By: Roli Srivastava

A bug that doctors until about three years ago treated with moderate-class antibiotics is now causing worry in intensive care units of hospitals across the country. Doctors report that third-generation antibiotics — carbapanems — are failing to treat the Klebsiella pathogen, leading to higher mortality in patients and peg the resistance at up to 50 per cent. In Mumbai, the bug is being recorded in 10-20 per cent of the patients in ICUs of major public hospitals. 

Cases of colistin-resistant Klebsiella have started emerging, including four in Mumbai. Colistin is the last antibiotic available in the world for infections that the strongest antibiotics fail to treat. 

Klebsiella causes urinary tract infections, ventilator-acquired pneumonias and blood stream infections (sepsis) among other conditions and is proving to be fatal in 30 to 40 per cent of the patients who have contracted it — usually during a long stay in the hospital, particularly in the intensive care unit. 

“For the first time, we have seen Klebsiella resistant to colistin,” said Dr. V. Balaji, Head of Microbiology, Christian Medical College, Vellore, where six such cases have been recorded. Dr. Balaji, who also heads the antimicrobial stewardship and infection control and prevention of the Indian Council of Medical Research (ICMR), said it was difficult to find the resistance mechanism and that they were working on it. Citing a pan-India study the CMC has done, he pegged resistance to carbapanem between 50 and 60 per cent. 

Referring to the four cases of colistin-resistant Klebsiella in different hospitals in Mumbai, consultant microbiologist at Hinduja Hospital, Dr. Camilla Rodrigues said with carbapanems failing to work on Klebsiella, colistin consumption has gone through the roof. “Organisms that are intrinsically resistant to colistin will now come back,” she said. 

Double whammy

It is a double whammy for high-risk patients who have compromised immunities. “Patients such as those suffering from lymphoma or who have undergone transplants are particularly difficult to treat,” said Dr. Chand Wattal, head of the Microbiology Department at Sir Ganga Ram Hospital in Delhi. He said colistin-resistant Klebsiella has started showing up in the last three to four months in Delhi. 

In Mumbai, cases of carbapanem-resistant Klebsiella are being routinely recorded, but resistance to colistin remains rare. At J J Hospital, Byculla, carbapanem resistance is being reported in 12 to 21 per cent of the total cases. “The concern is that we are getting less armour against Klebsiella,” said Dr. Abhay Chowdhury, head of the Microbiology Department at JJ Hospital. His counterpart at KEM hospital, Dr. Preeti Mehta said 20 per cent of the total ICU cases at any given time have contracted Klebsiella. “This has come up in the last two years. It is manageable, but if it is not detected early, then it leads to high mortality,” she said. 

At Sion hospital, three to four such cases are being recorded every month. “Two to three years ago, there were no cases of carbapanem-resistant Klebsiella. There would be a few cases in between, but now 10 per cent or so of the total isolates are resistant,” said Dr. Sujata Baveja, head of the Department of Microbiology at Sion hospital. 

Serious implication

The implication of the growing resistance is serious. Simply put, higher the level of resistance, higher the mortality. 

“If Klebsiella is resistant to carbapanem, a higher dosage or combination therapy is the next step, but this requires careful laboratory evaluation and patient monitoring, which may not be possible in many hospital settings. Besides, a high level of resistance means many treatment failures and thus higher mortality,” said Dr. Kamini Walia from the Division of Epidemiology and Communicable diseases, ICMR. 

Carbapanem usage is rationed. “It is a third-generation drug and is used when everything else has failed. Colistin is toxic and the only drug we have now (when everything else has failed). We have nothing left,” she said. According to her, better infection control practices are now an absolute necessity that hospitals need to follow. 

But the concern is here to stay, and only getting graver. With resistance to colistin in other parts of the world much higher, it is only a matter of time when the last antibiotic fails on Klebsiella even in India, said Dr. Balaji.

Originally Published: The Hindu