GAO Finds Gaps in Antibiotic Resistance Surveillance by CDC

Though healthcare providers are increasingly fearful of emerging strains of antibiotic-resistant bacteria infections in patients, the Centers for Disease Control and Prevention has serious gaps in how it monitors those infections, according to a report by the Government Accountability Office.

"CDC does not monitor the use of antibiotics in inpatient settings – where antibiotic use is often intensive and prolonged and thus, the risk of antibiotic resistance is greater – although the agency believes such information would help it target and evaluate its own prevention efforts to reduce the occurrence of resistance," the report concluded.

In part, the GAO criticized the CDC's current use of sampling of healthcare facilities for resistant strains saying it "is not representative – and incomplete information about the entire scope of healthcare-associated infections (HAIs) that are resistant to antibiotics – present data gaps that limit CDC's ability to produce accurate national estimates of antibiotic resistant HAIs in healthcare settings."

Although the CDC uses the National Healthcare Safety Network to monitor infections, "the facilities that participate are not a nationally representative sample."

As of the start of this year, all acute care hospitals that participate in the Centers for Medicare & Medicaid Services' Hospital Inpatient Quality Reporting Program are obligated to report into NHSN central-line associated bloodstream infections for certain procedures from their intensive care units.

To remedy that, the report says, CDC will conduct an inpatient antibiotic usage prevalence survey of acute care hospitals this year by sampling selected hospitals in five states and five cities in other states. But the GAO says that's insufficient because of its limited sample size and to date, the survey is not scheduled to be repeated to assess trends.

But the GAO report said that although the number of these healthcare facilities has been increasing substantially, because they can enroll voluntarily or by state mandate, "this group of facilities is not representative of facilities nationwide, as a random sample would be."

Thus, this data does "not reflect the full scope of HAIs that occur within these facilities, further limiting CDC's ability to provide accurate national estimates about antibiotic-resistant HAIS."

Additionally, the types of infections are limited, with some facilities reporting on central-line associated bloodstream infections, but not other infections such as those from urinary tract infections from catheters. Also, only some units within hospitals may report, such as just intensive care units, to the exclusion of other specialty care units.

"Without an accurate national estimate of antibiotic-resistant HAIs, CDC cannot assess the magnitude and types of such infections that occur in all patient populations," the report says.

Asked for comment, Steve Solomon, MD, Director of CDC's Office of Antimicrobial Resistance, said in an e-mail that the agency "has undertaken numerous initiatives to augment and enhance its surveillance of both antimicrobial resistant infections and antimicrobial use."

He pointed to several reports, including the Public Health Action Plan to Combat Antimicrobial Resistance produced by the Interagency Task Force on Antimicrobial Resistance (ITFAR) and the recently posted, 2009-2010 Progress Towards Implementation of A Public Health Action Plan To Combat Antimicrobial Resistance.

"We believe that when these many activities come to fruition, they will provide a complete and accurate national picture of the public health impact of antimicrobial resistance," he wrote.  The CDC is developing what Solomon describes as a detailed strategic plan for the prevention of antimicrobial resistant infections that will include surveillance and monitoring of antimicrobial resistant infections and antibiotic use.

The CDC is taking other steps too, including one to get a better handle on Clostridium difficile infections, by expanding its monitoring in more geographic locations from seven to 10 this year.

Another growing concern is the failure of all federal agencies to monitor disposal of antibiotics, which can increase the population of resistant bacteria, the GAO report said. "Federal agencies do not collect data regarding the disposal of most antibiotics intended for human use" although the U.S. Environmental Protection Agency and the U.S. Geological Survey have done some environmental measurements.