The awful toll of superbugs in India’s hospitals

Ranjit Devraj写道，随着超级细菌产生多药耐药性，婴儿在印度医院缺乏工作抗生素而垂死。

[NEW DELHI] The vigil for multidrug-resistant bugs is tight at the Holy Family Hospital, a charitable institution in the Indian capital known for its dedication to neonatal care.

“We cannot afford to have newborns falling prey to difficult-to-treat bugs,” says Sumbul Warsi, medical director of the 345-bed hospital and leading paediatrician. “We have infection control nurses collecting data daily — hand-washing is observed and audited, swabs are taken from the nursery and equipment and decontamination carried out when warranted.”

Despite the vigilance, drug-resistant microbes pop up frequently at the hospital, as they do at health facilities across India. When these microbes infect newborns less than 28-days old, there is a high risk of potentially fatal neonatal sepsis, where the body’s own response to infection can cause organs to shut down.

这种情况影响印度的每千只活产16。根据南亚关于该主题的科学文献的评论，这些婴儿中有三分之一因缺乏工作抗生素而死英国医学杂志by researchers at the All India Institute of Medical Sciences (AIIMS) in New Delhi.

Warsi blames the situation squarely on “irrational and inappropriate” use of antibiotics. “Overuse of antibiotics in intensive care units due to decreased immunity of patients, frequent resort to invasive procedures, free availability of antibiotics over the counter and misuse [in] agricultural — all contribute to antibiotic resistance and rising instances of neonatal sepsis,” she says.

In March, a newborn at Warsi’s hospital developed breathing difficulty and was given medicines that allow the lungs to inflate more easily, and placed on ventilation. But, the baby ended up being infected with铜绿假单胞菌, a multidrug resistant bacterium.

“We then resorted to colistin, a reserve antibiotic used exclusively for MDR (multidrug-resistant) gram-negative bacteria,” explains Dinesh Raj, a paediatrician who works with Warsi. “But the baby died because it took several days before a positive culture ofP. aeruginosacould be developed in the lab.”

有限公司listin has been used successfully in similar neonatal sepsis cases, though. In February, a newborn became infected withKlebsiella pneumoniae,一种常见的耐药细菌。“在这种情况下，婴儿反应良好，”拉吉说。自1960年以来，菌群就已经存在，但由于其毒性很少使用。现在，由于抗药性病原体的复兴，它被用作最后手段的药物。

Lax laws

The question troubling Raj is how long colistin will remain effective, given that poultry farmers freely use it and other antibiotics to boost chickens’ growth. While India’s Drugs Technical Advisory Board, part of the Ministry of Health and Family Welfare, has recommended that colistin and other antimicrobials should not be used in agriculture, there is no formal ban.

India’s agricultural ministry also recognises the dangers of widespread misuse of antibiotics in animal feed and supplements. An advisory notice issued in 2014 named Oxytetracycline, Doxycycline, Ciprofloxacin and Neomycin as antibiotics detected in tissues of marketed poultry. But little has been done by way of enforcement.

政府为抑制滥用抗生素采取的最全面的行动是2017年对AMR的国家行动计划的采用，重点是加强监视和鼓励在医院和社区中合理使用抗生素。

But an Antimicrobial Resistance Surveillance and Research Network set up in India in 2013 has so far been confined to 20 top medical colleges and hospitals and the study of selected drug-resistant bacteria.

Superbug surveillance

Chief among the microbes under surveillance is methicillin-resistantStaphylococcus aureus(MRSA), which is commonly found in hospitals and in patients who have undergone procedures involving invasive devices such as catheters.

MRSA infections began in hospitals but are now caught in the community from other people and livestock, which underscores the steady spreading of the bacteria. The superbug is resistant to beta-lactam antibiotics, a broad-spectrum group which includes methicillin as well as oxacillin and the cephalosporins. It is now endemic in India, surveys show.

根据AIIMS科学文献综述（包括109项研究，其中69项来自印度）是MRSA以外的南亚医院中最常见的MDR生物Klebsiella,Acinetobacter, and E. coli。

审查表明我的感染源n neonatal sepsis is likely to be unhygienic practices in labour rooms and neonatal intensive care units rather than vertical transmission from mothers, as commonly believed. It found common pathogens isolated in hospitals exhibited far higher resistance to WHO-recommended first-line drugs – the go-to choice for doctors – than those isolated in community-based studies, pointing to overuse of antibiotics and poor diagnostics.

Over-the-counter drugs

Adding to the calls for state intervention, the AIIMS review says misuse of antibiotics in agriculture should be stopped and there should be tighter restrictions on over-the-counter sale of antibiotics.

But doctors and patients also need to shoulder some responsibility, according to Warsi. “It is important to educate the community about the importance of rational use of antibiotics,” she says. “Simultaneously, doctors need be taught not to bow to pressures from pharmaceutical companies to push their products and also resist demands by patients for quick satisfaction.”

有限公司unter sales of antibiotics have been restricted by India’s Central Drugs Standard Control Organisation since 2014, when 24 antibiotics were brought under the ‘Schedule H1’ list of antibiotics. These Schedule H1 drugs can be sold only against prescriptions, with dispensing pharmacists required to register details such as the patient’s name and the quantity of medicines dispensed. The register is subject to audit and authorities have cancelled the retail licenses of hundreds of violators.

但是，没有对提供医生激励措施（如付费假期）推动特定品牌抗生素的药物奖励的制药公司施加惩罚。2015年，政府引入了制药营销实践守则，但根据法律不可强制执行。

Scary sanitation

卫生条件不佳与医疗废物处置相结合是AMR的另一个主要贡献者。通常，从进入水课程的医院和药物制造厂中找到废水，从而创造出促进MDR细菌生长的疾病。

Of particular worry is horizontal gene transfer, where genetic material moves directly from one organism to another without any reproduction. “Horizontal gene transfer is the primary mechanism by which antibiotic resistance spreads across bacterial species,” says pathologist Sudhir Kulkarni at Batra Hospital in New Delhi.

现在，印度水平基因转移的危险正在全球感受到。2008年，在去过印度的一名瑞典患者中发现了含有称为NDM-1酶的细菌。该酶使细菌对几种抗生素具有抗性，并且能够通过水平基因转移在物种上移动。

2010年5月，发现一个在印度患有透析的人大肠杆菌expressing NDM-1. The following year, a study published byLancet Infectious Diseases显示出NDM-1阳性细菌不仅在医院中，而且在新德里中部周围的12公里半径中，即使在饮用水样本中也是如此。beplay足球体育的微博

“It’s scary how fast India is slipping back into the pre-antibiotic era, only because nothing smart is being done to stop smart bugs developing multidrug resistance,” says Kulkarni.