The Super Bug

(This is a guest post by Indu Ravishankar. Indu is a MBBS from

Kasturba Medical College, Manipal.)

The year was 1932. The name was Prontosil. It seems very long
ago, indeed. This antibiotic, credited to have saved numerous
lives during the Second World War including that of two premier
world leaders- Roosevelt and Churchill is a long forgotten relic.
Reason? Indubitably, the discovery of Penicillin that followed a
few years later, led the world on to the new craze. And, as the
discoveries moved on, so did the world’s attention. However,
the damage was already done. Overenthusiastic, overzealous
use had already sown the seeds. Now the year is 2010. And the
buzzwords are MRSA, ESBL, MDR, XDR and superbugs.

From the 1940’s, to the 2000s, we have seen the discovery of
progressively novel, improved, and effective drugs. But if we have
been at work, so have the micro organisms. For after all, Darwin’s
theory of Natural Selection and Survival of the Fittest still hold
good, and true. Is it just that, or do we have a bigger responsibility
to the situation we currently find ourselves in? I am referring to the
latest distressing medical sensation- the superbug.

The superbug is not a ‘bug’. It refers to a gene in the bacteria,
named NDM1 (New Delhi metallo lactamase1) that confers
resistance to the bacteria against the drug that originally was
quite effective in destroying it. It is not a recent phenomenon, and
it is definitely not unforeseen. It did not happen in a day, this was
a latent catastrophe waiting to be exposed. It is the culmination of
years of use, misuse, and abuse. Analogous to a long-term side
effect. What first started as Drug resistant bacteria paved the way
for the more resourceful ones called Multi Drug Resistant (MDR)
bacteria, ultimately evolving into the Extremely Drug Resistant
(XDR). And now it is the superbug.

How much blame do we take for it? More than we would care to
accept.

No one likes being sick. And no one wants to see another person
sick. I definitely do not want to go to work sniffing, hardly able to
breathe through my blocked nose. And neither do I want to see
my colleague blow oodles of yellowish green mucous into his
tissue. So, what happens is that, the minute a person gets the
inklings of a cold, or a sore throat, or a feverish feeling, he/she
immediately rushes to the nearest doctor, who may very well be a
fresh medical graduate, overly enthusiastic in both diagnosing
and treating what is obviously a very minor ailment. What most
people miss here is that over 90% of the ‘common’ cold is viral in
etiology. And viruses do not respond to antibiotics. So taking
antibiotics for common cold is like trying to drive a car with no
wheels. Absolutely useless. The consequent improvement in
symptoms is often wrongly attributed to the antibiotic effect, for
viral infections spontaneously resolve in a few days.

There is also the ‘pressure’ that a doctor gets from the patient to
prescribe antibiotics. Most people these days, thanks to Google
are very ‘well read’ about the ‘possibilities’ of serious infectious
conditions. Type in any symptom, go to Wrong diagnosis dot
com, and you have almost 70 diseases listed for each symptom.
From the most common, to the rarer, and to the almost unknown.
There is a reason why doctors study medicine for 5 and half
years. If diagnosing diseases and prescribing medicines was so
easy, things would be very different indeed! Therefore, when the
said patient comes in, with complaints of cold, cough and other
non-specific symptoms and the doctor tries to say that it is just
viral, that it requires nothing more than saline gargles, Vitamin

C and plenty of fluids, he is met with a lot of resistance, and lot
incredulity. Well, the fact is that any symptom, however irrelevant
it maybe to the doctor, always feels very significant to the
concerned person. When in that state of mind, the first thought
that comes to his/her mind is- this doctor is a quack. Hence,
in order to save face, and practice, and for speedy recovery,
antibiotics are often prescribed quite unnecessarily and lavishly.

There is also the practical issue of empirical treatment that is
generally followed. Tests to detect the organism and its specific
drug susceptibility take on an average 3-5 days to be reported,
during which period, the doctor prescribes a certain antibiotic
presuming a particular organism to be the cause based on his
clinical acumen. Most often, he is right, but for the rare cases
where he is not, the issue of drug resistance being an additive
consideration, forces him to switch over to a different antibiotic
later based on the test results. So it sums up to ineffective
antibiotic for ineffective duration, and a potent antibiotic later. It
is a double-edged sword, and it is what is universally done, for
logistical purposes. Saves time, and provides for prompt relief.

There also seems to be an inclination among people to back
off the second some additional test is advised. The label
of ‘unnecessary and irrelevant investigations’ is immediately
attached to the doctor. At which point, once again, there seems
to be no other option, but to prescribe an antibiotic, a broader
spectrum one at that, with the hope that it is effective. Repeated
and very frequent exposure of the antibiotic to the organism leads
on to the development of resistance. Remember DDT and the
mosquitoes?

The next level where things go wrong is with the choice of

antibiotics and the duration of its use. There seems to be a
common misconception that the broadest spectrum of antibiotic
available is always the best. This is not true. Most of the time,
bacterial infections are due to single organisms. Mixed infections
occur in the critically ill, immunocompromised and hospitalized
patients. So, when a simple antibiotic like Ampicillin would do,
many a time, broader spectrum antibiotics like cephalosporins or
macrolides are prescribed. It is cost ineffective, not indicated, and
is associated with the disadvantage of increasing the rate of short
term side effects related to the individual drug, as well as the long
term effect of possible drug resistance.

When an antibiotic has been prescribed for a said duration, it
has to be taken for that period. Most often, within 2 or 3 days of
initiating the treatment, there is a discernable and substantial
improvement in the symptomatology of the patient, which leads
to a self-declaration of cure, and cessation of the drug, without
the doctor’s advice. This, I feel, is the most important contributory
factor to the development of resistance. These, coupled with
the fact that most antibiotics are very expensive, patients often
strike a bargain. It seems almost moronic to continue taking a
tablet that costs 70 bucks for a disease that appears to have been
cured. This allows the resistant bacteria to proliferate. What also
happens subsequently is that, the next time they are confronted
with the same symptoms, there is an inclination to self medicate,
with the same antibiotic. Although there maybe no proof of it
being the same causative organism.

Sometimes in the case of serious infections such as tuberculosis
or HIV, the treatment protocol is against the use of single
chemotherapeutic agents. In situations like this, combination

drugs are mandatory. For, even if the mycobacterium or the HIV
strain develops resistance to one drug, the hope is that the other
drug would take care of the situation to a certain extent. There
is nothing stopping them from developing resistance to all the
drugs, as well, exemplified by the emergence of extremely drug
resistant mycobacteria. With tuberculosis being widespread,
even in the developed nations as part of the re emerging
diseases, its treatment certainly poses a major challenge. With
the advent of national health programs, considerable effort has
been made to categorize tuberculosis treatment regimens, to
ensure a uniform protocol for both its diagnosis and treatment.
This does decrease the misuse of antibiotics to a certain extent.

Another major contributory concern in some countries is the
availability of drugs over the counter. No prescriptions are
required. I was very surprised to note that, Ketamine, an
anesthetic drug was available over the counter! With money being
no issue for the richer section, the broadest spectrum antibiotics
are available very easily, with the patient self prescribing it, and
discontinuing it once the symptoms subside. A vicious cycle gets
set up, a fertile ground is provided for the resistant bacteria, and
they continue to find ingenious methods to circumvent every
effective known antibiotic.

Not surprisingly, in developing countries, spurious antibiotics are
rampant and find their way into the market. Spurious medications
often do not contain the drug in the concentration that is required
for bacterial kill. Diluted medications, once again promote the
growth of resistant bacteria. This is a problem, specifically seen
in developing nations. Another reason why self-medication is
suicide.

Indiscreet use destroys the symbiotic colonization as well, once
again predisposing to more infections and drug resistance.
Studies have shown that the presence of commensals in the skin
and the gut actually prevent pathogenic colonization. That is a
self-goal, attacking the very protectors.

Now, does the idea of a super bug seem surprisingly alarming?
Alarming, yes. But there is no surprise here.

We have been providing fuel to the fire, at every level. It is
almost as if we have been on a steadfast campaign to prove
Darwin’s theory of natural selection, even at the cost of our own
downfall. The superbug per say is not any more infectious than
the next bacterium. However, the genes are transferrable, from
one pathogenic microorganism to another. In addition, very
soon, the rate at which drug resistance is attained will overshoot
our capacity to discover fresh cure. It could be any one of us,
there, in that ICU, with a simple infection that could have been
easily cured, if it had not been for all the over use, misuse and
the abuse. So the next time anyone of us is down with a simple
cold/cough/fever, I hope we take the time to consider popping
some pills randomly. Trust the human body’s ability to mount an
immune response. Everything else that we do is only supportive
to that massive primary effort.