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The new ‘superbug’: The tip of an iceberg?   

The recent report about the origin of new multi-drug resistant gram-negative enteric bacteria from India in a reputed international medical journal and the allegations of ulterior motives behind this report have raised a controversy of sorts in both academic and non-academic circles. People from India or those NRI suffering from prejudice meted out by their bosses in western world have reacted sharply, condemning the authors and their ‘backers’ for blaming Indian health infrastructures particularly the big corporate hospitals in metro cities for the mess. Many see this an attempt to hurt the burgeoning medical tourism industry of the country.

I was a bit surprised. Not because of the turn of events that followed publication of the article. It was quite expected. We are not good at taking criticism in a healthy way. The way ICMR, health ministry, and particularly the health minister have responded to the above report reflects as if the health ministry is running some very efficient bacterial surveillance program in the country and someone has castigated its performance. As a matter of fact, there is hardly any indigenous program run by the health ministry or by the other health agencies. Barring few individual surveillance programs of international agencies, we hardly have any surveillance of bacterial pathogens in the country. Rather than accepting the malaise and making efforts to initiate a comprehensive surveillance program to estimate the real burden of drug-resistant pathogens, improving hospital infection control methods and sanitation, and launching an effective policy for rational use of new antimicrobials, the minister chose a more convenient way of out-rightly rejecting the findings and dismissing the report as a deliberate attempt by western outfits to discredit Indian hospitals. The ICMR also ruled out such an existence and blamed bias toward India as the main reason behind publication and pointed fingers at conflicting interests of the authors of the paper. This is the real malaise that is not confined to health ministry. In fact, every government department and every official reacts in this knee-jerk manner.

But, these were not the reasons for my surprise. The long time lag in spotting these resistant bugs and bringing their existence in to public domain were the most amusing. These bacteria are doing rounds for last few years. Why didn’t anyone notice this phenomenon for all these years? Why flurry of reports only after publication or presentation of these findings at international conferences?

I think, we should not bother about the real origin of this group of bacteria or the real intent of the authors behind the publication. The more worrisome is the fact that this is indeed a reality and we must remain prepared to face the stiff challenge posed by the gram negative community. So far, the carbapenems are thought to be really invincible tools in our armory to take on tough pathogens, especially the in-house grown bugs. However, the occurrence of these new resistant mechanisms has undermined their paramount position. We are frequently getting nosocomial infections by the Enterobacteriaceae and other gram negative organisms resistant to carbapenems for last 2-3 years in our neonatal ICUs. These groups of bacteria are becoming increasingly difficult to treat and eradicate. And this is not very surprising considering the ease with which even General Practitioners get access to these salts at their backyards and the amount of indiscriminate use in the last 5 years. This is indeed a very scary situation. The reasons and remedies are all known to us but very difficult to implement, enforce and practice. What are the options now? The only group of antibiotics showing some sensitivity against this group of bacteria is older antibiotics like Polymyxin-B and Polymyxin-E (also called as Colistin). So we are left with very limited options and are forced to use these potentially toxic antibiotics with very limited data on safety and efficacy of their intravenous use in pediatric and neonatal age groups. So far, they seem to be working in combination with other antibiotics, but for how long?

What is the way out, then?

There is a gap between the burden of infections due to multidrug-resistant bacteria and the development of new antibiotics to tackle them. There is a need to review the antibiotic prescription practices of the clinicians. Often, high-end antibiotics are prescribed for infections caused by viruses! Unfortunately, majority of the prescriptions are irrational as they are based by the information gathered from representatives of pharma companies, especially for the newer antibiotics. There is a need to check and control on the prescriptions of any newly introduced broad-spectrum antibiotics or that target highly resistant organism both in indoor and outdoor practices.

Hospital antibiograms can be a useful means for guiding empiric therapy and tracking the emergence of bacterial resistance among nosocomial isolates. Antibiograms may be distributed as printed cards, as part of institutional handbooks on antimicrobial therapy, or on the institutional intranet. In fact, the antibiograms are the major factor that converts antimicrobial therapy from “empiric” to “rational”. The concept of “empiric” antibiotic therapy should be changed to the more rational “presumptive antimicrobial therapy” based on the info gained from locally prepared antibiograms.

Further, there should be active surveillance of antibiotic use and resistance rates and all attempts should be made to optimizing antibiotic use with treatment guidelines along with education of professionals and the public. Prevention of acquiring new resistance can be achieved with infection control measures and immunization. Industry should also revise its antibiotic development policy and international health agencies, national governments and NGOs should support them in financial resource mobilization and slackening of regulatory issues. There should be refined regulation of antibiotic registration for use with central prescribing restrictions and advertising restrictions.

Apart from the medical consequences of antibiotic resistance there is a direct cost to society. Newer antibiotics come with a higher cost, implementing hospital practices to control spread of resistant bacteria and investigation of outbreaks add to the cost of health care. Society expects antibiotics to be inexpensive in comparison with other therapeutics. Perhaps this must change. We should remember the words of Adam Smith: “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest”.

-Vipin M. Vashishtha,

August 29, 2010, Bijnor.