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ANTIMICROBIAL RESISTANCE - INDIA

********************************A ProMED-mail post<http://www.promedmail.org>ProMED-mail is a program of theInternational Society for Infectious Diseases<http://www.isid.org>; Date: Thu 1 May 2014Source: The Times of India, Mumbai/Times News Network (TNN) [edited]<http://timesofindia.indiatimes.com/city/mumbai/Drug-resistance-now-routine-even-in-typhoid-doctors-want-antibiotic-policy/articleshow/34495091.cms?>; While an antibiotics policy is on the anvil for the 3 major municipalhospitals in Mumbai, the majority of private hospitals, nursing homes,and standalone consultants there continue to prescribe antibioticsarbitrarily. Studies show the rate of resistance to antibiotics hasquadrupled from 5 percent to 20 percent in civic hospitals. What therate is in private hospitals remains anyone's guess. A WHO report released on Wednesday [30 Apr 2014] warned that the worldis darting towards a post-antibiotic era, where common infections andsurgeries can turn fatal because of ineffective drugs. Unsurprisingly,the report has set alarm bells ringing. It says that many of the 114nations that contributed to the study lack measures to curb drugresistance. India may be among these since it is still designing anational policy whose implementation may take years. Given the prevalence of drug resistance, years may be too long a wait. Recently, a Nalasopara woman suffered multiple complications,necessitating 2-month hospitalization, after being infected with methicillin-resistant _Staphylococcus aureus_, a hospital-acquired infection that can become life-threatening. A child birth at Cama andAlbless Hospital had become near-fatal for the 33-year-old mother. Inanother case, a man spent about a month at PD Hinduja Hospital after contracting pneumonia and developing resistance to the medication. "Resistance to the best of antibiotics is turning routine. Not justfrom hospital, people are getting resistant bugs directly from thecommunity. We see resistance in ailments like gastroenteritis,pneumonia, typhoid and malaria," said Dr Khushrav Bhajan, intensivist,Hinduja Hospital. Many like Dr Bhajan feel the abuse of antibiotics begins with general physicians, continues with hospitals and nursing homes operating without antibiotic stewardship, and extends to the local chemist whodispenses drugs without valid prescription. "Barring a few majorhospitals, nobody has a policy to regulate antibiotic use," said DrLalit Kapoor of the Association of Medical Consultants. "Worse are thecombinations of drugs used." Specialists concede that prescription ofmultiple antibiotics by doctors is sometimes at the insistence ofpatients wanting to recover quickly. Appropriate drug combinations hold the key to beat resistance, said DrRohini Kelkar, head of Tata Memorial Hospital's microbiologydepartment. "It is preferred to a single antibiotic regimen. Theproblem is that clinicians treat the bacteria, not the infection." [Byline: Sumitra Deb Roy] --Communicated by:ProMED-mail from HealthMap Alerts<[e-mail]> [This news report above refers to a recent WHO publication (1) and itssummary (2), which ProMED-mail posted on 1 May 2014 (Antibioticresistance - worldwide: WHO 20140501.2442194). 1. Antimicrobial resistance: global report on surveillance -- 2014.Full report:<http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1>.2. Antimicrobial resistance: global report on surveillance -- 2014Summary:<http://apps.who.int/iris/bitstream/10665/112647/1/WHO_HSE_PED_AIP_2014.2_eng.pdf?ua=1>;. In this report, WHO cited increasing antibiotic resistance in the WHOSouth-East Asia Region, which is home to a quarter of the world'spopulation, specifically mentioning high levels of Enterobacteriaceaeresistance to 3rd generation cephalosporins and fluoroquinolones andhigh levels of _S. aureus_ infections resistant to methicillin. Butthe problem of antibiotic resistant pathogens in this region is muchmore extensive. It includes, for example, multidrug resistant_Mycobacterium tuberculosis_, _Salmonella typhi_ , _Campylobacter_,and _Vibrio cholerae_, carbapenemase-producing Enterobacteriaceae, anddrug-resistant malaria parasites, as has been reported in priorProMED-mail posts listed below. Antibiotic resistance is not restricted just to hospitals in India,but is circulating widely in the community, and its causes are notrestricted just to overuse of antibiotics by physicians or pharmacistswho dispense antibiotics without valid prescriptions. Its causes arecomplex and will require wide-ranging efforts to control. India is a large producer of the world's supply of genericantibiotics. In fact, India's pharmaceutical industry supplies 40percent of over-the-counter and generic prescription drugs consumed inthe United States, and the US scrutiny of Indian drug plants last year(2013) led to a flood of new penalties, including half of the warningletters the agency issued last year to drug makers(<http://www.nytimes.com/2014/02/15/world/asia/medicines-made-in-india-set-off-safety-worries.html>).This level of antibiotic production in India, however, poses risks tohuman health by exposing people and wildlife to the drugs and bycreating local environmental conditions for pathogens to developantibiotic resistance. Antibiotic resistant organisms and their mobilegenes that encode resistance to antibiotics can be incorporated in thehuman microbiome and then spread in an environment of unsanitarydisposal of human fecal waste and a contaminated water supply. A study found high levels of antibiotics downstream from a waste-watertreatment plant that received effluent water from 90 Indian drugproduction facilities near Hyderabad, India -- much higher levels thanlevels measured in waters that receive sewage effluent in the USA. Inaddition, high levels of antibiotics were found both in well waterthat was used for drinking by local villagers and in lakes that do nottake in wastewater from the sewage plant, suggesting that drugcontamination of surface, ground, and drinking water was moregeneralized (Fick J, Soederstroem H, Lindberg RH, et al: Contaminationof surface, ground, and drinking water from pharmaceutical production.Environ Toxicol Chem. 2009 Dec; 28(12): 2522-7. doi: 10.1897/09-073.1;available at<http://onlinelibrary.wiley.com/doi/10.1897/09-073.1/full>;). A subsequent study of DNA sampled from river sediment downstream fromthe Indian treatment plants identified a high prevalence of genes thatencode resistance for multiple classes of antibiotics and geneticelements (including integrons, transposons, and plasmids) thattransfer resistance genes from one bacterium to another. The resultssuggested that environmental releases of effluent contaminated withantibiotics promote resistance genes and genetic elements for theirmobility. (Kristiansson E, Fick J, Janzon A, et al: Pyrosequencing ofantibiotic-contaminated river sediments reveals high levels ofresistance and gene transfer elements. PLoS One. 2011 Feb 16; 6(2):e17038. doi: 10.1371/journal.pone.0017038; available at<http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017038>;). Extended-spectrum beta-lactamases (ESBLs) are plasmid-encoded enzymesthat mediate resistance to extended-spectrum (3rd generation)cephalosporin antibiotics as well as many other beta-lactamantibiotics, including penicillins, cephalosporins, and the monobactamaztreonam. In a study of 3004 Gram negative bacilli collected fromintra-abdominal infections in the Asia-Pacific region during 2007,ESBL rates in Enterobacteriaceae were highest in India (about 70percent or more were ESBL-producers); additionally, in India, thefrequency of ESBL-producers in the community-acquired-intra-abdominalinfections of 79.0 percent was virtually identical to that inhospital-acquired infections (78.9 percent)(<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2715591/>;). The veryhigh rates of ESBL-positive strains were seen over the entire countryand were not restricted to any single city or region. Antibiotic-resistance in bacteria has been found to be about 60 timesgreater in May and June than other times of the year in water sampledfrom the Upper Ganges River in the foothills of the Himalayas, one ofthe most pristine locations in Asia, and linked to the annual humanpilgrimages to the region, when hundreds of thousands of people visitsacred sites(<http://www.ncl.ac.uk/press.office/press.release/item/water-samples-from-the-upper-ganges-river-shed-light-on-the-spread-of-potential-superbugs>;). New Delhi metallo-beta-lactamase-1 (NDM-1) is a plasmid-encoded enzymethat mediates resistance to almost all beta-lactam antibiotics. Thegene encoding NDM-1 has been found in 51 of 171 samples of pools ofwater in streets or rivulets and 2 of 50 samples of public tap watercollected from sites within a 12 km [7.5 mi] radius of central NewDelhi (<http://www.ncbi.nlm.nih.gov/pubmed/21478057>;). Acquisition of antibiotic resistant bacteria is not only a problem forIndians living in the country, but also for tourists. A study foundthat the risk of acquisition of an ESBL-producing _Escherichia coli_was highest for travelers visiting India -- 88 percent of healthySwedish volunteers traveling to India who were negative pre-travel,were colonized with ESBL-producing _E. coli_ after the trip to India(<http://aac.asm.org/content/54/9/3564.full>;). Travel to otherdestinations was associated with the following rates of post-travelESBL colonization: 32 percent for Asia (India excluded), 29 percentfor the Middle East, 13 percent for Southern Europe, and 0 to 4percent for other parts of the world. Control of antibiotic resistance in India presents an immensechallenge. These examples suggest that control in India will requirenot only regulation of antibiotic use and infection control inhealthcare facilities, but also require much improved level ofenvironmental sanitation, quality control and testing of drinkingwater, and also improved wastewater management in one of the world'slargest centers for antibiotic production. - Mod.ML A HealthMap/ProMED-mail map can be accessed at:<http://healthmap.org/promed/p/482>.] [See Also:Antibiotic resistance - worldwide: WHO 20140501.2442194NDM-1 carrying Enterobacteriaceae - China: (HK) 20140501.2442036Enterobacteriaceae, carbapenem resistant - France: ex India20140412.23991512013----Salmonellosis, st. Paratyphi A - Japan: ex India, multidrug resistance20131117.2057055Bacterioides fragilis - USA: (WA) ex India susp, multidrug resistance20130830.1912302Campylobacteriosis - India, Canada: drug resistance 20130717.18279162012----NDM-1 carrying Vibrio cholerae - India 20120801.1224333Typhoid fever update 2012 (09) 20120420.1107274NDM-1 carrying Enterobacteriaceae - Ireland: 1st rep, ex India20120217.1044861Tuberculosis, TDR - India (04): (MH) fatal 20120119.1015543Tuberculosis, TDR - India: (MH, KA) 20120110.10056632011----Antibiotic resistance, Salmonella typhi - India (02): (Mumbai)fluoroquinolones 20111105.3296Antibiotic resistance, Salmonella typhi - India: (Mumbai)fluoroquinolones 20111031.3235NDM-1 carrying Enterobacteriaceae - India (02): nosocomial infections20111006.3009NDM-1 carrying Enterobacteriaceae - India: (New Delhi) water supply20110411.11452010----NDM-1 carrying Enterobacteriaceae (04): Taiwan ex India 20101005.3604NDM-1 carrying Enterobacteriaceae - worldwide ex India, Pakistan [phone].3325NDM-1 carrying Enterobacteriaceae - worldwide ex India, Pakistan20100817.2853NDM-1 carrying Enterobacteriaceae - N America, UK ex India20100815.28122009----Malaria, artemisinin resistance - SE Asia [phone].4386].................................................sb/ml/mj/jw*##########################################################*************************************************************ProMED-mail makes every effort to verify the reports thatare posted, but the accuracy and completeness of theinformation, and of any statements or opinions basedthereon, are not guaranteed. 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