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  • MONTANA: A Summary of Select Antimicrobial Resistance Data

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

    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 
    • Data from Montana indicate that the incidence of MRSA is increasing.  Surveillance data of S. aureus isolates from Montana’s clinical laboratories spanning a ten year period, illustrate this point.  Between 1996 and 2006, the number of MRSA isolates detected increased from 378 to 2,664.  Over this same period, the percentage of all S. aureus isolates found to be MRSA has more than doubled from 17% to 40%.4 

    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 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 fluctuated in Montana over the past few years.  There were 3 in 2001, 3 in 2002, 3 in 2003, 6 in 2004, and 2 in 2005.7 
    • In 2003, the State of Montana Department of Public Health and Human Services Public Health Laboratory (PHL) surveyed laboratories in the State of Montana regarding antimicrobial resistance for the preceding year.  This survey was undertaken as a follow-up to a similar survey conducted in 1996 that collected data about reported AMR patterns during that year.
      • The levels of resistance to select antimicrobials reported for Streptococcus pneumoniae during 2002 has remained stable over the 6-year time period; however, the levels of resistance to ciprofloxacin, erythromycin, and penicillin has increased slightly over this period.8 
      • The levels of resistance to select antimicrobials for Staphylococcus aureus in 2002 include very high levels of penicillin-resistant S. aureus (90-91%).  For most of the antimicrobial agents that were included on both the 1996 and 2003 surveys, the levels of resistance has remained stable over the 6-year time period; however, the level of resistance to ciprofloxacin has increased slightly over this period.9 
      • The levels of resistance to select antimicrobials for Enterococcus species include 70 percent resistance to tetracycline, 40 percent resistance to ciprofloxacin, and 32 percent resistance to levofloxacin.10
      • The levels of resistance to select antimicrobials for Pseudomonas aeruginosa include 99 percent resistance to ampicillin, 97 percent resistance to sulbactum, and 27 percent resistance to ciprofloxacin and levofloxacin.11 

    Public health laboratory capacity:

    A key factor in Montana’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, Montana 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.

    1Dr. Fred Tenover, quoted in “The Bacteria Fight Back” Science, July 18, 2008. 
    2R. Monina Klevens et al. “Invasive Methicillin-resistant Staphylococcus aureus Infections in the United States,” JAMA, October 17, 2007: 1763-1771.
    3Elixhauser, 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.
    4The State of Montana Antimmicrobial Susceptibility Testing Survey 2007, August 2007. (p14)
    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 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown
    8Antimicrobial Susceptibility Patterns in Montana: A Survey of Laboratories in 2002, Montana Department of Public Health and Human Services, July 2004.
    9 ibid
    10 ibid
    11 ibid



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