New study uncovers alarming mortality and impaired quality of life associated with drug resistance in patient data across Asia

A new, multinational and longitudinal prospective study in Asia, the ACORN-HAI (A Clinically-Oriented Antimicrobial Resistance Surveillance Network – Healthcare-Associated Infections), has found a high rate of mortality and impaired quality of life associated with antimicrobial resistance (AMR) and multidrug-resistant (MDR) bacterial infections. Attributable deaths were especially pronounced in low- and middle-income countries (LMICs), as well as among children and young adults.

The ACORN-HAI study, funded by Wellcome, and led by Dr Mo Yin, Director of the ADVANCE-ID, based at the Saw Swee Hock School of Public Health, National University of Singapore (NUS), observed that severe MDR bacteria carbapenem-resistant Acinetobacter spp (CRA) and carbapenem-resistant Enterobacterales (CRE) were associated with the worst mortality and quality-of-life outcomes. Asia has the world’s most populous nations and has the highest antimicrobial consumption and AMR burden, in terms of mortality and poor quality of life. Dr Mo Yin is also an Adjunct Associate Professor at the NUS Saw Swee Hock School of Public Health and the NUS Yong Loo Lin School of Medicine.

The ACORN-HAI study brought together investigators, clinicians, microbiologists and research teams from 41 participating hospitals across 19 countries, with more than 10,000 patients across Asia to generate prospective, patient-level evidence linking antimicrobial resistance with treatment and clinical outcomes.

Hospitals were selected based on their ability to collect standardised microbiological and clinical data, ensuring reliable microbiological and clinical data capture across representative health-care settings. Embedding clinical data within surveillance adds clinical context to microbiological test results, providing actionable insights that can inform patient care and public health decision-making. 

Using these patient-level data, the ACORN-HAI projects estimated that 0.25 million of deaths annually in Asia were attributable to AMR in bloodstream infections and ventilator-associated pneumonia.

Key findings:

• AMR bacterial bloodstream infections and ventilator-associated pneumonia were common and associated with high mortality and reduced quality of life in Asia, particularly in infections due to carbapenem-resistant Acinetobacter spp and CRE, and among children and younger adults.
  • The ACORN-HAI study found 68·4% bloodstream infections and 31·6% ventilator-associated pneumonia infections in the sample data across Asia.
  • AMR-attributable mortality was the highest in ventilator-associated pneumonia Among children aged 5 – 14 years at about 11·7%; and young adults aged 15 – 49 years at about 11·2%. 
• The widespread use of suboptimal antimicrobial regimens highlights the urgent need for equitable access to effective therapies and context-specific evidence to guide antimicrobial stewardship. Most carbapenem-resistant Gram-negative infections were treated with carbapenems (57·8%) or polymyxins (35·6%). These antibiotics are either ineffective against Carbapenem-resistant infections or highly toxic.
• Higher rate of mortality in LMICs:
  • Infrastructural and resource limitations are particularly consequential in LMICs where AMR burden is high and surveillance systems are often lacking.
  • In many Asian countries, constrained laboratory capacity and inconsistent regulatory oversight prohibit the implementation of multinational, standardised prospective AMR surveillance. 
  • Ineffective treatment methods for CRA and CRE, are also associated with substantial toxicity.

Dr Mo Yin, who is the Principal Investigator of the study said, “ACORN-HAI has brought to light the underestimated burden of healthcare-associated infections in Asia, an issue that takes the lives of our patients every day but has received far too little attention. Time is running out to act. Many of the solutions are already here, including relatively simple measures that can make a meaningful difference, but we need to work more collaboratively to put them into practice”.

Chibuzor Uchea, Senior Research Manager at Wellcome said, “This study adds to our knowledge and understanding of the burden of AMR, which is foundational to tackling this growing crisis. In particular, it has uncovered the extent to which limited antibiotic access is driving the continued use of carbapenems to treat carbapenem-resistant infections across Asia. It is crucial that governments, public and private sectors work together to ensure equitable access, so that safe and effective treatments can reach those who need them most.”

Building stronger evidence on AMR in Asia

To determine how much additional risk to patients is specifically associated with antimicrobial resistance, longitudinal studies like the ACORN-HAI builds evidence on AMR and identifies pathogen distribution by standardising AMR surveillance. It is particularly important for Asia, as a combination of antimicrobial exposure and conditions may allow resistant AMR to emerge and spread. Limited laboratory capacity, weak antimicrobial stewardship, inconsistent regulations and countries with a dense population may carry a higher burden of antimicrobial resistance, as observed from the study.

ACORN-HAI was designed to address this evidence gap by prospectively following patients and linking microbiological information with clinical outcomes and treatment data.

The findings underscore the importance of improving access to effective diagnostics and newer antibiotics, conducting pragmatic clinical trials that address treatment questions relevant to Asian healthcare settings, and strengthening regional research and surveillance networks capable of generating locally relevant evidence.

Participating institutions

• Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
• Brunei: Raja Isteri Pengiran Anak Saleha Hospital
• Cambodia: Calmette Hospital
• China: The First Affiliated Hospital, Zhejiang University; Huashan Hospital Affiliated to Fudan University; Beijing Tsinghua Changgung Hospital
• Hong Kong, China: The Chinese University of Hong Kong
• India: Amrita Institute of Medical Sciences, Kochi; Medway Hospitals
• Indonesia: General Hospital H. Adam Malik, Sumatera Utara; Universitas Sumatera Utara, Faculty of Medicine; Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia
• Japan: Fujita Health University Hospital
• Malaysia: University Malaya Medical Centre; Sarawak General Hospital; Hospital Pakar Universiti Sains Malaysia; Sabah Women and Children's Hospital; Queen Elizabeth II Hospital, Kota Kinabalu, Sabah
• Mongolia: Mongolia-Japan Hospital of the Mongolian National University of Medical Sciences; Third State Central Hospital; Central Military Hospital
• Nepal: Patan Hospital, Kathmandu; B.P. Koirala Institute of Health Sciences; Bir Hospital, Kathmandu
• Pakistan: The Aga Khan University Hospital; Dow University of Health Sciences; Dr. Ziauddin Hospital Clifton Campus
• Philippines: The Medical City; Philippine General Hospital
• Singapore: National University Hospital; Singapore General Hospital; National Centre for Infectious Diseases
• Sri Lanka: National Cancer Institute
• Taiwan: Taichung Veterans General Hospital
• Thailand: Sunpasitthiprasong Hospital, Ubon Ratchathani; Faculty of Medicine, Khon Kaen University; Ramathibodi Hospital; Chulalongkorn University and King Chulalongkorn Memorial Hospital
• Timor-Leste: Hospital Nacional Guido Valadares
• Vietnam: Hospital for Tropical Diseases, Ho Chi Minh City; Trung Vuong Hospital, Ho Chi Minh City; National Hospital for Tropical Diseases, Ha Noi