Maryn McKenna

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Cost of Compassion: Drug Resistance in Military Hospitals

August 24, 2011 By Maryn Leave a Comment

Back in June, there was an unnerving report from the Centers for Disease Control and Prevention that NDM-1, the “Indian supergene” that renders common hospital-acquired infections practically untreatable, had been found in the military hospital at Bagram Air Base in Afghanistan.

The gene was being carried by a gut bacterium, Providencia stuartii, that was causing septicemia in an Afghan national who had been taken in by the military hospital. The particular strain of NDM-1 could be treated only by a single drug, aztreonam; it was resistant to everything else. Unsurprisingly, the victim died.

Though it wasn’t explicitly stated, the subtext of the CDC’s brief bulletin was clear: By extending compassion to the local resident (who was badly burned and had been treated at a hospital in Kabul), the military staff had brought into their hospital a highly resistant organism that could endanger their troops. It made me wonder, at the time, how often this happened, and what the consequences might be.

A study performed at Bagram, and published this month in Infection Control and Hospital Epidemiology, supplies an answer, and it’s a troubling one.

[Read more…]

Filed Under: Science, Science Blogs, Superbug Tagged With: Acinetobacter, gram negative, Military, Resistance, Science Blogs

NDM-1 in a U.S. Military Hospital in Afghanistan

June 9, 2011 By Maryn Leave a Comment

File under: Really not good news.

Deep in the back of the weekly bulletin of the Centers for Disease Control and Prevention, there is a note that NDM-1, the “Indian supergene,” has been isolated from a patient in a U.S. military field hospital in Bagram, Afghanistan.

It’s been a few months since NDM-1 was in the news, so let’s recap. The acronym (for “New Delhi metallo-beta-lactamase 1”) indicates an enzyme that allows common gut bacteria to denature almost all the drugs that can be used against them, leaving two or three that are inefficient or toxic. It was first identified in a resident of Sweden, of Indian origin, who had returned to India for a visit, was hospitalized there, went back to Sweden, and was hospitalized again.

[Read more…]

Filed Under: Science, Science Blogs, Superbug Tagged With: Acinetobacter, gram negative, Military, NDM-1, Resistance, Science Blogs

NDM-1: More Evidence It Started in India

January 5, 2011 By Maryn Leave a Comment

So it looks like the researchers who named NDM-1 — New Delhi metallo-beta-lactamase, the “Indian super-enzyme” that renders common gut bacteria impervious to all but one or two antibiotics — were right all along.

According to a study just published in Antimicrobial Agents and Chemotherapy, the problematic gene that produces it has been circulating in Indian hospitals since at least 2006.

Kinda undermines the claims by Indian politicians and the country’s health ministry that the resistance factor did not originate in India, but was given its name in an act of “malicious propaganda” aimed at undermining the subcontinent’s multimillion-dollar medical-tourism industry.

A brief recap: [Read more…]

Filed Under: Science, Science Blogs, Superbug Tagged With: gram negative, india, NDM-1, Resistance, Science Blogs

NDM-1: The early warnings

August 18, 2010 By Maryn Leave a Comment

Sorry to drop out of sight, constant readers; a little medical emergency at Casa Superbug, but all better now. There are some new developments regarding the novel resistance factor NDM-1, which renders Gram-negative bacteria resistant to almost all antibiotics:

  • Germany has announced its first identifications — plural, apparently. (Bloomberg News)
  • Vietnam says it has also recorded its presence.  (Thanh Nien Daily, h/t H5N1)
  • And France says that it will begin testing for the gene’s presence in bacteria carried by patients being admitted to hospitals, in hopes of keeping the plasmid from transferring to other bacterial species and creating a wider resistance problem. (Agence France Presse) This is a reasonable fear; it is analogous to the process by which MRSA became vancomycin-resistant (VRSA), by acquiring the gene for vancomycin resistance from VRE, vancomycin-resistant Enterococcus. But there’s much more to be said about what it will take for a hospital to keep this bug from entering or spreading; more on that in a future post.

Before we  get too much further from the initial news, I want to go back over
the history of NDM-1’s discovery — because, as with so many superbugs that take the public by surprise (recall the furor when the CDC’s estimate of 19,000 MRSA deaths a year was published in late 2007), it turns out that there have actually been alarm bells ringing on this for a while. Largely, of course, unheard.

The first finding was in an older man of South Asian origin, living in Sweden, who went back to India in 2007, was hospitalized in New Delhi as a result of longstanding health problems, returned to his new home, was hospitalized there also in January 2008, and was discovered there to be carrying this resistance factor. The first public description of his case was made in
October 2008, during a poster session at the annual ICAAC meeting (Interscience Conference on Antimicrobial Agents and Chemotherapy). That was later expanded to a journal article that was published in Antimicrobial Agents and Chemotherapy in
December 2009; the full text is online in PubMed Central.

In the interim, though, the UK’s Health Protection Agency published its first alert, in
July 2009, describing 19 patients carrying this resistance  in 2008 and the first half of 2009, 9 of whom had received medical care in South Asia:

One UK patient, who developed a bloodstream infection with an E. coli that produced NDM-1 enzyme had received treatment for a haematological malignancy in both India and the UK; two others had undergone cosmetic surgery in India and one of these presented to a UK hospital with a wound infection that grew a mixed microbial flora including K. pneumoniae with NDM-1 enzyme; others had received renal or liver transplantation in Pakistan.

Meanwhile, other researchers in Europe were becoming alert to the threat that NDM-1 posed if it were to spread widely; English researchers warned of it in
September 2009, and Scandinavian researchers did the same in
November 2009.

And in
June 2010, the CDC published its first report and warning of NDM-1 in patients in the US, noting that all three, who lived in different states, had received medical care in India.

But what’s important to note is that,  despite the surprise and indignation coming from South Asia after the publication of last week’s Lancet Infectious Diseases papers (article, editorial) describing the spread of NDM-1, the existence of that resistance factor has been discussed in Indian medicine since sometime last year.

From
August to November 2009. a team of physicians at the Hinduja National Hospital and Medical Research Centre in Mumbai surveyed their ICU patients, and found 22 isolates carrying NDM-1. Their paper was submitted very quickly, in
December 2009, and published in March 2010 in the Journal of the Association of Physicians of India:

We sought to identify NDM-1 positive strains among the carbapenem resistant Enterobacteriaceae isolates at our tertiary care centre. In a short span of 3 months, we identified 22 such organisms. The physicians at our institute follow the hospital antibiotic policy and do not indiscriminately use carbapenems. However being a tertiary centre we receive transfer in cases / referrals from other hospitals… The identification of NDM-1 in 22 of 24 isolates is a worrisome development indeed. NDM-1 being present among Enterobacteriaceae has the potential for further dissemination in the community. Such dissemination may endanger patients undergoing major treatment at centres in India and this may have adverse implications for medical tourism. Besides stringent infection control in hospitals, good sanitation in the community is also needed to contain the spread of such clones. (Deshpande et al., JAPI 2010)

News of their finding must have percolated through Indian medicine, because in
January 2010 — before their paper was published — a worried letter discussing NDM-1, by a South Asian scientist working at the Royal Infirmary of Edinburgh, was published in the Indian Journal of Medical Microbiology:

The virtual nonexistence of antibiotic policies and guidelines in India to help doctors make rational choices with regard to antibiotic treatment is a major driver of the emergence and spread of multidrug resistance in India. This is augmented by the unethical and irresponsible marketing practices of the pharmaceutical industry, and encouraged by the silence and apathy of the regulating authorities. Poor microbiology services in most parts of the country add to the problem. (Krishna, IJMM 2010, DOI: 10.4103/0255-0857.66477)

 And in
March 2010, Dr. K. Abdul Ghafur of the Apollo Hospital in Chennai published a passionate and despairing call to arms (“An obituary — on the death of antibiotics!“) alongside the Mumbai team’s findings. The full text is online and it is worth reading in its entirety:

Our country, India, is the world leader in antibiotic resistance, in no other country antibiotics been misused to such an extent. Microbes are the ultimate warriors. They have sophisticated weapons and use ingenious methods of attacks. They have always been many steps ahead of us. Even in the twenty first century with all the developments in the modern medicine, when we face microbes, we feel helpless. Whatever weapons we had in the form of antibiotics, we ourselves have ruined them. Indian medical community has to be ashamed of the NDM-1 (“New Delhi Metallo-1”) gene. Even though we have not contributed to carbapenem development, we have contributed a resistance gene with a glamorous name. The overuse of antibiotics is embedded in our Indian gene. It is an Indian tradition. (Ghafur, JAPI 2010)

That Ghafur’s plea went unheard is all the more striking — because for almost a decade, Indian researchers had been reporting, in their own journals, a steady and troubling expansion of carbapenem resistance in Indian hospitals. More on that when I post next.

Filed Under: Science, Science Blogs, Superbug Tagged With: gram negative, india, NDM-1

NDM-1: Novel, global, complex and a serious threat

August 11, 2010 By Maryn Leave a Comment

There’s news today in the journal Lancet Infectious Diseases of the further spread of a troubling new resistance problem that I first talked about in June: Gram-negative bacteria carrying a novel resistance factor that has been dubbed New Delhi metallo-beta-lactamase, or NDM-1.

In writing about resistant bacteria, it’s difficult to avoid overusing superlatives — but this resistance mechanism has spread widely, been transported globally, and brings common bacteria up to the brink of untreatable. It already has been found in India and Pakistan, Sweden, the Netherlands, Australia, Canada and the US, and has been distributed not just by travel but specifically by medical tourism. It has the potential to become an extremely serious global threat.

Pages: 1 2

Filed Under: Science, Science Blogs, Superbug Tagged With: gram negative, india, NDM-1, Science Blogs

News break: CDC alert on imported novel resistance

June 24, 2010 By Maryn Leave a Comment

There’s a troubling item in this afternoon’s issue of the CDC’s Morbidity and Mortality Weekly Report or MMWR: The first report in the United States of a novel resistance mechanism that renders gram-negative bacteria extremely drug-resistant and that has been linked to medical care carried out in India or Pakistan.

The short item describes three isolates (E. coli, Klebsiella pneumoniae and Enterobacter cloacae) found in three patients in three states between January and June of this year. All three isolates produced New Delhi metallo-beta-lactamase (NDM-1), which has never been recorded in the US before. Because of that novel mechanism, the three isolates were resistant to the carbapenems usually used on the most serious gram-negative infections, in fact to all beta-lactam antibiotics (penicillins, cephalosporins, carbapenems, monobactams, etc.) except for one monobactam, aztreonam — and they were also resistant to aztreonam through another mechanism that hasn’t been identified yet. All three of the patients found carrying this novel resistance factor had undergone medical care in South Asia recently.

This may be the first finding of this mechanism in the US, but it’s been causing alarm in Europe for at least two years.

[Read more…]

Filed Under: Science, Science Blogs, Superbug Tagged With: gram negative, india, NDM-1, Science Blogs, UK

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