With a fever to 103ᵒF and pain in the right side of his back, my friend called me from the hospital, panicked and scared. He had a kidney infection, which his doctors said was caused by an extended spectrum beta-lactamase (ESBL)-producing organism, which is resistant to many antibiotics and is usually acquired in health care facilities in the United States. He was perplexed as to where he could have contracted this organism: He had no significant health problems, had not been hospitalized recently, and had not taken any antibiotics. His only risk factor was a recent vacation in India.
This type of infection is relatively rare in the U.S. However, India is rife with antibiotic-resistant organisms. There, an estimated 70 to 90 percent of people have ESBLs residing in their gut. For Americans who have not been hospitalized recently, in certain communities, it has been shown that the greatest risk factor for the onset of such an infection is recent travel to India. In order to prevent spread throughout the U.S. and the world at large, the need to contain such infections in India is urgent.
Medically unsound practices may be part of the superbug problem. In India, antibiotics have been available over the counter for decades. This practice has led to the development and spread of ESBL-producing organisms and, more recently, the NDM-1 (New Delhi metallo-beta-lactamase 1) gene, which confers resistance to the strongest antibiotics available. The NDM-1 strain was first reported in 2010 among patients in India and Pakistan and those in the U.S. and Britain who had received medical care in those countries. Since that time, the NDM-1 gene has spread around the globe. Responding to concerns of Indian physicians and the international community, this year the Indian government mandated that a prescription would be required for all antibiotics, but this rule is not strictly enforced.
India is rife with antibiotic-resistant organisms. There, an estimated 70 to 90 percent of people have ESBLs residing in their gut.
This problem of rising resistance to available antibiotics initially captured headlines when it was discovered that patients traveling to India for cheaper procedures—medical tourists—were returning with drug-resistant infections which can be transmitted to non-travelers. But in the U.S., these dangerous organisms have also been on the rise as well. Klebsiella-pneumoniae carbapenemase (KPC)-producing bacteria were first described in New York City. An outbreak of KPC infections occurred at the National Institutes of Health in 2011; 18 patients were infected and 11 died. NDM-1 and KPC fall into the category of carbapenem-resistant Enterobacteriaceae (CRE). In the U.S., it is estimated that 9,300 infections annually are caused by CRE, resulting in 610 deaths. There may be different genes that allow these infections to be resistant to almost all antibiotics, but their effects on infected patients are unequivocally devastating.
Travel, whether for business, pleasure, or medical reasons, has turned infectious diseases that were once restricted to geographic regions into global challenges. Last month, citing threats to the economy and public health, President Obama issued an Executive Order to combat antibiotic-resistant bacteria both domestically and internationally. The scientific community, and government and funding agencies, all recognize that battling the emergence of these organisms is a top priority.
Recently, Prime Minister Narendra Modi and President Obama met to discuss and strengthen the relationship between India and the U.S. Issues that are of interest to both nations have been discussed—security, counter-terrorism, climate change, trade, and energy, to name a few. Given the public health and economic implications that superbugs can have in both countries, this topic should have been on the agenda as well. Today, much of the U.S. and international medical resources are devoted to battling Ebola, multi-drug resistant tuberculosis, and HIV. Some observers question whether the international community can afford to tackle yet another issue. But when one has seen the consequences of such infections, the answer is: How can we afford not to?
Last week, national and international infectious diseases experts met in Philadelphia for ID Week to discuss the most pressing challenges facing the infectious diseases community, including Ebola, Enterovirus D68, tuberculosis, HIV, and multi-drug resistant organisms. In order to protect medical tourists and the global community at large, we also need to actively engage in our fight against superbugs. An important element of preventative efforts in the U.S. is extending our efforts beyond our own borders, specifically to India, one of the hotbeds of superbug emergence. If we don’t tackle this problem now, we risk devastating consequences, both here and abroad.