NDM 1: New Delhi Metallo-Beta-Lactamase-1

NDM 1 or New Delhi Metallo-beta-Lactamase 1, is a Plasmid mediated gene which confers high degree of antibiotic resistance in bacteria which carries this gene, particularly against Penicillin group, Cephalosporins, Fluoroquinolones and Cabapeneme Group of antibiotics! And thus is a potential threat to the entire health care delivery system!

Carbapeneme Back Bone

The NDM-1 enzyme was first described by Yong et al. in December 2009 in a Swedish national who fell ill with an antibiotic-resistant bacterial infection that he acquired in India. The infection was unsuccessfully treated in a New Delhi hospital and after the patient's repatriation to Sweden, a carbapenem-resistant Klebsiella pneumoniae strain bearing the novel gene was identified. The authors concluded that the new resistance mechanism "clearly arose in India, but there are few data arising from India to suggest how widespread it is." 
In March 2010 a study in a hospital in Mumbai found that the majority of carbapenem-resistant bacteria isolated from patients carried the bla_NDM-1 gene.

Colistin

In May 2010 a case of infection with E. coli expressing NDM-1 was reported in Coventry in the United Kingdom. The patient was a man of Indian origin who had visited India 18 months previously, where he had undergone dialysis. In initial assays the bacteria was fully resistant to all antibiotics tested, while later tests found that it was susceptible to tigecycline and colistin. The authors warned that international travel and patients' use of multiple countries' healthcare systems could lead to the "rapid spread of NDM-1 with potentially serious consequences".

As of June 2010, there were three reported cases of Enterobacteriaceae isolates bearing this newly described resistance mechanism in the US, the CDC stated that "All three U.S. isolates were from patients who received recent medical care in India." However, US experts have stated that it is unclear if this strain is any more dangerous than existing antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus, which are already common in the USA.

In July 2010 a team in New Delhi reported a cluster of three cases of Acinetobacter baumannii bearing bla_NDM-1 that were found in the intensive care unit of a hospital in Chennai, India in April 2010. As previously, the bacteria were fully resistant to all the aminoglycoside β-lactam and quinolone antibiotics, but were susceptible to tigecycline and colistin. This particularly broad spectrum of antibiotic resistance was heightened by the strain bearing expressing several different resistance genes in addition to bla_NDM-1.

NDM-1 Maping: Indian Subcontinent and Great Britain

A study by a multi-national team was published in the August 2010 issue of the journal The Lancet Infectious Diseases. This examined the emergence and spread of bacteria carrying the bla_NDM-1 gene. This reported on 37 cases in the United Kingdom, 44 isolates with NDM-1 in Chennai, 26 in Haryana and 73 in various other sites in Pakistan and India. The authors' analysis of the strains showed that many carriedbla_NDM-1 on plasmids, which will allow the gene to be readily transferred between different strains of bacteria by horizontal gene transfer. All the isolates were resistant to multiple different classes of antibiotics, including beta-lactam antibiotics, fluoroquinolones, and aminoglycosides, but most were still susceptible to the polymyxin antibiotic colistin.

And hence many of the western countries have warned their citizens not to avail the cheaper health facilities (specially the Cosmetic Surgeries) in the Indian subcontinent! They have also warned that availing multi-countries' Health care facilities may lead to rapid spread of this gene and may create a pandemic like situation!

So, the question is are we really responsible??

My opinion, Yes we may be! I say so because of to main reasons: First, the general practice that we clinicians follow here is 'Hit and Trial' method of treating the diseases and thereby exposing our weaponry (Antibiotics) to the microbes. Their genes get a 'new thing' to mutate against! Secondly, the ease with which drugs (specially the antibiotics) can be procured from the pharmacists! Antibiotics are just like OTC drugs (Over the Counter) here in India. In west, they keep the record of each and every pill! Who prescribed it? For what?? Who took it?? and so on....

This misuse of antibiotic, I guess, is the root of all evil... This has to be stopped! I don't know what will be the financial consequences of tight regulation of medicines? If you happen to read CMDT or Harrison you can see the cost of drugs in their columns! Its way too high... what we get here in rupees they have to pay for the same in Dollars!! ( i.e. if we pay 50 rupees they pay 50 dollars approx.!!!!) 

What's the conclusion then??
We just can't close our eyes and ignore the study that has been conducted. The study has brought forward a serious issue which needs immediate addressing! And we also can't deny the fact that we have been irrational in antibiotics use and also that we don't have a proper regulatory mechanism/policy for the distribution and its use! And that is why, I guess, Asia is among the hot-spots of emergence of drug resistance. 

I think, we just need to put this blame game- who is responsible who is not aside, and think as responsible minds how to contain NDM1 spread... and prevent it from being a new pandemic! And am sure we will find our way through...

Dr. Virat Kuntalam

dr.viraat@gmail.com

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