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Rapid Emergence of Multidrug-

Resistance among Gram Negative 

Isolates at a Tertiary Pediatric and 

Maternity Hospital in Ulaanbaatar, 

Mongolia 

Susanna Felsenstein1*, 

Sarantsetseg Bira2, Narangerel 

Altanmircheg2, Enkhtur 

Shonkhuuz3, Ariuntuya 

Ochirpurev4, David Warburton5,6 
 
1Department of Paediatric Infectious 
Diseases and Immunology, Liverpool, 
United Kingdom; 
2Central Laboratory Department, 
National Center for Maternal and Child 
Health, Ulaanbaatar, Mongolia; 
3Critical Care Medicine, National Center 
for Maternal and Child Health, 
Ulaanbaatar, Mongolia; 
4Health emergencies and food safety, 
Office of the WHO Representative in 
Mongolia, Ulaanbaatar, Mongolia; 
5Keck School of Medicine,  
University of Southern California, USA; 

 

 

 

 

 

 

 

 

 

 

 

6Ostrow School of Dentistry,  
University of Southern California, USA 
 
*Corresponding author

 

Vol. 9, No. 1 (2020)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2020.371 |   http://cajgh.pitt.edu 

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Abstract 

Introduction: Information on microbiological and susceptibility profiles of clinical isolates in Mongolia is scarce, hampering 

infection control and clinical care. 

Methods: Species and resistance profiles of 6334 clinical gram negative isolates, collected at Mongolia’s National Center for 

Maternal and Child Health between 2014 and 2017 were analyzed.  

Results: Annual proportion of multidrug-resistance among E. coli and Enterobacter isolates increased from 2.8% to 16.6% and 

3.5% to 22.6% respectively; Klebsiella isolates exhibiting susceptibilities suggestive of extended spectrum beta-lactamase (ESBL) 

production from 73% to 94%. By 2017, 60.6% of Klebsiella isolates were multidrug-resistant, most originated from intensive care 

wards.  Enterobacteriaceae exhibiting susceptibility patterns suggestive of ESBL production and multidrug-resistant organisms 

were common and their incidence increased rapidly. 

Conclusion: These findings will serve to build strategies to strengthen microbiological surveillance, diagnostics and infection 

control; and to develop empiric therapy and stewardship recommendations for Mongolia’s largest Children’s and Maternity 

hospital. 

Keywords: Gram Negative Bacterial Infections; Beta Lactamases; Drug Resistance, Multiple; Intensive Care Units; 

Mongolia; Stewardship 

Rapid Emergence of Multidrug-

Resistance among Gram Negative 

Isolates at a Tertiary Pediatric and 

Maternity Hospital in Ulaanbaatar, 

Mongolia 

Susanna Felsenstein1, Sarantsetseg 

Bira2, Narangerel Altanmircheg2, 

Enkhtur Shonkhuuz3, Ariuntuya 

Ochirpurev4, David Warburton5,6 
 
1Department of Paediatric Infectious 
Diseases and Immunology, Liverpool, United 
Kingdom; 
2Central Laboratory Department, National 
Center for Maternal and Child Health, 
Ulaanbaatar, Mongolia; 
3Critical Care Medicine, National Center for 
Maternal and Child Health, Ulaanbaatar, 
Mongolia; 
4Health emergencies and food safety, 

Office of the WHO Representative in 
Mongolia, Ulaanbaatar, Mongolia; 
5Keck School of Medicine,  
University of Southern California, USA; 
6Ostrow School of Dentistry,  
University of Southern California, USA 

Research 

Introduction 

Antimicrobial resistance (AMR) in Asia 

increases at concerning rates1-6. The World Health 

Organization (WHO) projects an attributable cost of 

700.000 lives annually and 1.35 trillion USD in countries 

of the Western Pacific Region (WPRO) alone for the next 

decade7. 

Numerous, rapidly evolving and readily 

transmissible mechanisms of antimicrobial resistance in 

gram negatives, particularly the rise in carbapenem 

resistant enterobacteriaceae over the last two decades is 

of grave concern, and the cause of significant morbidity 

and mortality8,9.   Data on AMR in Mongolia is scarce, 

and the country is not part of transnational surveillance 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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networks6,10. A surveillance system at urban and rural 

level training health care providers in infectious diseases 

management and control is established but 

implementation is challenging10,11. However, the 

Mongolian National Statistical Office and the United 

Nations International Children's Emergency Fund 

(UNICEF) report a four-fold reduction in infant and 

under 5's mortality over the last two decades, mainly by 

control of respiratory and vaccine-preventable 

diseases12,13, illustrating the major strides made in 

improving child and maternal health. 

Mongolia features one of the lowest population 

densities worldwide. Approximately half of the 3 million 

inhabitants reside in the capital Ulaanbaatar, the 

remainder in provincial capitals, many of which follow a 

traditional nomadic lifestyle. The country’s economy is 

growing rapidly, mainly as a result of an expanding 

mining industry12. Despite rapid modernization, 

especially in Ulaanbaatar, many parts of the country are 

remote and not readily accessible. Hence, challenges in 

combating the spread of AMR are complex10,14. Health 

care provision and access, development of diagnostic 

facilities, staff education, antimicrobial surveillance, 

auditing of prescription practices and enforcement of 

drug regulation remain a challenge.  

The National Center for Maternal and Child 

Health (NCMCH) is the largest government-run pediatric 

and maternity hospital and only tertiary referral center. 

The pediatric hospital has 270 medical and 150 surgical 

beds accommodating 19 subspecialties and treats 

approximately 40.000 inpatients and over 175.000 

outpatients each year.  The adjacent 250-bedded 

maternity hospital provides gynecological and obstetric 

care, and manages approximately 12.000 deliveries per 

annum15. 

The aim of this study is to provide pathogen and 

susceptibility data for gram negative organisms (GNOs) 

among in- and outpatients of different ages in 

Ulaanbaatar; allowing the development of evidence-

based empirical antimicrobial treatment and infection 

control policies.  

 

Methods 

Data collection 

All gram negative isolates of cultured 

specimens submitted to the microbiology laboratory at 

NCMCH between 01/2014 and 08/2017 were included. 

Data was collected via the WHONET database (version 

5), retrospectively (2014-2016) and prospectively 

(2017), including demographic data, specimen type, in-

/outpatient status, hospital ward, species identification 

and antimicrobial susceptibility testing (AST) profile, 

and adequacy of microbiological work-up. The study was 

approved by the NCMCH ethics committee (NCMCH-

AS2014).  

Susceptibility testing  

At times, test panels differ from the Clinical and 

Laboratory Standards Institute (CLSI) and the European 

Committee on Antimicrobial Susceptibility Testing 

(EUCAST) guidelines due to limitations of AST 

available. Additions or omissions to standard test panels 

are specified in the text. Organisms identified by means 

other than culture and stool samples are processed at 

another facility and were excluded. Molecular detection 

of organisms and/or determination of susceptibility status 

was not available during the study period. 

Of identical organisms isolated from a patient 

within 30 days, only the first isolate was included. Only 

species with a minimum of 30 isolates per year, per 

specimen category and antimicrobial agent tested, were 

used for guiding empirical antimicrobial 

recommendations. Susceptibility is interpreted as per 

CLSI 2016 and CESAR (Central Asian and Eastern 

European Surveillance of Antimicrobial Resistance) 

guidelines6,16. Resistant and intermediately resistant 

isolates are reported as one category (%R/I). AST to 

antimicrobials not recommended for treatment of an 

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Organism 2014 2015 2016 2017 Total 

Escherichia coli 1220 (67.3%) 1379 (57.1%) 602 (40.4%) 78 (12.6%) 3279 (51.8%) 

Enterobacter 510 (28.1%) 873 (36.2%) 648 (43.5%) 417 (67.5%) 2450 (38.6%) 

E. cloacae 327 859 472 78 1736 

Enterobacter spp. (unidentified) 172 2 163 335 672 

E. aerogenes 10 7 7 4 28 

E. sakazakii 0 2 6 0 8 

Pantoea spp. 0 3 0 0 3 

P. agglomerans 1 0 0 0 1 

Klebsiella 26 (1.4%) 70 (2.9%) 119 (8.0%) 67 (10.8%) 282 (4.5%) 

Klebsiella spp. (unidentified) 5 1 65 62 133 

K. pneumoniae 20 53 13 0 86 

K. oxytoca 1 16 41 5 63 

non-aer. Pseudomonas spp., 

Chryseobacterium, Flavimonas 
5 (0.3%) 10 (0.4%) 62 (4.2%) 38 (6.1%) 115 (1.8%) 

Pseudomonas aeruginosa 17 (0.9%) 38 (1.6%) 11 (0.7%) 0 66 (1.0%) 

Proteus mirabilis 34 (1.9%) 19 (0.8%) 24 (1.6%) 12 (1.9%) 89 (1.4%) 

Raoultella spp 2 (0.1%) 12 (0.5%) 9 (0.6%) 1 (0.2%) 24 (0.4%) 

R. ornitholytica 1 4 7 1 13 

R. terrigenica 0 8 2 0 10 

R. planticola 1 0 0 0 1 

Serratia odifera 0 8 (0.3%) 0 0 8 (0.1%) 

Serratia marescens 0 2 (0.1%) 1 2 (0.3%) 5 (0.1%) 

Acinetobacter baumannii 0 0 6 (0.4%) 0 6 (0.1%) 

Elizabethkingia meningoseptica 0 0 4 (0.3%) 1 5 

Burkholderia cepacia 0 0 1 1 2 

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Organism 2014 2015 2016 2017 Total 

Kluyvera 0 0 1 0 1 

Chromobacterium violaceum 0 1 0 0 1 

Salmonella 0 1 0 0 1 

Pasteurella spp 0 0 1 0 1 

Moraxella 0 0 0 1 1 

Total 1814 2413 1489 618 6334 

Table 1. Species identification of gram negative isolates. 

organism are excluded except for service utilization 

analysis. Confirmation of phenotypical presence of 

extended spectrum betal lactamases (ESBL) by Double 

Disk or minimal inhibitory concentration (MIC) and 

confirmation of AmpC status was not available. ESBL 

status attribution relied on disk diffusion interpreted as 

per CLSI, CDC and CESAR recommendations6,14-19. 

Species isolates assumed to be AmpC-producers were 

excluded from ESBL analysis.  

Carbapenem susceptibility testing became 

available in July 2016. Classification of carbapenem 

susceptibility used the most conservative estimate: if 

tested for one carbapenem only or if the test result was 

concordant, the report was analyzed as the final result. 

Discordant carbapenem susceptibilities, with resistant or 

intermediate susceptibility for at least one, were reported 

as carbapenem resistant (CR)6,19. Resistance to antibiotic 

classes was reported by combining the results of 

antibiotics representative for a class and the outcome 

based on the most resistant result.  Multidrug-resistance 

(MDR) was defined as resistance to three or more 

antimicrobial classes in isolates with a valid result for at 

least three, calculated as resistance or intermediate 

resistance to at least one antibiotic in each of class19, and 

documented by number of antimicrobial classes to which 

resistance was identified. 

 

Statistical analysis  

Quantitative variables were reported as absolute 

numbers and percentages. For continuous variables 

comparisons between groups to test equality were 

performed using the t-test when appropriate, or Mann-

Whitney test when skewed. Tests of association between 

categorical variables were based on Chi-square and 

Fisher-Exact Tests. All P values reported are two-sided 

and considered statistically significant if < .05. Statistical 

computations were performed using SPSS 22.0 (SPSS 

Inc. Chicago, Illinois). 

 

Results 

Epidemiology and origin of isolates: In total, 

6334 (53.3%) GNOs were included. E. coli and 

Enterobacter spp. were most common, accounting for 

90% of isolates (Table 1). 

Neonatal samples were dominated by wound 

(24.9%) and blood stream isolates (37.1%) (BSI); 

pediatric samples by wound (28.8%) and urinary 

(42.3%), isolates from adults by genital (63.5%) and 

urinary (30.8%) samples. Predominant GNOs differed 

considerably depending on  age group (Figure 1). Sample 

numbers submitted from neonatal (NICU) and pediatric   

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Figure 1. Five most common species by age group: Panel 1A: neonates (≤1month); Panel 1B: children (1month to ≤18 

years); Panel 1C: adults (≥18 years).

intensive care (PICU) units increased over time, 

accounting for 45.8% of all isolates by 2017 (Figure 2). 

Enterobacter spp.:  Frequency of Enterobacter 

spp. isolates increased over time. Most were inpatient 

isolates (n=2051, 84%), almost half (n=1078, 44%) from 

neonates and children. The annual increase of 

Enterobacter spp. among neonatal BSIs was significant 

(P<0.001), contributing to a third of gram negative BSIs 

(42/140; 30%) in 2017. 

Whilst in 2014/15 Enterobacter susceptibility to 

quinolones and aminoglycosides was reliable, resistance 

increased sharply from 2016 (Supplemental Figure 1A), 

especially among inpatients and BSIs. From 2017, 

virtually all Enterobacter spp. blood isolates were 

aminoglycoside resistant (46/47, 97.9%).  In the first half 

of 2017 alone, 57/277 (20.6%) of Enterobacter isolates 

tested were carbapenem resistant (CR), particularly 

blood (17/47; 36.2%) and urinary isolates (25/87; 

28.7%).  CR Enterobacter isolates originated mainly 

from NICU (47/93; 50.5%) and PICU (30/93; 32.3%). 

E. coli: Among E. coli, adult samples accounted 

for 75.1% (n=2459/3274), predominantly from urine 

(n=1207, 36.8%) or genital tract (n=1498, 45.8%). The 

number of E. coli isolates fulfilling criteria for ESBL 

confirmatory testing doubled over the study period from 

27.0% to 60.3%; attributable to inpatient and NICU 

isolates (Figure 3). Aminoglycoside susceptibility 

remained stable at 75% whilst quinolone susceptibility 

decreased, one third of isolates were no longer 

susceptible by 2017 (Supplemental Figure 1B). Only 

5.3% (172/3246) of E. coli isolates underwent 

Carbapenem susceptibility testing. The proportion of CR 

isolates increased from 12.8% (2016) to 28.2% (2017), 

almost all were inpatient samples (29/32), 72% (n=23/32) 

from ICUs (Supplemental Figure 1B). MDR increased 

between 2016 and 2017 among E. coli from 2.8% to 

16.6% (Figure 4). 

Klebsiella spp.: Almost all Klebsiella isolates, 

98.2% (277/282) originated from inpatients, most 

(208/282, 73%) from NICU, 66.3% of which were BSIs 

(138/208); the remainder wound (9.2%) and urine 

isolates (6.7%). In nine instances, Klebsiella was isolated 

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Figure 2. Ward attribution of samples (in %), by year 

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from neonatal CSF.  The majority showed susceptibility 

patterns suggestive of ESBL production, most frequently 

among isolates from neonates (adults: 64%, 16/25; 

children: 83.1%, 49/59; neonates: 94.4%, 187/198), but 

increasing across all age groups from 73% in 2014 to 

94% in 2017. Most were gentamicin resistant by 2017 

(53/64, 83%), as opposed to only 25% (6/24) in 2014. 

Again, this was most pronounced among neonates, where 

aminoglycoside resistance increased from 26% (n=23; 

2015) to 95.7% (n=46; 2017). Quinolone resistance 

increased from 5.5% (3/55; 2015) to 60.6% (40/66; 2017) 

(Supplemental Figure 1C). Only 135/282 (48%) 

underwent carbapenem susceptibility testing, 24.7% 

(19/77; 2016) and 28.1% (16/57; 2017) were identified 

as CR and originated mainly from NICU, where CR rates 

increased from 13.8% (8/58, 2016) to 32.5% (14/43, 

2017). 

Remaining GNOs, including Pseudomonas 

spp., Raoultella spp., Serratia spp., Acinetobacter spp.: 

Documentation of specimen origin was only available for 

42/66 (63.6%) of P. aeruginosa isolates, urines and 

wound swabs predominated. Reduced susceptibility to 

ceftazidime (13/54; 24%), gentamicin (12/62, 19.3%) 

and quinolones (8/55; 14.5%) occurred, however isolate 

numbers with susceptibility data available for all 

antimicrobials of interest were lower than 30 per year. All 

multidrug resistant isolates originated from NICU (n=3) 

and PICU (n=2), carbapenem susceptibility was not 

documented. 

Samples yielding isolates of the non-aeruginosa 

Pseudomonas spp. group increased significantly 

(p<0.001) with PICU (n=42) and NICU(n=42) 

contributing most isolates. The majority did not undergo 

susceptibility testing. 

Raoultella spp. were mainly isolated in 2015/16, 

when 16/24 isolates, mainly R. terrigenica of identical 

susceptibility pattern, were isolated from specimens of 

multiple wards.  Most Serratia isolates were identified in 

2015 (10/13), mainly on neonatal wound swabs and BSIs, 

and genital samples from maternity wards. Quinolone 

susceptibility was universal (13/13; 100%), a quarter 

were aminoglycoside resistant. Infections with 

Chryseomonas luteola occurred exclusively in 

November/December 2015; isolated from urine (n=3), 

pleural (n=2) and peritoneal (n=2) fluid; and confined to 

NICU (n=5) and the pediatric nephrology ward (n=4). 

Acinetobacter baumannii was isolated in six 

patients: four from neonatal BSIs and one from neonatal 

CSF and a joint aspirate of a young child - all in 

November 2016. All were quinolone, aminoglycoside 

and carbapenem susceptible. 

ESBL production and Multidrug resistance 

across species over time: Rates of ESBL phenotype 

diverged when comparing in- and outpatients in ESBL 

producers (Figure 3). In 2014, 29% of in- and 19.5% of 

outpatient isolates would have required confirmatory 

testing, by 2017, this applied to 83% respectively 32% 

(P<0.001). 

MDR increased significantly more among 

inpatients, too (P<0.001, Figure 4). In earlier years, only 

half of Klebsiella and Enterobacter isolates could be 

included, as the choice of antimicrobials tested for were 

not agents recommended for treatment, or susceptibilities 

for too few antimicrobials were documented, however 

adequate microbiological work up was achieved for 

almost all isolates by 2017. MDR among E. coli tested 

increased from 2.8% in 2014 to 17.2% by 2017; among 

Enterobacter from 3.5% to 22.6%. The increase in MDR 

was most pronounced among Klebsiella spp. where no 

multidrug-resistance was identified in 2014/15, affected 

a third in 2016 and doubled within a year to 60.6% of 

isolates by 2017.  

 

Discussion 

This data represents the largest published 

dataset on pathogen and resistance profile of clinical 

GNOs from Mongolian patients. Mongolia’s health care 

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Figure 3. Extended spectrum beta lactamase phenotype of organisms over time (in %). 

system has evolved to apply novel therapeutic options, 

that are associated with an increasing use of 

antimicrobials for nosocomial infections in intensive care 

settings and hence accompanied by new challenges in 

governance and stewardship. 

With ESBL confirmation testing indicated for 

the majority of inpatient isolates, this study identified an 

urgent need for implementation of improved 

microbiological diagnostics enabling accurate 

identification of drug-resistant GNOs; and steps are 

being taken to address it15. Confirmatory testing is being 

introduced as a result of the here presented data, which 

illustrates an improvement in the detection of MDR and 

ESBL status since 2017 as a result of these efforts. Staff 

training supported by online resources and international 

collaborations is being undertaken9. More standardized 

susceptibility testing is being done, to first line 

antimicrobials initially, followed by second line testing 

where indicated, and ESBL and Carbapenemase testing 

is done where indicated. All Klebsiella isolates will 

undergo AST for quinolones and aminoglycosides.  

It must be acknowledged that the present study 

has important limitations. First, a more detailed 

molecular and genotypic characterization of the 

organisms would have been of interest, at both local level 

- impacting infection control and treatment options - and 

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Figure 4. Multidrug-resistance status in Enterobacter spp., E. coli, and Klebsiella spp. (in %) 

on a transnational level, putting Mongolian 

isolates into context within Asia. Financial restraints and 

the need for prioritization within the healthcare sector 

have hampered molecular diagnostics at NCMCH to 

date, and diagnostic possibilities for AST remains 

limited. We found that the microbiological work up was 

not always in keeping with recommendations made by 

professional agencies 6,16-19. Especially the lack of ESBL 

confirmation posed difficulties, limiting treatment 

recommendations that could be inferred.  

The results of the available testing presented 

here however are concerning and serve as an opportunity 

to put AMR in Mongolia at the forefront of public health 

policies in the months and years to come. It is of utmost 

importance that data is made accessible to clinicians and 

to serve as an indicator for stakeholders that AMR poses 

a clinical risk at NCMCH, and in the Mongolian capital 

at large.   

Only a minority of E. coli and Enterobacter spp. 

isolates underwent Carbapenem susceptibility testing, 

the data may not reflect true susceptibility rates. A 

sizeable proportion of isolates underwent testing for less 

than three antimicrobials, disqualifying them from MDR 

analysis, particularly impacting Enterobacter and 

Klebsiella spp. isolates.  

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Whilst the representation of phenotypical ESBL 

status may overestimate the true rate of ESBL producers 

by 5-30%20, it is concerning to see such rapid increase in 

organisms of ESBL phenotype. Data on the resistance 

among uropathogenic E. coli in Mongolia from 201621 

supports our findings of a high burden of ESBL and 

MDR, identifying resistance to beta-lactams in over 80%. 

Susceptibility to nitrofurantoin and imipenem was 

relatively preserved, but 93.9% of E. coli isolates were 

multidrug resistant. While in this cohort, MDR rates 

among E. coli were lower, proportion of CR isolates was 

much higher. Testing to more antimicrobial classes, 

including Co-trimoxazole and Nitrofurantoin21, may 

have contributed to this discrepancy. In addition, we 

excluded 643 E coli isolates from MDR analysis, as they 

underwent testing for fewer than three antimicrobials. 

However, our data encompasses a larger sample; and 

results did not change upon subanalysis of urine isolates 

(n=1201): 13.4% were multidrug resistant, relying on 

gentamicin, quinolone, beta-lactams and, since 2016, 

carbapenem testing.  

Kao et al22 report findings closely resembling 

our study: in 104 isolates from NCMCH in 2013, 18% of 

E. coli isolates were ESBL producers, mediated by 

TEM1 and associated with fluoroquinolone resistance. 

Our data shows rising rates the following year, 

identifying 27% of E. coli inpatient- and 19% of 

outpatient isolates as ESBL producers. The diagnostics 

available at NCMCH may influence ESBL rates, 

underlining the need for rapid introduction of ESBL 

confirmatory testing, not only to ensure accurate 

surveillance but also to avoid unnecessary use of 

carbapenems. Given that ESBL rates in our cohort 

doubled between 2014 and 2017 from 27% to 60%, the 

difference between the two studies may reflect the true 

increase in ESBL rates over time.   

In summary, the here presented data is in 

keeping with studies reporting susceptibilities that 

included the confirmation of ESBL. As no significant 

changes to the diagnostic work up occurred during the 

study period it has to be assumed that the significant 

increase in multidrug resistance, ESBL production and 

Carbapenem resistance may well reflect an 

approximation of the true development of AMR, which 

was mainly driven by inpatient isolates. This information 

may represent a chance to effectively impact spread of 

MDR and ESBL positive GNOs in Mongolia by 

intensifying infection control in health care facilities. 

Proportion of ESBL phenotype and carbapenem 

resistance was extraordinarily high among nosocomially 

acquired Klebsiella BSIs on NICU, steeply rising since 

2016. CR affected one third of Klebsiella isolates on 

NICUs by 2017. In keeping with reports from ICUs 

globally, Carbapenemase-positive Klebsiella has been 

included in the WHO global priority pathogen list23. 

Given the level of concern due to these results, 

a detailed assessment of clinical and infection control 

practices on NICUs was performed. NICU staff were 

aware of the high prevalence of Klebsiella, and despite 

empiric treatment of neonatal BSIs with imipenem, 

neonatal demise due to Klebsiella BSIs whilst on 

imipenem therapy was reportedly common, though no 

mortality data was available. Neonatal PICC lines were 

not routinely used, and staff did not feel competent in 

sterile line insertion. Nursing staff were unfamiliar with 

line care, hub sterilization before flushing and 

connecting, fixation of lines etc. Newborns requiring 

antibiotic treatment or total parenteral nutrition 

underwent frequent peripheral re-cannulations, 

performed routinely every three days. 

In the interim, guidelines addressing infection 

control procedures, central venous access insertion and 

line care have been provided to staff. Sterile line insertion 

was supervised and training provided. The introduction 

of medium-term, silver or heparin coated long lines for 

neonates has been discussed24. Ongoing data collection 

on central line access related BSIs on NICU including 

associated morbidity and mortality following these 

interventions will inform future clinical practice. 

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Central Asian Journal of Global Health 

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Our study emphasizes the preeminent role BSIs 

have played in the overall increase of MDR at NCMCH, 

especially affecting intensive care units. With a use of 

ICU beds in Mongolia equivalent to that of Western 

European or North American countries at 11.7 per 

1.000.000 inhabitants25, the intensive care environment 

appears to be a major contributor to the emergence of 

AMR. CR and MDR in ICUs is well recognized to be a 

pressing issue in other countries in Central Asia, such as 

Kazakhstan26.  

The largest published record of clinical GNOs 

in Mongolia to date emphasizes the importance of 

consequent surveillance and raises attention to 

multidrug-resistance in Central Asia, and highlights the 

intensive care environment as important source of AMR 

emergence27. The data presented here will form part of 

the National Action Plans including surveillance systems 

nested under the multi-sectoral framework and the One 

Health Approach of the WHO for Mongolia28,29. 

International collaboration, financial reprioritization and 

educational support for health care professionals will be 

required in order to assist measures combating the spread 

of AMR in Mongolia. 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 9, No. 1 (2020) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.371|http://cajgh.pitt.edu 

 

 

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FELSENSTEIN 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 9, No. 1 (2020) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.371|http://cajgh.pitt.edu 

 

 

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