Antimicrobial Resistance

Antimicrobial Resistance

Anti-microbial ResistanceThe issue of antimicrobial resistance in general is becoming a significant public health issue globally, but with particular concern in Southeast Asia where the health care delivery system is fraught with a lack of appropriate medical training and compounded with a high degree of usage of antibiotic medications, frequently overprescribed or purchased without medical supervision.  

A WHO fact sheet on Cambodia written in May 2013 states:“Many infectious diseases risk becoming untreatable and uncontrollable, which could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.” The document further states that the prevalence of multi-drug resistant TB and malaria are increasing.   Resistance to the commonly used ciprofloxacin creates increasing difficulty in treating childhood diarrhea, gonorrhea, typhoid fever and other infections. Emerging concerns to resistance are also arising for HIV treatment providers and for anti-viral medications in general.

Overall, information about antimicrobial resistance in Cambodia is quite limited. However, a national workshop conducted with support from DGD/ITM in 2011 and an ensuing published paper revealed:

Resistance data as available from routine clinical samples or prospective surveillance studies from 10 laboratories showed alarming overall resistance rates, For example, 70–90% multidrug resistance and 70–80% decreased ciprofloxacin susceptibility in Salmonella-Typhi, 20–40% meticillin resistance rates in Staphylococcus-aureus and, 30–50% ESBL production in E. coli.

Recently published data from the SHCH-ITM blood culture surveillance study carried out confirmed high rates of multi drug resistant bacteria causing life threatening illness. The microbiology laboratory at SHCH is one of the few laboratories in the country where this kind of diagnosis can be accurately made.

Typhoid fever, a bacterial infection caused by the consumption of contaminated water or food, is a serious problem in developing countries worldwide. The illness causes high fever, abdominal pain and occasional confusion. Recently, SHCH laboratory and our longtime partner the Institute of Tropical Medicine (ITM) published findings http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20594,

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20592

about an emerging strain of typhoid bacteria: Salmonella paratyphi A. SHCH uses systematic blood cultures in patients with fever, to detect and isolate specific bacteria. This is done in only a handful of other hospitals in Cambodia. “Our partnership with ITM allows for a rigorous and systematic collection of blood samples and revision and communication of our findings; a role that is currently not fully filled by the public and private laboratories in Cambodia,” said Dr. Phe Thong, a clinical supervisor. “This joint effort allows us to sample more blood, which permits wider research and knowledge of how to track and eradicate. The partnership with ITM has been a vital part in solving this problem.

 From 2011-2013 there were 71 cases of paratyphoid A in Cambodia, 69 more than there were between 2007 and 2010. SHCH has already notified World Health Organization’s Cambodia and the Ministry of Health about this growing concern, with concurrent information also published by the European CDC noting an increase in infections for European travelers returning from Cambodia. Luckily, these Salmonella Paratyphi A did not display a lot of antibiotic resistance. Nonetheless, precautionary measures are vital in securing public health.   The SHCH-ITM team’s findings indicate that the bacterium is most likely coming from an unsanitary water or food source in Phnom Penh and is moving out into the provinces as people leave for holidays to visit family and friends.     

Until the year 2013 the disease was rare, but at the Sihanouk Hospital Centre of HOPE in Phnom Penh, it now accounts for 90% of the enteric fever cases. In travellers, Salmonella Paratyphi A represented 30.9% of imported cases of enteric fever in the European Union in 2011. There has been no clear explanation for this emergence of Salmonella Paratyphi A.