File under: Really not good news.

Deep in the back of the weekly bulletin of the Centers for Disease Control and Prevention, there is a note that NDM-1, the "Indian supergene," has been isolated from a patient in a U.S. military field hospital in Bagram, Afghanistan.

It's been a few months since NDM-1 was in the news, so let's recap. The acronym (for "New Delhi metallo-beta-lactamase 1") indicates an enzyme that allows common gut bacteria to denature almost all the drugs that can be used against them, leaving two or three that are inefficient or toxic. It was first identified in a resident of Sweden, of Indian origin, who had returned to India for a visit, was hospitalized there, went back to Sweden, and was hospitalized again.

In 2009, the United Kingdom's public-health agency sent out an alert saying the same resistance mechanism was increasing rapidly there, going from unknown in 2007 to 18 instances in the first half of 2009, most of them in people who had gone to India for medical care or had frequent family travel back and forth. In June 2010, the CDC flagged NDM-1's first U.S. appearance, in three patients in three different states, again with ties to South Asia. And then things started to get very interesting and worrisome, with warnings from the WHO, reports of wide distribution in the U.K. and South Asia, and several pieces of evidence suggesting that bacteria producing this enzyme were not only a health care phenomenon, but were circulating outside of hospitals and might be spread via drinking water and sewage.

For simplicity, keep these facts in mind: Bacteria bearing NDM-1 appear to circulate in South Asia in an untracked manner, appear to spread in health care settings by contaminated surfaces and the hands of health care workers, easily share their resistance DNA with other bacteria, and render common infections almost untreatable. (For more, here's my archive of NDM-1 posts.)

Now, today's news: The CDC reports that the field hospital in Bagram took in as a referral a burn patient from Kabul, an Afghan national who had been scorched in a natural-gas explosion. The person had already been treated in a Kabul hospital and arrived at Bagram five days after the injury. At Bagram, the patient (gender and age not specified) was admitted to the ICU and was found to have septicemia caused by a gut bacterium, Providencia stuartii, that was carrying NDM-1. This particular variety – the NDM-1s have varied slightly in their resistance patterns – was susceptible to only a single drug, aztreonam. It was completely resistant to the carbapenems, the drugs of last resort for serious hospital infections.

The patient, unsurprisingly, died. The isolate retrieved from the patient was the first sighting on record of NDM-1 in a military hospital.

I need you to think, for a minute, about what military field hospitals treat these days: severe injury from improvised explosive devices, traumatic amputations, major head wounds. Military trauma medicine is excellent – but battlefield injuries are inherently life-threatening, messy, complex to repair and slow to heal, and military trauma victims often undergo multiple transfers from field hospitals to major medical centers in Europe and the U.S. and then on to rehab hospitals.

Now toss into that mix any highly communicable hospital-associated organism that has acquired the gene for hyper-resistant NDM-1.

You don't even have to imagine what comes next, because we already know: Multidrug-resistant Acinetobacter baumanii has been spreading through the military hospital system for almost a decade, with grave consequences for injured military personnel.

*Acintobacter *slipped by the military medical system before they noticed, and became established in military hospitals before infection-control efforts were prepared to counter it. It's an urgent question whether the military system, with today's warning, will be able to gear up for NDM-1's arrival in order to keep a second, likely worse epidemic at bay.

Cite: Notes from the Field: Detection of NDM-1 *bla NDM-1 Carbapenem Resistance in a Clinical Isolate of *Providencia stuartii in a U.S./Coalition Medical Facility — Afghanistan, 2011. MMWR, June 10, 2011 / 60(22);756.

See Also:

Providencia, PHIL/CDC