cdc antibiotic resistant threats 2013 report
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ANTIBIOTIC RESISTANCE THREATSin the United States, 2013
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TABLE OF CONTENTSForeword 5
Executive Summary 6
Section 1: The Threat of Antibiotic Resistance 11
Introduction 11
National Summary Data 13Cycle o Resistance Inographics 14
Minimum Estimates o Morbidity and Mortality rom Antibiotic-Resistant Inections 15
Limitations o Estimating the Burden o Disease Associated with Antibiotic-Resistant Bacteria 18
Assessment o Domestic Antibiotic-Resistant Threats 20
Running Out o Drugs to Treat Serious Gram-Negative Inections 22
People at Especially High Risk 24
Antibiotic Saety 25
Gaps in Knowledge o Antibiotic Resistance 27
Developing Resistance:Timeline o Key Antibiotic Resistance Events 28
Section 2: Fighting Back Against Antibiotic Resistance 31
Four Core Actions to Prevent Antibiotic Resistance 31
1 Preventing Inections, Preventing the Spread o Resistance 32
CDCs Work to Prevent Inections and Antibiotic Resistance in Healthcare Settings 32
CDCs Work to Prevent Antibiotic Resistance in the Community 34
CDCs Work to Prevent Antibiotic Resistance in Food 36
2 Tracking Resistance Patterns 39
3 Antibiotic Stewardship: Improving Prescribing, Improving Use 41
4 Developing New Antibiotics and Diagnostic Tests 44
Section 3: Current Antibiotic Resistance Threats in the United States, by Microorganism 49Microorganisms with a Threat Level o Urgent 50
Clostridium difcile 51
C a r b a p e n e m - r e s i s t a n t E n t e r o b a c t e r i a c e a e 53
Drug-resistant Neisseria gonorrhoeae 55Microorganisms with a Threat Level o Serious 58
Multidrug-resistantAcinetobacter 59
Drug-resistant Campylobacter 61
Fluconazole-resistant Candida (a ungus) 63
Extended spectrum -lactamase producing Enterobacteriaceae (ESBLs) 65
Vancomycin-resistantEnterococcus (VRE) 67
Multidrug-resistant Pseudomonas aeruginosa 69
Drug-resistant non-typhoidal Salmonella 71
Drug-resistant Salmonella Typhi 73
Drug-resistant Shigella 75
Methicillin-resistant Staphylococcus aureus (MRSA) 77
Drug-resistant Streptococcus pneumoniae 79Drug-resistant tuberculosis 81
Microorganisms with a Threat Level o Concerning 84
Vancomycin-resistantStaphylococcus aureus (VRSA) 85
Erythromycin-resistant Group A Streptococcus 87
Clindamycin-resistant Group B Streptococcus 89
Technical Appendix 93
Glossary 107
Acknowledgements 112
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FOREWORDAntimicrobial resistance is one o our most serious health threats Inections rom resistant
bacteria are now too common, and some pathogens have even become resistant to
multiple types or classes o antibiotics (antimicrobials used to treat bacterial inections)The loss o eective antibiotics will undermine our ability to ght inectious diseases
and manage the inectious complications common in vulnerable patients undergoing
chemotherapy or cancer, dialysis or renal ailure, and surgery, especially organ
transplantation, or which the ability to treat secondary inections is crucial
When rst-line and then second-line antibiotic treatment options are limited by resistance
or are unavailable, healthcare providers are orced to use antibiotics that may be more toxic
to the patient and requently more expensive and less eective Even when alternative
treatments exist, research has shown that patients with resistant inections are oten
much more likely to die, and survivors have signicantly longer hospital stays, delayed
recuperation, and long-term disability Eorts to prevent such threats build on theoundation o proven public health strategies: immunization, inection control, protecting
the ood supply, antibiotic stewardship, and reducing person-to-person spread through
screening, treatment and education
Dr Tom Frieden, MD, MPH
Director, US Centers or Disease Control and Prevention
Meeting the Challenges o Drug-Resistant Diseases in Developing Countries
Committee on Foreign Aairs Subcommittee on Arica, Global Health, Human Rights,
and International Organizations
United States House o Representatives
April 23, 2013
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ANTIBIOTIC RESISTANCE THREATS INTHE UNITED STATES, 2013
Executive SummaryAntibiotic Resistance Threats in the United States, 2013 is a snapshot o the complex problem
o antibiotic resistance today and the potentially catastrophic consequences o inaction
The overriding purpose o this report is to increase awareness o the threat that antibiotic
resistance poses and to encourage immediate action to address the threat This document
can serve as a reerence or anyone looking or inormation about antibiotic resistance It is
specically designed to be accessible to many audiences For more technical inormation,
reerences and links are provided
This report covers bacteria causing severe human inections and the antibiotics used to
treat those inections In addition, Candida, a ungus that commonly causes serious illness,
especially among hospital patients, is included because it, too, is showing increasing
resistance to the drugs used or treatment When discussing the pathogens included in this
report, Candida will be included when reerencing bacteria or simplicity Also, inections
caused by the bacteria Clostridium difcile (C. difcile) are also included in this report
Although C. difcile inections are not yet signicantly resistant to the drugs used to treat
them, most are directly related to antibiotic use and thousands o Americans are aected
each year
Drug resistance related to viruses such as HIV and inuenza is not included, nor is drug
resistance among parasites such as those that cause malaria These are important
problems but are beyond the scope o this report The report consists o multiple one ortwo page summaries o cross-cutting and bacteria- specic antibiotic resistance topics
The rst section provides context and an overview o antibiotic resistance in the United
States In addition to giving a national assessment o the most dangerous antibiotic
resistance threats, it summarizes what is known about the burden o illness, level o
concern, and antibiotics let to deend against these inections This rst section also
includes some basic background inormation, such as act sheets about antibiotic saety
and the harmul impact that resistance can have on high-risk groups, including those with
chronic illnesses such as cancer
CDC estimates that in the United States, more than two million people are sickened every
year with antibiotic-resistant inections, with at least 23,000 dying as a result The estimatesare based on conservative assumptions and are likely minimum estimates They are the best
approximations that can be derived rom currently available data
Regarding level o concern, CDC has or the rst time prioritized bacteria in this report
into one o three categories: urgent, serious, and concerning
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Urgent Threats Clostridium difcile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Serious Threats Multidrug-resistantAcinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a ungus)
Extended spectrum -lactamase producing Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA)
Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus
The second section describes what can be done to combat this growing threat, including
inormation on current CDC initiatives Four core actions that ght the spread o antibiotic
resistance are presented and explained, including 1) preventing inections rom occurring
and preventing resistant bacteria rom spreading, 2) tracking resistant bacteria, 3)
improving the use o antibiotics, and 4) promoting the development o new antibiotics and
new diagnostic tests or resistant bacteria
The third section provides summaries o each o the bacteria in this report These
summaries can aid in discussions about each bacteria, how to manage inections, andimplications or public health They also highlight the similarities and dierences among
the many dierent types o inections
This section also includes inormation about what groups such as states, communities,
doctors, nurses, patients, and CDC can do to combat antibiotic resistance Preventing
the spread o antibiotic resistance can only be achieved with widespread engagement,
especially among leaders in clinical medicine, healthcare leadership, agriculture, and public
health Although some people are at greater risk than others, no one can completely avoid
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the risk o antibiotic-resistant inections Only through concerted commitment and action
will the nation ever be able to succeed in reducing this threat
A reerence section provides technical inormation, a glossary, and additional resources
Any comments and suggestions that would improve the useulness o uture publications
are appreciated and should be sent to Director, Division o Healthcare Quality Promotion,National Center or Emerging and Zoonotic Inectious Diseases, Centers or Disease Control
and Prevention, 1600 Cliton Road, Mailstop A-07, Atlanta, Georgia, 30333 E-mail can also
be used: hip@cdcgov
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THE THREAT OFANTIBIOTIC RESISTANCE
IntroductionAntibiotic resistance is a worldwide problem New orms o antibiotic resistance can
cross international boundaries and spread between continents with ease Many orms o
resistance spread with remarkable speed World health leaders have described antibiotic-
resistant microorganisms as nightmare bacteria that pose a catastrophic threat to people
in every country in the world
Each year in the United States, at least 2 million people acquire serious inections with
bacteria that are resistant to one or more o the antibiotics designed to treat those
inections At least 23,000 people die each year as a direct result o these antibiotic-resistant
inections Many more die rom other conditions that were complicated by an antibiotic-
resistant inection
In addition, almost 250,000 people each year require hospital care or Clostridium difcile
(C. difcile) inections In most o these inections, the use o antibiotics was a major
contributing actor leading to the illness At least 14,000 people die each year in the United
States rom C. difcile inections Many o these inections could have been prevented
Antibiotic-resistant inections add considerable and avoidable costs to the already
overburdened US healthcare system In most cases, antibiotic-resistant inections require
prolonged and/or costlier treatments, extend hospital stays, necessitate additional
doctor visits and healthcare use, and result in greater disability and death compared withinections that are easily treatable with antibiotics The total economic cost o antibiotic
resistance to the US economy has been difcult to calculate Estimates vary but have
ranged as high as $20 billion in excess direct healthcare costs, with additional costs to
society or lost productivity as high as $35 billion a year (2008 dollars)1
The use o antibiotics is the single most important actor leading to antibiotic resistance
around the world Antibiotics are among the most commonly prescribed drugs used
in human medicine However, up to 50% o all the antibiotics prescribed or people are
not needed or are not optimally eective as prescribed Antibiotics are also commonly
used in ood animals to prevent, control, and treat disease, and to promote the growth
o ood-producing animals The use o antibiotics or promoting growth is not necessary,
and the practice should be phased out Recent guidance rom the US Food and Drug
Administration (FDA) describes a pathway toward this goal2 It is difcult to directly
compare the amount o drugs used in ood animals with the amount used in humans, but
there is evidence that more antibiotics are used in ood production
1 http://wwwtutsedu/med/apua/consumers/personal_home_5_1451036133pd(accessed 8-5-2013); extrapolated rom
Roberts RR, Hota B, Ahmad I, et al Hospital and societal costs o antimicrobial-resistant inections in a Chicago teaching
hospital: implications or antibiotic stewardship Clin Inect Dis 2009 Oct 15;49(8):1175-84
2 http://wwwdagov/downloads/AnimalVeterinary/GuidanceComplianceEnorcement/GuidanceorIndustry/UCM299624
pd
http://www.tufts.edu/med/apua/consumers/personal_home_5_1451036133.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdfhttp://www.tufts.edu/med/apua/consumers/personal_home_5_1451036133.pdf -
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The other major actor in the growth o antibiotic resistance is spread o the resistant strains
o bacteria rom person to person, or rom the non-human sources in the environment,
including ood
There are our core actions that will help ght these deadly inections:
preventing inections and preventing the spread o resistance
tracking resistant bacteria
improving the use o todays antibiotics
promoting the development o new antibiotics and developing new diagnostic
tests or resistant bacteria
Bacteria will inevitably nd ways o resisting the antibiotics we develop, which is why
aggressive action is needed now to keep new resistance rom developing and to prevent
the resistance that already exists rom spreading
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NATIONAL
SUMMARY DATA
Antibiotic-resistant infections can happen anywhere. Data show thatmost happen in the general community; however, most deaths relatedto antibiotic resistance happen in healthcare settings, such as hospitals
and nursing homes.
WHERE DO INFECTIONS HAPPEN?
CS239559
Estimated minimum number o illnesses anddeaths caused by antibiotic resistance*:
*bacteria and ungus included in this report
2,049,442
23,000
At least illnesses,
deaths
250,00014,000
At least illnesses,
deaths
Estimated minimum number o illnesses anddeath due to Clostridium difcile (C. difcile),a unique bacterial inection that, although
not signifcantly resistant to the drugs used totreat it, is directly related to antibiotic use andresistance:
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Simply using antibiotics creates resistance. These drugs should only be used to treat infections.
Fertilizer or watercontaining animal fecesand drug-resistant bacteriais used on food crops.
Animals getantibiotics anddevelop resistantbacteria in their guts.
George getsantibiotics anddevelops resistantbacteria in his gut.
Drug-resistant bacteriain the animal feces canremain on crops and beeaten. These bacteriacan remain in thehuman gut.
Drug-resistantbacteria canremain on meatfrom animals.When not handledor cooked properly,the bacteria canspread to humans.
Healthcare Facility
Resistant bacteriaspread to otherpatients fromsurfaces within thehealthcare facility.
Resistant germs spreaddirectly to other patients orindirectly on unclean handsof healthcare providers.
George stays athome and in thegeneral community.Spreads resistantbacteria. George gets care at a
hospital, nursing home orother inpatient care facility
Vegetable Farm
Patientsgo home.
How Antibiotic Resistance Happens
Examples of How Antibiotic Resistance Spreads
4.Some bacteria give
their drug-resistance toother bacteria, causing
more problems.
3.The drug-resistant
bacteria are now allowed togrow and take over.
1.Lots of germs.
A few are drug resistant.
2.Antibiotics kill
bacteria causing the illness,as well as good bacteriaprotecting the body from
infection.
239559
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MinimumE
stimatesofMo
rbidityandMortalityfromA
nti
biotic-ResistantInfections*
An
tibiotic-
Res
istan
t
Microorgan
ism
In
ections
Inc
lude
d
inCase
/Dea
thEs
tima
tes
Inec
tion
sNo
tInc
lude
d
Es
tima
ted
Annua
lNum
ber
oCases
Es
tima
ted
Annua
lNum
ber
oDea
ths
Carbapenem-
res
istan
t
En
tero
bac
teriaceae
(CRE)
Healthca
re-associatedInfections
(HAIs)ca
usedbyKlebsiellaandE.coli
withons
etinhospitalizedpatients
Infectionsoccurringoutsideofacutecarehospitals(e
g,
nursing
homes)
Infectionsacquiredinacutecarehospitalsbutnotd
iagnoseduntil
afterdischarge
InfectionscausedbyEnterobacteriaceaeotherthan
Klebsiellaand
E.coli(e
g,
Enterobacterspp.)
9,3
00
610
Drug-res
istan
t
Neisseria
gonorrhoeae
(any
drug
)
Allinfect
ions
Notapplicable
246
,000
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