India faces higher risk from super bug

Brushing aside theories that NDM1 should be treated like any other drug-resistance strain, the scientists asserted that it was a far more serious threat than other forms of drug resistance and India is extremely vulnerable because of its poor sanitation and unregulated antibiotic use.

Responding to a series of letters in the November issue of the journal “Lancet Infectious Disease”, many of which are written by angry Indian doctors, six members of the original team said that the bacteria is “extremely promiscuous” which not only spread very fast in the last three years but also crossed the “genus barrier”, which will make its management more tough for the doctors in future.

Limited options

Researchers said NDM-1 was more dangerous than MRSA (another super-bug called methicillin resistant staphylococcus aureus). While MRSA is a “gram positive bacteria” for which more drug options are available, NDM-1 is a “gram negative” bacteria with limited treatment options.

Gram negative bacteria are difficult to treat as they have an additional membrane around their cell walls, that protects them against many antibiotics. Bacteria with NDM-1 potentially herald the end of treatment with drugs like beta-lactams, fluoroquinolones and aminoglycosides – the main antibiotics for gram negative bacteria.

Reporting of NDM1 in the same journal in August triggered a major controversy because of its concluding paragraph in which authors cautioned the UK patients to rethink on visiting the Indian subcontinent for surgeries or other expensive medical infections because the NDM-1 risk may outweigh the benefits in the long run.

This quote was taken to be a general warning against medical tourism to India, which currently caters for 4,50,000 patients per year, generates $ 2 billion per year and is expected to increase by 30 per cent every year. The Centre, however, downplayed the cautions and discredited the research.

The authors said out of the 29 UK patients, 17 had previously travelled to the subcontinent, with 14 being hospitalised there. Even though the UK reference laboratory was looking for carbapenem resistant bugs since 1998, more than five super bug cases were beginning to show up from 2008. In the same year, NDM-1 appeared.

NDM-1-positive bacteria, mostly with direct links to India or Pakistan, were reported in Australia, Austria, Canada, Belgium, France, Germany, Hong Kong, Japan, the Netherlands, Norway, Oman, Sweden, Singapore, Taiwan, the UK, and the USA.

Unregulated antibiotic use

Because of “heavy and unregulated” antibiotic use and poor sanitation, many NDM-1 bugs in the gut can spread to a wider population through the faecal-oral route. According to a UN report, 65 crore people in India do not have adequate sanitation, and the sewage treatment system in Delhi struggles to cater for 50 per cent of the population. 

“This paradox (state of the art surgery vs poor sanitation) presents an immense challenge and should be of great concern to WHO and to the Indian health authorities,” the authors said.