Dr Va Meng
Pulmonologist and Head of Pulmonary Centre, and Critical Care of Respiratory
Khmer–Soviet Friendship Hospital
Cambodia

Founder and CEO of AIR Plus Clinic
BOD of Cambodian Pulmonology CPA

Clinicians worldwide are facing a formidable challenge in the management of community-acquired pneumonia (CAP): the alarming rise of antimicrobial resistance (AMR) amongst causative bacterial pathogens.^1,2 This phenomenon threatens to render current antibiotic ineffectiveness, potentially necessitating more complex treatment regimens or poorer patient outcomes.³

Not all bacteria develop resistance at the same rate, and resistance patterns vary geographically, complicating treatment approaches and requiring local species-level research to understand resistance mechanisms and transmission dynamics.

In this interview, Dr Va Meng, based in Cambodia, provided valuable insights into the prevalence and trends of AMR, its impact on treatment strategies and the measures being implemented to mitigate this growing threat within the Cambodian healthcare landscape.

Q1: What are the current prevalence rates of AMR in CAP-associated pathogens in Cambodia, and have you observed any concerning trends in resistance to specific antibiotics?
While precise, up-to-date data can be challenging to obtain, existing studies indicate a high prevalence of AMR in Cambodia.^{2, 4} Of particular concern is the resistance observed in Streptococcus pneumoniae to cotrimoxazole, which is commonly used as a first-line treatment. Additionally, we are seeing emerging resistance in Klebsiella pneumoniae to amoxicillin-clavulanic acid and some third generation cephalosporins. An analysis of clinical isolates from 51 countries, spanning from 2006 to 2019 and covering 13 drug-bacterium pairs taken from the ATLAS database, revealed that carbapenem resistance has increased in over 60% of the investigated countries during this period.⁵ Specifically, we have seen significant increases in carbapenem-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii, with 83% of the collected data showing statistically significant upward trends (24 statistically significant positive slopes).⁵ These concerning changes in AMR seen in the data analysed mirror the trends observed in neighbouring countries, posing a significant challenge for CAP management in the region.¹

Q2: What are the main factors contributing to the rise of AMR in Cambodia? Are there specific challenges related to access to diagnostics or antibiotic stewardship that are exacerbating AMR?
The rise of AMR in Cambodia is driven by several critical factors:

• Overuse and misuse of antibiotics: The prevalent overuse and misuse of antibiotics in both healthcare settings and through over-the-counter sales contribute to the selective pressure on bacteria, accelerating the development of resistance.
• Limited access to diagnostics: The insufficient availability of diagnostic tools results in reliance on empirical treatment, whereby antibiotics are prescribed without precise identification of the causative pathogens. This practice often leads to the use of broad-spectrum antibiotics, which hinders targeted therapy and further promotes resistance.
• Lack of robust antibiotic stewardship programs: This deficiency impacts proper monitoring and regulation of antibiotic use, both in hospitals and the community, resulting in widespread inappropriate antibiotic prescribing practices.
• Socioeconomic factors: Socioeconomic issues, such as poverty, limited health literacy and traditional health beliefs play an important role in the inappropriate use of antibiotics. These factors contribute to behaviours such as self-medication and non-compliance with treatment protocols, exacerbating the problem of AMR.

These factors collectively contribute to the increasing prevalence of AMR in Cambodia, complicating the management of CAP and other infectious diseases, and emphasising the need for a comprehensive approach to mitigate AMR.

Q3: In your experience, how does rising AMR complicate the treatment of CAP for patients in Cambodia? Are there specific types of CAP that are becoming more difficult to treat owing to resistance?
The rising AMR significantly complicates CAP treatment. The primary challenge lies in the failure of first-line antibiotics, requiring the use of broader-spectrum alternatives. These alternatives often come with an increased potential for side-effects and higher treatment costs.

This situation leads to several adverse outcomes for patients, including treatment delays, prolonged hospital stays and increased mortality rates. In particular, CAP caused by multidrug-resistant Klebsiella pneumoniae and Acinetobacter baumannii are increasingly difficult to treat.

Q4: What strategies and guidelines are currently being implemented in Cambodia to address AMR in CAP treatment, and how do these local guidelines compare to international recommendations from organizations such as the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA)?
In Cambodia, guidelines have been implemented to address AMR in the treatment of CAP which align with international recommendations from organisations such as the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA).^6,7 These guidelines emphasise the following strategies:

• Strengthen diagnostic capacity: Efforts are being made to improve microbial testing for accurate pathogen identification, and establishment of additional microbial investigation centers that offer services at prices affordable to economically disadvantaged populations.
• Promote antibiotic stewardship: Antibiotic stewardship programs are to be implemented, which focus on monitoring antibiotic use, educating healthcare professionals and ensuring appropriate prescribing practices, thereby reducing the misuse of antibiotics and limiting the spread of resistance.
• Raise public awareness: Public education campaigns are being conducted to increase awareness about AMR. These campaigns emphasise the importance of proper antibiotic use and the need to seek medical advice rather than self-medicating.
• Regulate antibiotic sales: Measures are being taken to reduce the sale of antibiotics by pharmacies without a prescription. These efforts include educating the public about the risks associated with antibiotic resistance and the importance of using antibiotics only when prescribed by a healthcare professional.

Q5: Looking to the future, what steps do you believe are most crucial to manage and reduce the impact of AMR on CAP treatment in Cambodia?
To effectively manage and reduce the impact of AMR on CAP treatment in Cambodia, several steps are crucial:⁸

• Continued investment in diagnostic tools: It is imperative to make rapid and accurate diagnostic tests accessible at all levels of healthcare. This involves ensuring that these tests are affordable for economically disadvantaged populations.
• Scaling up antibiotic stewardship efforts: Expanding antibiotic stewardship programs nationwide is essential. These programs must be integrated into routine medical practice to promote appropriate antibiotic use and reduce the development of resistance.

• Enhancing surveillance: Strengthening surveillance systems to track AMR trends is critical. Accurate and up-to-date data will inform treatment guidelines and public health interventions, enabling a more targeted response to the AMR threat.
• Research and innovation: Investing in research and innovation is vital to explore new treatment options, develop vaccines and investigate alternative approaches to combat AMR.

By collaboratively addressing these challenges, Cambodia can make significant strides in mitigating the impact of AMR on CAP treatment and safeguarding public health.

References:

1. Goyet S, et al. PLoS One 2014;9:e89637.
2. Reed TAN, et al. Int J Infect Dis 2019:85:98-107.
3. Salam MA, et al. Healthcare (Basel) 2023;11:1946.
4. Auguet OT, et al. EClinicalMedicine 2021:36:100910.
5. Rahbe E, et al. Lancet Planet Health 2023;7:e547-e557.
6. Moran G. J Emerg Med 2006;30:377-387.
7. Metlay JP, et al. Am J Respir Crit Care Med 2019;200:e45-e67.
8. World Health Organization. Global action plan on antimicrobial resistance: https://www.emro.who.int/health-topics/drug-resistance/global-action-plan.html. Accessed 5 June 2024.