As a resident of New Delhi, I am not happy that bacteria reportedly impervious to almost all types of modern antibiotics now evoke images of my city. But after a week of living with the hysteria over New Delhi metallo-ß-lactamase 1 (NDM-1), I wonder if my family and I would feel significantly safer had the storm been over superbug abracadabra instead of the one named after India’s capital city.
Arguments supporting and critiquing the recent report in the Lancet Journal of Infectious Diseases about the new drug-resistant superbug continue. Most people I know, however, care more about their own health than what happens to medical tourism, and are more concerned about whether the superbug threatens Indians than how it affects the West.
In all the vitriolic exchanges on the airwaves and in the columns of newspapers in the wake of the NDM-1 controversy, a few key issues stand out. While doctors and patients clamour for newer and more powerful antibiotics to fight bugs such as NDM-1, many of them are not using existing drugs responsibly. Microbiologists have long been warning about indiscriminate use of antibiotics, which only adds to the resistance the bug develops to the medicine. A new generation of therapies to fight infections such as NDM-1 will not be fully effective until we acknowledge and address the condition in which large numbers of already immune-compromised people, including medical tourists, find themselves today.
“The basis of an infection such as NDM-1 is not always down to the hospital where the tourist received a clinical service. There are many points along the road to and from that hospital where a bacterial agent can infect the body. A patient leaving, say, the US Midwest for Mumbai for an invasive medical procedure (heart, lung, liver surgery and so on) is already immune-compromised. The long 18- to 24-hour flight and transit time exposes that patient to any number of free-floating bacteria not found in the patient’s local environment. Once in a five-star “medical tourist” hospital, the patient can be assured that the operating room personnel follow strict measures of infection control. The quality of those measures deteriorates as the patient is moved to post-operative care by nurses, nursing assistants and orderlies, and is further jeopardised by janitors, administrative staff and cleaning personnel,” pointed out Dr Jeremiah Norris, director of the Centre for Science in Public Policy, Hudson Institute, Washington DC, in a recent letter to London’s Financial Times.
The “medical tourist” package often includes a recuperation period at a beach resort such as Goa. “Once there, the recovering patient, now more immune-compromised than before he entered the hospital, is exposed to new opportunistic infections by waiters and other beach personnel. The immune-compromised patient then endures another 18- to 24-hour flight and transit time back to the US, and once en route is exposed to another set of waiting bacterial agents. Because these are indifferent to time and space, whichever latent bacterium missed its chance with the tourist in India can now mutate with those present in the new environment and infect the patient…” Dr Norris added.
While the NDM-1 controversy has been viewed largely through the prism of the medical tourism industry, the underlying problems affect locals much more. Indeed, one of the critical issues on which there is no disagreement in the otherwise polarising discussion on NDM-1 is antibiotic abuse and growing drug resistance in this country. Such drug resistance increases healthcare costs, as well as the severity and death rates from certain infections that could have been avoided with prudent antibiotic use.
Indian microbiologists have been flagging the urgent need for microbiological laboratory support for doctors and strict guidelines on antibiotic prescriptions and policies for a long time. As has been widely reported in the media, months before the NDM-1 superbug came under global scrutiny, doctors from the P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, had raised the first alarm bell on superbug infections.
The Hinduja study, published in the Journal of the Association of Physicians (JAPI), went unnoticed, Dr V. Lakshmi, head of the department of microbiology at the Nizam’s Institute of Medical Sciences, Hyderabad, told this newspaper.
“Most often high-end antibiotics are prescribed for infections caused by viruses that are obviously unresponsive to antibiotic therapy. Unfortunately, a majority of the prescriptions are irrational as they are biased by the information gathered from the representatives of the pharmaceutical companies, especially for the newer antibiotics,” Dr Lakshmi had written in an article in the Indian Journal of Medical Microbiology in 2008.
Another important issue is the indiscriminate dispensing of antibiotics off pharmacy counters without licensed prescriptions. The third deficiency in the system that exacerbates the problem is the vast differences between various microbiology laboratories across the country that are performing antibiotic susceptibility tests. Many operate without strict adherence to standard procedures.
Although several cases of antibiotic resistance and the spread of resistant strains within hospitals and the community have been published and continue to be reported from India, there is a “definite need for nationwide statistics to be generated and made available to the clinicians and infectious disease specialists. Based on these figures and resistance patterns of the prevailing common pathogens, country and region specific guidelines and policies on antibiotic prescription and usage may be formulated,” the article said.
Every three months, the microbiology department in Nizam’s Institute of Medical Sciences puts out data that include lists of organisms found from clinical samples of hospitalised patients, said Dr Lakshmi. Such practices should be replicated.
Antibiotic abuse is not unique to India or the developing world. The 2007 bestseller Good Germs, Bad Germs by Jessica Snyder Sachs pointed out: “Doctors today are definitely less likely than they were a decade ago to prescribe antibiotics when none are needed — that is, for conditions such as viral infections that don’t respond to drugs. But unnecessary prescriptions still account for around one-third of all the antibiotics we (Americans) take. In survey after survey, physicians claim that the main reasons they prescribe antibiotics unnecessarily is ‘patient insistence.’”
Behind this strange implication — that the sick are twisting the arms of doctors — is the tacit admission that physicians find it faster to scribble a prescription than to explain to a patient that antibiotics work only against living organisms such as bacteria, not against viruses — the cause of most respiratory infections, including colds and flu, noted Sachs.
Drug resistance is a worldwide problem but it is important to stress that developing countries facing such resistance have some extra challenges. “Poor environmental sanitation, nutritional deficiencies in the host and certain endemic infections further enhance the risk of dissemination of resistant strains both in the community and in health centres,” said Dr Lakshmi.
Patralekha Chatterjee writes on contemporary development issues in India and other emerging economies and can be reached atPatralekha.firstname.lastname@example.org