Containment of Antibiotic Resistance in Cambodia

This post was written by Dr. Ellen Jo Baron who participated in the National Workshop

Photos of the Workshop Speakers and Participants

November 16-18, 2011, the first National Workshop on the Containment of Antibiotic Resistance was held in Phnom Penh. Sponsors included the Sihanouk Hospital Center of Hope, the Institute for Tropical Medicine (Antwerp, Belgium), the Cambodian Ministry of Health, World Health Organization, Foundation Merieux, and the University Research Company (URC)  Cambodia.  More than 200 participants (see Figure 1) attended the first day and one-half program, which highlighted the problems of shockingly high rates of antibiotic resistance, particularly among gram-negative rods, in Cambodia.  Apparently, Cambodia is second in the world after India (similar rates as found in Thailand and Vietnam) for drug resistance.  Greetings from WHO (Figure 2), Ministry of Health (Figure 3), and some of sponsors began the event.   One of the most articulate and insightful presenters, Dr. Erika Vlieghe from ITM, Antwerp, began the scientific section of the program with a colorful talk on the basic science behind antimicrobial resistance and some potential avenues for combating the problem.  This was followed by Dr. Sin SanSam (Department of Health Services, Cambodia) who discussed the National Strategic Plan for Infection Control in Healthcare Facilities.  There appears to be a good deal of progress in this area, with best practices identified and some hospitals, including Kampong Cham (whose laboratory has been supported by DMDP) being named as Centers of Excellence.

The general presentations were followed by a series of specific talks by laboratory or physician representatives of hospital laboratories or reference laboratories outlining their practices and key recent findings.  Dr. Thong Pe presented data from 500 bloodstream isolates over the past 3 years from Sihanouk Hospital Center of Hope.  50% of E. coli produced extended –spectrum beta-lactamases (ESBLs).  70% of Salmonella typhi had reduced susceptibility to fluoroquinolones and were multi-drug resistant.  It was with some relief that we learned that only 22% of Staphylococcus aureus were methicillin-resistant (MRSA).  Next, Dr. Thay Kosal from Khmer-Soviet Friendship Hospital discussed the early results of microbiological studies just starting up, with minimal samples, mainly urine, sputum, and blood, having been processed.  However, beta-lactamases and quinolone resistance enzymes were predominant.  Ph. Nhem Somary (Figure 4) gave a complete master class in what a good laboratory should be doing – all of us from DMDP were so proud of her.  She presented data from the first 3 quarters of 2011 gathered from 651 samples.  This laboratory had isolated the first Cambodian Streptococcus suis from cerebrospinal fluid, an emerging cause of meningitis in Southeast Asia.  Kampong Cham has also seen a number of Burkholderia pseudomallei and last year isolated >90 Vibrio cholerae.   The hospital sees numerous multi-drug resistant organisms and is tracking them with the WHONET database program, available free from the WHO website.  This program produces reports and histograms that allow easy visualization and interpretation of complex results.  More aligned with findings in the West and in Europe, the Kampong Cham laboratory found 45% MRSA among their S. aureus isolates.  Dr. Thou Seng An from the same hospital had been using the laboratory’s services for a study of surgical site infections after Cesarian section.   With >200 patients enrolled, only 6.25%  infections were seen; staphylococci (aureus and lugdunensis) predominated. 

 Dr. Bertand Guillard from Pasteur Institute discussed his findings on samples of convenience (those sent to him for characterization or for studies).  Results included 60% of Streptococcus pneumoniae had reduced penicillin susceptibility, Acinetobacter were showing 18% carbapenem resistance, ESBLs in E. coli were up to 30% and increasing, and even 3.5% of Neisseria gonorrhoeae were cefixime resistant.  Dr. Chad Yasuda presented the NAMRU-2 data, primarily based on a study on typhoid.  They found 56% of all S. typhi tested were multi-drug resistant.  NAMRU-2 has been a strong supporter of DMDP, serving as our organism reference laboratory without charge.

 Next. Angelo Caon, an Australian VIDA volunteer (same program that originally supported Joanne Letchford) presented data from Takeo Hospital, which we also support.  The beautiful new laboratory was outfitted by Foundation Merieux (Figure 5). Although only recently starting to function, Takeo has data from 404 samples, 25% urines, with impressive isolations of S. suis, B. pseudomallei, and S. typhi.  Angelo echoed the high rates of resistance seen by others. Ms. Srey Viso from National Pediatric Hospital also has benefited from DMDP training and mentorship, especially Joanne Letchford (Figure 6).  Her data were impressive, with 144 pathogens isolated from 615 specimens received in the last 6 months.  Using the WHONET program, Viso presented histograms and visual images to enhance the impact of the results (Figure 7), which highlighted resistance in Enterobacteriaceae and Klebsiella species.

 Data from other locations, including Kantha Bopha hospitals in both Phnom Penh and Siem Reap, showed high rates of multi-drug resistance in E. coli.  Dr. Catrin Moore from Angkor Hospital for Children, supported by the Wellcome Trust, and Mahidol University of Oxford, receives >3000 samples/year.  Patients are admitted primarily for pneumonia, dengue, diarrhea,  and septicemia.  They are seeing ESBLs in Klebsiella and reduced ciprofloxacin susceptibility in S. typhi.  A key finding, probably reflective of developing world in general, is that patients have evidence of antibiotic activity in their urine at the time of admission.  The last laboratory to report was the National Institute of Public Health, serving since 2004 as the national reference laboratory.  Our board member, Dr. Jim McLaughlin, was instrumental in supporting development of this laboratory and we presented our basic training there in 2007.  They have been monitoring Vibrio cholerae, S. pneumoniae, and S. typhi.  Ms. Chhay Heng Leang reported on 217 V. cholerae from last year, of which 100% were resistant to nalidixic acid, trimethoprim-sulfa, and tetracycline.  Although they were susceptible by disk diffusion to ciprofloxacin, their methods could not determine if ciprofloxacin actually was effective (in typhoid, if nalidixic acid is not susceptible, other fluoroquinolones will be less active even if they are susceptible in vitro). 

 The second half day concentrated on a broader perspective, including infection control activities, WHO directives, and a very comprehensive talk by Ph. Sam Sopheap covering the national strategic plan for laboratory services, which was crafted with help from Dr. Jim McLaughlin.  The speakers gathered on the stage for a final round of applause from the audience (Figure 8) and after lunch, the participants moved into focus groups.  Joanne Letchford and Ellen Jo Baron joined Dr. Jan Jacobs and Dr. Birgit De Smet to present a wet laboratory workshop for technologists at the University for Health Sciences laboratory (Figure 9). 

 The laboratory was presented over two days, with lectures followed by demonstrations (Figure 10).   Topics included sample handling, principles of resistance, and Dr. Baron presented the talk on Quality Assurance and Quality Control with translation ably handled by Mr. Sek Sophat, now working for URC to promote QA and QC throughout Cambodia. At the end, the participants gathered for a photo (Figure 11).