When the drugs don't work (1/4/11)

LONDON, 31 Mar (Reuters) - David Livermore is in a race against evolution. In his north London lab, he holds up an evil-smelling culture plate smeared with bacteria. This creamy-yellow growth is the enemy: a new strain of germs resistant to the most powerful antibiotics yet devised by humankind.

Out on the streets, Steve Owen is running the same race -- physically pounding the pavements to draw attention to the problem of drug-resistant infections.

Owen's father Donald died four years ago of multiple organ failure in a British hospital. He had checked in for a knee operation. But what he got was methicillin-resistant Staphylococcus aureus, commonly known as MRSA, a so-called "superbug" that all the drugs his doctors prescribed couldn't beat. After almost 18 months of severe pain, the infection got into his blood, overpowered his vital organs and killed him.

Owen and his wife Jules have pledged to run 12 big races in as many months, to raise funds for a charity that is working to fight MRSA. "It just shouldn't have happened," says Jules, as the pair nurse their own aching limbs after running a half-marathon. "It was his knee -- that's not something he should have died from."

Welcome to a world where the drugs don't work.

After Alexander Fleming's 1928 discovery of the first antibiotic, penicillin, we quickly came to assume we had the chemicals to beat bacteria. Sure, bugs evolve to develop resistance. But for decades scientists have managed to develop new medicines to stay at least one step ahead of an ever-mutating enemy.

Now, though, we may be running out of road. MRSA alone is estimated to kill around 19,000 people every year in the United States -- far more than HIV and AIDS -- and a similar number in Europe. Other drug-resistant superbugs are spreading. Cases of often fatal "extensively drug resistant" tuberculosis have mushroomed over the past few years. A new wave of "super superbugs" with a mutation called NDM 1, which first emerged in India, has now turned up all over the world, from Britain to New Zealand.

NDM 1 is what's growing on the plates that Livermore holds in his gloved hands. "You can't win against evolution," says the scientist, who spends his days tracking the emergence of superbugs in a national reference laboratory at Britain's Health Protection Agency. "All you can seek to do is to stay a jump ahead."

That's not happening now for a number of reasons. For a start, antibiotics are everywhere, giving bacteria countless opportunities to evolve escape routes. The drugs can be picked up, without prescription, for pennies in countries like Thailand, India and parts of Latin America. Even though their use is controlled in the west, the system encourages doctors to shoot the bugs first and ask questions later. Perhaps most worryingly, the world's top drug companies, faced with decreasing returns and ever more expensive and difficult science, have not only slowed their efforts to develop new antibiotics but have been quitting the field in droves.

Today, only two large companies - GlaxoSmithKline Plc and AstraZeneca Plc -- still have strong and active antibiotic research and development programmes, according to the Infectious Diseases Society of America. Back in 1990, there were nearly 20.

That could have a profound impact on how we treat our sick. "If some of the most potent multi-resistant strains that we see now accumulate, then modern medicine -- from transplants to cancer treatment and even quite straightforward gut surgery, potentially becomes untenable," says Livermore. "You need the ability to treat infections in vulnerable patients. Lose that and a swathe of modern medicine becomes unstable."

Are we about to start going backwards, to a pre-antibiotic era in which things like hip replacements, chemotherapy and intensive care are simply impossible? It's a big enough fear for the World Health Organization to devote this year's World Health Day on April 7 to antimicrobial resistance in a bid to safeguard these drugs for future generations.

"Modern medicine can't function without effective antibiotics," says Derek Butler, chairman of the MRSA Action UK charity for which the Owens are raising money. "If we lose these magic bullets, medicine will be set back over 80 years.

RAT ON THE WARD

One aspect of the race against bugs has changed little since Fleming's time, or Florence Nightingale's before that. Hospital hygiene is the basic, unglamorous and underpaid work that forms the vital first-line of defense against pathogens. If it is done properly, it can ease the demand for drugs in the first place. Yet Steve Owen remembers his dad telling him he'd seen a rat running through his ward - a shock in a developed world hospital.

Bugs are no respecters of age. Donald Owen was 82 when the treatment for his knee problems ended up killing him. Susan Fallon's daughter Sammie was just 17 when she was admitted with flu-like symptoms to another British hospital in April 2008. Pretty, petite -- at only five feet tall she was "like a little doll", her mother says -- Sammie dreamed of being a professional photographer. When her hospital blood tests came back with worrying results, doctors ordered more, including a bone marrow biopsy. That led to a diagnosis of a rare blood disorder which required chemotherapy. She also picked up a superbug. Just over a month later, before any treatment had a chance to work, Sammie was dead.

The experience left her mother bereft, angry and with a fear of hospitals and the people who work in them. "I don't know which one came in without washing their hands and gave this bug to Sammie," she says. "But if I went into hospital now I'd be saying 'Wash your hands before you come near me' -- I'd be really vigilant."

In developed nations, a big push to improve hospital hygiene is starting to keep MRSA in check. At the same time, cheap international travel is breaking down the geographical barriers to infection. Medical progress is accelerating in places like India, China and Brazil, but often more swiftly than basic infection control in hospitals, Livermore says. "It's sexier to say you can do a kidney transplant, but it's not so sexy that infection control nurses go around and berate people for not washing their hands. And yet it may well be that the infection control nurse would save more lives than the renal surgeon."

The fact that the latest superbug -- NDM 1 stands for New Delhi metallo-beta-lactamase, an enzyme that gives bacteria multidrug resistance -- first emerged in India comes as little surprise to many microbiologists. Use of antibiotics is rampant and unregulated in a country with appalling sanitation, high rates of diarrheal disease and overcrowding -- ideal conditions for resistance to develop. A week-long course of antibiotics can cost as little as 30 or 40 U.S. cents from one of the thousands of chemist shops that all too often dispense poor advice along with their non-prescription drugs.

On top of this, even in the developed world, the antibiotics used today are "broad" products, whose blunderbuss approach can kill a wide range of bugs but also trigger knock-on problems. One reason for this is that for the first 48 hours, patients are effectively treated blind while lab staff go through the process of growing a culture sample to see just which microbe is to blame. In particular, Clostridium difficile infection has become a significant problem in hospitals because such broad-spectrum antibiotics damage gut flora, which creates an environment for it to flourish.

From Reuters

दवा या गरीबों के साथ मजाक ?

जयपुर.हृदय रोग के इलाज में काम आने वाली एथेनोलोल की जो जेनेरिक 14 टेबलेट महज 1.46 रुपए में उपलब्ध होती हैं, उसी साल्ट से बनीं ब्रांडेड दवा बाजार में बिक रही है 40-45 रुपए में। कैंसर जैसी बीमारी से लड़ने वाले जिस पेक्लिटेक्सल इंजेक्शन की कीमत 338.66 रुपए है वह बाजार में ब्रांड के नाम पर 4300-4500 रुपए में धड़ल्ले से बिकता है।
यही नहीं बुखार, खांसी, जुकाम सहित अन्य आम बीमारियों के लिए जो सरकारी जेनेरिक दवाएं मामूली कीमत में मिलती हैं, वही ब्रांडेड के नाम पर कई गुना दरों पर बिक रही हैं।
कमीशन के भारी खेल के चलते आसमान छुती ब्रांडेड दवाओं की कीमत मरीजों की जिंदगी पर भारी पड़ रही है।
डॉक्टरों की मानें तो जेनेरिक दवाओं में भी करीब-करीब वहीं साल्ट इस्तेमाल होते हैं जो ब्रांडेड दवाओं में। कीमतों में यह फर्क दवा कंपनियों, एमआर, दवा विक्रेताओं और दवा लिखने वालों के बीच के कमीशन खेल के चलते है।
चिकित्सा मंत्री एमादुद्दीन एहमद खान का कहना है कि निशुल्क दवा योजना के तहत उपलब्ध करवाई जा रही जेनेरिक दवाओं से भारी दवा कीमतों से लूट रहे लोगों को आसान इलाज उपलब्ध हो सकेगा।
राजस्थान मेडिकल कारपोरेशन के एमडी सुमित शर्मा बताते हैं, यह सोचना कि सस्ती दवाई आम तौर पर कारगर नहीं हो सकती, यह तथ्य पूरी तरह निमरूल है। शर्मा कहते हैं कि योजना के तहत शुरुआती दौर में कुछ डॉक्टर हो सकता है जेनेरिक दवाएं लिखने में परहेज करें, लेकिन यह स्थिति धीरे-धीरे नियंत्रण में आ जाएगी।
दवाओं के दाम में जमीन-आसमान का फर्क
दवाई पैकिंग साइज जैनेरिक ब्रांडेड
दर्दनिवारक
डाइक्लोफेनिक सोडियम 10 टेबलेट 2.29 25-29
एंड पेरासिटामोल टेबलेट
डाइक्लोफेनिक सोडियम 10 टेबलेट 1.24 23-41
टेबलेट 50 एमजी
एंटिबायोटिक
एजीथ्रोमाइसिन 10 टेबलेट 58.80 308.33
सेफिक्साइम आईपी 100 एमजी 10 टेबलेट 12.81 120
सेफालेक्सिन कैप्सूल 10 कैप्सूल 18.97 162-160
जेंटामाइसिन इंजेक्शन 2 एमएलएएमपी 2.02 7.66-9
एंटीनियोप्लास्टिक
डोक्सोरूबिसिन इंजेक्शन 25 एमएल 212.47 1725
पेक्लिटेक्सल इंजेक्शन 16.7 एमल 338.66 4022-4500
कार्डियोवस्क्यूलर
एथेनोलोल आईपी 50 एमजी 14 टेबलेट 1.46 40-45
एटोरवेस्टेटिन आईपी 10 एमजी 10 टेबलेट 2.98 103.74
क्लोपिडोग्रेल आईपी 75 एमजी 10 टेबलेट 6.10 215.50
हार्मोस एंड इंटोक्राइन ड्रज्स
गलीमेप्राइड टेबलेट आईपी 2 10 टेबलेट 11.154 117.40
साइकोट्रोपिक ड्रग्सएल्प्लाजोलम आईपी 0.5 एमजी 10 टेबलेट 1.47 25-26
डाइजेपाम आईपी 5 एमजी 10 टेबलेट 1.30 30.22
ओलेन्जापाइम टेबलेट 10 टेबलेट 2.77 38.52
सेरट्रेलाइन टेबलेट 10 टेबलेट 3.47 50-56
(कुछ दवाओं में वैट की अतिरिक्त राशि)

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