Transcript of November 13, 2019, AR Threats Report – Tele-briefing

OPERATOR: Welcome and thank you for standing by.  At this time, all lines are in a listen only mode.  During the question and answer session, please press star one on your touch tone phone.  I would also like to inform parties that today’s conference is being recorded.  If you have any objections, you may disconnect at this time.  Now I’d like to turn today’s conference over to Mr. Ben Haynes.  Thank you, sir.  You may begin.

BENJAMIN HAYNES: Thank you, Ashley and thank you all for joining us today for the release of CDC’s 2019 AR Threats Report.  We are joined today by CDC Director Dr. Robert Redfield and Dr. Michael Craig from CDC’s Antibiotic Resistance Coordination and Strategy Unit who will both provide opening remarks.  I’d now like to turn the call over to Dr. Redfield.

ROBERT REDFIELD: Thank you, Ben and thank you all for joining us today to discuss the 2019 AR Threats Report. Today’s report shows us that antibiotic resistance is a larger threat in the United States than previously estimated, and the report further underlines that this deadly threat is not going away. Each year, antibiotic-resistant bacteria and fungi are causing at least 35,000 deaths and more than 2.8 million infections across our country.  A death from an antibiotic-resistant infection occurs about every 15 minutes, and a resistant infection occurs every 11 seconds.  Antibiotic resistance threatens both our nation’s health and our global security and that’s why we all play an important role in stopping it.  The good news is that we know how to protect ourselves from this threat, and we are seeing progress nationwide.  In fact, since the first AR Threat Report released in 2013, we’ve reduced the number of deaths from antibiotic-resistance by 18% overall and by nearly 30% in hospitals alone.  CDC data show that comprehensive prevention strategies are saving lives, and preventing device- and procedure-related infections, using infection prevention and control to stop transmission in health care facilities, and containing these threats before they take hold.  This success is undoubtedly due to the many public health and health care professionals who stand up to this threat every day, as well as every single U.S. state health department, more than 350 industry, and health care and animal partners, and other federal agencies who committed to take action against it.  Bacteria and fungi will continue to develop resistance to the drugs designed to kill them, and without continued action, could undo the progress that we are sharing this afternoon.  Candida auris is a newly listed urgent threat in this report.  This fungus has only recently emerged as a deadly germ.  To underscore the challenge we are facing, Candida auris emerged on five continents at the same time.  One in three patients infected by invasive Candida auris dies, and some samples of the resistant and rare fungus have been shown to be resistant to all three classes of antifungal drugs.  With emerging threats like this, the modern medicine available to us today may very well be gone tomorrow if we don’t slow the development of antibiotic resistance.  Antibiotic resistance remains a significant enemy and we need to ensure our interventions are effective and monitored through the programs we institute.  We must remain vigilant.  That’s why CDC has been leading the public health charge against antibiotic resistance.  We will continue to invest in our country’s public health infrastructure and in states essential programs such as the antibiotic-resistant lab network, and by more than 500 local AR experts who will rapidly detect and prevent the spread of antibiotic-resistant germs.  CDC works closely with partners like the Centers for Medicare and Medicaid Services, data analysts, and human and animal health care providers to improve the use of the antibiotics that we have today.  CDC and the Food and Drug Administration will continue to supply samples of resistant germs from our anti-biotic-resistant isolate bank to innovators who can undercover new drugs and treatments.  We’ve invested $110 million dollars in researchers who are studying prevention strategies that can be scaled up across the nation and we will support these kinds of important discoveries into the future.  Finally, CDC partners with the private industry to enhance our food products, medical devices, and surveillance capability.  Our nation’s health departments, protecting us on the front lines, need even stronger lab capacity and specialized technologies, more boots on the ground to stop the spread of bacteria and fungi, and tailored interventions to improve the antibiotics that are used in humans, animals, and in the environment.  The global community needs more innovation, new treatment options, reliable diagnostics, and better data that will help protect people and animals.  And our detection, prevention and innovation strategies that have proven effective in the United States should be scaled up worldwide, where appropriate.  Despite significant progress, this threat remains our enemy, and CDC remains committed to leading the nation in the fight against antibiotic resistance.  Join us in this important mission to effectively communicate the risks posed by antibiotic resistance and the important role that each of us has in combating this threat.  Now I’d like to turn the call over to Michael Craig to discuss some of the details of the antibiotic threat report.

MICHAEL CRAIG: Thank you, Dr. Redfield, and thanks to all of you for joining us today to hear more about this deadly and complex topic. As Dr. Redfield mentioned, the new AR Threats Report shows that antibiotic-resistant bacteria and fungi still cause more than 2.8 million infections and 35,000 deaths in the United States each year. This doesn’t include the burden of c. difficile, which is also highlighted in the report and contributes another 220,000 infections and more than 12,000 deaths annually.  The same strategies that can help us fight antibiotic-resistant infections, stopping the spread of germs and improving antibiotic use, can help us to fight c. difficile.  All together and unfortunately the U.S. toll of all the threats in the report exceed 3 million infections and 48,000 deaths annually.  We used several data sources to generate these national estimates.  We also did look back at our 2013 report’s data.  CDC used the best data available at the time, but we knew and said then that our estimate was conservative and likely underestimated the true burden of antibiotic resistance, and we were right.  With new data available, we looked back and found the number of deaths from antibiotic-resistant infections was nearly two times higher than what was reported in 2013.  Since then, as Dr. Redfield previewed, we’ve seen good progress, notably, the data show a nearly 18% reduction in deaths from antibiotic-resistant infections, when compared to the revised 2013 numbers, and deaths from antibiotic-resistant infections in hospitals alone have been reduced by nearly 30% since the last report.  Specifically, five of the previously listed serious germs have had declines in infections, and carbapenem-resistant enterobacteriaceae, which you may have heard us call “nightmare bacteria,” has remained stable, a significant accomplishment, given just how quickly it spread in the early 2000s and how deadly it can be.  In addition to investing more than $300 million in state and local health departments since 2016 CDC strategies have helped hospitals in the United States, such strategies include preventing the spread of germs and device and procedure-related infections, the containment strategy to quickly detect and stop spread of emerging threats, and improving antibiotic use, nationwide.  Unfortunately, the number of people facing antibiotic resistance in the United States is still too high.  The 2019 report identifies 18 germs as urgent, serious, or concerning.  In addition to the hard-to-kill fungus, Candida auris, that Dr.  Redfield described, carbapenem-resistant acinetobacter has been listed as a new urgent threat because it is spreading in health care and is often resistant to many antibiotics.  CDC is also concerned about other rising resistant infections in our communities.  These infections are putting people at risk and undermining gains made in health care.  Infections in the community can happen to healthy people making spread more difficult to identify and contain.  The urgent threat drug-resistant gonorrhea has increased since the 2013 report, and esbl-producing enterobacteriaceae, which was previously found more often in health care, is on the rise in communities.  It is one of the leading causes of death from resistant germs, and is making common infections like urinary tract infections harder to treat.  Severe invasive infections caused by group a. strep, which germ that also causes strep throat has also increased since 2000.  CDC and partners are taking action to prevent and stop the thread of infections in the community, but stronger focus and interventions are needed.  Finally, CDC has listed three watch list germs that public health experts are monitoring in the United States but that could become more common here if we don’t maintain our aggressive detection, prevention and response approach.  Antibiotic resistance is a global problem and every person, industry and country around the world contributes to it.  Given the chance, resistant germs will infect our bodies, take up residence in our health care facilities, contaminate our food and water, and move across our communities and globe.  The 2019 AR Threats Report gives us a snapshot in time showing that we cannot rely on antibiotics alone, but we can take action against antibiotic resistance.  Infection prevention and control in health care facilities works.  Improving the use of antibiotics we already have works.  Proper food handling works.  Safe sex works.  Vaccines and keeping hands clean works.  CDC will continue to lead the public health response, but we can each play our part in the fight against antibiotic resistance.

BENJAMIN HAYNES: Thank you, gentlemen.  Ashley, we’re ready to take questions now.

OPERATOR: We will now begin the question and answer session.  If you would like to ask a question, please press star one.  Please unmute your phone, and record your name clearly when prompted.  Your name is required to introduce your question.  To withdraw your request, press star two.  One moment, please, for the first question.  Your first question comes from Helen Branswell.  Your line is open.

STAT NEWS/HELEN BRANSWELL: Hi. Thanks so much for taking my question which is undoubtedly a stupid one.  I’m having a hard time figuring out the math on this.  This report says not including c. diff. patients–  there are 35,000 people a year who die.  The 2013 report said 23,000 people.  You folks are saying that revising up the 2013 numbers, you see that there were nearly twice as many deaths as you had captured in the 2013 report?  I don’t — the math doesn’t track for me, and I also am not clear how then we are now also reporting 18% fewer deaths.  Can someone talk me through this, please?

MICHAEL CRAIG: Absolutely, Helen and happy to do so and appreciate that we are updating numbers here, and we’re not only providing a new estimate of what’s happening today, but we’re actually updating our previous estimate, because we have new data sources, and what we’re essentially doing is recalculating what the estimate was in 2013, because we have better data sources now to provide a more comprehensive estimate than what we had available to us in 2013. And in 2013 originally, we put out a conservative estimate which was the 23,000. Using the new data sources we have now and looking back in time, we see that it was a conservative estimate.  There were more infections and notably there were nearly twice as many deaths and that’s the 44,000 number.  And when we look at the trends of that data, moving forward, we see actually though that we’ve made progress, so that 44,000 number from 2013 and overall AR deaths has declined to around 35,900 to what it is today.

STAT NEWS/HELEN BRANSWELL: Okay.  All right, thank you.

OPERATOR: Your next question comes from Mike Stobbe.  Your line is open.

AP/MIKE STOBBE: Thank you for taking my call.  Kind of along with Helen was talking, in the recalculation — i have two questions.  The first one is about the recalculation.  Could you just one more time — so what was the old methodology?  Really this had to do with several hospital-acquired infections, you used to survey a couple hundred hospitals?  Was that how the 23,000 was arrived at, and then this time, you based it on electronic health records for all hospitals?  Is that the difference?  And then I have a follow-up.

MICHAEL CRAIG: Thanks, Mike. So you’re touching on it. We used different methodology but I will say a bottom line point is that for each pathogen we used the best data we have for that pathogen and used different surveillance systems to provide the best estimates we can because the antibiotic resistance is so complex and so diverse.  So the major update here is related to primarily the health care associated resistant infections and yes we updated that methodology pretty significantly and used electronic health records for the first time and the richness of the data that we have is much more extensive than what we had.  We have data for these estimates, from over 700 hospitals and really accounting to millions and millions of patient records, whereas last time it was significantly more limited.  And that is really what is making these numbers much more accurate, much more comprehensive and much more rich than we had previously.

AP/MIKE STOBBE:  I’m sorry, just a little more detail, though.  So electronic health records for 700 hospitals this time, and before it was reports from how many hospitals?

MICHAEL CRAIG: It was around 180.

AP/MIKE STOBBE: Okay.  And also, of the drug-resistant deaths in 2017, is it right that 85% of them come from the seven hospital acquired infections?

MICHAEL CRAIG: Yes, i think that when we look at the number, the health care associated resistant infections account for 85% of the deaths.

BENJAMIN HAYNES: Next question, please, Ashley.

OPERATOR: Your next question comes from Christina Caron, your line is open.

NEW YORK TIMES/CHRISTINA CARON: Hi, thanks so much for taking my call.  I cover parenting and I am especially interested in how this data might be interpreted by parents especially those of young children, ages zero through 6.  Do we know how many of these 44,000 deaths or so were among young children?  Do we have an age breakdown, and I’m also just curious to know what we can tell parents about how they can play their part in avoiding antibiotic-resistant infections and limiting use of antibiotics.

MICHAEL CRAIG: Yes, it’s a great question. I think the thing that we highlight, one, is that we don’t have data that breaks this out unfortunately for younger ages.  There are a lot of important messages for the average person, for protecting themselves, as well as protecting their family, including young children.  I’m a father of two small girls myself, and this is something that I take to heart.  The things that we would remind people always are- use antibiotics appropriately.  That means follow your doctor’s guidance in terms of when to start, when to stop.  Never ask for an antibiotic.  If you are unwell and you think you might need an antibiotic, instead of asking for an antibiotic, ask what can make me feel better.  Sometimes what can make you feel better is not an antibiotic.  Antibiotics sometimes have very bad side effects.  Also note for small children it can be one of the leading causes for emergency room visits related to adverse events.  The other thing we would note is there is a lot of prevention messages that everybody needs to follow and these are the things that everybody knows.  This is practicing good hand hygiene and other good hygiene practices.  This is getting vaccinated.  This is if you’re sexually active, following safe sex practices.  This is safe food handling like cooking your meat thoroughly.

ROBERT REDFIELD: And would just try to emphasize, since you’re communicating to parents, you know, I always want to take advantage of any opportunity that you’re getting a message, and that we go back to what was just said about the importance of vaccination. It’s the most powerful tool we have to eliminate disease.  And as you know, our recent MMWR came out several weeks ago.  While a majority of parents do vaccinate their children, almost 99% of children had received at least one vaccine, we actually had 20 states in this nation where less than 90% of the children had received their MMR series.  So whenever you’re writing about preventing from antibiotic resistance and our concerns that we have here, I would ask you to take advantage of reminding people, one of the most important prevention opportunities they have is to embrace vaccination and not leave it on the shelf for themselves and their children and their family.

NEW YORK TIMES/CHRISTINA CARON: Yes a great point and follow-up question for Dr. Craig.  You mentioned one of the leading cause of emergency room visits related to adverse events.  What exactly was one of the leading causes of emergency visits?

MICHAEL CRAIG: The use of antibiotics.

ARJUN SRINIVASAN: That’s right, side effects from antibiotics.

NEW YORK TIMES/CHRISTINA CARON: Side effects, okay.

ARJUN SRINIVASAN: That’s right, exactly. we know there’s more than 100,000 people per year in the United States, closer to 200,000 people per year wind up in an emergency department because they have a side effect from an antibiotic, and that is especially common in children.

NEW YORK TIMES/CHRISTINA CARON:  I see.

BENJAMIN HAYNES: That was Dr. Srinivasan.

NEW YORK TIMES/CHRISTINA CARON: Okay, thank you.

BENJAMIN HAYNES: Next question, please, Ashley.

OPERATOR: Your next question comes from Tom Avril with the “Philadelphia Inquirer.”  Your line is open.

PHILADELPHIA INQUIRER/TOM AVRIL: –Thank you very much.  Could you just tell us what the raw number is for the hospital portion of it, health care acquired?  I assume by that term you mean not present on admission.  Is that right?  In other words you have revised numbers for 2013 and 2012 and the new numbers.  Could you tell us what the before and after is that led you to the 28% decline and whether they were hospital acquired or someone were simply identified in the hospital?

MICHAEL CRAIG: Yes, so the data that we have looked at hospital and then community, and community was inclusive of non-hospital health care settings, as well as the true community. I don’t have the breakdown for the aggregate numbers in front of me by health care and community, but we can follow up and get you more clarity. We can say, though, in terms of looking at the change over time, and the new data, we have really the prevention of antibiotic resistant deaths.  We have an 18% improvement overall, and that’s really being driven by a 28% improvement in hospitals specifically.

PHILADELPHIA INQUIRER/TOM AVRIL: right, but again, is it hospital acquired or simply identified in the hospital?

ARJUN SRINIVASAN: Right. The data for the pathogens that are primarily in health care is data comes from electronic health data systems of hospitalized patients, some of those infections, as you’re pointing out, had their onset while the person was in the hospital. Some of those were infections that the person came to the hospital with, and those are separated in the report, and so you will see in the report a breakdown of the infections that are what we call hospital onset, happened in the hospital, and ones that are community onset.  Now it’s important to note, as Michael was just mentioning, some of those can be onset infections- the person might have come from a nursing home.  That is information we don’t know.  we can tell you they were either in the hospital when the infection occurred or came to the hospital with the infection.

MICHAEL CRAIG: And that improvement of the reduction in deaths is largely those hospital onset cases that Dr. Srinivasan just reported to you.

PHILADELPHIA INQUIRER/TOM AVRIL: Thank you.

BENJAMIN HAYNES: Ashley, we have time for two more questions, please.

OPERATOR: Sure.  Next question comes from Amy Birnbaum with CBS News.  Your line is open.

CBS NEWS/AMY BIRNBAUM: Hi.  I had two questions.  Could you elaborate a little bit on what you described the spread of C. auris, you said it was simultaneously.  What are the mechanisms and why is that particularly concerning?  And I didn’t hear when you said, you said it spread across four continents at the same time?  And then the other thing I wanted to ask was, I’m a little confused about, maybe you could give us a little overview of what type of reporting there is, what kind of mandatory reporting is required for these emerging threats?  Thank you.

MICHAEL CRAIG: Thanks, Amy. Candida auris is one of the greatest examples that we can probably give you, contemporary examples of the challenge of antibiotic-resistant infections emerging. It is a pathogen we didn’t even know about when we put out the last report in 2013, and since then, it has circumnavigated the globe and caused a lot of infections and deaths as it has spread.  As Dr. Redfield alluded to, we are still trying to figure out its origins.  It is unique and surprising and because it has emerged in multiple spots around the world and seems to have emerged simultaneously and we don’t know why or where or what the root causes are but something CDC is actively looking at, as well as the academic community and we want to try to get to the bottom to understand that emerging specifically.

ROBERT REDFIELD: It’s one of the reasons antimicrobial resistance is so complicated. Because it’s not just what happens in the clinical field. Where we focused on both community and hospital-acquired antibiotic resistance, but it also encompasses the animal industry.  It also encompasses the agricultural industry, and this is one of the reasons last year Secretary Azar put out a challenge to all the nations and all the institutions around the world to confront antimicrobial resistance to bacteria and fungi, recognizing that it really involves agricultural, involves animals, it involves the practice of clinical medicine, and again, we don’t know exactly why this organism all of a sudden appeared really on a global scale.  That’s unusual.  Usually we see an outbreak and we define it and then there’s gradual spread, so that’s an area that we continue to try to better understand.

MICHAEL CRAIG: Your second question was about CDC data sources, and what reporting is required. As I noted at the outset, we use the best data we have by pathogen and it does vary by system that we use to track that data. There’s a number of things that are required in here that are nationally notifiable.  Sometimes they’re nationally notifiable by pathogen but not resistance so we have to use other data sets to get information about that resistance.  Some of them, especially some of the ones on the health care associated infection side are required to be reporting under the requirements from the Centers for Medicare and Medicaid services, and that data is posted on the CMS hospital compare website, and you can go actually to facility-specific page and see how their reporting varies for certain things like C. diff. or MRSA.  In addition, there are other requirements that sometimes state health departments have in place so that they will also report out what is the infections they’re seeing in a health care facility or for certain types of infection, so there are 18 pathogens here and the bottom line is the report of it nationwide can vary significantly but there’s a lot of reporting for the various pathogens covered here.

BENJAMIN HAYNES: Last question, please, Ashley.

OPERATOR: Last question comes from Steven Johnson with “Modern Health Care” magazine.  Your line is open.

MODERN HEALTHCARE MAGAZINE/STEVEN JOHNSON: Thank you.  I have a couple questions.  One, I was wondering it seems like the findings of the report that the hospitals are driving the decreases that you’re seeing in infections and in deaths.  What is being done for those community onset infections, those places such as retail clinics, urgent care centers, those kinds of things, what can be done from a federal standpoint in order to drive antibiotic stewardship in those areas? And also I was wondering, based on the findings, is it — are the infections that are community onset, are they less severe than the ones that you’re seeing in-patient centers?

MICHAEL CRAIG: Great question. The first one on antibiotic stewardship, I’ll start and turn it to Dr. Srinivasan to go into more detail. I’ll say at the onset there’s been a lot of efforts that CDC has led over the past few years to improve antibiotic use, wherever antibiotics are used, and that really means a very concerted effort working with different types of health care facilities on our core elements, which help provide a framework for making improvements on antibiotic use, but I will also just note and Dr. Srinivasan can highlight further there’s a lot more work we need to do, a lot more improvement we need to do everywhere.

ARJUN SRINIVASAN: Exactly right, Michael. You mentioned urgent care center so that’s a community where we know there’s a lot of antibiotic use, a lot of potentially unnecessary antibiotic use particularly for respiratory conditions like bronchitis and we are working with the partners at the urgent care community has really engaged. They’ve come here to visit with us and we had discussions.  They’re talking about this at their national meeting.  I think what you’re seeing is a coalescence of people who are recognizing this problem.  Dr. Redfield mentioned many of them, hundreds of them assembled at the AMR challenge to make concrete commitments for what they were going to do, including some urgent care partners, so I think there is a lot of will now, and the good news is, this report demonstrates some of the ways that we can take that will and make progress.

MICHAEL CRAIG: Your second question was about the severity of illness for some of the community infections, and for some of these infections, they may not be as deadly as some of the ones that we see in hospitals or in health care, but what we are seeing and what the report highlights is for many of the infections we’re seeing higher levels of resistance which is making those harder to treat for some of the outpatient settings and for the things like ESBL were seeing that that harder to treat ultimately means those patients have to be hospitalized, they have to go on more aggressive stronger antibiotics that might have more side effects and that can be very challenging, so we’re in a place where things like normal urinary tract infections that used to be provided in an outpatient and that you would resolve in a couple days are now harder to treat, and that you potentially have to be hospitalized for those.

MODERN HEALTHCARE MAGAZINE/STEVEN JOHNSON: Thank you.

BENJAMIN HAYNES: Thank you, gentlemen, and thank you all for joining our call today.  This will conclude the briefing.  If you have additional questions, please contact the CDC media office at 404-639-3286 or email media@cdc.gov.  Thank you.

OPERATOR: Thank you for joining today’s conference call.  You may disconnect at this time.

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