Abstract
Due to the high burden of antibiotic-resistant infections, several US states mandate public reporting of these infections. To examine the extent to which state departments of health require reporting of antibiotic-resistant infections, we abstracted data from lists of reportable conditions from all 50 states at 2 time points, May 2013 and May 2015. Requirements varied substantially by state. In 2015, most states (n = 44) required reporting of at least 1 antibiotic-resistant infection; vancomycin-intermediate and/or vancomycin-resistant Staphylococcus aureus was the most frequently reportable infection (n = 40). Few states required reporting of methicillin-resistant S aureus (n = 11), multidrug-resistant gram-negative bacteria (n = 9), or vancomycin-resistant enterococci (n = 8). During the 2 years we studied, 2013 and 2015, 4 states removed and 9 added at least 1 reporting requirement. The changes in reporting requirements suggest flexibility in health departments’ response to local surveillance needs and emerging threats. Future studies should assess how data on antibiotic-resistant infections through different sources are used at the state level to drive prevention and control efforts.
The number of infections caused by antibiotic-resistant organisms has increased sharply during the past several decades. An estimated 2 million infections and 23 000 deaths are caused by antibiotic-resistant organisms annually in the United States. Additionally, approximately 250 000 people are hospitalized each year with Clostridium difficile–associated diarrhea, which is associated with the use of antibiotics. 1 Given the high morbidity, mortality, and costs associated with antibiotic-resistant infections, the spread of antibiotic resistance was identified as 1 of the top 5 threats to health in the United States 2 and led to development of the White House’s “National Action Plan for Combating Antibiotic-Resistant Bacteria” in 2015. 3
In the United States, individual states, not the federal government, determine which diseases and conditions are legally reportable. 4 Since 2003, states have enacted legislation, promulgated administrative regulations, or both that require hospitals to report data on health care–associated infections to their state health departments. 5,6 As of January 2013, 20 states mandated public reporting of methicillin-resistant Staphylococcus aureus (MRSA); 19 states required reporting of C difficile; and 3 states required reporting of vancomycin-resistant enterococci (VRE). 4 Nationally, beginning in January 2013, the Centers for Medicare & Medicaid Services began requiring the reporting of MRSA bacteremia and C difficile laboratory-confirmed events using the National Healthcare Safety Network as part of the Hospital Inpatient Quality Reporting program. 7
Methods
We investigated the extent to which regulations concerning reportable conditions required health care providers to report antibiotic-resistant infections. To do this, we abstracted data in May 2015 from the most recently updated lists of reportable conditions for all 50 US states from state health department websites. We abstracted data from regulations concerning reportable conditions applicable to providers in each state. The states were divided between 2 authors (M.P.M., E.C.) who met weekly to discuss any challenges and to ensure consistent data entry, methods, and definitions. We conducted an identical search for a point in time 2 years earlier, May 2013, to assess changes in reporting requirements between May 2013 and May 2015. We studied only state reporting requirements applicable to providers, and we did not study reporting requirements for any other entities, such as laboratories. This study used a review of publicly available information and was not considered human subjects research. As such, institutional review board approval was not needed.
Results
In 2015, 44 states required provider reporting of at least 1 antibiotic-resistant infection. Only California, Colorado, Idaho, Massachusetts, Montana, and Vermont did not require such reporting (Table). Cases of vancomycin-intermediate and/or vancomycin-resistant S aureus (VISA/VRSA) were the most frequently required reportable infections (n = 40 states). Eleven states required reporting of MRSA; 9 states required reporting of multidrug-resistant gram-negative bacilli; and 8 states required reporting of VRE. Only 2 states required reporting of C difficile (New Mexico and Tennessee) and vancomycin-resistant S epidermidis (Arizona and Connecticut).
State provider reporting requirements for antibiotic-resistant infections, United States, May 2015a
Abbreviations: CARB, cephalosporin and carbapenem; MRSA, methicillin-resistant Staphylococcus aureus.
aData sources: Data were taken from each state health department’s website.
bIn addition to specific categories of resistant infections, such as MRSA and vancomycin-resistant and/or vancomycin-intermediate S. aureus.
VISA/VRSA were reportable in 36 states, whereas 4 states required reporting of VRSA only (Figure A). Among 8 states that required VRE reporting, 4 required reporting of VRE in general; 2 required reporting of invasive VRE; and 1 each required reporting of nosocomial VRE and related cases, clusters, and outbreaks (Figure B). Of the 11 states with MRSA reporting requirements, 6 required reporting of cases of invasive MRSA only; the remaining requirements included reporting of MRSA clusters, nosocomial cases, those associated with community settings, and/or MRSA cases in infants (Table).
Provider reporting requirements for (A) vancomycin-intermediate and/or vancomycin-resistant Staphylococcus aureus (VISA/VRSA) and (B) vancomycin-resistant enterococci (VRE), by state, United States, 2015. Data were abstracted from a review of reportable disease lists available on state health department websites.
The requirements for reporting multidrug-resistant gram-negative bacilli also varied across states in 2015 (Table). Of the 9 states that required reporting of multidrug-resistant gram-negative bacilli, all but 1 state required reporting of organisms resistant to carbapenem; 6 states required reporting of carbapenem-resistant Enterobacteriaceae; 1 state required reporting of specific types of carbapenem-resistant Enterobacteriaceae (ie, Klebsiella pneumoniae and Escherichia coli); and 1 state specified requirements for both carbapenem-resistant Enterobacteriaceae and K pneumoniae reporting. Two states required reporting of carbapenem-resistant Acinetobacter, and 1 state required reporting of resistant Acinetobacter and Pseudomonas species in a limited catchment area. Additionally, 2 states had reporting requirements for both carbapenem- and cephalosporin-resistant Enterobacteriaceae.
Between May 2013 and May 2015, 13 states changed their reporting requirements for at least 1 antibiotic-resistant infection. Four states removed an antibiotic-resistant infection from their reporting requirements: 2 states each removed MRSA requirements (Georgia and West Virginia) and VRE requirements (Arkansas and Vermont). In addition, Vermont stopped requiring the reporting of VISA/VRSA. During the same period, 9 states added at least 1 reporting requirement for an antibiotic-resistant organism: 6 states (Alaska, South Dakota, Tennessee, Texas, Utah, and Washington) began requiring reporting of at least 1 type of multidrug-resistant gram-negative bacillus, and 3 states (Alaska, Arkansas, and Hawaii) began requiring reporting of VISA and/or VRSA. In addition, Tennessee began requiring the reporting of C difficile in a limited catchment area, and Illinois added a broad requirement to report extensively drug-resistant organisms, in addition to requiring reporting of MRSA and VISA/VRSA, which were previously designated as reportable.
Discussion
Surveillance systems of reportable conditions play a critical role in providing state health departments with data needed to monitor disease trends and control disease. State requirements for reporting all diseases and conditions vary by state, so it should not be surprising that requirements for reporting antibiotic conditions vary as well. As of October 2016, the only antibiotic-resistant infection that appeared on the list of “Nationally Notifiable Conditions” was VISA/VRSA, 8 and 40 states required reporting of those infections. However, reporting to the National Notifiable Diseases Surveillance System is voluntary, and each state determines whether to make the conditions on the list reportable in its own state and whether to require reporting of other conditions that are not nationally notifiable. 8
We found multiple changes in the provider reporting requirements for antibiotic-resistant infections from 2013 to 2015, affirming that rules on state-reportable conditions flex for different conditions. For example, 6 states added a requirement for reporting of at least 1 type of multidrug-resistant gram-negative bacillus, possibly in response to the rise of multidrug-resistant gram-negative bacillus cases in recent years. 9 Changes in national reporting affect state reporting requirements. For example, (1) national reporting policies for hospital-onset C difficile infections and MRSA bloodstream infections in all acute care and long-term acute care hospitals and (2) access to these data for states through the National Healthcare Safety Network are likely to have influenced future reporting requirements for these infections at the state level.
State reporting laws/mandates for healthcare-associated infections are enacted through statutes and administrative regulations and may be more difficult to change than requirements for state reportable conditions. 4 Requiring reporting through rules for reportable conditions may offer states a more flexible way to gather data on antibiotic-resistant infections to respond to local surveillance needs and emerging threats at the state level. Understanding the various surveillance requirements for health care providers and the numerous methods used to collect data on antibiotic-resistant infections at the state level is important to help policy makers and state epidemiologists focus prevention efforts and minimize redundancy and reporting burden placed on providers.
Limitations
An important limitation of this analysis was that we focused only on reporting requirements for health care providers and did not include reporting requirements for laboratories, which differ from provider requirements in some states. Another limitation is that we counted as having a reporting requirement only states with infections listed on the reportable conditions list. In some states, a reporting requirement might exist for certain infections, even if the infection is not listed on the reportable conditions list. For example, Illinois has a registry for reporting carbapenem-resistant Enterobacteriaceae and other multidrug-resistant infections; however, the registry applied only to hospitals, hospital-affiliated clinical laboratories, independent or freestanding laboratories, long-term care facilities, and long-term acute care facilities. No carbapenem-resistant Enterobacteriaceae reporting requirements are currently reflected on the state reportable conditions lists; therefore, we categorized this state (and other similar states) as not having a provider reporting requirement for carbapenem-resistant Enterobacteriaceae. Including only provider requirements and focusing solely on infections reflected on the state reportable conditions lists may have underestimated the surveillance efforts directed at antibiotic-resistant infections at the state level.
Conclusion
This study showed that reportable conditions requirements for clinicians varied substantially by state in 2015 and that multiple changes in the conditions required for reporting occurred between 2013 and 2015. These findings suggest flex in the health departments’ response to local surveillance needs and emerging threats. Future research should assess how data on antibiotic-resistant infections through different sources are used at the state level to drive prevention and control efforts.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the National Institute of Nursing Research (R01NR010107; principal investigator: P. Stone).