In 2016-2017, ReAct supported a research project in Vietnam on preserving efficacy of last-line antibiotics. Results indicate very high rates of resistance to most antibiotics, including carbapenems.
The project carried out studies in a total of 13 hospitals around the country, both secondary level and highly specialized hospitals. The team focused on measurable outcomes that were outside the hospitals normal work for improvement, i.e. surveillance of resistance and healthcare associated infections, antibiotic use and understanding transmission pathways and carriage by genomic analysis of the resistant bacteria.
High rates of resistance to antibiotics
Results indicate very high rates of resistance to most antibiotics, including carbapenems. A prior point prevalence study had already given input on which bacteria most commonly cause healthcare associated infections and had sparked isolation efforts to decrease transmission. In this project, the research team provided specific culture plates and training to be able to screen patients for carbapenem resistance in the gut microbiome.
Reduction in carbapenem resistance rates possible
The endemic situation with carbapenem resistance results in significant excess mortality, excess cases of healthcare associated infections and higher health care costs. The team estimated that a reduction in carbapenem resistance rates that would be reasonably possible to achieve by improved patient screening, could lead to significant cost reductions.
Dramatic increase in CRE carriage during hospital stay
According to the current study, 32% of patients were carriers of resistance at admission, whereas 82% were carriers after eight days of treatment. Carriage of carbapenem resistance is strongly associated with healthcare associated infections and increases the mortality to approximately double that of HAIs without carbapenem resistance. Resistance to colistin, the last-line drug is fortunately still relatively low, and carriage of resistance results in a crude mortality of 66%. One interesting result from the genomic analysis was a shift in carbapenem resistance genes was observed (from KPC to NDM-1) sparked by introduction of ceftazidime/avibactam, although the bacterial strain was not changed. This implies that has occurred a transfer of genes in the hospitals, rather than transmission of new bacteria into the hospital.
Some lessons were learned from the project, including:
- Being realistic. Real commitment is needed from hospitals and leadership who are able to allocate resources for the research.
- Incentives for participation are needed. In order to leverage efforts to participate, the hospitals need to sense that they can gain from the partnership, for example by getting training or access to supplies or technologies.
- Understanding the system and culture you’re working within. Understanding the influencers and internal reward or blame systems determine what and how things can be done.
Given the high prevalence of resistance both in the community but especially in the hospitals, stewardship is very difficult to accomplish. This was also seen in this project, where stewardship and infection prevention did not go as expected. Examples include hand disinfection not being refilled or plastic protective aprons not being used due to sweating.
Project raised awareness about antibiotic resistance
However, the project has had a major impact in raising the awareness of the problem of antibiotic resistance and possible solutions. This has lead to a willingness to change and that Infection prevention has gained a higher status in the health care system of Vietnam.