The U.S. Centers for Disease Control and Prevention has just published a first-of-its-kind assessmentof the threat the country faces from antibiotic-resistant organisms, ranking them by the number of illnesses and deaths they cause each year and outlining urgent steps that need to be taken to roll back the trend.
The agency's overall — and, it stressed, conservative — assessment of the problem:
- Each year, in the U.S., 2,049,442 illnesses caused by bacteria and fungi that are resistant to at least some classes of antibiotics;
- Each year, out of those illnesses, 23,000 deaths;
- Because of those illnesses and deaths, $20 billion each year in additional healthcare spending;
- And beyond the direct healthcare costs, an additional $35 billion lost to society in foregone productivity.
"If we are not careful, we will soon be in a post-antibiotic era," Dr. Tom Frieden, the CDC's director, said in a media briefing. "And for some patients and for some microbes, we are already there."
The report marks the first time the agency has provided hard numbers for the incidence, deaths and cost of all the major resistant organisms. (It had previously estimated illnesses and deaths from some families of organisms or types of drug resistance, but those numbers were never gathered in one place.) It also represents the first time the CDC has ranked resistant organisms by how much and how imminent a threat they pose, using seven criteria: health impact, economic impact, how common the infection is, how easily it spreads, how much further it might spread in the next 10 years, whether there are antibiotics that still work against it, and whether things other than administering antibiotics can be done to curb its spread.
Out of that matrix, their top three "urgent" threats:
- Carbapenem-resistant Enterobacteriaceae or CRE, a set of ICU germs that are resistant to almost all antibiotics: 9,000 infections per year, 600 deaths
- Antibiotic-resistant gonorrhea, which currently responds to only one drug: 246,000 infections per year
- Clostridium difficile, which is growing in resistance to one class of drugs, but more important, serves as a marker for the use of other antibiotics: 250,000 illnesses, 14,000 deaths.
There are 12 resistant bacteria and fungal infections in a second category, which the agency dubs "serious" (requiring "prompt and sustained action"); they include the hospital infections Acinetobacter,Pseudomonas aeruginosa, and VRE; the foodborne organisms Campylobacter, Salmonella andShigella; MRSA; Candida, a fungal infection; and TB, among others. The last category, "concerning" (requiring "careful monitoring and prevention") includes rare but potent vancomycin-resistant staph, VRSA, as well as strains of strep resistant to two different categories of drugs.
For each organism, the report explains why it is a public health threat, where the trends are headed, what actions the CDC is taking, and what it is important for health care institutions, patients and their families, and states and local authorities to do to help. It also makes explicit where the trend of increasing and more common resistance is taking the country, outlining the risks to people taking chemotherapy for cancer, undergoing surgery, taking dialysis, receiving transplants, and undergoing treatment for rheumatoid arthritis.
(The report also — and this is so important that I'll take it up in a separate post tomorrow — tackles the issue of how agriculture, as well as healthcare, contributes to the increase in resistant organisms nationwide.)
The report lists some serious concerns the CDC has regarding how well resistance is monitored: in "gaps in knowledge," it specifically names limited national and international surveillance, as well as the lack of data on agricultural use of antibiotics. And it calls for action in four areas: gathering better data; preventing infections, through vaccination, better protective behavior in hospitals, and better food handling; improving the way in which antibiotics are used, by not using them inappropriately in health care or agriculture; and developing not just new categories of antibiotics but better diagnostic tests so that resistant organisms can be identified and dealt with sooner, before they spread.
In an interview before the report became public, Frieden said that some of these actions are already happening. "My biggest frustration is the pace of change," he told me. "Hospitals are making progress, but it's single digits in terms of the number of hospitals that are being very proactive. The challenge is scaling up what we know works, and doing that fast enough so that we can close the door on drug resistance before it's too late."
I talked about the report's calls for action to Dr. Ed Septimus, who is a professor of internal medicine at Texas A&M Health Sciences Center in Houston and a frequent spokesperson for the Infectious Diseases Society of America, the professional group for the physicians who usually treat resistant infections.
"We have gotten some action in Congress," he said, mentioning the GAIN Act, which passed and offers incentives for drug development, and the STAAR Act, which aimed to improve surveillance and antibiotic conservation, but did not pass. "The FDA is considering regulations that would allow a special designation for drugs for unmet needs, and resistance would qualify; and the NIH has prioritized research on resistance higher than it did 10 years ago. So there is movement — but in terms of funding, it is a slow difficult process.
"Still, there are things we can do without funding," he said: hospitals could create their own stewardship programs, and could work with nursing homes, whose patients bring some of the most resistant organisms into hospitals but who usually lack the budget for infection prevention.
"It's up to us to make the recommendations in this report happen," Septimus said. "If we do nothing but say, 'Here's the problem,' then the problem will continue to grow."
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