Sunday, August 22, 2010

The New Delhi bacteria should have been named the USA bacteria!

We all think that the name has been "conferred" by an article co-authored by 30 researchers, of which 14 have distinctly Indian names, and 3 others could well be hailing from the Indian sub-continent. And what does this article say? (You may have to register (it is free) on Lancet's website to see the full text of this article).

"We identified 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan."
" The CTX-M-15 extended-spectrum β-lactamase (ESBL) encoded by blaCTX-M-15 was first reported in India in the mid-1990s."
"Recent surveys have identified ESBLs in 70—90% of Enterobacteriaceae in India and; although these collections might be a biased sample, they do suggest a serious problem, making the widespread use of reserved antibiotics such as carbapenems necessary."
"We recently reported a new type of carbapenem resistance gene, designated blaNDM-1.22 A patient, repatriated to Sweden after admission to hospital in New Delhi, India,..."
"22 Yong DToleman MAGiske CG, et alCharacterization of a new metallo-β-lactamase gene, blaNDM-1, and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India.Antimicrob Agents Chemother 2009535046-5054"
"We sought molecular, biological, and epidemiological data on New Delhi metallo-β-lactamase 1 (NDM-1) positive Enterobacteriaceae in India and Pakistan and investigated importation of the resistance gene into the UK by patients returning from the Indian subcontinent."
"Isolates of bacteria were identified from Chennai and Haryana in India. UK isolates were identified from referrals to the Antibiotic Resistance Monitoring and Reference Laboratory by UK microbiology laboratories between 2003 and 2009. We also identified isolates from other sites around Bangladesh, India, and Pakistan."
"Isolates, NDM-1-positive bacteria from Mumbai (32 isolates), Varanasi (13), and Guwahati (three) in India, and 25 isolates from eight cities in Pakistan (Charsadda, Faisalabad, Gujrat, Hafizabad, Karachi, Lahore, Rahim Yar Khan, and Sheikhupura) were also analysed in exactly the same manner but in laboratories in India and Pakistan."
"In addition to the collections of isolates from Chennai and Haryana detailed above, we have confirmed by PCR alone the presence of genes encoding NDM-1 in carbapenem-resistant Enterobacteriaceae isolated from Guwahati, Mumbai, Varanasi, Bangalore, Pune, Kolkata, Hyderabad, Port Blair, and Delhi in India, eight cities (Charsadda, Faisalabad, Gujrat, Hafizabad, Karachi, Lahore, Rahim Yar Khan, and Sheikhupura) in Pakistan, and Dhaka in Bangladesh"


An extract from the abstract of the cited article 22 states, "A Swedish patient of Indian origin traveled to New Delhi, India, and acquired a urinary tract infection caused by ... The third region consisted of a new MBL gene, designated bla(NDM-1), flanked on one side by K. pneumoniae DNA and a truncated IS26 element on its other side" This last sentence is the culprit for naming the bacterium after New Delhi.
The common co-authors of both articles are Timothy Walsh and Mark A Toleman, both from the Department of Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, Cardiff, UK. 
The damaging part of the Lancet Infectious Diseases Journal article is reproduced below: 

"Several of the UK source patients had undergone elective, including cosmetic, surgery while visiting India or Pakistan. India also provides cosmetic surgery for other Europeans and Americans, and blaNDM-1 will likely spread worldwide. It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals. The potential for wider international spread of producers and for NDM-1-encoding plasmids to become endemic worldwide, are clear and frightening."

This is the last paragraph of the article, apparently written blithely and off-the-cuff, and has nothing whatsoever to commend it scientifically. They were obviously stung to the quick by this article that has been cited. Hence, this paragraph was obviously intended to defend the NHS. There is no data whatsoever to back up this contention -- that elective, including cosmetic surgery in India caused the UK infections studied. Consider that they haven't mentioned the following before they rattled off such a paragraph: 
  • How many of the 37 UK patients underwent elective surgery in Indian hospitals? 
  • What is the proof that the surgery in those cases caused the infection? 
  • How did the other UK patients contract the infection? And the question that has the most devastating answer:
  • How many countries' hospitals have exported similar bacterium to the UK?
What is totally beyond me is how can such obvious personal biases be allowed to creep in into articles that are published after being scientifically peer-reviewed in a journal that many think is the holy grail of medical science?
There is a Health Protection Report put out by the UK's Health Protection Agency  which contains something that indicts other European countries as the source of the same health risks. Consider this extract from that Report: 
"Laboratories should be especially alert to carbapenem-resistant isolates from patients with a history of hospitalization in countries where carbapenemase-producing Enterobacteriaceae are prevalent - particularly Greece, Turkey, Israel and the USA, as these have been a repeated source of introduction to the UK."

Why did the authors not cite this Report put out as long back as 30 January 2009? Instead, they chose to malign an article in the mainstream press dated 17 January, 2010, and conveniently ignored this much earlier important Health Protection Report of its own Health Protection Agency. Instead, they chose to echo the name given to the same bacterium by an article first published in September, 2009. The New Delhi bacterium has thus been unjustifiedly and inappropriately named. This bacterium  got its name, however unjustifiedly,  because of a Swedish tourist to India getting a urinary tract infection, and has nothing to do with elective surgery done in India

Apparently the bacterium deserves the moniker, USAM-1 bacterium more than its current name. Surprisingly, the same HPA issued a more recent National Health Alert in which it refers to its earlier (30 Jan 2009) report and quotes it thus: "that many producer isolates were from patients previously hospitalised in Greece, Turkey and Israel." The mention of USA as a source of repeated introduction into the UK has been quietly edited out in the more recent National Health Alert. What's worse, queries of the public are directed to one Dr David M Livermore who is also a co-author of the article with the paragraph  damaging to the medical tourism industry. Despite his otherwise sterling reputation, he is apparently compromised by severe conflicts of interest: He admittedly "has received conference support from numerous pharmaceutical companies, and also holds shares in AstraZeneca, Merck, Pfizer, Dechra, and GlaxoSmithKline, and, as Enduring Attorney, manages further holdings in GlaxoSmithKline and Eco Animal Health.

I have written to Dr Livermore asking, inter alia, how the reference to the USA as a source of repeated introduction of carbapenemase-producing Enterobacteriaceae into the UK while drafting the National Resistance Alert 3 ADDENDUM.  His immediate response has been unenlightening. I am hoping that he will respond more openly. .


  1. Why USA bacteria? USA is last on that list. You are overlooking the fact that India, along with MANY other countries, has little regulation on obtaining antibiotics. This is a HUGE factor in the development of drug-resistant bugs. Also, medical tourism cannot be overlooked as one method of transmission of all forms of infection including drug resistant bacteria and India/Pakistan are the places that seem to be prevalent for this. I don't discount the possible biases of the original article's author but one must be realistic in looking at the actual risk factors involved.