Sunday, July 6, 2014

“Hospital Infection Control Committee” must address the issue of “Antibiotics Policy” with reference to the emerging “Antibiotics Resistance” and “Gloomy” days ahead

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 sca...
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)

Recently, the concern of the Prime Minister of UK Mr. David Cameron may be seen here.
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


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.

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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