Press Briefing Transcript

CDC Telebriefing on today's drug-resistant health threats

Monday, September 16, 2013 Noon ET

• Audio recording [MP3, 8.84 MB]

OPERATOR: Good morning and thank you all for holding. Your lines have been placed on a listen-only mode until the question and answer portion of today's conference. If you would like to ask a question, please press star one on your touch tone phone. And I would like to remind all parties, the call is now being recorded. If you have any objections, please disconnect at this time. I would now like to turn the call over to tom skinner. Thank you, sir. You may begin.

TOM SKINNER: Thank you. And thank you all for joining us today for the release of a landmark report of the CDC detailing drug-resistance threats in the United States. We're joined today by the director of the CDC, Dr. Tom Frieden, as well as Dr. Michael Bell, deputy director of CDC division of health care quality promotion. Dr. Frieden will provide some opening remarks, and then we will get right to your questions. Dr. Frieden.

TOM FRIEDEN: Thank you all very much for joining us. CDC works 24/7 to save lives and protect people, and part of that includes sounding the alarm about health threats, before they get out of control. Today I’d like to discuss the urgent health threat of antimicrobial resistance. In other words, what happens when the microbes can outsmart our best antibiotics. We're releasing really a landmark report. For the first time ever, we've had a snapshot of antimicrobial resistance threats that have the most impact on human health. Some of the numbers in this report are new. Some were existing. But in any case, this is the first time they have been put together to give an overall picture of drug resistance in the U.S. In addition, also for the first time, we have ranked the microbes, according to the threat level. We looked at seven different factors. Health impact, economic impact, how common the infection is, a ten-year projection on how common it could become, how easily it spreads, the availability of effective antibiotics, and barriers to prevention. What we hope is this report will prioritize and propel both research and implementation of efforts to prevent and stop the spread of drug resistant microbes.

Past research tells us, many people may see antimicrobial resistance as a problem that happens somewhere else, to other medical practices, to other farms, other patients, and other people. And this report clearly shows that antimicrobial resistance is happening here, in every community, in every health care facility, in medical practices throughout the country. We are bringing this to the fore, partly because we believe that we have a four-part solution that will make a really big difference. This is going to require a lot of action from a lot of different parts of our society. But one of the reasons we're issuing the report now is that it is not too late. If we're not careful, the medicine chest will be empty when we go there, to look for a life-saving antibiotic for someone with a deadly infection. But if we act now, we can preserve these medications while we continue to work on development of new medications. The report shows that at least 2 million people per year in the U.S. get infections that are resistant to antibiotics and 23,000 die as a result of these infections. I want to emphasize, this is a bare minimum, a very conservative estimate. For example, for some germs, we count only infections resistant to several antibiotics, not just one. Also, for healthcare associated infections in hospitals, only those in hospitals are included in this report, and we know that there are many more infections in nursing homes, dialysis facilities, long-term hospitals and assisted living facilities.

Most of the 18 microbes included in this report are common. We rank them in three groups: urgent, concerning, and important. And for the urgent group, there are three that we look at in particular. What's called CRE, or carbapenem-resistant enterobacteriaceae, C. difficile, and drug-resistant gonorrhea. The reason each of those are urgent, is that CRE is the nightmare bacteria we reported on in March, bacteria that can resist essentially all antibiotics, kill a high number of people who get it in their blood and spread resistance capabilities widely to various other strains of bacteria. For C. diff this is a life-threatening infection associated with 14,000 deaths and a quarter of a million hospitalizations per year. For gonorrhea, more than 800,000 infections in the U.S. each year, and a growing proportion are resistant to even the last line of medications that we have. If resistance to cephalosporins becomes widespread, this could cause tens of thousands of additional cases of pelvic inflammatory disease, infertility and significant rise in healthcare costs. There are also infections that we rank as serious threats, and that includes MRSA or methicillin resistant staph aureus, and although we're making progress, reducing MRSA in adult hospitals there are still more than 80,000 serious MRSA infections each year and more than 11,000 result in death. For nontyphoid salmonella infections, we're talking about 1.2 million infections each year, more than $350 million in medical costs. And infections, finally, that are ranked as concerning include bacteria such as drug-resistant streptococcus, which is the cause of the so called flesh-eating bacteria, and leading cause of serious bacterial infections in newborns. Without urgent action now, more patients will be thrust back to a time before we had effective drugs. We talk about a pre-antibiotic era and an antibiotic era. If we're not careful, we will soon be in a post antibiotic era. And, in fact, for some patients and some microbes, we are already there. Losing effective treatment will not only undermine our ability to fight routine infections, but also have serious complications, serious implications, for people who have other medical problems. For example, things like joint replacements and organ transplants, cancer chemotherapy and diabetes treatment, treatment of rheumatoid arthritis. All of these are dependent on our ability to fight infections that may be exacerbated by the treatments of these conditions. And if we lose our antibiotics, we'll lose the ability to do that effectively.

Until now, we have seen a steady pipeline of new antibiotics coming on to the market. But unfortunately, it does seem that the pipeline is nearly empty for the short-term. And experts tell us new drugs could be nearly a decade away. And that's a real problem. There are, however, four things we can do now that can make a really big difference. The first is preventing infections and the spread of resistance. That's possible to do through immunization, infection control, healthcare, safe food preparation, hand washing. That's very important. The second is to ever more closely track drug resistant infections. We do that somewhat, but we can do that better. Third is to improve what we call antibiotic stewardship. And that is perhaps the single-most important action. Up to half of antibiotic use in humans in this country is either unnecessary or inappropriate. We have a lot of room for improvement, and we think that by doing that, we can both save lives and save money, and preserve the antibiotics. And fourth, we need to develop new drugs to better treat infections in the future. These are important. They're not easy. We're taking some actions on them. But one of the reasons we're raising the alarm now is to accelerate the pace of implementation of those actions. Antibiotics really are a precious national resource, and preserving them is going to require a lot of cooperation and engagement by everyone who uses antibiotics. Healthcare providers, health care leaders, agriculture industry, manufacturers, policymakers and patients. So I thank you very much for your interest and for your joining the call, and we'll be happy to take questions at this time.

OPERATOR: Thank you. At this time, if you would like to ask a question, please press star one on your touch tone phone. You will be prompted to record your name. Thank you. Our first question today is from Mike Stobbe from Associated Press.

MIKE STOBEE: Hi. Thank you for taking my question. I have two, actually. The first one regards the overall estimate of 23,000 deaths per year. Where would that rank among the leading 20 causes of death in the U.S. or would that overlap with something like septicemia, I was wondering where that ranked? And my second question was, Dr. Frieden, you talked about one of the future steps being increasing surveillance. I was wondering what plans specifically CDC has to improve surveillance of antibiotic resistance?

TOM FRIEDEN: Let me make a couple comments on both of those issues and then turn it over to Dr. MICHAEL BELL to comment further. In terms of the ranking, I think one of the things we look at is not only the number, but also the preventability, and the trajectory. And in both of those regards, we're quite concerned about antimicrobial resistance. Because we should be able to drive these down, and if we don't make progress, we'll see significantly more problems in the future. In addition, of course, to the economic costs of drug resistance. For the -- and, again, to emphasize, these are minimal estimates, because they don't include many entities and aspects that we know are problems. For the issue of surveillance, one thing to mention is our work on advanced molecular detection, where we think we will be able, over the coming years with investment, to develop ways to detect resistant organisms much more quickly, to detect whether they're colonially related, so whether it’s part of an outbreak, to figure out how they're spreading to prevent more effectively. So I think developing the ability to find and stop them better with better diagnostic tests will be extremely important to strengthening surveillance. Dr. Bell?

MICHAEL BELL: I think Dr. Frieden got that exactly right. The numbers that you mention are confusing. All infections, if they're untreated and severe, lead to sepsis and death. And when you look at that kind of overlapping connection, it's very easy for the numbers to become confusing. I think what we can say is these numbers reflect deaths that we don't think would have happened if it weren't for the resistant infection. The -- issue regarding surveillance, I’ll also add that CDC is in the process of releasing additional functionalities, additional modules for its National Healthcare Safety Network, it’s a free online surveillance system that healthcare facilities use to process improvement to make sure their care gets better and better. And that is going to be including the antimicrobial use and resistance module, whereby we'll be tracking how the country is using their drugs and how that's tied to rates of resistance. So we can draw some connections. One other thing about the deaths. You'll see in the report, there's also an additional 14,000 deaths that are from clostridium difficile, C. diff, and that’s a disease which while not actually resistant itself, is tied directly to the excess use of antibiotics and is a large burden of illness in our healthcare system.

TOM SKINNER: Next question, Ilan.

OPERATOR: Thank you. Our next question is from Miriam Falco from CNN news in Atlanta.

MIRIAM FALCO: Hi there. I have two questions too. Number one, if you go to the doctor and the doctor tells you need an antibiotic, should you be saying no? Or if -- are doctors doing a better job when patients ask for antibiotics by saying no to their patients, which can be hard. And then secondly, a lot of people think they're getting their antibiotic resistance from the food they eat, because they don't know what's being injected into their -- the pork or the whatever produce -- not produce, but meats they're eating. What is being done on that side, which is not your direct area of expertise, but you have to work with them? What's being done to reduce the amount of antibiotic resistance that's not coming from humans, but being a burden for humans?

TOM FRIEDEN: Right. Actually -- this is Dr. Frieden. I think for both of those questions, the bottom line is stewardship. Antimicrobial stewardship. We are entrusted these wonderful antibiotics that have been developed over decades. And we need to preserve them for people in the future. So if you go to your doctor, one of the things we hear from doctors is, well, patients demand antibiotics. They feel I haven't done an adequate job caring for them if they don't get an antibiotic prescription. So for patients to understand that more medications is not better, the right medications is better. And then for healthcare systems, to work with doctors and nurse practitioners, physician assistants and others to look at antimicrobial use and prescription patterns. Earlier this year, we published some information that showed really a striking variability across the country, a two-fold difference in how often antibiotics are prescribed. So there's a push and a pull factor in improving antimicrobial stewardship. And as Dr. Bell mentioned, the National Healthcare Safety Network, which works in hospitals, primarily, but is extending to other systems, is adding new modules, which are quite important, that will enable doctors and hospitals to look carefully at both the -- what's called the antibiogram or antimicrobial resistance pattern within their institution and prescribing patterns within their institution. And that's an important tool. In terms of agriculture, as you indicate, the USDA and FDA are the lead on this issue, but we continue to promote the concept that if an animal is sick using antibiotics to treat that animal is obviously important. We want to increase the rational use of antibiotics and improve antimicrobial stewardship so we can preserve antibiotics and not increase the unnecessary use of antibiotics.

TOM SKINNER: Next question.

OPERATOR: Our next question is from David Hoffman from Washington Post.

DAVID HOFFMAN: Tom, I’d like to ask, given the situation you describe, it sounds like very serious one, and you have recommended four things, largely for others to do. Doctors and stewardship and so on. What is the United States government -- what is the Obama administration going to do specifically in response to this? What are the administration's government's policy responses?

TOM FRIEDEN: Well, actually, there's quite a bit that the U.S. government is doing and is proposing to do going forward. If you look at those four areas, and I think, you know, that's the framework that we use, so that's the way to kind of think about it, that's for all actors, all players to be involved. In terms of prevention, one of the things that we're doing, for example, is expanding our work with detection and control of outbreaks in hospitals. And hospitals remain the source of much of the most -- many of the most resistant organisms. So CDC and CMS are working together in ways that we never have before. CMS is encouraging and incentivizing participation in NHSN, the National Healthcare and Safety Network. We're seeing a widespread adoption of that system and use of the information to feedback to hospitals and identify ways to improve performance. In terms of tracking of drug-resistant infections, we're expanding systems to do that, not only NHSN, but health-wise in the president's budget proposal for fiscal '14, there is a proposal to expand the advanced molecular detection initiative, that would allow us to track this in much closer to real-time. In terms of antimicrobial stewardship, this is something we all need to work on together, but between the federal government, federal providers, as well as the private sector, we're improving systems. We already have several hospital systems that have implemented stewardship programs and CDC now recommends that every hospital implement a stewardship program. We have been able to show in various settings that that not only reduces drug resistance and reduces antimicrobial use and reduces expenditure, but also reduces complications. So I think there are emerging lessons here, and we're working across government and with the private sector to implement those emerging lessons. And in terms of new drugs, the NIH is very involved in developing new pathways, new drugs. The FDA is involved in fast-tracking and encouraging companies. So I think there really is a cross-government focus on accelerating our response to antimicrobial resistance.

TOM SKINNER: Next question.

OPERATOR: Our next question is from Betsy McKay from Wall Street Journal.

BETSY MCKAY: Hi. Thanks. I also have two questions. One is, could either of you give us an idea of how many new forms of antibiotic resistance are emerging, either in this country or from abroad? In other words, you know, how much is -- worse is the problem getting now, say the past two, three, five years, whatever time frame makes sense? Secondly, I wondered if you're seeing any benefits yet in terms of rates or numbers of infections from these improved efforts towards antibiotic stewardship by healthcare settings or doctors and so forth?

TOM FRIEDEN: So in terms of the forms of resistance, unfortunately, they're almost as varied as there are microbes. And we're seeing and being able to document additional mechanisms of resistance. It's important to divide microbes into different types, because the resistance mechanisms are different and the drivers are somewhat different. But one of the ones that's most concerning is CRE, or carbapenem-resistant enterobacteriaceae, because those are resistant to virtually all antibiotics and you get jumping genes, basically from one organism to another. So it's not only Klebsiella but also E.coli and pseudomonas that can all develop the resistance that emerges in one of the organisms. That's very concerning to us. But we're seeing the more the selective pressure, the more the means of resistance that microbes develop. In terms of benefits, we are seeing really positive developments in many places. So, for example, going back 20 years, we saw a reversal of multidrug-resistant tuberculosis as we implemented effective stewardship programs and patient treatment programs. We saw that go down by 80 percent in just a short period of time. We have seen CRE come down in Florida, and in other countries. We have seen C. diff driven down quite rapidly in other countries and in parts of this country, where we have implement that well. We have seen MRSA come down by about half, if you look at the past decade or so. So there are certainly bright spots. But we need more than bright spots. We need to change the tide related to mixed metaphors. We need to change the way this is developing nationally.

MICHAEL BELL: I’ll just add, we're not so much concerned because there are more resistant organisms being recognized, we're just getting closer and closer to the cliff. When we're dealing with untreatable infections, we no longer have the second-tier drug to rely on. That's when it becomes a life or death matter.

TOM SKINNER: Next question Ilan.

OPERATOR: Our next question is from Michael Smith from MedPage Today.

MICHAEL SMITH: Yeah, good morning, everyone. I guess good afternoon now. I was just at the --- meeting in Denver, and I was actually struck -- and I just want you to put this in a little bit of context. I was struck by the number of presentations that actually dealt with new antibiotics. Many of them were early-stage presentations. But there seemed to be something unusual there, because I’ve been to that meeting every year for several years. And there's never been quite so many new drugs, new names of drugs on the list, as far as I could tell. Maybe you could put that into context of what you're saying. Is that sort of the last gasp and the pipelines empty after that, or is that perhaps a sign of development that will help?

MICHAEL BELL: This is MICHAEL BELL. I think that it's encouraging to hear new drugs being presented. It's important to realize, in many cases, a quote, new drug is a variant of an existing drug and can be marketed for a while. It may have some benefit. But the quickness with which it develops from that can be really remarkable. The availability of completely new types of medications, again, we look forward to that, and that's an encouraging sign. But by the same token, if you go back to 1928 when Fleming discovered penicillin, we have seen every last antibiotic end up having substantial resistance develop. And so just having a new drug is not going to be enough. We applaud FDA’s efforts to make new drug development less burdensome and more rapid. But at the same time, we're reassured by the fact they're careful to make sure they're safe. Once they're safe and proven, we need to be sure that we intensely maintain stewardship so that we don't waste yet another precious drug.

TOM SKINNER: Next question, please.

OPERATOR: Our next question is from Deborah Kotz from Boston Globe

DEBORAH KOTZ: Hi, thanks for taking my question and I also actually have two questions, if you don't mind. First of all wanted to ask about something that Dr. Frieden was talking about, stewardship programs in hospitals. I was wondering if there were any in the Boston area that have participated in such programs and what the result was of those. You said something about seeing infections go down by 80 percent. And I was curious if that was related to any Boston hospitals. And secondly, I had heard something that the FDA had -- Dr. Hamburg had mentioned I believe last year, about thinking about allowing drug companies who develop these new antibiotics that really could be reserved for only those infections that folks respond to no other antibiotic treatment and whether there could be special approval for drugs like that. Wondering if the CDC is in on that effort and if it's going anywhere?

MICHAEL BELL: So this is MICHAEL BELL. With regard to your first question, I don't know specifically whether there's a hospital in the Boston area that's participated. We have promoted the use of stewardship programs across the healthcare system. And we encourage every facility to monitor the quality of the antimicrobial prescribing. We are working very diligently to benchmark what we think is appropriate prescribing to make that possible, more uniformly, across the country. So I hope that there are. In the very high-quality facilities for which that city is known, I’m sure there must be, but I don't know the specifics.

TOM SKINNER: Next question, please?

OPERATOR: Our next question is from David Sell from Philadelphia Inquirer.

DAVID SELL: Thank you. This also relates to drug companies. Basically, drug companies get paid to sell more medicine, of whatever kind. They would prefer the highest profitable medicine. What can you do to essentially discourage them from promoting the use of the medicine that they would profit from?

TOM FRIEDEN: Well, I think we have a partnership with industry, and there is an interest in making sure the medications they bring on to the market stay viable for the immediate and long-term. So I think there is actually a -- an alignment of interests there.

TOM SKINNER: Next question, please.

OPERATOR: Our next question is Sydney Weiner from NBC News.

SYDNEY WIENER: Hi there. Thanks for taking my question. You mentioned at the beginning of the call that part of the reason you're releasing this report now is that there's still time. Time to make sure that medicine chest isn't empty for somebody with an infection. If the trajectory doesn't change, if these steps that you've been talking about aren't implemented, what does that time line look like? When is that day coming?

TOM FRIEDEN: Well, we can't predict the future, but we know that already today there are patients in hospitals in 38 states who have had CRE. That's up from one state ten years ago. So really, we do have limited time. And for some patients and some organisms, it's already too late. But what we need to do is make sure that we detect and protect. That we find the problem and we protect others from it and we provide every patient the best possible care. The problem is that we -- we have a limited number of new tools to deploy. What we do know is that some of the tried and true approaches work. They're just not being used as widely as they should be.

TOM SKINNER: Next question, Ilan.

OPERATOR: Our next question is from Maryn McKenna from Wired.

MARYN MCKENNA: Hi. Thanks for doing this and for the report. I wanted to loop back to a question that was asked earlier, because I feel like I could use a little more detail. And that's the question that -- second question Miriam Falco asked about the agricultural use of antibiotics. You obviously take that up in the report, and as part of the graphic on page 14. But could you say a bit more about CDC's understanding of how antibiotics are used in agriculture in the U.S., to what degree that's contributing to the resistance problem and what might possibly -- what sort of change might be possible?

TOM FRIEDEN: We know that for the whole pathway, we need to address from farm-to-table. And that at various different steps, there are things that can be done to increase or decrease the likelihood of infections generally and resistant infections specifically. We also know that there are specific situations in which the widespread use of antimicrobials in agriculture has resulted in an increase in resistant infections in humans. We know, furthermore, that FDA has undertaken efforts to reduce or phase out use of antimicrobials for growth promotion in animals. And that this is an issue that agriculture department, FDA, and others really have the lead on. Dr. Bell?

MICHAEL BELL: Hi, Maryn. I think it's safe to say that, you know, we support appropriate antibiotic use across the board. There is always going to be bleed over in the environment and the ecosystem. And we're sensitive to that. I'll also say, though, when you think about where some of these bacteria are actually making people very sick, there's an overlap in places like intensive care units and so we continue to focus a great deal on healthcare settings. But the reality of some relationship, I think, is exactly as Dr. Frieden stated.

OPERATOR: Thank you. Our next question is from Carolyn Lochhhead from San Francisco Chronicle.

CAROLYN LOCHHEAD: Hi. This is sort of a relook at this last question. According to many people, the vast majority of antibiotics are used in livestock, and yet the FDA has only issued a voluntary guidance that isn't even completely final yet. Do we know how big a role agriculture is in this problem?

TOM FRIEDEN: I think that the -- as Dr. Bell indicated, right now the really most acute problem is in hospitals. And the most resistant organisms in hospitals are emerging in those settings, because of poor antimicrobial stewardship among humans. That having been said, any widespread use of antimicrobials in the environment increases the risk that transposable genetic elements will -- bred through the system and create even more resistance and resistant problems in the future.

TOM SKINNER: Next question, Ilan?

OPERATOR: Our next question is from Michelle Castillo from CBSNews.com.

MICHELLE CASTILLO: Hi, good afternoon. Talking more about the problem in hospitals, is there anything that patients should be aware of that they should ask their doctors to do or -- or other procedures that patients themselves should undergo in order to help prevent the spread of anti -- drug-resistant bacteria?

TOM FRIEDEN: There are a couple simple things that are really important, making sure that doctors wash their hands regularly. And we have encouraged hospitals and hospitals have encouraged patients to be -- feel comfortable asking their doctor if they have washed their hands. In dwelling catheters, whether intravenous lines or urinary catheters are major sources of infections and may make it very difficult to clear infection. So beginning to look and relook at whether it's really necessary to have those in, and how quickly they can come out is important. One of the things that we have worked on with both hospital leadership, as well as CMS, as well as the Consumer Union, is the transparent display of information on hospital infection rates through Hospital Compare and other sites. So you can get online and see what your infection rates are in different places. Dr. Bell?

MICHAEL BELL: I'll just reemphasize that as Dr. Frieden mentioned, asking is probably the most important role for a patient or family member. Being comfortable or if you're not comfortable, force yourself anyway, to ask questions. And questions can be things like, does the facility have an antibiotic stewardship program. What are you doing to make sure my mom doesn't get an antibiotic-resistant infection? Questions like that can raise awareness, and open a dialogue that can be very helpful.

MICHELLE CASTILLO: Thank you.

TOM SKINNER: Next question, Ilan?

OPERATOR: Our next question is from Jennifer Yang from Toronto Star.

JENNIFER YANG: Hi. Thanks for the report and taking my question. I was just wondering if the CDC has -- has any previous estimates of the scale of the problem in the United States. Currently you're finding that more than two million are getting infected every year. What were previous estimates pegging it at? And secondly, because I am reporting from up here in Canada and this is a global issue, I'm wondering if you could speak about the problem in a more global context, as well, and what you're seeing across the world.

TOM FRIEDEN: Sure. This is actually the first time we have made this estimate, so there is no prior number to compare it to. Globally, we think there are real gaps in our awareness of antimicrobial resistance around the world. We’ve seen resistant organisms in the U.S. that initially emerged in other parts of the world, whether Europe or Asia, and have now become prevalent in the U.S. and it's a reminder that really we are all connected. And one of the things we're connected by is our susceptibility to infections and the importance of tracking and preventing resistant organisms around the world. So this is certainly an area where we at CDC work with more than 50 countries to strengthen their ability to diagnose, treat and prevent infections, particularly low and middle-income countries and to standardize and improve the quality of laboratory testing for drug resistance, and to develop new tools so we can rapidly identify drug resistance and stop it before it spreads widely around the world. But this is certainly an area that is of concern globally and not just in the U.S. There are certainly areas where we don't have as good monitoring or surveillance of drug resistance, as we would wish, and we often will see in the U.S. for the first time or the E.U. organisms that emerged elsewhere may have spread widely elsewhere, but weren't widely recognized elsewhere.

JENNIFER YANG: Thank you.

TOM SKINNER: Yeah, Ilan, we've got time for one more question.

OPERATOR: Thank you. Our final question today is from Tony Pugh from McClatchy Newspapers. Tony, your line is open. Please check your mute feature.

TOM SKINNER: Okay, Ilan, we'll go to the next question.

OPERATOR: Thank you. Our next question then is from Mr. Al-Faruque from FDA news.

FERDOUS AL-FARUQUE: Hi. I have two questions. First is the list that you provide in this report somewhat mirrors the qualified infection disease products list that was proposed by the FDA, and also proposed by industry. How much have you worked with industry and FDA to come up with this report, and will this report be updated in the future, and how often? My second question is, in terms of developing new antibiotics and diagnostic tests, the Gain Act provides certain incentives like five-year extra exclusivity, fast track and all that. Is there anything else the CDC would like to propose to lawmakers to add extra incentives for drug companies?

TOM FRIEDEN: So I'll let Dr. Bell comment on the first question you asked. We will be updating these numbers regularly and publishing them. In terms of congressional action at this point, we are highlighting what the problem is, and we certainly welcome creative approaches to try to address the problem in the various different aspects. Dr. Bell?

MICHAEL BELL: Yeah, and related to the list of organisms, this is a special list in the sense that we have broken it down into the urgent, serious, and concerning categories. I think the list jives very nicely, as you mentioned, with the FDA’s perspective. The list was built from a public health perspective. So this wasn't so much about working with industry, but as really our role in protecting the public, identifying which ones were the most threatening and in need of action. So that having been said, you know, we think there's benefit in several of these lists that are going around for different purposes. In terms of drug development, the GAIN Act list and the FDA lists make a tremendous amount of sense. We think they're well in line with the lists we present here.

TOM FRIEDEN: So that concludes our briefing. Let me just recap that these are the – this is the first time we have released these estimates. They're very concerning. They show us that if we're not careful and if we don't take action urgently, the medicine cabinet may be empty for patients with life-threatening infections in coming months and years. But we do see a real ray of hope in the effective interventions that can prevent and reverse drug resistance. And we welcome the attention to this, because there is something that every part of the health system can do, and every part of, more broadly, we can do to preserve antibiotics so that they are still the wonder drugs they are today for our kids and our grandkids. So thank you for joining us and Tom Skinner will just have some final remarks.

TOM SKINNER: Before we close, I want to make sure reporters are aware of the resources on CDC's media site that accompany this report. There's a digital press kit available, which includes images of the organisms discussed today during today's telebriefing, as well as info graphics on resistance, how it happens and spreads. Also included in the digital press kit are video clips, broadcast-quality video clips with Dr. Frieden, as well as an animated video about this report. So if you want to tap into these resources, please visit WWW.CDC.GOV/MEDIA. So thanks for joining us today, and this concludes our telebriefing.

OPERATOR:Thank you. And this does conclude today's conference. You may disconnect at this time.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES