Action Plan — Introduction and Overview
In the 1940s, the widespread availability of penicillin and the subsequent discovery of streptomycin led to a dramatic reduction in illness and death from infectious diseases. However, bacteria and other disease-causing organisms — viruses, fungi, and parasites — have a remarkable ability to mutate and acquire resistance genes from other organisms and thereby develop resistance to antimicrobial drugs. When an antimicrobial drug is used, the selective pressure exerted by the drug favors the growth of organisms that are resistant to the drug's action. The extensive use of antimicrobial drugs has resulted in drug resistance that threatens to reverse the miracles of the last half century.
Drug-resistant pathogens are a growing menace to all people, regardless of age, gender, or socioeconomic background. They endanger people in affluent, industrial societies like the United States, as well as in less developed nations. Examples of clinically important microbes that are rapidly developing resistance to available antimicrobials include bacteria that cause pneumonia, ear infections, and meningitis (e.g., Streptococcus pneumoniae ), skin, bone, lung, and bloodstream infections (e.g., Staphylococcus aureus [2, 3]), urinary tract infections (e.g., Escherichia coli ), foodborne infections (e.g., Salmonella ), and infections transmitted in healthcare settings (e.g., enterococci  and Klebsiella spp. ).
For example, up to 30 percent of S. pneumoniae found in some areas of the United States are no longer susceptible to penicillin, and multidrug resistance is common. Approximately 11 percent of S. pneumoniae are resistant to "third generation" cephalosporin antibiotics, and resistance to the newest fluoroquinolone antimicrobials has already been reported (8). Nearly all strains of Staphylococcus aureus in the United States are resistant to penicillin, and many are resistant to newer methicillin-related drugs (2). Since 1997, strains of S. aureus with decreased susceptibility to vancomycin, for many years the only uniformly effective treatment, have been reported (9, 10).
Many other pathogens B including the bacteria that cause tuberculosis (11) and gonorrhea (12), human immunodeficiency virus (13), the fungi that cause yeast infections (14), and the parasites that cause malaria (15) — are also becoming resistant to standard therapies. If we do not act to address the problem of AR, we may lose quick and reliable treatment of infections that have been a manageable problem in the United States since the 1940s. Drug choices for the treatment of common infections will become increasingly limited and expensive — and, in some cases, nonexistent.
While anyone may acquire a drug-resistant infection, certain people are at increased risk, e.g., patients in hospitals and children in daycare centers. Drug-resistant infections may be acquired in healthcare settings (e.g., staphylococcal infections in intensive care units), in the community (e.g., pneumococci acquired from a classmate) and through the food supply (e.g., salmonella acquired from meat or eggs), both domestically and overseas. However, resistant microbes are increasingly appearing in new settings. Methicillin-resistant S. aureus, which for 30 years with few exceptions was a problem only in hospitals, is now occurring in the community (3, 16).
The costs of treating AR infections place a significant burden on society — a burden that is likely to grow larger as the number of cases of drug-resistant illness increase. Individuals infected with drug resistant organisms are more likely to require hospitalization, to remain in the hospital for a longer time, and to have a poor prognosis. For example, it has been estimated that the in-hospital cost of hospital-acquired infections caused by just six common kinds of resistant bacteria are at least $1.3 billion per year, in 1992 dollars (17). This estimate does not include the costs of infections caused by other pathogens, the costs of lost workdays, post-hospital care, or resistant infections in the outpatient or extended care facility settings.
AR will always be with us. The challenge before us is to transform this increasingly urgent threat into a manageable problem. Over the past ten years, the Institute of Medicine (18), the American Society for Microbiology (19), World Health Organization (20) other panels of distinguished experts, the Congressional Office of Technology Assessment (17), and the General Accounting Office (21 , 22 ) have provided recommendations and options for government action to address the dangers posed by AR. The experts agree that we need to improve surveillance for emerging AR problems, to prolong the useful life of antimicrobial drugs, to develop new drugs, and to utilize other measures, e.g., improved vaccines, diagnostics, and infection control measures to prevent and control AR.
Despite the urgency of the problem, the achievement of these goals has not been simple or straightforward, and accomplishments to date have been insufficient. Monitoring, preventing, and controlling AR requires sustained effort, commitment, and collaboration among many groups in the public and private sectors, and involvement of the general public. It also requires support and leadership from the federal government and a willingness to address complex and sometimes controversial scientific, medical, and economic issues.
A Public Health Action Plan to Combat Antimicrobial Resistance
A Public Health Action Plan to Combat Antimicrobial Resistance provides a blueprint for specific, coordinated federal government actions to address this emerging threat. The plan builds upon reports prepared by expert panels in recent years. This document is Part I of the plan, focusing on domestic issues. However, AR transcends national borders and requires a global approach to its prevention and control. Part II of the plan, to be developed after the World Health Organization finalizes its Global Strategy for the Containment of Antimicrobial Resistance (23), will identify federal actions that more specifically address international issues with input from and in collaboration with WHO and additional partners. A National Action Plan to Combat Multi-drug Resistant Tuberculosis has been published previously (24).
This plan was developed by an Interagency Task Force on Antimicrobial Resistance that was created in 1999. The Task Force is co-chaired by the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH), and also includes the Agency for Healthcare Research and Quality (AHRQ), the Health Care Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Department of Agriculture (USDA), the Department of Defense (DoD), the Department of Veterans Affairs (DVA), and the Environmental Protection Agency (EPA).
The plan is based in part on input obtained at a public meeting held in Atlanta, Georgia, in July 1999 (25). Present at the public meeting were consultants from a wide variety of groups, including state and local health agencies, universities, professional societies, pharmaceutical and biotechnology companies, healthcare delivery organizations, agricultural producers, consumer groups, and the public. A draft of the plan was released for public comment in June 2000 (26), and the plan was modified following consideration of comments received.
Partnerships, Implementation, and Coordination
The plan reflects a broadly based consensus of federal agencies on federal actions to combat AR. However, implementation of this plan will require collaboration with many partners (b). More specific details of these collaborations will be developed by the agencies as the actions are implemented.
The plan will be implemented incrementally as resources become available. The agencies recognize that a number of the items may require either new statutory authority or changes in regulatory requirements. The extent to which such measures may be needed to implement a given action item will be considered by the agencies involved.
The plan includes a summary and a list of issues, goals, and action items addressing surveillance, prevention and control, research, and product development (d). For each action item, coordinator and collaborator agencies/departments are specified. Contingent on available resources, the coordinators will assume the primary responsibility of carrying out the specified action items and the collaborators will assist and/or carry out part of the specified action. Additional agencies may become collaborators in the future.
The Task Force identified 13 top priority action items. Approximate timelines were also identified for all action items; these timelines provide another indication of priority but also take into account prerequisites for certain items and the achievable pace of action on sometimes complex issues. Designation of top priorities and timelines was a difficult task given the realization that many items could be considered top priority and should ideally begin immediately. For action items with multiple component parts, the agencies involved will further develop priorities and timelines, with appropriate input from outside partners, as they implement the action item.
The Interagency Task Force will continue to facilitate coordination among agencies and monitor implementation of the plan. During the coming years, the Task Force will publish periodic reports detailing how the plan is being implemented, solicit comments from the public — and if necessary, update the plan. Details of current agency activities regarding AR are beyond the scope of this document, but may be obtained by contacting the specific agencies.