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Published Date: 2010-08-15 05:00:04
Subject: PRO/EDR> NDM-1 carrying Enterobacteriaceae - N America, UK ex India
Archive Number: 20100815.2812

NDM-1 CARRYING ENTEROBACTERIACEAE - NORTH AMERICA, UK ex INDIA, PAKISTAN
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[1] UK
Date: Wed 11 Aug 2010
Source: BBC [edited]
<http://www.bbc.co.uk/news/health-10925411>

A new "superbug" that is resistant to even the most powerful antimicrobial
agents has entered UK hospitals, experts warn. They say bacteria that make
an enzyme called NDM-1 have traveled back with NHS patients who went abroad
to countries like India and Pakistan for treatments such as cosmetic
surgery. Although there have only been about 50 cases identified in the UK
so far, scientists fear it will go global. "The fear would be that it gets
into a strain of bacteria that is very good at being transmitted between
patients," said Dr David Livermore, a researcher from the Health Protection
Agency.

NDM-1 can exist inside different bacteria, like E. coli, and it makes them
resistant to one of the most powerful groups of antimicrobial agents,
carbapenems. These are generally reserved for use in emergencies and to
combat hard-to-treat infections caused by other multi-resistant bacteria.
Experts fear NDM-1 could now jump to other strains of bacteria that are
already resistant to many other agents.

Ultimately, this could produce dangerous infections that would spread
rapidly from person to person and be almost impossible to treat. At least
one of the NDM-1 infections the researchers analysed was resistant to all
known antibiotics. Similar infections have been seen in the US, Canada,
Australia and the Netherlands and international researchers say that NDM-1
could become a major global health problem.

Infections have already been passed from patient to patient in UK
hospitals. The way to stop NDM-1, say researchers, is to rapidly identify
and isolate any hospital patients who are infected. Normal infection
control measures, such as disinfecting hospital equipment and doctors and
nurses washing their hands with antibacterial soap, can stop the spread.
Currently, most of the bacteria carrying NDM-1 have been treatable using a
combination of different antibiotics.

"There is little drug control in India and an irrational use of
antibiotics," Delhi-based Dr Arti Vashisth told the BBC. Doctors say common
antibiotics have become ineffective in India partly because people can buy
them over the counter and indulge in self-medication. They also take small
doses and discontinue treatment.

[byline: Michelle Roberts]

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[2] Canada
Date: Thu 12 Aug 2010
Source: The Globe and Mail [edited]
<http://www.theglobeandmail.com/life/health/doctors-brace-for-more-cases-as-indian-superbug-hits-canada/article1669006/>

At least 2 Canadians have become infected with a dangerous new "superbug"
from India that is spreading around the world, partly due to medical
tourism. The bug, which is resistant to almost all antimicrobial agents,
has Canadian public-health experts bracing for outbreaks. "There will be
others. It's just a matter of time," said Dylan Pillai, a medical
microbiologist at the Ontario Agency for Health Protection and Promotion.
"It's just the nature of the beast."

Researchers reported dozens of cases of British, Indian and Pakistani
patients who contracted infections caused by bacteria harboring an enzyme
called New Delhi metallo-beta-lactamase, or NDM-1, in the journal The
Lancet Infectious Diseases on Wednesday, 11 Aug 2010.

Of 29 Britons, more than half had recently travelled to India or Pakistan
and 14 had been admitted to hospitals in the subcontinent, where the
drug-resistant enzyme originated, including for kidney transplants and
cosmetic surgery. 2 cases have been confirmed among Canadians who spent
time in India.

"At a global level, this is a real concern," lead author Timothy Walsh, a
professor of medical microbiology and antimicrobial resistance at Cardiff
University in Wales, told Reuters. "Because of medical tourism and
international travel in general, resistance to these types of bacteria has
the potential to spread around the world very, very quickly. And there is
nothing in the [drug development] pipeline to tackle it."

In a commentary accompanying The Lancet study, Johann Pitout, a University
of Calgary professor of pathology and laboratory medicine, urged screening
patients who undergo medical procedures in India before they receive
treatment in their home countries. "The consequences will be serious if
family doctors have to treat infections caused by these multiresistant
bacteria on a daily basis," he wrote.

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[The publications referred to are:
Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic
resistance mechanism in India, Pakistan, and the UK: a molecular,
biological, and epidemiological study. The Lancet Infectious Diseases,
early online publication, 11 Aug 2010 doi:10.1016/S1473-3099(10)70143-2.
<http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(10)70143-2/fulltext>
Pitout JDD. The latest threat in the war on antimicrobial resistance. The
Lancet Infectious Diseases, early online publication, 11 Aug 2010.
doi:10.1016/S1473-3099(10)70168-7.
<http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(10)70168-7/fulltext>

As reported in the 25 June 2010 Morbidity and Mortality Weekly Report
(2010;59: 750), during the first half of 2010, 3 isolates of
_Enterobacteriaceae_, an _E. coli_, a _Klebsiella pneumoniae_, and an
_Enterobacter cloacae_, were identified at CDC to carry NDM-1 which confers
resistance to all beta-lactams except aztreonam (a monobactam) and were
also resistant to aztreonam. All 3 isolates were from patients who received
recent medical care in India.

Yong and colleagues (Yong D, Toleman MA, Giske CG, et al: Characterization
of a new metallo-betal-lactamase gene, bla-NCm-1, and novel erythromycin
esterase gene carried on a unique genetic structure in _Klebsiella
pneumoniae_ sequence type 14 from India. Antimicrob Agents Chemother.
2009;53: 5046-54). The plasmid carrying NDM-1 also carries several other
resistance genes and appears to easily transmit itself to other organisms.
The authors state "the dissemination of this plasmid among clinical
bacteria would be a nightmare scenario."

This gene cassette of wide-spectrum antimicrobial resistance appears to
have developed in the Indian subcontinent where the use of antimicrobial
agents is quite poorly controlled as stated in the above postings.
Organisms carrying this resistance combination have already been introduced
into western Europe, the USA, and Canada. The best methods of control are
rapid recognition by standard microbiologic methodology in patients having
the appropriate medical/travel history and aggressive handwashing techniques.

The amazing overuse of our current antimicrobial armamentarium that I am
currently observing in my clinical practice in the USA will no doubt serve
as an efficient multiplier of these isolates just as intravenous drug abuse
and sexual promiscuity facilitated the explosion of HIV 30 years ago. This
misuse, in my opinion, is directly related to the lack of control of
antimicrobial usage in intensive care units and emergency care settings by
intensivists and ER physicians who often react with unwisdom and "cookbook"
protocols instead of using common sense and rational prescribing patterns.
Once the patient moves out of the ICU or ER, the physicians do not even see
the products of their unwise labors.

In the USA, reimbursements for medical care are based on procedures, not
thought processes. Until the power of therapeutic nihilism is recognized,
that is, using these agents only when rational, in combinations that make
sense, and in settings where therapeutic interventions can have the ability
to produce measurable and meaningful improvement in a patient's life, the
medical community will continue down the slippery slope into an era where
no therapeutic options will exist. - Mod.LL]

See Also