The Rise and Spread of MCR-1

The year 2017 may be the year of the rooster, but it’s starting to look more like the year of the MCR-1 gene. The MCR-1 gene provides bacteria with resistance to the antibiotic colistin, which is considered a last-resort antibiotic. This past year, researchers found the first stateside MCR-1 positive E. coli isolate from a US patient. The emergence of the MCR-1 gene in a Pennsylvania woman, with no international travel for the previous year, points to the growing threat of microbial resistance. although the patient had no contact with livestock and a minimal role in meal preparation with store-bought groceries, she did have multiple and repeated admissions at four healthcare facilities in 2016.

Since this information was published, surveillance efforts have found additional cases around the world. Unfortunately, this week two studies were published in The Lancet Infectious Disease, that revealed the expansive spread of the resistant gene in Chinese healthcare settings. Chinese detection of MCR-1 began in 2015 and the spread is considered to be linked to agricultural practices, which prompted the 2016 ban of colistin use in animal feed.

While MCR-1 infections in humans have been pretty minimal, the growing concern is related to several vulnerabilities. First, as the WHO noted in 2015, there is a pretty abysmal international strategy for combatting antimicrobial resistance (AMR). While many governments are committed to the issue, there are major gaps across all six WHO regions and no consistent surveillance strategy. The WHO does have GLASS (Global Antimicrobial Resistance Surveillance), but continues to struggle to gain the support and international coordination that is needed. The Global Health Security Alliance (GHSA) includes antimicrobial resistance as one of its action packages, and while more states are joining the initiative, there is much work to be done. Perhaps one of the most prevalent issues noted across the board is the lack of a coordinated and collaborative approach to surveillance, response, and prevention.

Second, the role of agriculture and medical tourism is becoming increasingly highlighted in the fight against AMR. We know that agricultural use of antibiotics in feed and water is a common strategy to facilitate growth in animals, and while the new FDA rule (Guidance for Industry #213) hopes to make this practice more regulated, it’s only a small step in the right direction. Many countries and companies are working towards eliminating antibiotic usage in agricultural practices; however, it is both an arduous and slow endeavor.

In addition, medical tourism has also grown in popularity, with many traveling to countries like India for more affordable surgeries. Unfortunately, antibiotic regulations in foreign healthcare facilities aren’t always as stringent and infection control practices can be highly questionable. At the recent ASM conference last year, one infectious disease physician noted, in his presentation on AMR, that it recently became their hospital-wide practice to isolate any patient who had been hospitalized in a foreign country within the last year until further screening could be done.

Finally, it’s important to highlight the financial hurdles and lack of incentives. Antibiotic development has slowed in recent decades and there are several roadblocks for combatting AMR in the realm of political economy. The rise of the MCR-1 gene is not the first and it definitely won’t be the last in the battle against microbial resistance. Hospital initiatives to screen patients and establish antibiotic stewardship committees are necessary, but often a result of pursuing glamourous new accreditations and not necessarily for the overarching importance of contributing to the fight. The spread of MCR-1 in China shines the light on the desperate need for a re-invigorated and re-incentivized fight against microbial resistance.