Management

Superbugs in ICUs

It is scary to think about a 'superbug' that could be resistant to every antibiotic we have available, which is a definite possibility

"In hospitals and increasingly in the world at large, new 'superbugs' are coming into being that are resistant to multiple antibiotics and increasingly hard to kill off" - Dr Sandeep Budhiraja Chief Max Institute of Internal Medicine Max Healthcare

The advent of penicillin drugs in the early 1940s ushered in a triumphant era of medicine. With stunning speed, pharmaceutical chemists armed doctors with one antibiotic after another, giving them an arsenal of magic bullets to knock out the germs that cause everything from pneumonia to gonorrhea. It was only a matter of time, it seemed, before all infectious diseases would be conquered. But now, the invisible legions of malevolent microbes are fighting back, and medicine is no longer so confident of winning the battle. Not only have many diseases caused by viruses, such as AIDS, proved to be extraordinarily difficult to cure, but even old, easily treated bacterial ailments do not always respond to drugs as they once did. Using marvelous powers of mutation, some strains of bacteria are transforming themselves into new breeds of superbugs that are invulnerable to some or all antibiotics.

Superbugs

In hospitals and increasingly in the world at large, new superbugs are coming into being that are resistant to multiple antibiotics and increasingly hard to kill off. But they are not alone: even common infections are getting harder to defeat easily. Harmful bacteria are mutating faster and becoming resistant to numerous antibiotics. As a result, some of these bacteria are surviving the drug's attack and may in fact grow stronger, lending credence to the fear of a 'superbug'.

Consequences of antibiotic resistance include the need for more toxic medications, an increase in the duration of illness, risk of medical and surgical complications and even death. There is a relative lack of new classes of antibiotics in the drug development pipeline, considering the ever-increasing numbers of antibiotic-resistant bacteria. It is scary to think about a 'superbug' that could be resistant to every antibiotic we have available, which is a definite possibility.

Risk factors for colonisation with an antimicrobial-resistant micro-organism can be patient-related, hospital-related or treatment-related.

Overuse: A Major Hurdle

Part of the challenge in developing new drugs comes from the overuse of antibiotics. Bacteria and viruses cause disease differently. Antibiotics that work against bacterial infections, such as strep throat, do not work against viruses, such as those that cause colds. Moreover, antibiotic misuse against a virus is potentially dangerous, since beneficial bacteria may be killed, opening the door for harmful bacteria to establish themselves in their place. Physicians and patients equally contribute to this problem. Studies show that patients often demand antibiotics, regardless of their illness. Or patients are appropriately prescribed antibiotics for bacterial infections but do not finish their course of treatment, which does not kill all of the bugs. Both physicians and patients should be vigilant about antibiotic use and treat infections as specifically as possible.

From Bugs to Superbugs

Bacteria have certain traits they can turn on to protect themselves, and they can acquire other traits they need from other bacteria in the environment. For example, one bacterium might have resistance to drug A, another to drug B, and a third to C, and suddenly you see one that has resistance to A, B and C, because it is picked up all those resistances. It's not a question of just one resistance. It is multiple. This is almost science fiction kind of biology, where resistance genes jump back and forth like trading cards- it's quite fascinating. No one would have imagined this kind of gene exchange. These things don't happen purposefully-it's all random. That said, if a physician prescribes the right antibiotics, the invading organisms usually can be defeated. But that seems to be happening less and less, as bacterial organisms have gained more ability to fight back against antibiotics.

That's made possible, in no small part, because there is an unfortunate over-use and misuse of antibiotics.

The Sad News

The real news is not the fact that these bugs exist, but how woefully unprepared we are to deal with them. As we make progress in fields like cancer, we are taking a U-turn on bacteria. Despite advances in drug development, the bugs have increased their 'IQ' nearly as fast as research, outwitting our medicines. Efforts have turned to preventing bacterial spread and clamping down on antibiotic prescribing. There is no question that poor hospital hygiene, overuse and sometimes misuse of antibiotics contribute to educating bugs at our expense. But preventative efforts alone won't solve our bacterial challenges. What we need most are better diagnostic tests and new medicines. This is high-stakes science, but the pipeline isn't promising. Since 1998, just 10 new antibiotics have been approved by the FDA, only two of which work in fundamentally new ways. Only 13 new antibiotics are in development inside big drug companies, compared to an average of 60 more than a decade ago.

As resistance to antibiotics has grown and the number of antibiotics that can be used to combat deadly infectious diseases has declined, the situation has been aggravated by big pharmaceutical companies largely abandoning this area of drug development. The return on the investment is not as good as that found for a cholesterol-lowering agent or agents for cardiac problems or sexual impotency.

The Culprits

New resistance problems have emerged recently among hospital and community-acquired pathogens such as in Staphylococcus aureus, Enterococcus faecium and Pseudomonas aeruginosa. Hospital-acquired and now community-acquired methicillin-resistant S aureus are emerging worldwide whereas vancomycin-resistant S aureus remain extremely rare. Hospital-acquired outbreaks of vancomycin-resistant enterococci and multidrug resistant Pseudomonas aeruginosa infections are increasingly reported worldwide. Whereas novel molecules are being developed for treating Gram-positive infections, difficult to non possible-to-treat pandrug-resistant Paeruginosa infections may become a therapeutic challenge soon.

The most publicised superbugs are the strains of drug-resistant tuberculosis bacteria. Malaria, tuberculosis, cholera and dysentery may claim more than 10 million lives each year. While inadequate medical care and sanitation are mainly responsible for the death toll, increasing microbial resistance to drugs is making a bad situation worse. The anti-malarial drug chloroquines is no longer broadly effective, and even the newest substitute, mefloquine, is encountering resistance from some strains of the malarial parasite.

Antibiotic-proof bacteria are spreading because of the enormous increase in tourism and business travel in recent decades. The major problem in ICUs of India is that of ESBL group of Gram negative bacteria more than that of MRSA. These include multi-drug resistant E.coli, Klebsiella, Pseudomonas and Acinetobacter. Nosocomial fungal infections are also not uncommon.

Let us Join Hands

We can all help by taking these steps:

• Never take an antibiotic for a virus. Your doctor can order tests to definitively determine if an antibiotic is really necessary and which antibiotic, if needed, will prove the most successful.
• If an antibiotic is necessary, take the full course exactly as prescribed. Always take a probiotic, such as lactobacillus acidophilus, after taking an antibiotic to restore beneficial bacteria.
• Avoid the long-term use of oral antibiotics for acne.
• Don't eat animal products from antibiotic treated animals. Certified organic animal foods are your safest choices.
• Good hand hygiene practices by healthcare professional
• Barrier precautions by healthcare professionals, while handing infectious patients.

sbudhiraja@maxhealthcare.com