Carbapenems were the last β-lactams retaining near-universal anti-Gram-negative activity, but carbapenemases are spreading, conferring resistance. New Delhi metallo-β-lactamase (NDM) enzymes are the latest carbapenemases to be recognized and since 2008 have been reported worldwide, mostly in bacteria from patients epidemiologically linked to the Indian subcontinent, where they occur widely in hospital and community infections, and also in contaminated urban water. The main type is NDM-1, but minor variants occur. NDM enzymes are present largely in Enterobacteriaceae, but also in non-fermenters and Vibrionaceae. Dissemination predominantly involves transfer of the bla(NDM-1) gene among promiscuous plasmids and clonal outbreaks. Bacteria with NDM-1 are typically resistant to nearly all antibiotics, and reliable detection and surveillance are crucial.
E. coli is one of the most prevalent human pathogens, and the window of opportunity to control it from becoming widely resistant is rapidly closing. No vaccine is likely to become available and one that affects commensal gut strains would probably be undesirable, even though these might act as vectors of potent resistance, including NDM-1. Therefore, everything must be done now to prevent infections due to bacteria with NDM-1, otherwise infections as common as pyelonephritis might soon become life-threatening owing to the lack of effective treatment.