Antibiotic-resistant infections pose greater threat than estimated

Steven Ross Johnson  November 13, 2019

The Centers for Disease Control and Prevention on Wednesday said more people are dying of antibiotic-resistant infections, despite hospitals' efforts to prevent acquired conditions.

More than 2.8 million infections occur each year, causing more than 35,000 deaths, according to the latest CDC estimates. Although that's more infections than the agency estimated for 2013, when there were 2.6 million annual infections, the mortality rate has dropped from 44,000 deaths per year. That's an 18% drop since the CDC revised its 2013 numbers.

CDC Director Dr. Robert Redfield said the revised numbers stemmed from new data sources that were previously unavailable. He urged clinicians to continue vigilant infection control to ensure those numbers continue to decrease.

"Despite significant progress this threat remains our enemy," Redfield said.

The CDC added two germs to its "urgent threat" infection list since the 2013 report: a drug-resistant form of candida auris and carbapenem-resistant acinetobacter. The former is a fungal infection that kills one in three patients it affects. The infection was elevated to "urgent" status due to its rapid global spread over the past year, with more than 836 cases confirmed in the U.S. as of Oct. 29.

The latter infection causes pneumonia and wound, bloodstream and urinary tract infections and was responsible for 8,500 hospitalizations and 700 deaths in 2017 with nearly all cases acquired in healthcare settings.

"With emerging threats like this, the modern medicine available to us today can very well be gone tomorrow if we don't slow the development of antibiotic resistance," Redfield said.

The decrease in deaths and rise in total infections may reflect a shift in where care is given. Outpatient sites generally see less severe infections than hospitals.

"We probably have made some significant strides in the hospital setting but the question me is what is going on in the community," said Dr. Emily Sydnor Spivak, associate professor of medicine at University of Utah Health's Division of Infectious Diseases. "Do we need to transition and do a lot more in the outpatient setting and agriculture sector."

Antibiotic-resistant infections that are most often acquired within healthcare settings accounted for 85% of all deaths calculated in the report. That stems partly from decades of antibiotic overprescribing. The more an antibiotic is used, the less effective it becomes as resistance increases.

Antibiotic stewardship efforts have focused on hospitals. In 2017, the Joint Commission began requiring acute-care and critical access hospitals as well as nursing homes to have an antibiotic stewardship program as a condition of maintaining their accreditation.

By 2018, more than 76% of the country's nearly 5,000 acute-care hospitals reported having an antibiotic stewardship program.

In September, the CMS finalized a rule requiring all hospitals that participate in Medicare and Medicaid to have an antibiotic stewardship program.

That work has led to a more than 27% decrease in the number of antimicrobial-resistant infections acquired in hospitals from 2012 to 2017, according to the CDC report. Deaths from antibiotic-resistant infections over that period fell by 28% in hospitals.

The report's findings confirm the need to focus effort on improving antibiotic use within community-based settings, according to Dr. David Hyun, senior officer at the Pew Charitable Trusts' Antibiotic Resistance Project.

"It has been encouraging to see those efforts are making a positive impact, but it also underscores we have a long way to go," he said. "Places like outpatient centers need the same level of attention that hospitals have received in recent years."

Hyun and others have pointed out there is a large gap in antibiotic oversight at outpatient facililities including retail health clinics and urgent care centers.

A 2018 JAMA Internal Medicine study found 40% of all outpatient antibiotic prescriptions were written at an urgent care center or retail health clinic, but 46% of those patients didn't require those drugs.

"We have more obvious federal policy levers for inpatient settings," said Kathy Talkington, project director for Pew's Antibiotic Resistance Project. "In the outpatient setting it's less clear what those policy levers are — it's clearly an area we need to keep focusing on to figure out what incentives need to be in place to drive good stewardship."

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