World Health Organization (WHO) announced that Swine Flu H1N1 pandemic is over but announced a new global threat to human race. This time the threat is through a new bug (Bacterium). The bug is mysteriously or possibly mischievously named NDM-1 meaning New Delhi Metallo-beta-Lactamase-1 (NDM-1), pointing to the origin of the superbug from New Delhi. The controversy about this superbug started with the British investigators (Timothy Walsh from department of immunity, infection and biochemistry, department of medicine, Cardiff University) publishing a report in “Lancet Infectious Diseases”, a coveted British Journal.
Uptill now the most dangerous bacterium which can infect humans and cause disaster has been named as MRSA, meaning Methicillin Resistant Staphylococcus Aureus. The bug (Staphylococcus aureus) is a common bacterium causing skin infections like boils and superficial wound infections. The bacterium is sensitive to penicillin antibiotic and easily treatable. Some of these bacteria produce an enzyme called penicillinase, which can destroy penicillin antibiotic. Such bacteria become resistant to penicillin antibiotics but can be easily treated with penicilinase-resistant penicillin’s which include Methicillin and its allied antibiotics. However, sometimes these bacteria produce enzymes which can destroy even Methicillin as well and thus become resistant to all penicillin family. MRSA are dangerous bugs and can infect newborns with high mortality, and devices like cardiac valves, pace makers etc with disastrous consequences. Many hospitals which do not follow strict infection control guidelines are potential sources of MRSA. Epidemic of MRSA have been reported to have originated from many such hospitals with disastrous human consequences. These bacteria need treatment with vancomycin, a toxic antibiotic, whose use needs close monitoring.
The superbug NDM-1 is a new entrant to family of most dangerous bugs. These bacteria produce an enzyme called Metallo-beta-Lactamase-1 (MDM-1). This enzyme destroys the most potent of the antibiotic, carbapenem, known to kill most of the known bacteria. Enzymes such MDM-1 are produced by strands of DNA which bacteria are known to transfer between one another. Currently E Coli and Klebsiella pneumoniae are the two bacteria who are host to MDM-1. What makes the superbug more dangerous is its ability to jump across different bacterial species. The superbug has the potential to get copied and transferred between bacteria, allowing it to spread rapidly. If it spreads to an already hard-to-treat bacterial infection, it can turn more dangerous. The British investigators reported on 50 patients who were infected with the superbug. The superbug was named as New Delhi Metallo-beta-Lactamase-1(NDM-1) after the national capital (New Delhi), where a Swedish patient was reportedly infected after undergoing a surgery in 2008. Most of other patients had carried this infection from India, Pakistan and Bangladesh. A joint study was led by Chennai-based Karthikeyan Kumarasamy, pursuing his PhD at University of Madras and UK-based Timothy Walsh from department of immunity, infection and biochemistry, department of medicine, Cardiff University. They found the bug in most of the hospitals in Chennai and Haryana with estimated prevalence of this infection 1.5%. They reported the superbug in 44 patients in Chennai, 26 in Haryana, 37 in the UK and 73 in other places across India, Pakistan and Bangladesh. Based on these findings investigators commented: “NDM-1 is becoming more common in Bangladesh, India, and Pakistan and is starting to be imported back to Britain in patients returning from these countries. India provides cosmetic surgery for other Europeans and Americans, and it is likely NDM-1 will spread worldwide.”
NDM-1 superbug can be diagnosed when patient is infected with gram negative bacteria (sepsis) with culture report reported as resistant to all antibiotics. Such infections are commonly been reported in our hospitals but now has been named as above. Treatment options of such infections are limited. The current treatment option is to treat them with a cocktail of antibiotics. Most new antibiotics currently under development are effective only against gram positive bacteria like super bug MRSA. Unfortunately, bacteria that carry the MDM-1 enzymes are gram negative. Selection of antibiotic therapy should be tailored to antimicrobial susceptibility results for agents outside the beta lactam and carbapenem classes. In addition, antibiotic susceptibility testing should be requested for tigecycline, colistin and aztreonam.
However there may be more than what meets the eye in these reports! Indian surgeons rubbish the claim of superbug NDM-1 reports and contest that it's just another attempt to stop thousands of pounds from leaving the floundering British economy to boost healthcare in India. According to CII estimates, 1.1 million foreigners travel to India each year for cheaper treatments and surgeries. A heart bypass surgery costs $ 6,500 (R 3, 03,550) in a corporate hospital in India, as compared to $30,000 (R 14, 01,000) to $50,000 (R 23, 35,000) in the US. So convinced are British scientists about the superbug infection being fuelled by India's Rs 1,200-crore medical tourism industry that they have chosen to provocatively name the newly-identified gene that causes the drug resistance as the New Delhi Metallo-beta-lactamase (NDM-1). There are several comments passed by Indian Surgeons regarding these reports which include as follows: "It's a false alarm, I track infection and have not seen a single case in my hospital. Hospital-acquired infections are far more common in Britain and the West than in India," "We offer better surgical outcomes at one-fifth the cost, Most hospitals in India, including have national and international accreditations... who send auditors to track quality - including infections - four times a year. The audits show that corporate hospitals here are safer than the West. They're definitely safer than Britain's National Health Service."
Thus there is a major controversy surrounding these reports of the superbug NDM-1. How can this be sorted out and the significance of these reports validated? Indian researchers need to go on a war footing to look for these organisms in septic patients in primary, secondary and tertiary care hospitals. These protocols can be supervised by agencies like ICMR & NICD. Such reports if based on sound and dedicated protocols should be published in International journals with high impact factor and which undergo strict peer-review. Only after these reports are available, a true story of the superbug can be drafted. Till then, Western Govt:, Western media and WHO shall continue to raise the alarm and warn patients of Indian Superbug infections and its consequences if they choose to have surgeries done in Indian hospitals. Through this, there may be a serious threat to booming medical tourism to India.
Outside these reports, we as physicians in India should look at ourselves including our healthcare. MRSA, NDM-1 and other infections in our hospitals do exist as in the West and can only be detected and controlled with strict infection control policies of each and every healthcare unit. In the West, each and every health unit has strict infection control policies of stringent nature. In fact the only policy a healthcare worker cannot break is that of infection control guidelines. This policy has several components which I might unravel some other time. Surgeons in Delhi-based tertiary-care hospitals have raised voice that such hospitals do follow infection control policies comparable to the Western standards and are being monitored by International agencies. However, I as a neutral person can vouch that no Indian hospital can reach the Infection control standards defined in the West. Let us assume that many such hospitals do adhere to such standards. What about hundreds and thousands of other primary and secondary care in India where these policies are not even introduced. Most of the patients which are being referred to such tertiary hospitals come from the grass root primary and secondary hospitals and this is/can be a major source of resistant bugs and superbugs to Apical/tertiary Institutions in which Western patients come for affordable surgeries. Thus if we have to face the West regarding Bugs and Superbug story we need to improve healthcare at grassroots level and introduce healthcare policies which are optimum and also monitored stringently. This shall go a long way in sustaining our medical tourism industry in future.
