NDM-1

What the Experts Say

Experts Explain the NDM-1 Superbug Threat at ICAAC

Scientific Publications on NDM-1

• Emergence of a new antibiotic resistance mechanism in India, Pakistan and the UK. Kumarasamy KK., et al. The Lancet Infectious Diseases.2010; 10:597-602
• The latest threat in the war on antimicrobial resistance. Pitout JDD. The Lancet Infectious Diseases. 2010; 10:578-579
• Characterization of a new Metallo-Beta-Lactamase gene, blaNDM-1, and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Yong D., et al. Antimicrobial agents and chemotherapy. 2009; 53:5046-5054

Questions and Answers on NDM-1

What is NDM-1?

• NDM-1 is a Metallo Beta-Lactamase essentially found in Enterobacteriaceae (principally E. coli and K. pneumoniae).
• NDM-1 stands for New Delhi Metallo-beta-lactamase-1, since it was first identified in a Swedish patient of Indian origin, who had been admitted to hospital in New Delhi, India in 2008.
• The NDM-1 gene produces an enzyme which makes bacteria resistant to almost al b-lactams including carbapenems (imipenem, meropenem, ertapenem, doripenem). Carbapenems are powerful, broad-spectrum antibiotics, which are often considered to be the last line of defense against multi-resistant strains of bacteria, such as E. coli and K. pneumoniae.

How does it spread?

• The gene for NDM-1 is found on plasmids (DNA strands), which can easily spread from one strain of bacteria to another, particularly in patients receiving antibiotic treatment.

Where has it spread so far?

• So far, the large majority of cases have been reported in India, Pakistan and Bangladesh.
• However, cases have also been reported in the United Kingdom (37), the US (3), France (2), Sweden (1), as well as Australia, Hong Kong, Canada, Belgium, Germany, the Netherlands, Kenya and Oman. Cases found outside of the Indian sub-continent have been linked to patients recently receiving medical care or cosmetic surgery in that region.

Why is it a major health risk?

Lack of effective antibiotics

• NDM-1 bacteria are resistant to most antibiotics (fluroquinolones, aminoglycosides and beta-lactams), except tigecycline and colistin.
• Currently, there are few new antibiotics against Gram-negative bacteria in development and none that are effective against NDM-1.

High risk of rapid NDM-1 transmission

• The NDM-1 type of plasmidic resistance means it can transfer easily to other bacteria and has been identified in several different and unrelated bacterial strains. Transmission can be accelerated by “medical tourism”, and by the high level of population exchanges between India and Pakistan and other countries around the globe. NDM-1 is found in E. coli - the most frequent cause of urinary tract infections, which is commonly found in the community. The fact that E. coli is a typical community-acquired bacteria may also accelerate the spread of NDM-1 resistant strains, since the resistance is not limited to the healthcare setting. The spread of this new resistance gene is strongly facilitated by the following conditions:
  • low level of hygiene
  • overpopulation
  • hot, humid climate
  • widespread over-the-counter use of antibiotics.

How is NDM-1 different from other types of carbapenemases?

• There is no major difference from other carbapenemases (same shortage of antibiotics), except that NDM-1 occurs in E. coli, therefore presenting a greater risk factor since it could potentially migrate in the community.

What can be done to prevent it?

• Standard infection control / hygiene measures applied in the case of nosocomial or community-acquired infections can be applied to reduce the transmission of NDM-1.

Healthcare setting
Key measures for prevention are:

• increased screening (particularly all patients transferred from overseas hospitals)
• isolation of carriers and reinforced hygiene measures
• prudent use of antibiotics
• monitoring and surveillance of antibiotic resistance

Individual precautions
Actions which can help to reduce the transmission of E. coli and therefore NDM-1 include:

• frequent, thorough handwashing
• cleanliness when preparing and consuming food
• reinforcing precautions when in contact with persons with a urinary tract infection/diarrhea
• reinforcing contact precautions if you yourself have a urinary tract infection/diarrhea

Can it be treated?

• It is difficult to treat patients infected by bacteria which harbor this new resistance mechanism, since NDM-1 is highly resistant to almost all antibiotics, including carbapenems. Currently, it appears that two antibiotics (tigecycline and colistin) are still effective, but resistance can occur. The severity of infections involving NDM-1 can vary from mild to fatal.

Where can I learn more?

• Carbapenem resistance and NDM-1 - Q&A from the UK Health Protection Agency
• CDC MMWR (Morbidity and Mortality Weekly Report) June 25, 2010 / Vol.59 / No.24 / Page 250

Diagnostic Solutions for NDM-1

bioMérieux is actively committed to the fight against bacterial resistance and offers a complete range of products for the detection and screening of the most frequently found resistance mechanisms. For carbapenemase-producing Enterobacteriaceae, and namely NDM-1, the current bioMérieux ID/AST solutions are:

• VITEK® 2
• ADVANCED EXPERT SYSTEM™
• ETEST®

NDM-1 is a Metallo Beta-Lactamase essentially found in Enterobacteriaceae (principally E. coli and K. pneumoniae). VITEK 2 AST cards and ETEST accurately provide MIC results to specific carbapenem drugs that are commonly used to treat infections caused by resistant Enterobacteriaceae strains. Using these MIC results, ADVANCED EXPERT SYSTEM (AES) analyzes the antimicrobial susceptibility pattern of each organism and can actually determine the carbapenemase resistant phenotype. The ability of AES to detect resistant phenotypes is crucial for helping clinicians guide therapy and predict clinical outcomes. Also, bioART offers an additional tool that can be customized to alert users to carbapenem resistance patterns.

Contact your local bioMérieux representative for information on additional ETEST laboratory tools that we can provide to assist in the assessment of highly resistant strains.