How are New Delhi metallo-beta-lactamase (NDM)-producing bacteria managed in India?

From the Guidelines

The management of New Delhi metallo-beta-lactamase (NDM)-producing bacteria in India should primarily involve the use of ceftazidime/avibactam plus aztreonam as the preferred treatment option, given its strong recommendation and moderate certainty of evidence. This approach is based on the most recent guidelines endorsed by multiple Italian medical societies, as outlined in the International Journal of Antimicrobial Agents 1. The rationale behind this recommendation stems from the in vitro synergy displayed by the combination of ceftazidime/avibactam and aztreonam, as well as observational studies showing significantly lower 30-day mortality rates in patients treated with this combination compared to other antibiotics active in vitro, including colistin, tigecycline, and fosfomycin.

Key considerations in the management of NDM-producing bacteria include:

• The endemic nature of these bacteria in the Indian subcontinent, which necessitates a proactive and informed approach to their management.
• The limited therapeutic options available due to the bacteria's resistance to most antibiotics, including carbapenems.
• The importance of combination therapy, such as ceftazidime/avibactam plus aztreonam, which has shown promise in treating infections caused by NDM-producing Enterobacterales.
• The potential role of cefiderocol as an alternative option, although its recommendation is conditional and based on lower certainty of evidence compared to ceftazidime/avibactam plus aztreonam 1.

Infection control measures are also crucial in preventing the spread of NDM-producing bacteria, including:

• Patient isolation to prevent cross-contamination.
• Dedicated equipment and enhanced environmental cleaning to reduce the risk of transmission.
• Active surveillance cultures to monitor for the presence of these bacteria.
• Antibiotic stewardship programs to ensure the judicious use of antibiotics and mitigate the development of further resistance.

Overall, the management of NDM-producing bacteria in India requires a comprehensive strategy that incorporates evidence-based treatment options, such as ceftazidime/avibactam plus aztreonam, alongside rigorous infection control measures to prevent their spread and reduce the risk of morbidity, mortality, and compromised quality of life.

From the Research

Management of NDM-Producing Bacteria in India

• The management of New Delhi metallo-beta-lactamase (NDM)-producing bacteria in India is a challenging task due to the limited treatment options available 2.
• The Indian subcontinent is considered a main reservoir of NDM-1 producers, and the spread of these bacteria can be slowed down by implementing measures such as discouraging the over-the-counter sale of antibiotics and improving basic and extended knowledge on hygiene 3.
• The treatment of infections caused by NDM-producing bacteria is difficult, and the majority of isolates are multidrug resistant, with some being extensively drug resistant 2.
• The use of antibiotics such as tigecycline, eravacycline, and omadacycline has shown some effectiveness against NDM-producing bacteria, but the percentage of susceptible isolates does not exceed 90% for any of the FDA-approved antibiotics tested 2.

Spread of NDM-Producing Bacteria

• The spread of NDM-producing bacteria is not only limited to India but has also been reported worldwide, with cases identified in the United States, the UK, and other countries 4, 5.
• The blaNDM-1 gene, which encodes NDM-1, is located on self-transmissible plasmids that also carry a considerable number of other antibiotic resistance genes, making the spread of these bacteria a significant public health concern 6, 4.
• Human factors such as travel, sanitation, and food production and preparation have contributed to the spread of NDM-producing bacteria 5.

Public Health Concerns

• The emergence of NDM-producing bacteria has significant public health implications, and coordinated international surveillance is needed to monitor the spread of these bacteria 4, 5.
• The creation and transmission of blaNDM are potentially global health issues, requiring global priorities and individual efforts to slow down the spread of these bacteria 5.
• Improving infection control practices, such as proper hygiene and sanitation, and implementing measures to prevent the overuse and misuse of antibiotics can help reduce the spread of NDM-producing bacteria 3, 5.