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Statement on Antimicrobial Resistance: Solutions to a Growing Public Health Threat by James M. Hughes, M.D.
Director, National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the Senate Committee on Health, Education, Labor, and Pensions, Subcommittee on Public Health
February 25, 1999

I am Dr. James M. Hughes, Director,National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). I am here to discuss a very important topic: "Antimicrobial Resistance: Solutions to a Growing Public Health Problem." Thank you, Mr. Chairman and members of the Subcommittee, for your invitation to testify today on infectious disease surveillance and the emerging problem of antimicrobial resistance. Infectious diseases are the leading cause of death worldwide and the third leading cause of death in the United States. Antimicrobial resistance contributes to the burden of infectious diseases domestically and globally.

First, I would like to comment on the U.S. General Accounting Office report released today, EMERGING INFECTIOUS DISEASES: Consensus on Needed Laboratory Capacity Could Strengthen Surveillance. CDC reviewed the draft report, which highlighted the significant threat posed to the public's health by emerging infectious diseases, including those caused by organisms that are resistant to antimicrobial drugs. The report also presented a useful summary of surveillance activities at CDC. The report indicated that effective surveillance and timely responses to public health threats require a strong public health infrastructure consisting of epidemiologic and laboratory capacity, trained professional staff, and modern information systems. CDC concurred with the overall findings of the draft report, namely that clearer definition of the necessary core capacities for both epidemiology and laboratories at local, State, and Federal levels is needed and that an integrated system of infectious disease surveillance is critical to the success of comprehensive prevention programs. CDC recognizes these issues and is working with other agencies of the Department of Health and Human Services and other partners to address these issues.

I will now summarize CDC's efforts to curb the spread of antimicrobial resistance. We are facing a serious global problem of antimicrobial resistance that affects virtually all of the pathogens we have previously considered to be readily treatable. As we approach the 21st century, many important drug options for the treatment of common infections are becoming increasingly limited and expensive and, in some cases, nonexistent. A 1995 Office of Technology Assessment report estimated that the emergence of antimicrobial resistance among six common bacteria in hospitals adds approximately $661 million per year in hospital charges, and this estimate does not include indirect costs. While today's discussion primarily focuses on bacteria, drug resistance is also a serious problem in many viral, fungal, and parasitic diseases, including malaria.

Antimicrobial resistance is a complex and multifaceted public health issue. From a public health standpoint, the pathogens have been categorized according to where and how they are usually transmitted, such as drug-resistant infections acquired in the community (e.g., multidrug resistant pneumococcal infections), in the health care system, through the food supply, or internationally. CDC is working with partners in each of these settings to improve surveillance and implement prevention and control measures. While this approach has been useful, distinctions between these categories are becoming blurred. For example, as an increasing amount of health care is delivered outside the hospital, pathogens that are normally spread in hospitals may be transmitted in the community. Also, international travel and trade may result in drug-resistant pathogens that emerge in distant corners of the world being introduced into the United States . Therefore, the issue is becoming even more complicated, highlighting the importance of a coordinated, overarching multidisciplinary approach that involves physicians, epidemiologists, laboratory and behavioral scientists, veterinarians, and health educators.

CDC's vision is a world in which antimicrobial resistance is a manageable problem that does not compromise the availability of safe and effective drugs to control infectious diseases. Drug resistance is a target area in CDC's recently released plan, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. Public health priorities in the plan are organized under four broad, interdependent goals, each of which can be applied specifically to antimicrobial resistance: improving surveillance and response capacity, addressing applied research priorities, repairing the nation's public health infrastructure and training programs, and strengthening prevention and control programs required to control emerging and reemerging infectious diseases. Copies of CDC's plan have been provided to the Subcommittee.

Surveillance and Response

Public health surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of health data that results in public health action. These data are used to detect outbreaks, characterize disease transmission patterns, evaluate prevention and control programs, and project future health care needs. In the case of drug resistance, surveillance data available in a timely manner at national, state, and local levels are needed to help clinicians know which antimicrobials to prescribe, help researchers focus their efforts to develop new drugs and vaccines, and help public health officials mount campaigns to improve antimicrobial use and infection control practices.

In the United States , requirements for reporting diseases and conditions are mandated by individual state laws, but most states do not require reporting of drug-resistant infections. In those states where drug-resistant infections are reportable, the completeness of reporting varies. To obtain more systematic information, CDC, in collaboration with state and local health departments and other partners, conducts surveillance to monitor resistance for several pathogens and also collects data on outpatient drug prescribing.

As an example, among other important issues in infectious diseases and public health, resistance in Streptococcus pneumoniae causing invasive infections is monitored in selected areas through CDC's Emerging Infections Programs (EIP's). CDC funds EIP cooperative agreements with eight state and local health departments to conduct population-based surveillance and research that go beyond the routine functions of health departments.

Other surveillance systems that collect information on antimicrobial resistance include the National Nosocomial Infections Surveillance System, which is conducted in approximately 280 hospitals in which infection control practitioners conduct active surveillance for hospital-acquired infections. Resistance in foodborne pathogens such as Salmonella and Campylobacter is monitored in 15 states through the National Antimicrobial Resistance Monitoring System, focused on enteric bacteria, a collaborative project with the Food and Drug Administration and the United States Department of Agriculture that monitors resistance in foodborne pathogens in both humans and animals. Other projects monitor drug resistance in tuberculosis, gonorrhea, Helicobacter pylori, HIV, and malaria. Additionally, drug prescribing is monitored through CDC's National Center for Health Statistics' National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

Applied Research

In the area of applied research, priorities include developing new drugs and vaccines as well as identifying the emerging molecular mechanisms of drug resistance and epidemiologic risk factors associated with its development and spread; developing new and improved rapid diagnostic laboratory tests; and, in collaboration with other agencies and private industry, assessing the role of new vaccines and orphan drugs in preventing and controlling the spread of resistant infections. It is also a research priority to develop, implement, and evaluate preventive interventions, including infection control strategies, such as those in hospitals, day care centers, long-term care and home health care settings; improving drug-prescribing practices of health care providers; and the use of vaccines to prevent drug-resistant infections. Another priority is also evaluation research to assess the effectiveness of formulary controls, reimbursement policies, and regulatory activities in reducing the spread of antimicrobial resistance. Research is also necessary to evaluate the impact of drug resistance, including clinical outcomes and economic costs of treating resistant infections.

Infrastructure and Training

The public health infrastructure is the underlying foundation that supports the planning, delivery, and evaluation of public health activities and practices. CDC's ongoing effort to rebuild the U.S. public health infrastructure that addresses infectious diseases is critical to improve the capacity of health departments, health care delivery organizations, and clinical and public health laboratories to detect and report drug-resistant infections and to implement prevention and control strategies. Part of this effort includes enhancing capacity to respond to outbreaks and training public health professionals to be able to respond to emerging threats now and in the future.

CDC provides support for Epidemiology and Laboratory Capacity agreements (ELC's) to health departments in 28 states, New York City, and Los Angeles to help provide the technical tools, training, and financial resources to maintain surveillance for infectious diseases of public health importance, including those that are developing resistance to antimicrobial drugs. In addition, the Emerging Infectious Diseases Laboratory Fellowship Program is a partnership between CDC and the Association of Public Health Laboratories designed to prepare laboratory scientists for careers in public health. Last year an international component was added to the program. Working with the CDC Foundation and funded through an educational grant by Eli Lilly and Company, the goal of the international program is to enhance laboratory practices abroad.

Prevention and Control

Perhaps the most daunting challenge in a coordinated program to prevent the spread of antimicrobial resistance is translating information gleaned from surveillance and research into practical public health prevention and control measures, and then disseminating these prevention messages to clinicians and the public.

A key component of CDC's plan to address antimicrobial resistance is promoting judicious antimicrobial drug use. CDC has begun a campaign to improve physician prescribing practices and to educate patients about the proper use of antibiotics. The initial focus of this campaign has been pediatricians, since children are prescribed antibiotics at a 3-fold higher rate than adults. To provide guidance to clinicians, CDC and the American Academy of Pediatrics (AAP) co-sponsored the development of Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Infections, which was published as a supplement to the journal Pediatrics in January 1998.

In cooperation with professional societies, CDC has developed educational materials for physicians and parents, including a "prescription pad" for physicians to provide patients written instructions for treating symptoms of viral illnesses, for which antibiotics would be inappropriate. In collaboration with AAP and the American Society for Microbiology, CDC has also developed a brochure for parents, Your Child and Antibiotics, explaining why antibiotics should not be given for most colds, coughs, sore throats, and runny noses. These materials have been distributed widely and are available on the CDC website. Interventions using these materials and behavioral strategies such as physician-peer discussions are now being tested in several locations, including managed care settings in Boston and Seattle, rural communities in northern Wisconsin, and on a county-wide basis in Knoxville, Tennessee. Similar materials for adults are being developed.

CDC has also funded two 5-year prevention demonstration projects that will assess interventions to improve surveillance and antibiotic prescribing practices on a larger scale. One is a statewide approach involving community physicians in Wisconsin and the other involves hospitals in the city of Chicago. In addition, in 1997 and 1998, CDC established Centers of Excellence in Healthcare Epidemiology at eight academic and health care institutions to conduct research and demonstration projects that will improve the surveillance, prevention, and control of infections acquired in hospitals and other health-care settings. A priority of this program is the prevention and control of infections caused by bacteria and other microorganisms which have become resistant to antibiotics and other antimicrobial drugs.

Examples of Successes in Preventing Antimicrobial Resistance

Although there has been much discussion of how the problem of antimicrobial resistance is increasing, it is also important to note some successes that provide models for future programs. Public health officials in Iowa, in partnership with health departments in Nebraska and South Dakota, the Indian Health Service, and CDC, recently succeeded in halting an increase in rates of vancomycin-resistant enterococci (VRE) in hospitals and long-term care facilities in the tri-state Siouxland region surrounding Sioux City, Iowa.

VRE are transmitted in health-care institutions and are often not treatable with drugs currently available in the United States . Some patients carry the organism without experiencing symptoms, but others develop infections which may be life-threatening. After a rapid increase in VRE was reported in early 1997, a task force was formed by the Siouxland district health department, consisting of local physicians, infection control practitioners, and public health officials.

The VRE task force formulated several interventions, including strict implementation of infection control policies based on CDC guidelines, education of health care workers, and prudent use of antibiotics, especially vancomycin. This strategy was effective, and the key to success was the partnership between public health and clinical medicine so that when surveillance data indicated an emerging problem, science-based prevention and control measures could be implemented rapidly to prevent the spread of a serious drug-resistant infection in this community.

Another organism of particular concern is Staphylococcus aureus, the most common cause of hospital-acquired infections. Many strains of S. aureus are now resistant to every available antibiotic except vancomycin. Strains of S. aureus with decreased susceptibility to vancomycin were identified in Japan in 1996 and subsequently in Michigan, New Jersey, and New York. Recognition that these patients were infected with drug-resistant organisms led to timely implementation of infection control measures that were successful in each instance in preventing transmission of these organisms to other patients and health-care workers. These episodes highlight the vital importance of rapid laboratory tests to detect resistant organisms, prompt implementation of effective infection control measures, global cooperation in surveillance, and new drug development to replace antibiotics that lose their effectiveness.

Another success relies on modern information technology, which can facilitate rapid collection, analysis, and feedback of information to clinicians. A pioneering program of computer assisted decision support developed at LDS Hospital in Salt Lake City offers antibiotic recommendations to clinicians based upon computerized assessment of the patient's medical record and surveillance data on drug resistance in the health care system. This program was developed with input from local physicians, who view it as a valuable resource. The program is associated with decreased inappropriate antibiotic use, reduced frequency of adverse drug reactions, reduced patient care costs, and a stable rate of drug resistance.

Collaboration to Address Antimicrobial Resistance

Combating antimicrobial resistance will require federal leadership and close collaboration among public and private sector partners. CDC believes it is essential to work with FDA, NIH, AHCPR and other government agencies. Federal agencies need to work together with partners in clinical medicine, laboratory and behavioral science, State and local public health agencies, industry, and the public. Together, we need to develop public health goals and objectives, along with time frames for implementation.


In conclusion, recent increases in antimicrobial resistance are cause for serious concern but not pessimism. The rapid spread of resistance demands an immediate and aggressive response domestically and globally. By forming effective partnerships involving clinicians, researchers, public health officials, and patients, we can prolong the effectiveness of currently available antimicrobial drugs; accelerate the development of needed new tools, including rapid diagnostic tests, new antimicrobial agents, and new or improved vaccines; and reduce the threat of antimicrobial resistance for patients today and in future generations.

Thank you very much for your attention. I will be happy to answer any questions you may have.

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