September 19, 2011
As part of a blog series leading up to the 1st Global Forum on Bacterial Infections, we’ll be featuring perspectives from conference speakers and participants. The following is a CDDEP interview with Dr Chand Wattal, Hony. Senior Consultant & Chairman, Department of Clinical Microbiology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi. Dr Wattal is co-leading two sessions at the Global Forum: Microbiology Laboratories (hospital and other) and a hands-on session on Quality Control Requirements for Laboratory Certification in India.
CDDEP: At the Global Forum, you ll be speaking during a hands-on session on quality control requirements for laboratory certification in India, as well as during a parallel session on microbiology laboratories. What do you hope to focus on during these sessions?
CW: These are two important sessions. Laboratory certification in India is a hands-on session on various aspects of quality control requirements, which are voluntary and not mandatory in India so to motivate health care providers it is necessary to make them understand the benefits of accreditation by which quality can be established. Once we have quality control in place with reproducible results, it makes a difference in delivering quality health care. It is essential that the processes involved in the diagnostics services are of internationally recommended quality. This session is expected to be an interactive session, with a few people on board who are deep into the understanding of the nitty gritty of accreditation day in and day out. One of the experts is an expert in quality practices and the other is highly experienced in the steps involved in making accreditation of laboratories happen. The session will involve the participation of the delegates what does it mean to you, and then how would you go about it? It also involves the discussion regarding how to get this form and that form – since accreditation is very record intensive exercise. If one understands the basis it gets very easy to go through the experience of accreditation, which is by and large similar the world over.
The other is a session on microbiology laboratories and microbiology services. The theme is how to carry bench to bedside, including the concerns by way of technology, its interpretation, and the international guidelines and practices that one should follow. What does antibiotic resistance mean to a treating physician and what should he do and what modalities should be implemented so as to help him in achieving patient cure? It s very essential for a microbiology laboratory to provide a good database and to formulate guidelines based on that. This is precisely how I want to go about these two sessions and carry it forward. Three speakers will deliberate upon the above lines and also share their experiences from various parts of world, as to how Clinical Microbiology is practiced at their places. WHO Net, which is a very popular and complete software available for free on the net that helps in generating the resistance database (antibiogramme) will be discussed by none other than the one who built it, Dr. Thomas O Brien.
Much of your research has focused on trends in antimicrobial consumption and antimicrobial resistance. What is the role for microbiologists in containing antimicrobial resistance?
It s a really an important area and every institution must have a database generated by its qualified clinical microbiologist, and not a pathologist, who is expected to follow international interpretive guidelines and is able to generate very reliable and reproduceable data these are the ingredients to make a scientifically guided policy to handle the menace of resistance. You cannot apply a global database to a local scenario. You have to create your own. Once you have your reliable database, you will be able to monitor levels of resistance, and at the same time you need to conduct prescription auditing to understand the prescribing habits and usage at one’s own health care setting. The antibiotic policy which one need try to implement has to emerge out of this data. So there is a very important role of a clinical microbiologist at any health care setting to show the way forward.
What is the situation in India when it comes to preserving the effectiveness of important, first-line antibiotic treatments?
When we talk about development of antibiotic resistance, and when we say that in this part of the world first-line drugs are not effective, one needs to understand that we are talking of hospital settings. Distinction need be made between the community experience and the hospital, though the gap is narrowing. When it comes to community use or community-based implications, there is not much data in this part of the world available. Most of the data we are debating primarily is hospital based, and it s either from the ICUs or from the floor. Based on this, it s very difficult to say what has happened to the first-line drugs, particularly in the community. The first-line drugs are still there, and they are being used.
Shortly after NDM-1 first made headlines last fall as an emerging, potentially very dangerous, resistance-conferring gene, you wrote a letter to the Lancet talking about antibiotic resistance as a global issue. What steps can the global community take to limit the spread of emerging resistant infections, especially given unprecedented levels of international mobility and migration?
With the NDM-1 study, we had a problem with the findings since it was not representative of the community. Moreover, it was the financial interpretation which we did not appreciate. When you talk of multi-drug resistance organisms, (MDROs), these are primarily seen in a hospital ICU, in immuno-compromised and difficult to treat cases. Having said that, I would not ignore the isolation of MDROs because we have an example of the development of extended spectrum beta-lactamases (ESBLs) resulting in cephalosporin resistance in 1990s this was similarly hospital based to begin with but spread to the community. We find ESBLs producing gram negative organisms left, right, and center, causing disease in the patients in the hospitals, but also in the community causing urinary tract infections. So I wouldn t ignore NDM-1 as a mechanism of the development of resistance.
The global community has to identify the mode of spread, and then, the infection control practices are going to actually see us through. So the global community needs to respond with the implementation of universal precautions and understand the limitations that we have in treating these difficult to treat infections. We have to actually convince our health care providers, especially the administrators, that if you develop multi drug resistance with global spread then you may not have drugs to treat with.
The genetic evolution of bacteria, as we know, will keep it to stay ahead of us today it is NDM-1, tomorrow it is something else. It is a constant, evolving process, in nature. It s very essential for us to recognize how to limit the spread of disease by infection control practices. We don t have new antibiotics in the pipeline. We have bad bugs and no drugs. The kind of successes and the outcomes we re able to achieve today in medicine are happening because we have reliable antibiotics to help our patients. All kinds of transplants or surgical feats can come to a naught in absence of effective antibiotics. Development of multiple antibiotic resistance will be a huge setback to the mankind.
Finally, what are you hoping to take away from the 1st Global Forum on Bacterial Infections?
I m really excited about the Global Forum being held for the first time in the country. I expect it to achieve focus on the issue of antibiotic resistance. And not only resistance we have to go beyond that. We have to identify strong, researchable areas and a way forward. We have to take it to the next level. If we have good data, then what next? These are the issues that have to be discussed at the Global Forum. And we also need to discuss what is our understanding of antibiotic resistance at the community level in India as compared to around the globe? We know there are huge variations when we look at health care settings across the world. We will have the representatives from all over the world which will be a good learning experience. It is going to be an academically very exciting event.
