Clinical Updates
13 August 2010
Multidrug-resistant Enterobacteriacae (NDM1) in India, Pakistan and the United Kingdom
A recent report highlights the emergence of multidrug-resistant Enterobacteriacae in India, Pakistan and the United Kingdom (UK) [1]. Enterobacteriacae are a group of Gram-negative bacteria and include Escherichia coli and Klebsiella pneumoniae. These bacteria contribute to urinary tract and other infections including a range of healthcare associated infections. The New Delhi metallo-β-lactamase 1 (NDM-1) enzyme confers resistance to a group of antibiotics known as carbapenems [1-2]. Carbapenems are antibiotics usually reserved for treatment of serious and complex infections in hospitalised patients.
In 2008-2009, a study identified 29 patients in the UK with NDM-1 Enterobacteriacae. Seventeen of these individuals had travelled to India or Pakistan in the preceding year, of whom 14 were admitted to hospital whilst abroad, some for planned medical procedures such as organ transplantation and cosmetic surgery [1]. Since the study ended, a further 21 patients with NDM-1 Enterobacteriacae have been identified bringing the total to 50 [3].
In 2007, overseas healthcare providers reported that 50,500 UK travellers accessed elective medical treatment abroad [4]. India and Pakistan are recognised destinations for medical treatment.
Advice to travellers planning to receive medical treatment overseas
Normal infection control measures, such as disinfecting hospital equipment and careful hand washing are important in reducing transmission of this infection, as with any other healthcare associated infection. Appropriate use of antibiotics is also important.
Travellers should be aware that overseas health standards, infection control measures and safety standards in medical facilities may differ from those in the UK [5, 6].
If travellers arrange medical treatment abroad, they should receive a recommendation from a specialist in the UK prior to arranging treatment. They should have comprehensive travel insurance and declare medical conditions and planned activities such as medical treatments or procedures.
Travellers should review the medication regulations for the countries to which they are travelling (consult Home Office and embassies of the destination country/countries). This is especially important if intending to travel with a controlled drug.
Hepatitis B vaccination should be considered for those travelling in order to receive medical treatment.
General advice for travellers
These NDM-1 positive bacteria do not pose a general threat to travellers to India and Pakistan and no special precautions are needed. Anyone requiring emergency treatment abroad should let their doctor know about this on their return to the UK. The presence of these micro-organisms, although common in some geographical areas, is not a reason to avoid necessary emergency medical treatment. The risk of acquiring an infection with them is very low.
References
1. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis. On-line publication 11 August 2010: DOI:10.1016/S1473-3099(10)70143-2. [Accessed 12 August 2010].
2. Yong D, Toleman MA, Giske CG, et al. Characterization of a new metallo-β-lactamase gene, bla (NDM-1), and a novel erythromycinesterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother. 53:5046–54, 2009.
3. Health Protection Agency. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. 11 August 2010. [Accessed 13 August 2010]. Available at: http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPA
4. Treatment Abroad. Medical Tourism Survey. 2007. [Accessed 12 August 2010]. Available at: http://www.treatmentabroad.net/about/medical-tourism-survey/?locale=en
5. Treatment Abroad. Guide to medical tourism. 2007
[Accessed 12 August 2010]. Available at: www.treatmentabroad.net/guide
6. NHS Choices: Healthcare abroad. [Accessed 12 August 2010]. Available at: www.nhs.uk/Healthcareabroad/Pages/Healthcareabroad.aspx
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