In India, if chief of a medical
institution talks about the emerging “Microbial Resistance” and
constitutes an "Hospital Infection Control Committee" to take up the issue and to recommend an
“Antibiotic Policy”, most of the doctors become skeptical about
it; and think it to be an endeavour to curtail their liberty to prescribe
the antibiotic of their choice, which might have been influenced by
the Pharmaceutical Company's strategy to promote their product
adopting whatever means.
It is estimated that drug-resistant
strains of bacteria are responsible for 5,000 deaths a year in the UK
and 25,000 deaths a year in Europe; as usual the statistics from
India may be poor or incorrect.
If this trend of practising medicine
continues unabated, we are likely to face a situation, which is
variously described as, “Time Bomb”, “Leading to Dark Ages”
and “Gloomy Days Ahead” etc.
 |
| English: Magnified 20,000X, this colorized scanning electron micrograph (SEM) depicts a grouping of methicillin resistant Staphylococcus aureus (MRSA) bacteria. See PHIL 617 for a black and white view of this image. These S. aureus bacteria are methicillin-resistant, and are from one of the first isolates in the U.S. that showed increased resistance to vancomycin as well. Note the increase in cell wall material seen as clumps on the organisms’ surface. (Photo credit: Wikipedia) |
India has shown its' concern in the Chennai
Declaration, but the effect is yet to be felt in the grass root
level and more is needed to be done to further the actions to achieve
the targets of the declaration.
Antibiotic resistance is the ability of
a microorganism to withstand the effects of an antibiotic on it,
administered to kill or arrest its' growth.
Antibiotic resistance
evolves naturally via natural selection through random mutation, but
it could also be engineered by applying an evolutionary stress on a
population. Once such a gene is generated, bacteria can then transfer
the genetic information in a horizontal fashion (between individuals)
by plasmid exchange.
If a bacterium carries several
resistance genes, it is called multi-resistant or, informally, a
super-bug.
Other factors contributing towards resistance include
incorrect diagnosis and treatment with an antimicrobial, unnecessary
prescriptions, improper use of antibiotics, self medication by
patients, and the use of antibiotics as livestock food additives for
growth promotion.
Earlier
in May 2014, a Government body, NICE (National Institute for
Health & Care Excellence) said that one in 16 patients are
developing infections on NHS (National Health Service) wards because
of poor hygiene among staffs. NICE said 800 patients a day, the
equivalent of 300,000 a year, are infected by a member of staff or by
dirty equipment. It is estimated the infections cause 5,000 deaths
annually and contribute to another 15,000.According to WHO, in 2012, there were about 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant tuberculosis (XDR-TB) has been identified in 92 countries.MDR-TB requires treatment courses that are much longer and less effective than those for non-resistant TB. Resistance to earlier generation antimalarial drugs is widespread in most malaria-endemic countries. Further spread, or emergence in other regions, of artemisinin-resistant strains of malaria could jeopardize important recent gains in control of the disease.
There are high proportions of
antibiotic resistance (ABR) in bacteria that cause common infections
(e.g. urinary tract infections, pneumonia, bloodstream infections) in
all regions of the world.
A high percentage of hospital-acquired
infections are caused by highly resistant bacteria such as
methicillin-resistant Staphylococcus aureus (MRSA) or
multidrug-resistant Gram-negative bacteria.
Treatment failures due to resistance to
treatments of last resort for gonorrhoea (third-generation
cephalosporins) have now been reported from 10 countries. Gonorrhoea
may soon become untreatable as no vaccines or new drugs are in
development.
Apart from these, there has been
resistance to microbes like HIV, Fungus (Candida), C. Difficile and
Campylobacter etc.
It will be better to discuss the
pattern of developing resistance by a bacterium called Saphylococcus
aureus (colloquially known as "Staph aureus" or a Staph
infection) that has become a serious concern world-wide.
This bacterium can cause a large number
of infection in human starting from skin and soft tissue infection to
bloodstream infection, and has become resistant a host of
antibiotics.
Found on the mucous membranes and the
skin of around a third of the population, it is extremely adaptive
to antibiotic pressure. It was the first bacterium in which
penicillin resistance was found—in 1947, just four years after the mass production of the
drug started.
Methicillin was then the antibiotic of
choice, but has since been replaced by oxacillin due to significant
kidney toxicity. MRSA (methicillin-resistant Staphylococcus aureus)
was first detected in Britain in 1961 and is now "quite common"
in hospitals. MRSA was responsible for 37% of fatal cases of blood
poisoning in the UK in 1999, up from 4% in 1991.
Half of all S. aureus infections in the
US are resistant to penicillin, methicillin, tetracycline and
erythromycin. This left vancomycin as the only effective agent
available at a time.
However, strains with intermediate (4-8 ug/ml)
levels of resistence, termed GISA (glycopeptide intermediate
Staphylococcus aureus) or VISA (vancomycin intermediate
Staphylococcus aureus), began appearing the the late 1990s. The first
identified case was in Japan in 1996, and strains have since been
found in hospitals in England, France and the US.
The first documented strain with
complete (>16ug/ml) resistence to vancomycin, termed VRSA
(Vancomycin-resistant Staphylococcus aureus) appeared in the United
States in 2002.
A new class of antibiotics,
oxazolidinones, became available in the 1990s, and the first
commercially available oxazolidinone, linezolid, is comparable to
vancomycin in effectiveness against MRSA. Linezolid-resistance in
Staphylococcus aureus was reported in 2003.
Now, only a few arsenals are there with
us to treat multi-drug resiatance Staphylococcus Aureus, perhaps
drugs like quinupristin-dalfopristin, daptomycin, teicoplanin and tigecycline
etc.; and these hopes are fast fading away with reports of resistance coming in.
CA-MRSA (Community-acquired MRSA) has
now emerged as an epidemic that is responsible for rapidly
progressive, fatal diseases including necrotizing pneumonia, severe
sepsis and necrotizing fasciitis.
Methicillin-resistant Staphylococcus
aureus (MRSA) is the most frequently identified antimicrobial
drug-resistant pathogen in US hospitals. The epidemiology of
infections caused by MRSA is rapidly changing. In the past 10 years,
infections caused by this organism have emerged in the community. The
2 MRSA clones in the United States most closely associated with
community outbreaks, USA400 (MW2 strain, ST1 lineage) and USA300,
often contain Panton-Valentine leukocidin (PVL) genes and, more
frequently, have been associated with skin and soft tissue
infections.
Outbreaks of community-associated
(CA)-MRSA infections have been reported in correctional facilities,
among athletic teams, among military recruits, in newborn nurseries,
and among active homosexual men. CA-MRSA infections now appear to be
endemic in many urban regions and cause most CA-S. aureus infections.
However, the U.S. Food and Drug Administration on May 23, 2014, approved Dalvance (dalbavancin), a new antibacterial drug used to treat adults with skin
infections.
Dalvance is intended to treat acute bacterial skin and
skin structure infections (ABSSSI) caused by certain susceptible
bacteria like Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant strains) and Streptococcus pyogenes. The treatment is administered intravenously.Dalvance is the first drug designated as a Qualified Infectious Disease Product (QIDP) to receive FDA approval. Under the Generating Antibiotic Incentives Now (GAIN) title of the FDA Safety and Innovation Act, Dalvance was granted QIDP designation because it is an antibacterial or antifungal human drug intended to treat serious or life-threatening infections.
Dalvance is marketed by Chicago-based Durata Therapeutics. However, The situation is not very much encouraging and no quick solution seems to be within reach, except a much needed cohesive effort from all the stake-holders; from which the medical community can play a major and important role.
To elaborate on the causes of microbes
developing resistance, the following are important ones;
Inappropriate use:
- not completing a course of antibiotics as prescribed
- skipping doses of antibiotics
- not taking antibiotics at regular intervals
- saving some for later
Inappropriate prescribing includes:
- unnecessary prescription of antibiotics
- unsuitable use of broad-spectrum antibiotics
- wrong selection of antibiotics and inappropriate duration or dose of antibiotics
SUPERBUGS: THE GUIDE TO BUGS RENDERING ANTIBIOTICS OBSOLETE: READ MORE
MRSA - Patients infected with
MRSA (methicillin-resistant Staphylococcus aureus) are 64 per cent
more likely to die than those with a non-resistant form of S.
aureus.
People infected by resistant superbugs are also likely to stay longer in hospital and may need intensive care, pushing up costs.
C. difficile - This bacteria produces spores that are resistant to high temperatures and are very difficult to eliminate. It is spread through contaminated food and objects and can cause blood poisoning and tears in the large intestine.
E. coli - this now accounts for one in three cases of bacterial infections in the blood in the UK and a new strain is resistant to most antibiotics. It is highly contagious and could cause more than 3,000 deaths a year.
Acinetobacter Baumannii - a common bacteria which is resistant to most antibiotics and which can easily infect patients in a hospital. It can cause meningitis and is fatal in about 80 per cent of patients.
CRKP (carbapenem-resistant Klebsiella pneumoniae) - this is a bacterium that is associated with extremely difficult to treat blood infections and meningitis. It is resistant to nearly all antibiotics and is fatal in 50 per cent of cases.
Multi-drug resistant tuberculosis is estimated to kill 150,000 people globally each year.
NDM-1 - a bacteria detected in India of which some strains are resistant to all antibiotics.
People infected by resistant superbugs are also likely to stay longer in hospital and may need intensive care, pushing up costs.
C. difficile - This bacteria produces spores that are resistant to high temperatures and are very difficult to eliminate. It is spread through contaminated food and objects and can cause blood poisoning and tears in the large intestine.
E. coli - this now accounts for one in three cases of bacterial infections in the blood in the UK and a new strain is resistant to most antibiotics. It is highly contagious and could cause more than 3,000 deaths a year.
Acinetobacter Baumannii - a common bacteria which is resistant to most antibiotics and which can easily infect patients in a hospital. It can cause meningitis and is fatal in about 80 per cent of patients.
CRKP (carbapenem-resistant Klebsiella pneumoniae) - this is a bacterium that is associated with extremely difficult to treat blood infections and meningitis. It is resistant to nearly all antibiotics and is fatal in 50 per cent of cases.
Multi-drug resistant tuberculosis is estimated to kill 150,000 people globally each year.
NDM-1 - a bacteria detected in India of which some strains are resistant to all antibiotics.
Therefore, a policy need to be evolved
on practicing antibiotics in all the hospitals in a locality, for
which a sub-division may be taken as an unit. Much expected from the
Government in India to lead the way with co-operation from the
private hospitals. World leaders also think seriously over the emerging threat.
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