The recent appearance of NDM1 (New Delhi metallo beta lactamase), mistakenly referred to as a “super bug,” has made headlines worldwide and raised the specter of a new threat to patient safety around the world. Medical researchers and professionals are currently in a dead end to prevent the spread of multi-treatment resistant bacteria.
NDM is not actually a bacteria but rather a gene (an enzim) that attaches itself to resistant bacteria thereby rendering them even more virulent and resistant to antibiotics. Some antibiotics are still effective against these bacteria but not in all cases. Modern medicine has therefore hit a dead end when it comes to treating certain infections. The Lancet, a highly respected British medical journal, recently published articles warning about this new danger and calling for the implementation of standardized prevention and control measures internationally.
Impact of treatment resistance poses a serious threat to health care in western world
Several well-known pathogenic bacteria (bacteria causing health problems), notably the infamous E. coli bacteria, have already been affected by NDM1. E. coli is responsible for many nosocomial urinary infections (particularly among women) and has struck fragile hospital patients suffering from pulmonary infections, blood stream infections, and catheter-related infections. According to Professor Patrice Nordmann, catheter-related infections carry a high death risk (Le Point, August 2010). Sexually transmitted diseases are also on the increase throughout the world and are getting more and more difficult to treat.
Resistant bacteria: a biological reality
Germs or bacteria are living organisms that possess an amazing ability to adapt to their environment. Consequently disease-causing bacteria quickly develop a resistance to the very medications meant to eliminate them. These bacteria could be compared to the “Star Wars” missile defense system that uses missiles to shoot down incoming missiles.
This phenomenon has been known ever since A. Flemming discovered penicillin, the first ever antibiotic, in 1929.
- By 1941, penicillin had become the standard treatment for infection. Unfortunately, penicillin gave the medical world false hope that infectious diseases could be eradicated.
In 1943, the appearance of the first strains of penicillin resistant staphylococcus aureus demonstrated that bacteria quickly become resistant to new drugs. - In 1961, researchers developed methicillin, a powerful antibiotic that could effectively kill any penicillin resistant bacteria.
- By 1963, a methicillin resistant strain of staphylococcus aureus (MRSA) appeared and quickly became a serious threat to patient safety. In the United States, the spread of MRSA’s has reached epidemic proportions. According to an article published in the April 2010 issue of the Journal of Infection Control and Epidemiology, the MRSA infection rate in Quebec and Canada increased by 17% between 1995 and 2007.
- Since 2000, the infamous C.difficile that made headlines here in Quebec has spread to other Canadian provinces, the USA, and several European countries. The C. difficile bacteria become commonplace in hospitals throughout the Western world before mutating into a new, extremely virulent strain that is difficult to eradicate, and has caused numerous deaths.
Despite the fact that resistant bacteria have been known to the medical world for decades, they have become an increasingly dangerous and persistent threat. Paradoxically, modern medicine now finds itself confronted with a danger it helped create.
Resistance to antibiotics renders these bacteria more virulent.
Fighting resistant bacteria requires new, more powerful antibiotics prescribed at higher doses. Some bacteria are now resistant to entire families of antibiotics.
Antibiotics, however, are indispensable in the fight against infectious diseases. While hospitals have become the main source of resistant bacteria, these bacteria are now spreading to the general population. The treatments against these resisting bacteria add greatly to the cost of patient care and put even more pressure on financially overburdened healthcare systems in Quebec and around the world.
What to do? Solutions exist but must be rigorously implemented and reinforced.
The World Health Organization (WHO) argues that health care systems must implement strict preventative and control measures in order to stem the spread of “super bugs.”
Basic measures include:
- Quick tests to detect bacteria (MRSA and C. difficile in particular) at the time of admission to a hospital or clinic.
- Quarantining high-risk and infected patients. They must be placed in private rooms and not be allowed to share bathrooms.
- Strict enforcement of hand cleanliness measures for both medical workers and patients.
- The general cleanliness of the hospital environment must be improved.
Such measures are not easy to enforce and are certainly less glamorous that various high-tech medical techniques. Experience has shown that the more low-tech preventative techniques (such as hand washing) are the most effective way to reduce infection rates. Unfortunately, they are not universally applied. WHY NOT? The answer is simply that health care workers, like all humans, often find it difficult to change their habits even when evidence clearly demonstrates that it is beneficial to all concerned.
Requiring hospitals to publish their infection rate would certainly force health care authorities to act more quickly. France requires hospitals do this as do twenty-six American states.
Another key measure: Greatly reduce the overuse of antibiotics in order to prevent the development and spread of resistant bacteria. This battle has to be waged by both doctors and pharmaceutical companies. Furthermore, health care authorities must also address the issue of antibiotics in the food supply.
Action taken since the discovery of NDM1
Over the last two years, European health care authorities have launched a campaign to encourage doctors to reduce the number of antibiotic prescriptions. “Antibiotics and not automatic” is the campaign slogan. France reduced the number of antibiotics prescribed nationwide by 35% over one year. Over the last few years, the Scandinavian countries and Holland have also placed strict controls on the prescription of antibiotics. Consequently, nosocomial infection rates in these countries have been greatly reduced.
The European Centre for Disease Control (ECDC) just launched a study to determine risk factors and to evaluate the effectiveness of disease control measures throughout Europe.
France and a few other European countries implemented an obligatory quarantine policy for any patients who have recently visited countries affected by an NDM1 outbreak.
The question on everyone’s mind: Why not develop new families of antibiotics to eradicate super bugs?
The development of new antibiotics is absolutely necessary. However, one must realize that new drugs engender resistance to them. In other words, the strain simply mutates and becomes resistant to these medications. For the most part, pharmaceutical companies have avoided research in this area due to the enormous costs involved. Health care authorities have neither pressured the industry nor provided incentives to conduct research in this field.
Prevention: solution for the future.
Experience has demonstrated that the most effective way to fight treatment related infections is by strict prevention measures. The Dutch call this method “Search and Kill” and it has worked wonders in their hospitals. Why not implement this policy everywhere?
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