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  • TEXAS: A Summary of Select Antimicrobial Resistance Data

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

    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 
    • MRSA is a problem in Texas. According to Dr. Jan Patterson, president of the Texas Infectious Diseases Society, “I have seen instances in which these skin infections are problematic and disabling otherwise healthy, young people. We have seen very serious, life-threatening skin and soft tissue infections and pneumonia due to this organism acquired in the community in healthy people and children. These infections can be very unresponsive to treatment, requiring several antibiotic agents and multiple weeks in the intensive care unit.”4 
    • Health officials became alarmed about the spread of MRSA in Austin in 2003 when they saw many healthy people coming into hospitals with the infection. Hospital officials say they keep a close eye on it because of its severity. Area hospital officials' reports of MRSA incidence say it ranges from holding steady to increasing by as much as 40 percent since 2003. Dr. Steve Berkowitz, chief medical officer for St. David's HealthCare, said the average hospital in Austin probably sees 50 to 60 verifiable cases a year now.5 
    • The Texas Department of State Health Services partnered with an urban jail to investigate risk factors for MRSA carriage. This study assessed nasal carriage rate and strain-relatedness of MRSA among recently booked inmates. Of 403 inmates, 115 (28.5%) carried S. aureus; 18 were MRSA-positive (4.5%). Data suggest that MRSA is endemic in persons coming into Texas correctional facilities.6

    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.”7 
    • Noteworthy, these organisms are difficult to detect with the automated testing systems currently used in most hospital laboratories.8 
    • 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:

    • Texas has begun to see multiple drug-resistant E. coli urinary tract infections acquired in the community that are not susceptible to any of the usual outpatient antibiotic choices. There have been case presentations at Brooke Army Medical Center about the multiple drug-resistant Acinetobacter baumannii cases in soldiers returning from the Middle East. Texas is beginning to see cases of this difficult to treat drug-resistant organism occasionally in hospitals.9  In recent years, strains of Acinetobacter have been emerging that are resistant to nearly all known remedies.
    • 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 Texas over the past few years. There were 48 in 2001, 72 in 2002, 101 in 2003, 135 in 2004, and 173 in 2005.10

    Public health laboratory capacity:

    A key factor in Texas' 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, Texas 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 Dr. Jan Patterson, MD, University of Texas Health Science Center in San Antonio, in a letter to U.S. Senator Kay Bailey Hutchison dated October 7, 2007
    5 Mary Ann Roser, “Health officials make little headway against "superbug",” Austin American-Statesman, July 10, 2006
    6 Journal of Correctional Health Care, Vol. 13, No. 4, 289–295 (2007)
    7 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
    8 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
    9 Dr. Jan Patterson, MD, University of Texas Health Science Center in San Antonio, in a letter to U.S. Senator Kay Bailey Hutchison dated October 7, 2007
    10 CDC Wonder Death Certificate Data, cited in a July 28, 2008 communication to Senator Sherrod Brown



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