Though a paper on the ‘New Delhi Metallo-beta lactamase bacteria’ in the latest issue of a British medical journal has led to allegations of a ‘Western plot’ to undermine medical tourism in India, the first formal documentation of NDM-1 — dubbed the ‘superbug’ because of it being resistant to most antibiotics — was done by the P.D. Hinduja National Hospital and Medical Research Centre in Mumbai last year. The study was published in the Journal of the Association of Physicians in India (JAPI) in March 2010, with an accompanying editorial on the “worrisome” outcome calling for an end to the indiscriminate use of antibiotics.
The identification of NDM-1 being present among Enterobacteriaceae has the potential for further dissemination in the community, said the study “New Delhi Metallo-b lactamase (NDM-1) in Enterobacteriaceae: Treatment options with Carbapenems Compromised” by Payal Deshpande, Camilla Rodrigues, Anjali Shetty, Farhad Kapadia, Ashit Hedge and Rajeev Soman of the Hinduja hospital.
Such dissemination may endanger patients undergoing major treatment at centres in India and this may have adverse implications for medical tourism. Besides stringent infection control in hospitals, good sanitation in the community is also needed to contain the spread of such clones, the paper concluded.
The study conducted in the hospital itself found 22 patients having NDM-1 bacteria of a total of 24 carbapenem (a strong antibiotic) organisms that were collected in a period of three months. This made the hospital come up with an antibiotic policy that did not allow indiscriminate use of carbapenems. However, being a tertiary centre, the researchers claimed the hospital received transfer cases and referrals from other hospitals.
Carbapenems are among the few useful antibiotics multidrug-resistant Gram-negative bacteria. An alert issued in the U.K. in 2009 warned of an increasing number of carbapenems-resistant Enterobacteriaceae strains identified in U.K. hospital patients, many of whom had been hospitalised in India and Pakistan and had a new type of metallo beta lactamase designated as New Delhi Metallo-1, the study said.
The superbug, a bacterial gene called New Delhi metallo-lactamase-1 (NDM-1), was first identified last year in a Swedish patient admitted to a hospital in India. The bacterium was identified in 2008, but it was given an official identity in December 2009. As a standard practice bacteria are named after the place they are believed to have originated from. In this case, it was New Delhi.
The publication of the study was followed by an editorial in the same issue of JAPI by Dr. Abdul Ghafur K., consultant in Infectious Diseases and Clinical Mycology, Apollo Hospital, Chennai, who said the study was an eye opener on the deep trouble India was in.
“If a single hospital can isolate such a significant number of bacteria with a new resistant gene in a short period of time, the data from all the Indian hospitals, if available, would potentially be more interesting and shocking than the human genome project data, which is considered as a discovery more important than the moon landing itself.”
The Indian medical community has to be ashamed of the NDM-1 gene, Dr. Ghafur wrote. Even though we have not contributed to carbapenem development, we have contributed a resistance gene with a glamorous name. The overuse of antibiotics is embedded in our Indian genes. Accusing Indian physicians of adopting an “ostrich-like” approach to the problem, Dr. Ghafur says the easiest way of tackling the superbug problem is to deny the existence of the problem: stop looking for these bugs, stop looking for the hidden resistance mechanisms and close your eyes even if you find them.
“It is an Indian tradition. Why should we Indians worry? We can always depend on honey, yogurt and cow’s urine,” his editorial piece says.
According to Dr. Ghafur, we come across multi-drug resistant or even pan-resistant Gram-negative bugs quite often and such bugs are reported in almost all major centres in India and most international centres, though to a lesser extent than in India. “We Indians are the leaders in antibiotic resistance. Many multidrug-resistant superbugs are from bacterial cultures taken at the time of admission to the hospital. By the time a patient is being admitted to a tertiary care centre, that patient has already visited many other hospitals and doctors and has received multiple courses of different antibiotics. These patients are literally walking culture plates of superbugs and you don’t have to be Nostradamus to predict their clinical outcome,” he says in the editorial.
Criticising the indiscriminate use of antibiotics in India, Dr. Ghafur also blames international and Indian pharmaceutical companies for contributing to this resistance saga. The lack of restriction on the usage of newer antibiotics with specialist spectrum has given fertile ground for companies to exert their excessive pressure on doctors to increase prescription of antibiotics.
Further, the medical curriculum lacks importance on the teaching of infectious diseases to undergraduate and post graduate students. According to him, a general medicine candidate can clear his or her examination without reading the chapter on infectious diseases and antibiotic usage.
