for this highly resistant organism.  Patients with CREs have twice the mortality during hospitalization compared with other patients.11 
    • Clostridium difficile causes infections typically in people on antibiotics, and those with underlying medical conditions. A new, outbreak strain has been associated with fluoroquinolone resistance.  CDC estimates 500,000 cases of C. difficile infection annually in the U.S., contributing to between 15,000 and 30,000 deaths. The disease is very difficult to treat and recurs in at least 20% of cases.
      • Deaths from C. difficile in Minnesota have increased five-fold over the past few years, going from 11 deaths in 2000 to 55 in 2005.12  
      • There were 3,284 hospital discharges in 2006 in Minnesota that included C. difficile as a diagnosis, according to the Agency for Healthcare Research and Quality.  The cost per C. difficile patient in a hospital is estimated to be at least $3,500, making the annual healthcare cost for C. difficile in Minnesota nearly $11.5 million.13  
      • MDH has instituted surveillance for community associated C. difficile infection in St. Cloud, in order to characterize the epidemiology of C. difficile in people without traditional risk factors.
       

    Public health laboratory and epidemiology capacity:

    A key factor in Minnesota’s ability to detect, monitor and control antimicrobial resistance is the capacities of the public health laboratory and epidemiology at MDH.  In order to maintain an ability to detect emerging resistance of public health importance, and develop appropriate infection prevention and control interventions, it is critical that laboratory and epidemiological infrastructure be strengthened and sustained.

     



    1 Centers for Disease Control and Prevention: “Antibiotic / Antimicrobial Resistance”, http://www.cdc.gov/drugresistance/index.htm: accessed July 28, 2009.
    2 RM Klevens et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States, JAMA, 298: 1763-1771.
    3 Personal communication, Ruth Lynfield, MDH
    4 Minnesota Department of Health Disease Control Newsletter, Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2006
    5 HM Wu et al. Emergence of ciprofloxacin-resistant Neisseria meningitidis in North America, New Engl J Med, 2009; 360: 886-92
    6 J Rainbow, et al. Rifampin-Resistant Meningococcal Disease, Emerg Infect Dis. 2005; 11:977-979
    7 2007 MDH Antibiogram http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/antibiogram.html
    8 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
    9 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
    10 2006 MDH Antibiogram http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/antibiogram.html
    11 G. Patel, et al. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control and Hosp Epidem. 2008; 29:1099-1106
    12 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown
    13 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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