ECDC: Antibiotic Resistance In the EU – 2012

 

 

# 7980

 

 

Last September, in Referral: McKenna On CDC Antibiotic Resistance Report,  we looked at a new report from the CDC on the growing threat of antibiotic resistance – with  with Director Thomas Frieden warning, `“If we are not careful, we will soon be in a post-antibiotic era.”

 

This stark forecast echoed the sentiments that World Health Director-General Margaret Chan expressed a year ago (see Chan: World Faces A `Post-Antibiotic Era’).

 

On November 18th, the ECDC, Hong Kong’s CHP, and the United State’s CDC will kick off their antibiotic resistance awareness campaigns for 2013.  Here in the US, it signals the start of Get Smart About Antibiotics Week. 

 

Today, the ECDC has released a massive (218 pages) surveillance report report called Antimicrobial resistance surveillance in Europe 2012, along with a smaller (10 page) summary which will be easier to digest.

 

Highlights on antibiotic resistance

• Antibiotic resistance is a serious threat to public health in Europe, leading to increasing healthcare costs, prolonged hospital stays, treatment failures, and sometimes death.
•   
  Over the last four years (2009 to 2012), resistance to third-generation cephalosporins in K. pneumoniae and E. coli increased significantly at EU/EEA level. Combined resistance to third-generation cephalosporins and two other important antimicrobial groups (fluoroquinolones and aminoglycosides) also increased significantly at EU/EEA level for K. pneumoniae, but not for E. coli. 
• The increasing trend of combined resistance in K. pneumoniae means that only a few therapeutic options (e.g., carbapenems) remain available for treatment of infected patients. 
• Carbapenems form a major last-line class of antibiotics to treat infections with multidrug-resistant Gram-negative bacteria such as K. pneumoniae and E. coli, both common causes of pneumonia, urinary tract infections and bloodstream infections. However, the percentage of carbapenem-resistant K. pneumoniae is already high and increasing in some countries in the EU.
• Antimicrobial resistance data for Acinetobacter spp. are available in EARS-Net for the first time. Data for 2012 show large inter-country variations in Europe, and high levels of resistance (>25%) to carbapenems in nearly half of the reporting countries. 
• In contrast, in the past few years, the percentage of meticillin-resistant Staphylococcus aureus (MRSA) has shown a significant decreasing trend at EU/EEA level, and either a continuous decrease or a stabilising trend was observed in most EU/EEA countries during the last four years. Nevertheless, MRSA remains above 25% in almost one fourth of the reporting countries, mainly in southern and eastern Europe. 
• Prudent antibiotic use and comprehensive infection control strategies targeting all healthcare sectors (acute care hospitals, long-term care facilities and ambulatory care) are the cornerstones of effective interventions that aim to prevent selection and transmission of antibiotic-resistant bacteria.

 

Also released today is an ECDC Technical Report called Carbapenemase-producing bacteria in Europe which provides Interim results from the European survey on carbapenemase-producing Enterobacteriaceae (EuSCAPE) project 2013.

Bacteria resistant to the Carbapenem class of antibiotics (a class that includes imipenem, meropenem, doripenem, and ertapenem) – are called carbapenemases –  are of particular concern since Carbapenems are often the drug of last resort for treating difficult bacterial infections.

 

Short of seeing an extremely high mortality influenza pandemic, I can think of no looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be an extremely urgent public health concern.

 

So I expect I’ll be devoting a good deal of blog space to this topic over the next couple of weeks.

EID: Environmental NDM-1 Detected In Vietnam

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

# 6440

 

In a study reminiscent of one we saw published in April of last year (see Lancet Study: NDM-1 In New Delhi Water Supply), the CDC’s EID Journal has a letter by R. Isozumi et al. that appears (ahead of print) in their August issue, that reveals the detection of the NDM-1 gene in a river in Hanoi.

 

bla_NDM-1–positive Klebsiella pneumoniae from Environment, Vietnam

Rie Isozumi , Kumiko Yoshimatsu, Tetsu Yamashiro, Futoshi Hasebe, Binh Minh Nguyen, Tuan Cuong Ngo, Shumpei P. Yasuda, Takaaki Koma, Kenta Shimizu, and Jiro Arikawa

 

By way of explanation, bla_NDM-1 is the gene responsible for creating the NDM-1 (New Delhi metallo-β-lactamase) enzyme that can make many types of bacteria resistant to a wide spectrum of antibiotics.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

Over the past few years we have seen a worrisome expansion of β-lactamase enzymes in bacteria, and they are slowly eroding the value of much of our antibiotic arsenal.

 

Those that inhibit the antimicrobial actions of the (formerly resistant) Carbapenem class of antibiotics – called carbapenemases – are of particular concern. Carbapenems are often used as the drug of last resort for treating difficult bacterial infections, including Escherichia coli (E. coli) and Klebsiella pneumoniae.

 

So when the gene responsible for the NDM-1 enzyme begins to show up in the environment, doctors and researchers take notice.

 

The author’s of today’s EID Journal report state their reasons for concern:

 

The possible appearance of bacteria harboring bla_NDM-1 in Vietnam is of concern because cultural and economic links between Vietnam and India are strongly established, including extensive person-to-person exchanges that could enable easy exchange of pathogens. In addition, Vietnam faces a serious problem of antimicrobial drug resistance because drugs are freely available and used in an indiscriminate fashion. Thus, once bla_NDM-1–positive bacteria colonize persons in Vietnam, they would be able to spread easily and pose a serious public health threat.

 

To look for environmental bla_NDM-1, researchers examined water samples taken from 20 locations within 10 km of Hanoi, Vietnam. Samples were collected from rivers, lakes, and standing water in the streets.

The authors report finding the NDM-1 enzyme producing gene in two locations – 3km apart – in the Kim Nguu River, which flows through the city.  They write:

 

We harvested several species of bacteria from the 2 seepage samples positive for bla_NDM-1: Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, P. fluorescens/putida, and P. luteola. 

 

They also report finding 2 other βeta-lactamases (bla_TEM-1 and bla_CTX-M-3) that were highly resistant to another class of antibiotics called aminoglycosides (which include neomycin, streptomycin & tobramycin)

The authors conclude by saying:

Wide-scale surveillance of environmental and clinical samples in Vietnam and establishment of a strategy to prevent further spread of bla_NDM-1 are urgently needed.

It’s been nearly 2 years since The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. that awakened the world to the  emergence and growing prevalence of the NDM-1 enzyme.

 

Since that time, we’ve seen a slow, but inexorable spread of NDM-1 carrying bacteria around the globe. A few of my past blogs on the subject include:

 

Carbapenemases Rising

NDM-1: One Year Later

WHO Unveils 6-Point Plan To Preserve Antibiotic Effectiveness

Eurosurveillance On Antimicrobial Resistance

 

For a far more complete discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA. And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

 

Last March, Director-General of the World Health Organization Margaret Chan warned that the World Faces A `Post-Antibiotic Era’. One where even common infections may become untreatable.

 

While we aren’t there yet, reports such as the one today in the EID Journal add to the growing concern that someday, that fear may become a reality.

NDM-1: A Matter Of Import

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

# 6390

 

It’s been nearly 2 years since The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. on the emergence and growing prevalence a new enzyme – dubbed NDM-1 (New Delhi metallo-ß-lactamase-1) - on the Indian sub-continent that can confer resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems.

 

Carbapenems are newer generation beta-lactam antibiotics (a class that includes penicillins, cephalosporins, cephamycins, and carbapenems) that are usually reserved as an antibiotic of last resort.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

While the numbers were small, the authors identified a handful of patients in the UK who had recently travelled to the Indian Subcontinent and who returned with this resistant bacteria.

 

The reaction from officials out of India was both swift and disappointing. Rather than taking immediate action against a growing public health threat, they took umbrage instead.

 

They condemned of the use of `New Delhi’ in the naming of this resistance gene, called the paper a `conspiracy theory’, and issued broad denials of its prevalence in India or that medical tourism to their nation was responsible for its spread.

 

Under mounting pressure from the International community and editorializing in Indian newspapers, the Indian Health Ministry announced in October 2010 that they would impose new restrictions on the sale of 90 currently over-the-counter antibiotics.

 

But as the Deccan Chronicle reported as recently as last month, in an article called Medical body demands ban on 33 drugs in India (published May 20, 2012), little progress has been made:

 

Sale of antibiotics without prescription is rampant

Despite the government regulations restricting the sale of drugs without a prescription, medical stores continue to do so in the absence of active government monitoring. In particular, antibiotics can be obtained at medical stores just by naming them. Doctors say such an unchecked sale of antibiotics is harmful from the public's perspective.

 

Even though the policy framework of the Directorate General of Health Services seeks to regulate the unauthorised sale of antibiotics, the practice is rampant.

 

 

Six months after the first Lancet article - in April, 2011 - the same researchers published another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested.

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

 

And most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

 

Today the VOA (Voice of America) carries a report on the growing concerns over the spread of Drug Resistant bacteria across India. A problem exacerbated not only by the unregulated sale of antibiotics over the counter, but also by a lack of waste treatment facilities in that country of more than 1 billion people.

 

Concerns Mount Over India's Role In Incubating Drug-Resistant Bacteria

Kurt Achin

May 16, 2012

Medical research is once again pointing to India as a dangerous crucible of bacterial strains that resist many forms of antibiotic treatment. Cheap, under-regulated antibiotics and a severe shortfall of sanitation infrastructure fuel the problem.

 

<SNIP>

 

Unsanitary conditions in India are blamed for creating an environment for superbugs - both in emerging megacities, and in rural locations where toilet infrastructure is nearly nonexistent.

Nitya Jacob, head of water issues at New Delhi's Center for Science and Environment, co-authored a recent study called “Excreta Matters.”

"India has a capacity to treat only about a fifth of its sewage and I think about 40 percent of that capacity is concentrated in just two cities of Delhi and Bombay," said Jacob.

Superbug researcher Kumarasamy says the Indian government needs to act urgently to prevent the spread of drug-resistant diseases.

(Continue . . .)

 

More detail on the Excreta Matters study, referenced above, can be found on the Centre For Science and Environment website.

 

 

Meanwhile, as governments dither and regulations go unenforced - superbugs like NDM-1, acinetobacter, and a myriad of carbapenamases including: IMP, VIM, OXA, CMY, and most notably KPC (K. pneumoniae carbapenemase) - continue their pernicious spread around the world.

 

A story out of Edmonton, Canada last week illustrates this point, showing just how easily superbugs can be imported, and then spread:

 

Health officials admit superbug lead to death of patient at Royal Alex

Updated: Wed Jun. 06 2012 19:18:56
Julia Parrish, ctvedmonton.ca

Weeks after two types of drug resistant bacteria were brought into Edmonton by a woman who had surgery overseas, health officials have confirmed those `superbugs' lead to the death of another patient at the Royal Alexandra Hospital.

(Continue . . . )

 

 

Short of seeing an extremely high mortality influenza pandemic, I can think of no looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be an extremely urgent public health concern.

 

For more on these issues, you may wish to revisit:

 

Carbapenemases Rising

Chan: World Faces A `Post-Antibiotic Era’

WHO: The Evolving Threat Of Antimicrobial Resistance

 

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

NDM-1: One Year Later

 

 

# 5751

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

 

Although the antibiotic resistance enzyme now known as NDM-1 (New Delhi metallo-ß-lactamase-1) was first detected three years ago in a Swedish patient (with Indian origins), its notoriety truly didn’t begin until one year ago today with the publication of a controversial, and eye-opening research paper in The Lancet.

 

The NDM-1 enzyme confers resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems. And Carbapenems are often our drug of last resort against a variety of bacterial infections.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

One year ago, the following research article was published in the Lancet on its growing prevalence on the Indian sub-continent and its recent importation into the UK, US, and other countries (see NDM-1: A New Acronym To Memorize).

 

Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

Dr David Livermore, Prof Timothy Walsh, et al.

doi:10.1016/S1473-3099(10)70143-2

Published Online: 11 August 2010

 

 

The reaction from officials out of India was both swift and disappointing. Rather than taking immediate action against a growing public health threat, they took umbrage instead.

 

They condemned of the use of `New Delhi’ in the naming of this resistance gene, called the paper a `conspiracy theory’, and issued broad denials of its prevalence in India or that medical tourism to their nation was responsible for its spread.

 

It is worth noting that the naming convention for pathogens that invoked so much ire traditionally incorporates its place of discovery or emergence.

 

In 2001 a similar gene was discovered in Brazil and was dubbed SPM-1 (Sao Paulo metallo-beta-lactamase). Another, discovered in 1999 in Italy, is called VIM (Verona integron-encoded metallo-β-lactamase), while SIM stands for Seoul imipenemase found in Korea.

 

The day after this paper was published Health agencies around the world began voicing their concerns over the emergence of this new form of antibiotic resistance (see Public Health Agencies On NDM-1).

 

Under pressure from the International community and editorializing in Indian newspapers, the Indian Health Ministry announced in October 2010 that they would impose new restrictions on the sale of 90 currently over-the-counter antibiotics.

 

But as of today, amid strenuous protests from pharmacies, those restrictions have yet to be enforced according to this article in the Times of India.

 

With the specter of a new, more virulent, emerging forms of antibiotic resistance on the horizon, last fall the ECDC and EMEA produced a 54 page joint technical report called The Bacterial Challenge: Time To React to coincide with European Antibiotic Awareness Day in November 2010.

 

 

The World Health Organization (WHO) and the CDC - along with other public health organizations around the world – used this year’s World Health Day – 7 April 2011 to promote sane antibiotic usage and awareness of antimicrobial resistance.

 

 

Six months after the first Lancet article in April, 2011, the same researchers published a new study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested.

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

And alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

Once again the reaction out of India was one of denial (see Hopefully, It’s Just A Stage They Are Going Through). 

 

One year after the Lancet report on the spread of NDM-1 out of India and Pakistan, concerns over its emergence and spread have not diminished. While the end of the antibiotic era is not yet at hand, the fear is we may be drawing closer to that day.

 

In April of this year, Margaret Chan – Director General of the World Health Organization – in a speech for World Health Day 2011, issued this stark warning:

 

In the absence of urgent corrective and protective actions, the world is heading towards a post-antibiotic era, in which many common infections will no longer have a cure and, once again, kill unabated.

 

The implications go beyond a resurgence of deadly infections to threaten many other life-saving and life-prolonging interventions, like cancer treatments, sophisticated surgical operations, and organ transplantations. With hospitals now the hotbeds for highly-resistant pathogens, such procedures become hazardous.

 

 

Short of seeing an extremely high mortality influenza pandemic, I can think of no looming medical crisis more dire than the growing threat of antimicrobial resistance. 

 

For more on these issues, you may wish to revisit:

 

Carbapenemases Rising

Eurosurveillance On Antimicrobial Resistance

WHO: The Threat Of Antimicrobial Resistance

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.

Netherlands: Large Nosocomial KPC Outbreak

 

 

K. pneumoniae on a MacConkey agar plate.

# 5717

 

For nearly two months a hospital in Rotterdam in the Netherlands has been battling an outbreak of CRKP - Carbapenem-Resistant Klebsiella pneumoniae – which may have been linked to as many as 27 deaths.

 

The exact cause of death has yet to be determined in all of these cases.

 

Klebsiella pneumoniae is a Gram negative, rod shaped bacterium commonly found in the flora of the human intestinal tract. Most of the time, it resides harmlessly in the intestines.

 

But when K. pneumoniae moves beyond the intestinal tract – particularly in people with weakened immune systems – it can cause cause severe pneumonia, urinary tract infections (UTI), septicemia, and soft tissue infections.

 

Complicating matters, over the past decade doctors have seen the emergence of antibiotic resistant forms of K. pneumoniae – known as CRKP or  KPC (K. pneumoniae carbapenemase).

 

Bacteria resistant to the Carbapenem class of antibiotics – called carbapenemases – are of particular concern since Carbapenems are often used as the drug of last resort for treating difficult bacterial infections

 

K. Pneumoniae’s opportunistic qualities – attacking those with weakened immune systems - makes it an important, and difficult to control, hospital acquired (nosocomial) infection.

 

First a report from Xinhua News, and then I’ll return with more, including a press release from the hospital.

 

Multiple-resistant bacteria likely cause 27 deaths in Netherlands: hospital

2011-07-27 02:26:27

THE HAGUE, July 26 (Xinhua) -- Klebsiella bacterie Oxa-48, a kind of multi-resistant bacteria, may have caused 27 deaths in the Netherlands since June 1, a hospital source said Tuesday.

 

Though the 27 people died have all been infected with the bacteria, it didn't mean that all the deceased have died as a result of the bacteria, added the Maastad hospital in Rotterdam.

 

Research is under way to show the link between the deaths and the multiple resistant bacteria.

 

The hospital announced the first two death cases on June 1, while the latest report said 78 people are carrier of the bacteria and another 1,967 people are suspected carriers for the time being.

(Continue . . .)

 

 

According to the following (machine translated) press release from the Maastad hospital, there have been no new infections detected since July 18th, and while more infections may be discovered, the situations is `under control’.

 

Press Release: Update multi-resistant bacteria in Rotterdam Hospital: July 26, 2011

On July 26, 2011, the Hospital Rotterdam the next situation that: 78 carriers of multiresistant bacteria, 27 in 1967 and deceased persons suspected patients.

 

Compared to July 21 this represents an increase of 8 carriers, two deceased persons and 143 suspected patients.

 

An increase of carriers automatically means more suspected patients, as they have been in the vicinity of the carriers.  Given the current culture tests and examinations will increase the numbers in the near future.

 

At present, the Hospital Rotterdam, since July 18, no infections in patients receiving for the first time hospitalized. On this basis we can conclude that the outbreak is still under control.

 

This is the current state of affairs until July 26, 2011:

• The number of carriers of the bacteria increased from 70 to 78 patients
• • Of these 78 patients, a total of 27 deceased patients.
  • It does not mean these 27 patients were deceased by the bacterium.
  • Investigated the role of bacteria in the death of patients.
  • -Of the 78 patients are currently only 8 patients in the hospital, which cared isolated.

• The number of people in a room located in the 78 carriers of the bacterium has increased from 1824 to 1967 people.
  • The 143 additional people receive today a culture test by mail.
  • At present there are 43 patients included isolated and tested.
  • If it appears that more patients are infected, should be monitored in any patient with whom they have been in contact. This allows the number of infections is increasing.

 

 

While this is an unusually large nosocomial outbreak, it is by no means an isolated incident.

 

In 2010, a survey presented at the IDSA  conference in Vancouver showed that Chicago was reporting a 42% rise in the number of hospitals and long-term care facilities reporting cases of KPC over last year.

 

Similarly, Brazil reported a substantial outbreak of KPC in 2010, which has been identified in more than 200 patients, and blamed for 22 deaths last year.

 

There have been outbreaks in many other countries, including Italy, Israel, France, Germany, the United Kingdom, Argentina, Lebanon, Israel, Morocco and Tunisia, and Ireland.

 

The gene that gives K. Pneumoniae its carbapenem resistance resides on a plasmid — a snippet of transferable DNA – that has the potential to jump to other strains of bacteria.

 

A trait that was recently demonstrated in an EID Journal dispatch (Transfer of Carbapenem-Resistant Plasmid from Klebsiella pneumoniae ST258 to Escherichia coli in Patient) in June, 2010.

 

One of the big concerns is that that we will see a transfer of carbapenem drug-resistance into a highly fit E. coli clone that could spread widely around the world. 

 

From EID Journal Dispatch I referenced above, the authors write:

 

Such an event may have severe public health consequences, leading to elimination of any effective antimicrobial drug treatment against the most common human bacterial pathogens.

 

Ominous words.

 

Which is why such an emphasis is being placed on the proper stewardship over our dwindling arsenal of effective antibiotics.

 

Some recent blogs on this subject include:

 

Going, Going, Gonorrhea

The Path Of Increased Resistance

Carbapenemases Rising

WHO: The Threat Of Antimicrobial Resistance

 

Perhaps the single best place I can direct you to learn about the dangers and impact of antimicrobial resistance is our favorite `scary disease girl’ Maryn McKenna’s SUPERBUG BLOG  and her terrific book on the subject  SUPERBUG: The Fatal Menace Of MRSA.

India Looks For (And Finds) NDM-1

 

 

 

# 5521

 

 

Inoculated MacConkey agar culture plate cultivated colonial growth of Gram-negative, small rod-shaped and facultatively anaerobic Klebsiella pneumoniae bacteria. – CDC PHIL.

NDM-1, or New Delhi metallo-ß-lactamase-1, is an  enzyme that can confer resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems.

 

Of particular concern, this enzyme is carried by a plasmid – a snippet of portable DNA  - that can be transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

 

Last August a Lancet Infectious Diseases article was published on its growing prevalence on the Indian sub-continent and its recent importation into the UK, US, and other countries.

 

 

The Lancet Infectious Diseases, Early Online Publication, 11 August 2010

doi:10.1016/S1473-3099(10)70143-2Cite or Link Using DOI

Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

 

 

The reaction from officials out of India was both immediate and disappointing. Rather than taking action against a growing public health threat, they took umbrage instead.

 

They condemned of the use of `New Delhi’ in the naming of this resistance gene, called the paper a `conspiracy theory’, and issued broad denials of its prevalence in India or that medical tourism to their nation was responsible for its spread.

 

It is worth noting that the naming convention for pathogens that invoked so much ire traditionally incorporates its place of discovery or emergence.

 

In 2001 a similar gene was discovered in Brazil and was dubbed SPM-1 (Sao Paulo metallo-beta-lactamase). Another, discovered in 1999 in Italy, is called VIM (Verona integron-encoded metallo-β-lactamase), while SIM stands for Seoul imipenemase found in Korea.

 

Six months later (April, 2011), the same researchers published a new study, again in The Lancet, that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested.

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

And as feared, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

Once again the reaction out of India was one of swift denial (see Hopefully, It’s Just A Stage They Are Going Through). 

 

Indian newspapers, however, have continued to question the government’s response - putting pressure on officials to begin testing for the enzyme.

 

Over the past couple of days Indian media has carried reports out of Pune - a city of about 3.5 million (8th largest in India) located about 1400 kilometers from New Delhi – regarding the detection of 20 NDM-1 cases at Sassoon hospital.

 

Pune is less than 200 kilometers from Mumbai (formerly Bombay), which is the largest city in India (12.5 million people) and the 5th largest metropolitan area in the world.

 

Microbiologists tested samples of blood, urine and puss from 3,172 patients at the hospital and found that 885 had gram negative bacterial infections. 

 

Of those, 181 (20%) were resistant to the carbapenem family of drugs .

 

And twenty of those tested positive for the NDM-1 gene.

 

Some of the media coverage follows. From the Indian Express we get:

 

NDM-1 in Pune: Researchers

Posted: Sat Apr 23 2011, 01:11 hrs Pune:

‘Superbug gene detected in 20 patients’

The controversial multi-drug-resistant superbug, the origin of which has been a matter of debate with the Centre taking strong exception to it being named after New Delhi, researchers from the government-run B J Medical College (BJMC) and the National Centre for Cell Science (NCCS), in preliminary findings of a study to find the New Delhi metallobeta lactamase-1 (NDM-1) incidence in Pune, reported the strain in the city.

(Continue . . . )

 

And from Mid-Day News:

 

 

NDM-1 superbug has arrived in the city

By: Alifiya Khan
Date:  2011-04-25
Place: Pune

20 of 885 patients tested by Sassoon hospital found infected by antibiotic-resistant bug controversially named after Indian capital, says dean of govt healthcare facility

THE NDM-1 superbug has reached the city. So far 20 patients from Sassoon General Hospital have shown the presence of the multi-drug-resistant superbug. Shocking as it may sound, the presence of the New Delhi metallobeta lactamase-1 (NDM-1) superbug in the city is a fact that has been confirmed by the seniormost authority at the hospital.

(Continue . . . )

 

 

Absent from these media dispatches are details on the exact types of resistant bacteria that were detected.   

 

While 20 NDM-1 cases may not sound like a lot, these are the results from only 1 hospital over a 2-month period of time.  

 

It undoubtedly only represents the tip of the iceberg.

 

And as I described in my blog Carbapenemases Rising, the rising rate of regular carbapenem resistance is alarming as well.  Carbapenems are often used as the drug of last resort for treating difficult bacterial infections, including Escherichia coli (E. coli) and Klebsiella pneumoniae.

 

India, of course, isn’t the only country with NDM-1 cases or growing carbapenem resistance - although the Indian sub-continent does appear to be a focal point – a situation often blamed on their longstanding lax controls on the use of antibiotics.

 

Given the results of these studies published in the Lancet, and these latest findings from Pune’s Sassoon hospital - increased surveillance, openness, and international cooperation  – not indignation – are the responses needed today if a major public health crisis is to be averted.

 

One that has the potential to spread far beyond India, and that could – over time – greatly diminish our ability to fight bacterial infections with our dwindling arsenal of antibiotics.

 

For more on NDM-1 and antimicrobial resistance, you may wish to check out:

 

• Eurosurveillance On Antimicrobial Resistance

• ECDC/EMEA: Joint Report On Resistant Bacteria

• Carbapenemases Rising

• WHO: The Threat Of Antimicrobial Resistance

• NDM-1: A New Acronym To Memorize

 

 

And perhaps the single best place to learn about the dangers and impact of antimicrobial resistance is from our favorite `scary disease girl’ Maryn McKenna’s SUPERBUG BLOG  and her terrific book on the subject  SUPERBUG: The Fatal Menace Of MRSA.