ANTIBIOTIC RESISTANCE THREATS IN THE UNITED STATES 2019 Revised Dec. 2019 This report is dedicated to the 48,700 families who lose a loved one each year to antibiotic resistance or Clostridioides difficile, and the countless healthcare providers, public health experts, innovators, and others who are fighting back with everything they have. Antibiotic Resistance Threats in the United States, 2019 (2019 AR Threats Report) is a publication of the Antibiotic Resistance Coordination and Strategy Unit within the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention. Suggested citation: CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019. Available online: The full 2019 AR Threats Report, including methods and appendices, is available online at www.cdc.gov/DrugResistance/Biggest-Threats.html. DOI: http://dx.doi.org/10.15620/cdc:82532. ii U.S. Centers for Disease Control and Prevention Contents FOREWORD .............................................................................................................................................V EXECUTIVE SUMMARY ........................................................................................................................ VII SECTION 1: THE THREAT OF ANTIBIOTIC RESISTANCE ....................................................................1 Introduction .................................................................................................................................................................3 Everyone is at Risk ....................................................................................................................................................8 Stopping Spread of Antibiotic Resistance Saves Lives ..............................................................................9 Estimating Burden Data .......................................................................................................................................14 How Antibiotic Resistance Happens ................................................................................................................ 18 Take Action: Combat Antibiotic Resistance ................................................................................................. 29 SECTION 2: CHALLENGES AND OPPORTUNITIES IN DETECTION AND TREATMENT FOR ANTIBIOTIC-RESISTANT INFECTIONS ......................................................................................33 Introduction ..............................................................................................................................................................34 How Antibiotics Work ........................................................................................................................................... 36 Development Pipeline For Human Medicine: Antibiotics, Diagnostics, and Other Innovations ........................................................................................................................................... 41 SECTION 3: NATIONAL ACTION TO COMBAT ANTIBIOTIC RESISTANCE .....................................51 U.S. Action ................................................................................................................................................................. 52 CDC Leads Fight Against Antibiotic Resistance ........................................................................................54 Health Departments: Critical Partners .......................................................................................................... 59 More Action Needed: Furthering the Domestic and Global Fight ...................................................... 61 SECTION 4: PATHOGEN SUMMARIES ................................................................................................63 Urgent Threats ........................................................................................................................................................ 65 Serious Threats ........................................................................................................................................................ 77 Concerning Threats ............................................................................................................................................. 101 Watch List .................................................................................................................................................................107 SUPPLEMENTARY MATERIAL ............................................................................................................109 Acknowledgments ................................................................................................................................................ 110 Glossary ..................................................................................................................................................................112 Acronyms ..................................................................................................................................................................114 TECHNICAL APPENDIX ....................................................................................................................... 115 References .................................................................................................................................................................116 Data Methods ...........................................................................................................................................................118 The 2019 AR Threats Report is available online at www.cdc.gov/DrugResistance/Biggest-Threats.html. Antibiotic Resistance Threats in the United States, 2019 iii METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) iv U.S. Centers for Disease Control and Prevention Foreword In March 1942, Mrs. Anne Miller of New Haven, Connecticut, was near death.* Infectious germs had made their way into her bloodstream. Desperate to save her, doctors administered an experimental drug: penicillin, which Alexander Fleming discovered 14 years earlier. In just hours, she recovered, becoming the first person in the world to be saved by an antibiotic. Rather than dying in her thirties, Mrs. Miller lived to be 90 years old. Today, decades later, germs like the one that infected Mrs. Miller are becoming resistant to antibiotics. You could have one in or on your body right now —a resistant germ that, in the right circumstances, could also infect you. But—unlike the bacteria that threatened Mrs. Miller—the bacteria may be able to avoid the effects of the antibiotics designed to kill them. Unfortunately, like nearly 3 million people across the United States, you or a loved one may face an antibiotic-resistant infection. This report from CDC, the second of its kind, presents data about the top 18 pathogens that require attention now. It emphasizes that antibiotic resistance is a One Health issue that can spread through people, animals, and the environment; threatens our most vulnerable friends and family members; and affects nearly every aspect of life. Given the chance, these germs will infect our bodies, take up residence in our healthcare facilities, contaminate our food and water supplies, and move across our communities and around the globe. This report shows us, however, that the fight against antibiotic resistance, no matter how complex, is not hopeless. Antibiotic Resistance Threats in the United States, 2019 v To stop antibiotic resistance, our nation must: ■ Stop referring to a coming post-antibiotic era—it’s already here. You and I are living in a time when some miracle drugs no longer perform miracles and families are being ripped apart by a microscopic enemy. The time for action is now and we can be part of the solution. ■ Stop playing the blame game. Each person, industry, and country can affect the development of antibiotic resistance. We each have a role to play and should be held accountable to make meaningful progress against this threat. ■ Stop relying only on new antibiotics that are slow getting to market and that, sadly, these germs will one day render ineffective. We need to adopt aggressive strategies that keep the germs away and infections from occurring in the first place. ■ Stop believing that antibiotic resistance is a problem “over there” in someone else’s hospital, state, or country—and not in our own backyard. Antibiotic resistance has been found in every U.S. state and in every country across the globe. There is no safe place from antibiotic resistance, but everyone can take action against it. Take action where you can, from handwashing to improving antibiotic use. The problem will get worse if we do not act now, but we can make a difference. Simply, here’s what works. Preventing infections protects everyone. Improving antibiotic use in people and animals slows the threat and helps preserve today’s drugs and those yet to come. Detecting threats and implementing interventions to keep germs from becoming widespread saves lives. These actions are protecting us today and will continue to protect us, our families, and our nation from a threat that will never stop. I’m proud to serve alongside the experts who refuse to let this threat disarm us and who are diligently protecting our future by putting science and public health