A U.S. woman’s death that took place in September last year has had fingers being pointed at India. An incurable bacterial infection, believed to have been contracted from one of India’s hospitals, is said to have killed the Nevada resident, raising questions about the country’s efforts in tackling a threat bigger than any known epidemic.
The Indian connection
The story of the 70-year-old, described by the U.S. Centers for Disease Control and Prevention (CDC) in its Morbidity and Mortality report of January 13 goes thus — during the two years before her death in 2016, the woman was hospitalised multiple times in India for treatment of her fractured right thigh bone. Following an emergency hospitalisation in the U.S. in August last year, testing of a wound sample for antibiotic susceptibility found the infection-causing bacterium Klebsiella pneumoniae , which was resistant to all antibiotics available in the U.S.
In its description of the woman’s case, the CDC rather conservatively termed resistance to all 26 antibiotics, including the last-resort antibiotic colistin, “very uncommon”. The agency stated that in the more than 250 isolates of Carbapenem-resistant Enterobacteriaceae (CRE), including K. pneumoniae isolated from the Nevada woman, that it had tested, susceptibility of infection-causing bacteria to at least one of the antibiotics in use was seen in 80% of the cases, while 90% of the samples contained bacteria that could be treated by tigecycline, an antibiotic specifically developed for multidrug-resistant bacteria.
The Indian connection to the woman’s death was not restricted to the origin of her infection; the killer superbug’s resistance was attributed to a gene that produces an enzyme now popularly called New Delhi metallo-beta-lactamase-1or NDM-1. As its name suggests, the enzyme was first seen in a person who, according to the 2009 study that described the enzyme and the gene coding for it, had undergone a surgical procedure in 2007 at a New Delhi hospital. NDM-1 helps bacteria fend off carbapenems, a group of powerful antibiotics originally capable of killing several bacilli species. What makes NDM-1 frightening is that it is known to be transferred horizontally across bacterial species.
Resistance rampant in India
Encountering multidrug-resistant bacteria is fairly common in India. In 2016, K. pneumoniae made headlines when it caused varying degree of vision loss in a dozen elderly patients who underwent cataract surgeries at the state-run Sarojini Devi Eye Hospital in Hyderabad. Though the bacterium was found to be sensitive to Imipenem, a carbapenem antibiotic, the antibiotic could not help restore vision. An investigation found the bacteria in RL solution, which is used to wash the eyes during cataract procedure.
“It was a case of bacterial infection where one antibiotic was useful. However, at least one instance of bacteria resistant to all antibiotics is seen in our patients in as often as less than six months,” says Rajender Gupta, deputy superintendent of Sarojini Devi Eye Hospital. He maintains that such resistance is seen in patients availing treatment elsewhere before coming to the hospital, a tertiary eye-care centre. “In such cases, we try treatment with multiple antibiotics hoping it works. Otherwise, we leave it to nature as we cannot do much else.” At least three of those affected by the contaminated RL solution followed by The Hindu in the four months subsequent to their surgeries in June, complained of complete vision loss.
Lessons from the U.S.
Dr. Gupta’s words of helplessness in the face of absolute resistance eerily echoed in those of Washoe County health officials who said they have not seen such a pattern of resistance before in their area. These words also underscore a biological fact — bacteria evolve faster than what we can throw at them. Significantly however, the health administration in the U.S. quickly stepped in to prevent spread, yielding lessons for India.
After detecting the superbug, the Nevada hospital isolated the woman. Screening of other patients admitted to the same unit at the hospital did not show spread. The CDC also affirms that a surveillance programme under way since 2010 for multidrug-resistant bacteria in Washoe County, an area home to over 4,00,000 Americans, did not show any additional NDM-1 cases.
Contrastingly, large public hospitals in India — often the only point of care for most Indians — do not have comprehensive policies concerning antibiotic use and infection control. In private conversations with the writer, doctors at one of the two biggest government hospitals in Hyderabad have confided rampant irrational and incorrect antibiotic prescription practices within the institution, highlighting need for hospital-level policies. Private hospitals that claim to have robust infection-control practices and limited patient screening, admit it is hard to match American efforts.
Consequently, reports of colistin resistance from India in recent years have increased as dependence on it grows due to widespread resistance to other antibiotics. A study published by Indian researchers earlier this month in the Journal of Evidence Based Medicine and Healthcare described colistin- and carbapenem-resistant K. pneumoniae in newborns diagnosed with sepsis at a tertiary hospital in Jamshedpur. Fourteen of the 60 babies infected with bacteria following an outbreak between March and July 2016 reportedly died.
Lack of an action plan
Irrational antibiotic use both among humans and animals is recognised as one of biggest drivers of antimicrobial resistance (AMR). The World Health Organisation reported in the findings of a 2015 multi-country survey that 75% of respondents in India said they believed antibiotics treated flu and only 58% reported they knew use of antibiotics should only be stopped when the prescribed course ends. WHO has said candidly in the past that India lacks a National Action Plan to combat AMR.
However, a policy to combat antimicrobial resistance has been in place for more than five years. It envisages a separate schedule for antibiotics to prevent sale without prescription, hospital surveillance systems for monitoring resistance, enforcement of regulation in veterinary use of antibiotics and rational prescription of antimicrobials through evidence-based medicine. Sans an action plan, the policy remains unimplemented. The National Centre for Disease Control is now formulating a pilot plan.
“In Indian labs, it is not uncommon to test bacterial mixtures for a few antibiotics available at hand and unethically report sensitivity findings for as many 20 antibiotics, assuming findings from past testing apply. This is done to justify the cost,” says Sonam Kapur, senior professor, Department of Biological Sciences at BITS Pilani, Hyderabad. Prof. Kapur and her team of researchers have created a table-top device that can test antibiotic sensitivity of a urine sample in four hours as against conventional microbiological testing that takes anywhere between 24 and 72 hours.
For Prof. Kapur, the need for evidence-based medicine today is as much about resistance as it is about cure.
rohit.ps@thehindu.co.in
