Of bugs, superbugs and the buggers galore !!

The last week in the Indian media has been raging with reports about a new superbug, a new plasmid which confers resistance to all beta-lactam antibiotics which are of course our primary mode of treatment for gram negative bacterial infections. More than the concern for the antibiotic resistance, the media and the Indian politics is going gung-ho about the 'assumed' implications for medical tourism in India and the supposed attack on national pride!

It is appalling that the media is blowing an issue completely out of proportion without a clear understanding of the science behind it. There have been accusations to the tune of a conspiracy by the western powers to destroy the burgeoning medical tourism in India. The involvement of Wellcome trust and the Wyeth pharmaceuticals as funding sources for the study is also used as insinuations against the Western powers. The fact of the matter is that the media is trying to blow up a story without an accurate understanding and this is only diverting the public focus from the more important issue of the development of resistance in microbes to the other peripheral issues of private funding, national pride etc etc.

I am trying to present here the issue as i see it with my limited perspectives... based on a reading of the research paper and some of the more rational and balanced news reports...

Firstly, one must realize that bacteria from clinical and non-clinical settings are fast becoming resistant to conventional antibiotics. This is not a new phenomenon and has been a potential problem that was known for a long time. Since the bacterial life spans are short, the development of resistance in bacteria was always well anticipated and this has spurred the search for newer and newer antibiotics for a very long time. The possibility of horizontal gene transfer in bacteria only hastens the process of acquisition of resistance several fold and this has also been know for long!

Ten years ago, concern was focused on gram positive bacteria, particularly the meticillin-resistant Staphylococcus aureus (MRSA) and the Vancomycin-resistant Enterococcus spp. The current concern arises because clinical microbiologists are increasingly agreeing that multi-drug gram negative bacteria pose the greatest threat to public health particularly since there are fewer new and developmental antibiotics active against gram-negative bacteria. The increase in the resistance of Gram-negative bacteria is mainly due to mobile genes on plasmids that can readily spread through bacterial populations. Human air travel and migration, which are happening at unprecedented levels now, are also reasons for the spread of such resistance markers.

So what's the latest hue and cry all about ?

The latest in line of acquired resistance among bacteria is the new so-called super bug... This drug resistance bacterial gene, the so called super-bug was named as NDM-1 or New Delhi Metallo-beta-lactamase-1... Why NDM-1? Well, because, as is customary in the naming of a new pathogen or organism or species or chemical, NDM-1 was first identified in 2009 in a Swedish national who was admitted in New Delhi.

But for some reason this nomenclature for the plasmid is being perceived as a national insult especially in the way it is being projected in the media by the politicians... No one raised a question when Nasikabatrachus sahyadrensis, a new frog species found in Sahyadari was named so... There is even a Mycobacterium lineage named after Beijing... I don't remember Beijing raising a storm over that !! This is not a question of national pride... it is just a tradition of scientific nomenclature. How can we want to claim our name on anything complimentary (however distantly related it might be - from V Ramakrishnan's Nobel to the identification of N. sahyadrensis !!) and shun anything which might be remotely incriminating ? Why is the Indian media not putting forth the facts as they are and instead feeding the public frenzy ?

The entire controversy however began when Lancet Infectious Diseases published a study by Kumaraswamy et al in august 2010 ("Emergence of a new antibiotic resistant mechanism in India, Pakistan and the UK: a molecular, biological and epidemiological study"). The study reports the identification of gram negative enterobacteriaceae strains which are found to be resistant to Carbapenem, which is a powerful antibiotic and one of the last lines of treatment for infections caused by gram negative bacteria. The present report, has carried out a large scale sampling of enterobacteriaceae from different cities in India and the UK and has identified a good proportion of the bacteria to be resistant to Carbepenem. Interestingly, a previous study published by Journal of association of Physicians of India (JAPI) in March, around 22 cases of Carbapenem-resistant NDM-1 were collected within three months from a Mumbai hospital. Thus, the entire issue is not necessarily new although it has come to public light only relatively recently.

Magnitude of the problem ?

While i am saying that there is a needless media created hype surrounding the issue, the fact of the matter is that the issue is indeed important. The rise of resistance species is of critical importance and a recent editorial by Dr Ghafur highlights the major issues associated with this "super bug" in the Indian context in sharp, punishing tones !

The situation is critical especially in India since resistance to extended-spectrum beta-lactamases (ESBL) drugs like the third-generation Cephalosporins is between 60 to 70% on average, compared to the less than 15% seen in the developed countries. Thus, a more common way of treating the severe form of ESBL infections is through the use of Carbepenem - which becomes the drug of choice as it has the lowest resistance and the broadest action against gram negative infections. The emergence of resistance against Carbepenem is bad news undoubtedly but for the patients and physicians in India who now have to look for new antibiotics but this is a self created nuisance too. The spread of resistance is not surprising keeping in view the fact that the drug is over used by the physicians. The easy over-the counter availability of these drugs also makes the problem more acute as patients end up self medicating in sub-lethal doses (For the bacteria of course), thus, leading to the acquisition of resistance. These are problems which have been known to the medical community for a very long time but have not been addressed by the government, the media or the Public...

It took a report such as this where the introduction of NDM-1 to the UK was attributed to the emergent practice of medical tourism (where a number of patients in UK were coming to India for medical treatment, esp for things like cosmetic surgery, dental treatment etc as a cost effective measure which could aid the NHS in saving money). The Indian politicians of course do not want to let go of this easy source of foreign exchange and are over zealously contradicting the problem. The fact of the matter is that medical tourism is only part of the reason for the spread of the disease. In fact, typing the plasmid did not even identify common strains of E. coli of K. pneumoniae between the indian subcontinent and the UK or between the north and south India, suggesting disparate origins. The Indian subcontinent has always been a rich source of many infectious diseases - HIV, TB, Enterobacterial infections, malaria, dengue etc etc. There never was a hue and cry about any of these diseases ever affecting medical tourism. The western countries are also battling with their share of health concerns - emergent resistant strains like MRSA, VRSA; increasing health care costs etc etc. No one is going to stop traveling there !! Also the spread of the NDM-1 plasmid can occur because of routine travel of people... and there is no way that travel across the world is going to come down because of this "superbug"!!

It is thus pragmatic that the Indian media focus on the more important issues such as educating people against self medication and the government focus on increasing its efforts towards R&D for newer more effective treatments and towards getting a more accurate picture of the actual spread of the superbug; instead of raising a hue and cry about something which is frivolous and a completely fruitless exercise !!

The Indian government, public, medical community and the media need to work in close synchrony to understand the real severity of the problem and to counter the same - if not for the foreign currency but for the future health of this country where epidemics spread faster than wild fire and where health is already a major challenge. Thus, instead of creating a storm in the tea cup, the Indian media, the public and the politicians should focus on the threatening storm on the horizon and be prepared for that !!!