The growing peril of drug-resistant superbugs
Manoj Ghamandayan, 21, has little memory of the month he was hospitalised and nearly died.
It started out as a fever in the first week of October 2019. Then he began to have trouble breathing. Soon, Ghamandayan, an undergraduate Arts student from Haryana’s Jhajjar district, was admitted to Sunflag Global Hospital in Rohtak. He was diagnosed with dengue, a viral infection spread by the Aedes mosquito and scrub typhus, a bacterial infection. To help him recover, the hospital hooked him to multiple devices: 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 were superbugs — i.e, 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, Atul Gogia, deployed two last-line antibiotics called colistin and meropenem —both expensive, with toxic side effects. Yet these drugs are the only hope for patients when all else fails.
Ghamandayan eventually got better and was discharged nearly a month after he was first hospitalised. In all, he had spent Rs 6 lakh on his treatment.
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, which is why it is hard to get a countrywide picture of this problem.
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 and 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. “The rates of infections in Indian hospitals are just unacceptably high,” says Ramanan Laxminarayan, a public-health expert at Washington DC’s Center for Disease Dynamics, Economics & Policy (CDDEP).
But that’s just part of the problem. Many of the bugs that cause these infections have learnt 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 of them succumb: A 2018 study, carried out in 10 Fortis Group hospitals found that patients with multidrug resistant infections were almost thrice as likely to die as those with susceptible ones.
While there are no India-wide estimates of how many people die due to antimicrobial resistance, Laxminarayanan pointed out that a bulk of the deaths take place in hospitals. “So, if I were to prioritise measures to tackle drug resistance, infection control in hospitals would be number one.” To be sure, HAIs have always been a risk to hospitalised patients globally. But increasing antimicrobial resistance is throwing a new spanner in the works; it is turning previously curable maladies into death sentences. The problem is that infection-control is not easy. It requires hospitals to aggressively push a range of best practices, including frequent hand washing, and caution while setting up devices like ventilators and catheters. Not enough hospitals check these boxes.
Each morning, a medical intern at Kochi’s Amrita Institute of Medical Sciences heads off on a sleuthing exercise. She has one job – to count the number of doctors and nurses washing their hands. Wearing a face mask, so it’s hard to recognise her, she walks over to a different ICU each day. Here, she watches quietly as workers go about their daily jobs. When a doctor forgets to use an alcoholic hand-rub before touching a patient, the intern makes a note. When a nurse forgets to wash her hands before inserting a urinary catheter, she makes a note of that too. There really is no excuse, because every ICU bed has a bottle of alcoholic hand-rub next to it.
At the end of the month, the data collected by such interns is used by Amrita’s infection-control committee to calculate each ICU’s hand-hygiene compliance – the number of people who follow the hand-hygiene rulebook fully. When this number drops in any ICU, the hospital management has a chat with the staff.
There’s a compelling reason behind Amrita’s strict emphasis on washing hands. 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. “Whenever an ICU’s hand-hygiene is good — above 85% — we find that infection rates are low,” says Anusha G, a microbiologist who heads Amrita’s infection-control committee.
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 with over 1,000 beds — 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. The babies succumbed to unknown causes. 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 Vaibhav Galriya, secretary to Rajasthan’s medical education department. “There were many different reasons why the children died.”
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. “The hospital is working at 150% capacity,” he says. 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 I spoke to said that they were frequently forced to place more than one person per bed. Delhi’s Safdarjung hospital has 2,800 beds, but often accommodates up to 7,000 patients. “One patient is lying with a head on this side of the bed, and the other is lying with the head on the other side,” said Sunil Gupta, who was Safdarjung’s medical superintendent until December 2019, and is now with The National AIDS Control Organisation, describing the press of patients on any given day.
Safdarjung and other government hospitals in India are bound by a so-called no-refusal policy, which means that they cannot turn away patients.
“From the point of view of infection control, overcrowding is our biggest problem,” Gupta said. Safdarjung has an infection control policy, but implementing it is tough, doctors there said.
If overcrowding is a strain on government hospitals, even private hospitals don’t have it easy.
Hospitals that have strong infection-control programmes told me 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.
“Money, material and manpower have no value unless I am able to change the behaviour of people,” he said.
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% 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, 1 in 6 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.
Given the massive variations among hospitals, 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 1% of the estimated 80,000 hospitals in the country, have been accredited.
One of the biggest problems Indian hospitals face today is a bacterium called Klebsiella pneumonia. “Klebsiella consumes many patients,” microbiologist Chand Wattal, who heads the infection-control programme at Sir Gangaram Hospital, said.
According to ICMR’s surveillance data, nearly 61% of infections caused by the bacteria are not affected by drugs called cephalosporins. In such cases, doctors turn to carbapenems; 40% of all Klebsiella infections are resistant to that. Finally, doctors are left with colistin, which is what Ghamandayan was administered. While Ghamandayan was not infected with Klebsiella, the hospital bug he had contracted was also resistant to carbapenems.
Both colistin and carbapenems can hurt the kidneys. For carbapenem-resistant patients, the combined cost of colistin and higher doses of carbapenems can be as high as Rs 26,000 per day, estimated V Ramasubramanian, an infectious disease specialist and a member of the infection control committee at Apollo Hospital, Chennai.
“In the end, these multidrug-resistant infections are over ten times more expensive,” he said.
What happens when colistin begins to fail? Data from ICMR’s network shows that nearly 15% of Klebsiella in the network’s hospitals are already colistin resistant. In such patients, doctors sometimes find alternative drugs that work, but this isn’t guaranteed. This means that such patients die nearly half the time.
“In ICUs, Klebsiella is almost a death sentence,” said Wattal.
Back in Jhajjar, Ghamandayan is thankful that he escaped a similar killer super-bug. Perhaps he recovered because he was young and otherwise healthy. Luckily for him, the colistin worked. As antimicrobial resistance worsens in the country, such stories will get rarer.