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Indian Journal of Medical Microbiology, Vol. 28, No. 4, October-December, 2010, pp. 275-276 Editorial New Delhi metallo-beta-lactamase 1: Is there a need to worry? Reba Kanungo Editor, IJMM, A/3 No 38-Labourdinnaise Street, Pondicherry - 605 006, India Date of Submission: 15-Sep-2010 Code Number: mb10089 PMID: 20966553 Outrage and outcry aside, a recent report of New Delhi metallo-β-lactamase (NDM-1) drives home the concern of rapidly increasing antibiotic resistance among bacteria encountered in hospitals. Rhetoric and blame games apart, countries cannot be singled out for the spread of resistant strains. It has been seen globally that clonal spread of resistant organisms occurs in the best of health care settings in many countries. Emergence and spread of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enteroccocus (VRE), penicillinase-producing Neisseria gonorrhea (PPNG), and penicillin-resistant Streptococcus pneumoniae (PRSP) are examples of some organisms that have spread across countries. Globalization, rapid travel, and vanishing borders may have helped the organisms find a safe haven to travel via the human body. Studies conducted on the international spread of multiresistant PPNG detected in the 1960s in the SE Asia region show that it has now become a problem in the western hemisphere. [1] Several international and national medical and allied journals publish reports on the alarming rise of antibiotic resistance both in the hospital and the community. Basic research at the molecular level and new techniques to study genetic mechanisms facilitate detection of hither to unknown genes and plasmids. Studies on prevalence of resistance, risk factors in hospitals and community, vertical and horizontal transmission of antibiotic resistance are regularly published. This year more than 25 scientific articles dealing with antibiotic resistance have been published in the Indian Journal of Medical Microbiology alone. There have been several other articles and reviews published in these issues on infection control, hand washing, biomedical waste disposal, and antibiotic policy. All of these emphasize ways and means to contain infection. Uncontrolled infection and irrational use of antibiotics in the hospital is closely related to the emergence of resistant strains. It is a matter of concern that despite increasing reports of antimicrobial resistance, little effort is made to validate the results and translate the findings into practice. A concerted effort is required at individual, institutional, and national level to stop the rising trend of antibiotic resistance. Guest editorial in the July (2010) issue of the Indian Journal of Medical Microbiology carried a very apt article on "National Antibiotic Resistance Surveillance and Control. [2] The author has outlined action points for instituting guidelines for antibiotic policy by "a mechanism to monitor the changing pattern of antibiotic resistance and regulate antibiotic dispensation necessary to halt the rising trend." [2] It is also understood that with best of efforts, hospital infection could still persist albeit at very negligible levels. Clinical microbiologists have a significant role to play in controlling emergence of multi-drug-resistant bacteria. It is believed that a proactive approach to reporting susceptibility pattern of organisms will help clinicians use appropriate antibiotics. Unlike the west, there is still a long way to go, for clinical microbiologists in India, to be decisive members of the treatment team. However, a beginning must be made. Microbiologists must step out of the laboratories to play an active role in patient care. Auditing of antibiotic reports along with evaluating the impact of the report on treatment policy in the hospital could perhaps be a first step toward an integration of laboratory and clinical practice. A "super bug" is first detected and documented in the laboratory. The onus therefore is on the clinical microbiologist to improve laboratory standards, establish quality control measures, and use appropriate methods for reproducible results. Standardized techniques for susceptibility testing must include recommended media, antibiotic disks and powders, appropriate temperatures and duration of incubation, and accurate interpretation of the results. [3] Some laboratories have now incorporated routine screening of MRSA and ESBL and detection of other resistant markers in their daily laboratory procedures. Other clinical laboratories may find this an extra load on manpower and resources. However, implication of these tests on rational treatment cannot be overemphasized. Simple cost-effective methods recommended in the Clinical Laboratory Standards Institute guidelines are available for routine testing. [3] The quality of reporting must be improved for client satisfaction. To cite an example when reporting an MRSA, a line may be added on which group or class of antibiotics are to be avoided. The same holds true for a beta-lactamase or carbapenamase producers. In the absence of extra screening tests for the enzymes and other markers, a clinical microbiologist must be able to correlate group/class resistance to interpret susceptibility patterns rationally. In addition, frequent updating of current resistance patterns of common bacteria will help rationalize use of antibiotics. In the absence of a hospital infection control committee, the microbiology department can take up leadership in updating their clinical colleagues on the current status. The article on "The hospital antibiogram: A necessity" by Joshi, in the current issue, highlights some of the methods a laboratory can adopt to disseminate information on resistance pattern. [4] Quality laboratory data must be made available in real time to influence standard treatment guidelines. [1] These guidelines can be developed for each institute based on the surveillance of antibiotic resistance patterns. Prevention and containment of antimicrobial resistance has been outlined in a monograph by WHO SEARO, on regional strategy on guiding principles. The key principles are (a) to understand the emergence and spread of resistance; (b) to rationalize the use of available antimicrobials (this is useful for public sector hospitals where dispensation of antibiotics is subsidized or free of cost to the patient); (c) reduction of selection pressure by infection control practice; (d) to change the behavioral pattern in prescribing and rational prescription; (e) to promote discovery, development, and delivery of new drugs and tools; and (f) national coordination with defined functions of different sectors and programs. [1] These are practical and easy to follow guidelines, which can be adopted by concerned players in the health care sector. There is an urgent need to change the mindset of, and create awareness among all health care providers, policy makers, and administrators to the dangers of emerging antibiotic resistance. National and regional guidelines and policies must not only be made but also implemented and monitored to combat antibiotic resistance and contain emergence of "super bugs." References
Copyright 2010 - Indian Journal of Medical Microbiology |
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