Associate Professor Mattias Larsson on the challenges of antibiotic resistance in Vietnam

Mattias Larsson is a Swedish Associate Professor working in Vietnam. He is doing research for Global Health (IHCAR), Karolinska Institutet and Training and Research Academic Collaboration (TRAC) Sweden and is an Honorary Professor at Hanoi Medical University. Professor Larsson expresses his concern and says it is a worrying situation in the country. In his research project they found increasing levels of resistance and high levels of colonization with Gram negative bacteria resistant to almost all available antibiotics.

How long have you been working in Vietnam and what was the nature of the work you did there?

– I first came to Vietnam in 1997 and did my PhD on antibiotic use and resistance as well as interventions in private pharmacies to improve case management of respiratory infections and sexually transmitted diseases.

What is your assessment of the overall situation in Vietnam on the prevalence of antibiotic resistance?

– It is a worrying situation where we find increasing levels of resistance and high levels of colonization with Gram negative bacteria resistant to almost all available antibiotics.

– A one year point prevalence study we conducted during 2013 in 16 Vietnamese Hospitals showed that about one third of intensive care unit treated patients have Hospital Acquired Infections (HAI), most frequently caused by Gram negative bacteria with alarming rates of resistance to broad spectrum antibiotics such as carbapenems.

– We have also assessed resistance mechanisms in carbapenem resistant Klebsiella pneumoniae and followed cohorts of patients with healthcare associated infections due to this organism, the data shows high rates of crude mortality (withdrawal from treatment and death) of about 35% among patients with healthcare associated infections caused by Carbapenem Resistant Enterobacteriacae (CRE). The rate of mortality seems to be correlated to the resistance mechanisms, virulence factors and susceptibility pattern. CRE which are also colistin resistant have higher crude mortality than those that are just carbapenem resistant.

What are you working on now?

– Currently we are doing studies on CRE colonization in neonatal and pediatric intensive care units in several Vietnamese hospitals in Hanoi and Ho Chi Minh City and have found high colonization rates above 50% in point prevalence screenings, in central hospitals there is a high rate of colonization with CRE at admission indicating that many patients are colonized in provincial and district level health facilities. We have done point prevalence studies in some of the peripheral hospital intensive care units and also found high rates of CRE colonization.

– Community dissemination of CRE is the initiation of the post antibiotic era. The colonization with carbapenem-resistant Gram-negative bacteria is in normal cases not dangerous for the individual. However, in case of severe disease, injury or need for oncological care and treatment the CRE are opportunistic and may cause severe infections not treatable by common antibiotics. In case of resistance to last resort antibiotic, as colistin which is increasingly more prevalent, there is no available treatment. Hence the large scale dissemination of CRE will cause increased morbidity and mortality in severe infections, as we already see, as well as make advanced care such as surgery, transplantation and oncology increasingly difficult and dangerous.

What do you see being the major drivers of antibiotic resistance in Vietnam?

– The community use of antibiotics, mainly self-medication through private pharmacies. However, the high rate of antibiotic prescription and hospital use of broad spectrum antibiotics is also a problem. We have done community studies on antibiotic use and resistance in 1999, 2007 and 2013. In 1999 and 2007 the majority of children had used  antibiotics one month prior to the study, 75% and 68%, respectively. In 2013 that had decreased to 42%, however, it is still high. The kind of antibiotics used has moved from mainly betalactams like amoxicillin to cephalosporins like cephalexin. Most of the antibiotics used in community where obtained from private pharmacies of small clinics.

– For low and middle income countries with limited resources making medicines available through private pharmacies, small private clinics is a cheap way to provide health care as it is provided by the market. To make a firm diagnosis and treat based on indication takes more resources with skilled health staff and laboratory tests and examinations then to let the market provide the service for profit. However, it causes the “tragedy of the commons”, overuse of a common asset that is spoiled. We have now had antibiotics since 1940 but now we see the consequences of the unrestricted use in large parts of the world.

– Another problem is the common use of antibiotic in agri- and aqua-culture. As in most countries more antibiotics are used for animals than humans. Colistin, the last resort antibiotic for humans is used in huge amounts for animals. This may drive resistance in the community.

And what type of illness is most common (that you face) in context of antibiotic resistance?

– As stated above a large proportion of patients admitted to hospital carry Gram negative bacteria resistant to almost all available antibiotics. Hospital acquired infections with these bacteria are common and difficult to treat.

What is the typical reaction when you tell them that antibiotics may not help them?

– It is a difficult situation when patients are admitted to hospital with one disease and during treatment they develop hospital acquired infections with bacteria resistant to all available antibiotics. As I mainly meet children I have to inform the parents – which of course is very difficult.