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The growing peril of drug-resistant superbugs

Priyanka Pulla

In October 2019, Manoj Ghamandayan, 21, developed a fever. He then began having trouble breathing. Soon, Ghamandayan, from Haryana’s Jhajjar district, was admitted to Sunflag Global Hospital, Rohtak and diagnosed with dengue. The hospital hooked him to a mechanical ventilator to aid breathing, a catheter for draining urine, and a central line to pump medicines into his body.

But Ghamandayan got sicker. During his two-week stay at the hospital, he caught three healthcare-associated infections (HAIs) or infections that patients catch at hospital. Invasive devices like ventilators, central lines, and catheters pose the risk of HAIs because they breach the body’s protective barriers. For example, a ventilator’s breathing tube could easily transfer bacteria from a nurse’s hands to the patient’s lungs, triggering pneumonia.

Ghamandayan came down with two bacterial infections, Escherichia coli and Acinetobacter baumanii, and a fungal species called Candida. These pathogens are superbugs — ie, resistant to multiple antimicrobial drugs — which make them hard to treat. His family moved him to New Delhi’s Sir Gangaram Hospital, where his doctor deployed two last-line antibiotics called colistin and meropenem —both expensive, with toxic side effects, but the only hope when all else fails.

Ghamandayan eventually got better and was discharged nearly a month after he was first hospitalised. In all, the treatment cost `6 lakh.

Many in India face a similar fate – they get admitted to hospitals with seemingly treatable illnesses, only to contract HAIs caused by superbugs.

Few Indian hospitals track their HAI rates. But several stand-alone studies show that India has higher rates compared to richer countries like the US. For example, a study by the International Nosocomial Infection Control Consortium, which surveyed data from 40 hospitals in 20 cities in India, between 2004-2013, found that for every 1,000 days that patients were hooked to ventilators in Indian cardiac Intensive Care Units, there were around 11 times as many pneumonia cases as in American hospitals.

But that’s just part of the problem. Many of the bugs that cause these infections have learned to tolerate powerful antimicrobial drugs. Unpublished 2019 data from a 20-hospital surveillance network run by the Indian Council for Medical Research (ICMR) shows that key hospital bugs, like Acinetobacter baumanii and Klebsiella pneumoniae, have grown widely drug-resistant.

Patients infected with any of these bugs often have to be treated with last line drugs, which are both expensive and toxic. Many succumb.

While there are no India-wide estimates of how many people die due to antimicrobial resistance, public-health expert at Washington DC’s Center for Disease Dynamics, Economics & Policy (CDDEP), Ramanan Laxminarayan points out that a bulk of the deaths take place in hospitals. The problem is that infection-control is not easy. It requires hospitals to aggressively push a range of practices, including frequent hand washing, and caution while setting up devices like ventilators and catheters. Not enough hospitals check these boxes.

Kochi’s Amrita Institute of Medical Sciences has a strong emphasis on staff hand-hygiene compliance because data from the hospital’s 16-year-old infection-control programme has consistently shown, as multiple other studies have, that hand-hygiene is the most powerful way to curtail HAIs.

Yet, many hospitals don’t enforce this enough.

A spot check of Chennai’s Rajiv Gandhi General Hospital and Mumbai’s Lokmanya Tilak Municipal hospital– both large public hospitals — revealed a lack of soap in several toilets. Officials from both hospitals said it was hard to replace soap in patients’ toilets, given the large crowds.

In December 2019, 100 infants died at Rajasthan’s J K Lon Hospital. A government probe absolved the hospital of negligence and concluded that the children were already critically ill when they came to the government facility.

Over 40 of them suffered from low birth weight, while others were premature and had pneumonia or congenital defects, says secretary to Rajasthan’s medical education department, Vaibhav Galriya. But Galriya also admits to stark infection-control failures. For instance, the hospital was not checking children frequently enough for signs of infection. Further, more than one child was placed in a baby warmer — a device used to maintain the temperature of newborns. This meant that 70 babies were sharing 53 cribs on at one point, according to Galriya. Such a set- up would have allowed any hospital bug to spread like a wildfire.

The situation is not uncommon across crowded Indian government hospitals.

Private hospitals have the luxury to turn away patients, which allows them to follow a fundamental tenet of infection-control — maintaining distance between patients. But nearly all the government hospital officials said that they were frequently forced to place more than one person per bed. They are bound by a so-called no-refusal policy, which means that they cannot turn away patients.

But private hospitals don’t have it all easy. Hospitals that have strong infection-control programmes said that it is not just a medical challenge, but a behavioural one: for example, it requires motivating healthcare workers to wash their hands several times a day. This is the toughest part of the job, says Sanjeev Singh, who helped set up the 16-year-old infection-control programme at Kochi’s Amrita.

To get Amrita’s management onboard, Singh’s team demonstrated the cost-effectiveness of the hospital’s infection-control programme. It showed that every dollar spent on infection control in Amrita’s cardiovascular surgery unit in 2009 and 2010 led to $236 in savings. This benefited both the hospital and the patients: if patients spent less time hospitalised due to fewer HAIs, the hospital earned more by treating more patients in the same time.

Of course, hospitals must also be willing to spend on sterilisation facilities, on soap and alcohol hand rub, and on recruiting enough nurses to tend to all patients. When patients contract rare drug-resistant bugs, they must have enough rooms to isolate them. Tracking how many patients catch HAIs in the hospital is critical too, because it helps decide if the facility’s infection-control efforts are working.

A 2013 survey of 20 hospitals led by ICMR scientist Kamini Walia, found that only 60 per cent were tracking their HAI rates, such as ventilator-associated pneumonia, each year. A similarly low number of them had guidelines for isolating patients with drug-resistant infections.

“When people say infection control, they are usually talking about high-tech isolation precautions etc. But if you look at data, one in six hospitals in the world don’t even have running water. So how will they follow infection control?” asks Abdul Ghafur, an infectious disease specialist who spearheaded the Chennai Declaration, a 2012 resolution by the Indian healthcare community to tackle antimicrobial resistance.

One way out of India’s infection-control problem is for more healthcare facilities to be accredited. Accreditation means that an independent body, such as the National Accreditation Board for Hospitals and Healthcare Providers (NABH), puts its stamp of approval on the quality of care provided by a hospital, including its efforts to curtail infections. CDDEP’s Laxminarayan is batting for accreditation to be made mandatory.

But this may a tall order: in the last 14 years, since NABH was set up, only 638, or less than one percent of the estimated 80,000 hospitals in the country, have been accredited.                                       (HT Media)

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