Goldman DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: A challenge to hospital leadership. JAMA 1996; 275:234-240.

Emphasizing that hospitals face an unprecedented crisis due to increasing antibiotic resistance, the authors outline strategic goals to meet the threat and prevent the onset of a post-antibiotic era.

Strategic goals that must be impressed upon hospital leadership include improving antimicrobial prescribing by educational and administrative means, monitoring and providing feedback regarding antibiotic resistance, and defining and implementing health care delivery system guidelines for important types of antimicrobial use.

In particular, there are needs for better use of antimicrobial prophylaxis for surgery and optimizing initial choices and subsequent duration of empiric therapy. Systems are needed to recognize and report trends in antimicrobial resistance within institutions, including rapid detection and reporting of resistant microorganisms in individual patients. The authors also urged hospitals to increase adherence to basic infection control while providing the resources to implement antimicrobial-resistance measures in institutional strategic goals. Likewise, planning must address the issues of transferring and readmitting patients colonized with specific antimicrobial-resistant pathogens.

’The bottom-line is that industry is finding it increasingly difficult to keep pace with antimicrobial resistance, and hospitalized patients and their physicians find themselves in an astonishing predicament: nosocomial infections are occurring for which there is no treatment — a doomsday scenario that has been called ‘the post-antimicrobial era,’” the authors report.

While the onus falls on hospital leadership to get such programs in place, infection control and infectious diseases professionals have an essential role to play in this effort. They have specific expertise, vast experience, and most of all, skill in sound data collection, analysis, and interpretation.

’Intensive use of antimicrobials and failure to apply basic infection control practices and procedures consistently have led to increasing multidrug resistance in many nosocomial pathogens,” the authors state. ’As a result, physicians have a shrinking armamentarium of effective antimicrobials at their disposal for prophylaxis and treatment of hospital-acquired infections. A multidisciplinary, systems-oriented approach, catalyzed by hospital leadership, is required to address this urgent problem.”

Pinner RW, Teutsch SM, Simonsen L, et al. Trends in infectious diseases mortality in the United States. JAMA 1996; 275:189-193.

Despite historical predictions that infectious diseases would wane in the United States, infection-related mortality is on the rise, the authors found.

Reviewing U.S. mortality data from 1980 to 1992, they found the death rate due to infectious diseases increased 58% — from 41 to 65 deaths per 100,000 people. Age-adjusted mortality from infectious diseases increased 39% during the same period. Infectious diseases mortality increased 25% among those age 65 years and older — from 271 to 338 per 100,000.

Public health policy during the past two decades has been based largely on trends in the earlier part of this century when mortality from infectious diseases was declining. However, the thesis that infectious diseases would continue to decrease in the United States and other developed countries, and be replaced in time by noninfectious causes of death — the epidemiologic transition theory — now must be reconsidered, the authors note.

The dynamic factors that influence the emergence of infectious diseases, such as an increasing and aging population, changes in human behaviors, and rapid changes in technology and industry, create new niches for microbial pathogens, they emphasize. The increase was primarily driven by deaths due to respiratory tract infections, HIV, and septicemia. Respiratory tract infections caused 47% of deaths attributed to infectious diseases in 1992. Respiratory tract infections occur principally in older age groups, and aging of the population partially explains the increased crude death rates from this cause. However, the respiratory tract infections death rate also increased among those aged 65 years and older; approximately 85% of these deaths were recorded on death certificates as pneumonia of unspecified etiology, a category that includes common causes not specifically diagnosed — but may also include previously unrecognized causes. The possible contributions of changes in the spectrum of etiologic agents or their virulence, antibiotic resistance, or other factors requires additional study, the authors conclude.

Specific findings on infectious disease mortality over the period included:

• HIV deaths increased from virtually none in 1980 to 13 per 100,000 in 1992.

• Death due to septicemia increased 83% from 4.2 to 7.7 per 100,000.

• Respiratory tract infection deaths increased 20%, from 25 to 30 deaths per 100,000.