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Microbiological and Susceptibility 
Profile of Clinical Gram Positive 
Isolates at a Tertiary Pediatric and 
Maternity Hospital in Ulaanbaatar, 
Mongolia 

Susanna Felsenstein1, 
Sarantsetseg Bira2, Narangerel 
Altanmircheg2, Enkhtur 
Shonkhuuz3, Ariuntuya 
Ochirpurev4, David Warburton5,6 
 
1Cork University Hospital University 
College Cork, Wilton, Cork, Republic of 
Ireland; 
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

 
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Abstract 

Introduction: Information on microbiological and susceptibility profiles of Monoglian bacterial isolates is scarce. Resistance 
profiles, patient demographics and microbiological work-up of gram positive isolates were analyzed in order to develop infection 
control activities and policies at the National Center for Maternity and Children’s Health (NCMCH) in Ulaanbataar, Mongolia. 
Methods: All gram positive isolates of specimens submitted to the microbiology laboratory at NCMCH between January 2014 and 
August 2017 were included. Data collected included demographic data, specimen type, in-/outpatient status, hospital ward of 
sample origin, and antimicrobial susceptibility testing profile. Susceptibility testing was performed by trained microbiologists at 
the NCMCH microbiology laboratory. T-test, Mann-Whitney, Chi-square and Fisher exact tests were used as appropriate.  
Results: Of 11,889 isolates, 4012 (33.7%) were gram positive, with most identified as S. aureus (62.6%, n=2512). Rates of 
methicillin resistance (MRSA) remained stable at a quarter, but was significantly higher among inpatients (inpatients: 630/2002, 
31.5%; outpatients 67/290, 23.1%; p≤0.05) and sterile site isolates (sterile: 83/171, 48.5%; non-sterile: 416/1678, 24.8%; p≤0.01). 
The vast majority of S. pneumoniae isolates (12/14; 85%) was found to be penicillin resistant by oxacillin disk diffusion. While 
identification of Group B streptococci was rare (n=137) due to of lack of diagnostic measures available, the number of enterococcal 
isolates identified increased signifi-cantly due to implementation of improved microbiological work-up (2015: n=7; 2016: n=26; 
2017: n=83). 
Conclusion: Compared with published studies from neighboring nations, the rates of antimicrobial resistance among gram positive 
isolates at NCMCH, particularly with respect to S. aureus and S. pneumoniae, were much higher. Further improvement of 
microbiological diagnostics and collabo-ration of stakeholders is required to address the pressing infection control and stewardship 
issues and to ensure reliable identification of relevant pathogens in Mongolia. 

Keywords: Child Health; Women Health; Communicable Diseases; Epidemiology; Maternal and Child Health; Mongolia 

Microbiological and Susceptibility 
Profile of Clinical Gram Positive 
Isolates at a Tertiary Pediatric and 
Maternity Hospital in Ulaanbaatar, 
Mongolia 

Susanna Felsenstein1, Sarantsetseg 
Bira2, Narangerel Altanmircheg2, 
Enkhtur Shonkhuuz3, Ariuntuya 
Ochirpurev4, David Warburton5,6 
 
1Cork University Hospital University College 
Cork, Wilton, Cork, Republic of Ireland; 
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 

Gram positive organisms (GPO) include some 
of the most clinically relevant bacteria, such as S. aureus, 
S. pneumoniae and enterococci, which can cause a wide 
array of serious infections among hospitalized and 
community patients1.  

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The WHO estimates that globally, 700,000 
deaths each year are directly attributable to antimicrobial 
resistance (AMR), based on AMR data from Asian 
countries of the Western Pacific Region of the WHO 
(WPRO), including China, South Korea, and Malaysia2,3. 
This report emphasizes the need for the development of 
the national action plans for all nations, while 
underscoring the importance of the multidimensional 
One Health approach encompassing health care sector, 
public, veterinary, agricultural, environmental, and food 
sectors, as well as financial stakeholders4. A National 
Action Plan for Mongolia was approved in 20175.  AMR 
in Asia is increasing at alarming rates6-9, with little data 
availible on the susceptibility patterns of gram positive 
organisms in Mongolia. Mongolia is a vast country with 
an area of 1,500 million km2 and just over three million 
inhabitants featuring one of the lowest population 
densities worldwide. Half of the population lives in the 
capital Ulaanbaatar, while the rest inhabits rural areas, 
many following the traditional nomadic lifestyle of 
Mongolian herders10.  

In recent years, Mongolia has experienced rapid 
economic growth and modernization, especially in 
Ulaanbaatar. Contrasting this, many parts of the country 
remain extremely remote and difficult to access. This 
poses significant challenges to the introduction of 
antimicrobial surveillance and infection control, staff 
education and diagnostic tools, enforcement of drug 
regulation and auditing of prescription practices10,11.  In a 
community-based survey, over 70% of children had 
received antibiotics in the preceding six months, more 
than half of which had not been prescribed by a 
healthcare professional12. In 2018, the WHO released its 
first global report on the consumption and use of 
antibiotics, and Mongolia recorded the highest 
consumption among the six Western Pacific Region 
countries that submitted the data. A high burden of 
infectious diseases, such as respiratory and genitourinary 
infections, tuberculosis and sexually transmitted 

diseases, high usage of over-the-counter antibiotics, and 
widely prevalent antibiotic use based on self-diagnosis 
are among the contributing factors12,13. Multidrug-
resistant GPOs are a growing concern in other Central 
Asian countries14.  

The paucity of data on susceptibility patterns of 
GPOs in Mongolia impacts the development of infection 
control practices, antimicrobial stewardship, and poses a 
significant public health concern. 

The National Center for Maternal and Child 
Health (NCMCH), Ulaanbaatar, is the country’s largest 
governmentrun pediatric and maternity hospital, and 
national tertiary referal center. The pediatric hospital 
accommodates 19 medical and surgical subspecialties, 
320 inpatient beds, and provides treatment for 
approximately 40,000 inpatients and over 175,000 
outpatients per year.  The adjacent maternity hospital has 
250 inpatient beds providing gynecological and obstetric 
care, with just under 12,000 deliveries annually15. The 
NCMCH is the first Mongolian center to publish its data 
on gram positive AMR internationally.  

The goal of this study was to identify areas in 
need of further improvement in diagnostic 
microbiological work-up, surveillance of resistant 
organisms, enabling development of antimicrobial 
treatment guidelines, and improvement of infection 
control practices.  

 

Methods 

Data collection 

All gram positive isolates of specimens 
submitted to the microbiology laboratory at NCMCH 
between January 2014 and August 2017 were included. 
Data collection began with the introduction of routine 
electronic data collection in 2014. Data were collected 
retrospectively (2014-2017) and prospectively (2017) 
using WHONET vs. 516, an electronic laboratory 

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Organism 2014 2015 2016 2017 Total 

S. aureus 
414 

(47.0%) 
1036 (64.7%) 750 (70.6%) 312 (66.5%) 

2512 
(62.6%)* 

Coagulase negative 
staphylococci 

267 
(30.2%) 

432 (27%) 252 (23.7%) 45 (8.9%) 996 (24.8%)* 

Group B streptococci 19 (2.2%) 116 (7.2%) 3 (0.3%) 0 138 (3.4%)* 

Viridans streptococci 
102 

(11.6%) 
8 (0.5%) 10 (0.9%) 3 (0.6%) 123 (3%)* 

Enterococcus spp., 
unidentified 

4 (0.5%) 4 (0.2%) 22 (2.1%) 83 (17.7%) 113 (2.8%)* 

Group A streptococci 58 (6.6%) 1 (0.1%) 10 (0.9%) 18 (3.8%) 87 (2.2%) 

S. pneumoniae 4 (0.5%) 4 (0.2%) 10 (0.9%) 8 (1.7%) 26 (0.6%) 

Micrococcus spp. 11 (1.3%) 0 0 0 11 (0.3%) 

E. faecalis 1 (0.1%) 0 4 (0.4%) 0 5 (0.1%) 

E. avium 0 0 1 (0.1%) 0 1 (0.0%) 

Total 880 1601 1062 472 4012 (100%) 

*significant differences in annual isolation frequency (P≤0.05), for the five most frequently identified 
organisms per year 

Table 1. Species identification of gram positive isolates.

database made available by the WHO. Data collected 
included demographic data, specimen type, in-/outpatient 
status, hospital ward of sample origin, and antimicrobial 
susceptibility testing (AST) profile. Organisms identified 
by means other than culture (ie. latex agglutination) were 
not included (n=13). In cases of an identical organism 
being isolated from a patient within 30 days, only the first 
isolate was included.  

Susceptibility testing  

Susceptibility testing was performed by trained 
microbiologists at the NCMCH microbiology laboratory.  

Instances where NCMCH laboratory AST 
differed from Clinical Laboratory Standards Institute 
(CLSI) guidelines are specifically indicated17-19. 
Additions or omissions to standard test panels are 
indicated separately. Susceptibility interpretation is 
reported as per CLSI 2016 guidelines17. Fully resistant 
and intermediately susceptible isolates (%I/R) are 
reported as one category. Only species with a minimum 
of 30 isolates annually were used to test for antimicrobial 
succeptability18. Reports on isolates with less than 30 
isolates per year are explicitly specified. Molecular 
detection of organisms or susceptibility status was 
unavailable. 

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Figure 1. The prevalence of Methicillin-resistant Staphylococcus aureus in 2014-2917

While both CLSI and the European Committee 
on Antimicrobial Susceptibility Testing (EUCAST) now 
recommend induction of the mecA gene with cefoxitin19- 
23, the NCMCH relies on Oxacillin disk diffusion (DD) 
for diagnosis of methicillin resistant S. aureus (MRSA); 
hence these results were interpreted as per CLSI 2006 
guidelines22. Vancomycin resistance testing was done by 
DD. As no broth microdilution data was available, 
organism rates with DD diameters ≥15 mm on a 30 mcg 
Vancomycin disk were reported as susceptible (VSSA), 
the remaining as vancomycin resistant S. aureus 
(VRSA)22-23. In S. pneumoniae isolates, penicillin 
susceptibility was tested on 1 mcg Oxacillin disks. As no 
broth dilution was done, meningitis breakpoints and 
cephalosporin susceptibilities are not reported20,22,24. The 
ethics committee at NCMCH approved this study. 

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 or Mann-Whitney test when 
appropriate. Tests of association between categorical 
variables were based on Chi-square and Fisher Exact 
Tests. All P values reported are two-sided and were 
considered statistically significant if P<0.05. Statistical 
computations were performed using SPSS 22.0 (SPSS 
Inc. Chicago, Illinois). 

 

Results 

Of 11,889 isolates, 4012 (33.7%) were gram 
positive (Table 1). Neonatal samples accounted for 
n=951 (23.8%); pediatric samples for n=2,010 (50.2%), 
and adult samples from patients ages ≥18 years for 
n=1,043 (26.0%) of isolates. Three quarters of specimens 
originated from wound and surface swabs (26.3%), 
genital swabs (28.2%), urine (21.2%); and 598 (5%) from 
blood cultures. The remaining samples (7.6%) were 
obtained from respiratory secretions, cerebrospinal fluid,  

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S. pneumoniae (n, non-meningitis breakpoints) 2014 2015 2016 2017 Total 

Oxacillin 
1mcg disk, 
zone 
diameter in 
mm 

not done  3 4 3 2 12 

resistant 

8 0 0 0 1 1 

10 0 0 0 1 1 

14 0 0 1 0 1 

≤19 1 0 5 3 9 

susceptible 
23 0 0 0 1 1 

25 0 0 1 0 1 

Total  4 4 10 8 26 

Vancomycin 
30mcg 
disk, zone 
diameter in 
mm 

not done  2 2 0 0 4 

resistant 16 0 0 1 0 1 

17 0 0 1 0 1 

 
 
 
 

susceptible 

≥17 2 0 0 0 2 

18 0 0 0 1 1 

20 0 0 2 3 5 

22 0 0 0 3 3 

25 0 0 3 1 4 

26 0 2 2 0 4 

29 2 0 1 0 3 

Total  4 4 10 8 26 

Table 2. Interpretation of susceptibility data by non-meningitis breakpoints of S. pneumoniae isolates. 

joint and pericardial aspirates, and stool samples. The 
source of specimen could not be determined in 11.7% of 
cases. Two thirds of isolates (n=2,512; 62.6%) were 
identified as S. aureus; mostly from inpatients (86%, 
2,171/2,478).  Oxacillin susceptibility was available in 
92.5% (2,320/2,512) of isolates; two thirds (69.8%, 
1,620/2,320) were methicillin susceptible (MSSA), the 
remainder resistant (MRSA). Whilst in 2014 high rates 

of MRSA (60%, 224/377) were observed, they remained 
stable thereafter at approximately one quarter (Figure 1). 
MRSA was significantly more common among inpatients 
compared to outpatients (MRSA inpatients: 
n=630/2,002, 31.5%; outpatients: n=67/290, 23.1%; 
P=0.04). MSSA predominated on surface swabs (78.3%, 
875/1,117) and other non-sterile site cultures (82.0%, 
128/156); whereas S. aureus positive blood cultures grew 

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MRSA in 44.5% (23/53). The MRSA rate among sterile 
samples was overall higher (sterile: n=83/171, 48.5%; 
non-sterile: n=416/1,678, 24.8%; P=0.01; Figure 1) and 
increased significantly over the study period (P=0.02). 
The exception were swabs taken from burns, where 
MRSA accounted for 78% (40/51) of staphylococcal 
isolates. 

Vancomycin susceptibility was available for 
88.1% (n=661/750) of S. aureus isolates in 2016 and 
97.4% (n=304/312) in 2017. Resistance was reported in 
six instances, originating from the maxillofacial (n=4/6) 
and pediatric intensive care units (n=2/6). Non-reliable 
vancomycin susceptibility was more frequently 
documented in 2014/15 when staff had just started to 
undergo training, and quality control was being 
established for vancomycin susceptibility testing. Hence, 
vancomycin susceptibilities from 2014-2015 were not 
used for clinical management and are therefore not 
reported. Teicoplanin and daptomycin were not included 
in the test panel. Susceptibilities to clindamycin, 
rifampicin, or cotrimoxazole were only tested in a 
minority of isolates. 

Isolates of coagulase negative staphylococci 
(CoNS) (n=996) were comprised of S. epidermidis 
(85.5%, n=851), S. xylosus (n=12), S. saprophyticus 
(n=1), S. auricularis (n=1), S. sciuri (n=4), S. hominis 
(n=1), S. hemolyticus (5.3%, n=53), S. lugdunensis (n=1), 
S. warneri (n=1) and other, not further identified CoNS 
spp. (6.7%, n=71). Sample origin was available for 75% 
(744/996) of isolates. Of those, 9% (n=67/744) were 
sterile sites isolates, mostly (n=52/67) from blood 
cultures. Most originated from pediatric patients 
(75.8%), mainly from wound swabs. A substantial 
proportion (16.8%, n=167/996) did not undergo 
susceptibility testing. Cefazolin susceptibilities were 
available for 88.8% (n=884/996), 10.9% of which were 
resistant. Vancomycin susceptibilities were available for 
83.2% (n=829/996), of which 11% (n=12/829) were 
resistant, all identified between 2014 and 2015. Since 
2016, no vancomycin resistant CoNS were identified. 

Despite identification of Group B Streptococci 
(GBS) being mostly outsourced to another facility, 137 
GBS isolates were identified; 66 in children, 47 in adults, 
only twelve from neonatal isolates. In adults, GBS was 
mostly isolated from respiratory tract or wounds. Among 
n=716 urinary and n=3,313 genital tract samples from 
adults, only three uterine and one urinary sample were 
identified as GBS, the majority of isolates from these 
sites were gram negatives. 

Group A streptococcus (GAS) isolates were 
mainly found in nasopharyngeal specimens (59.8%; 
n=52/87); a quarter (n=10/46) of pediatric GAS isolates 
had been sampled from burns. All GAS isolates tested 
(n=48/60) were penicillin susceptible.  

Viridans streptococci or not further identified 
Streptococcus spp. originated mainly from respiratory 
and oral specimens. Penicillin susceptibility was tested 
by oxacillin disk diffusion, which is not recommended 
for viridans streptococci and hence not reported. 
However, disk diffusion is acceptable for testing of 
cephalosporin susceptibilities: 16.5% (n=15/91) were 
reported as not susceptible to cefotaxime, 0.7% (n=6/86) 
as not susceptible to ceftriaxone. 

Among 26 isolates of S. pneumoniae, five were 
blood stream- and six Cerebrospinal Fluid (CSF) isolates, 
the remainder originated from wound and eye swabs, all 
in children. Approximately half (n=14/26) underwent 
pencillin susceptibility testing by oxacillin disk diffusion. 
The majority 85.7% (n=12/14) were identified as 
resistant by this method, confirmation by Minimum 
inhibitory concentrations (MIC) testing was not 
available. Nearly all S. pneumoniae tested for 
vancomycin (n=20/22) were found to be susceptible with 
the exception of a neonatal eye swab and a pediatric 
wound isolate. Among CSF isolates, susceptibilities 
could not be retrieved in 4/6 instances, the remaining two 
were penicillin resistant per oxacillin disk when 
considering non-meningitis break points. Vancomycin 
susceptibilities however were available for all, and 

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vancomycin susceptibility with zone diameters 
exceeding 17 mm was universal. 

While in 2014 and 2015 only ten enterococcal 
isolates were identified, there were 26 in 2016 and 83 in 
2017, reflecting that standardized diagnostic measures 
for enterococcal identification were introduced in 
October 2016. Most (n=113/119) were reported as 
Enterococcus spp. and not further identified, five as E. 
faecalis, and one as E. avium. They originated equally 
from children (n=64) and adults (n=52). Six of 97 isolates 
that underwent vancomycin susceptibility testing were 
resistant, all of them sampled from adult outpatients. 
Ampicillin susceptibility was not documented even 
though it constitutes the antibiotic of choice. Gentamicin 
susceptibility was universal for all available (n=25/119), 
though specific testing for high-level enterococcal 
resistance was not done.  

 

Discussion 

This study is the largest report on the 
susceptibility profile of gram positive isolates from 
clinical specimens in Mongolia to date. The results 
highlight important points on the epidemiology of gram 
positive pathogens in Mongolia. Rates of MRSA 
remained stable at approximately one quarter overall. 
Methicillin resistance in S. aureus isolates from 
inpatients and sterile site specimens howvere increased. 
Hence, MRSA spread appears to be mainly nosocomially 
driven. The isolation of enterococci increased 
dramatically, reflecting improved diagnostic means. S. 
pneumoniae was frequently identified as penicillin 
resistant, a finding that bears important clinical 
relevance.  

In addition to the large sample size and a patient 
cohort representing patients of all ages and given the 
NCMCH is a tertiary referral center for patients from 
across all of the Mongolia, data were collected 
consecutively over several years, thereby enabling an 
observation over time. During the data collection period, 

several changes were implemented in order to improve 
diagnostic processes, quality control, and staff training. 
However, this also means that the study has important 
limitations. Adjustments made to microbiological 
diagnostics are reflected in a changing species and 
susceptibility profile over the study period. Susceptibility 
panels remained dependent on locally available 
equipment and antimicrobials used in clinical 
practice18,20. It is recognized that this will require ongoing 
adjustments, which are often subject to financial 
constraints.  

The study identified a need for further 
implementation of improved diagnostics through 
modernized equipment and staff training, in order to 
enable accurate identification of a wider range of gram 
positive pathogens. This need is currently being 
addressed.  

As a country at the threshold of developing into 
a modern state, Mongolia’s health care system has a 
unique opportunity to apply modern technology and 
therapeutic options, while facing new challenges in 
surveillance, governance, and stewardship policies. This 
situation is exemplified by the increasing use of 
antimicrobial agents for nosocomial infections in 
intensive care settings and the resulting spread of 
multidrug resistant organisms. Clinicians are 
increasingly confronted with the complications of 
modern intensive care medicine, expansion of intensive 
neonatal care, and surveillance of changing 
epidemiology of childhood infections as vaccination 
schedules are changing. An important gram positive 
vaccine preventable pathogen, S. pneumoniae, was not 
commonly identified. However, the majority of isolates 
available for analysis were penicillin resistant on 
oxacillin disk testing. This method may underestimate 
non-reliable penicillin susceptibility18,24. MICs to 
penicillin and vancomycin were unavailable, and while 
reliable conclusions regarding penicillin susceptibility 
cannot be drawn based on this data alone, the results 
should caution Mongolian clinicians against the use of 

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beta-lactam monotherapy in pneumococcal meningitis, 
especially in the absence of universal and reliable 
cephalosporin susceptibilities 24,25. These findings are in 
agreement with recent reports from the Russian 
Federation, where a survey identified 28% of 
pneumococcal isolates as penicillin resistant26. By 
contrast, among S. pneumoniae isolates in Kazakhstan27, 
penicillin susceptibility was almost universal. 

Pneumococcal vaccination of infants has 
recently been introduced to targeted populations in 
Mongolia but is not universal yet28. In the coming years, 
more widespread pneumococcal vaccination is likely to 
change the epidemiology of pneumococcal infections in 
Mongolia. Therefore, reliable identification, 
susceptibility testing and serotyping of S. pneumoniae in 
order to monitor vaccination impact must be ensured. 

A GBS screening program is not currently 
performed in Mongolia, hence the data presented is not 
representative of GBS carrier or infection prevalence 
among women or neonates in Mongolia. The lack of 
laboratory exposure to GBS diagnostics may explain the 
unusual susceptibility patterns, including the report of 
seven cephalosporin resistant isolates. Misidentification 
cannot be ruled out, however it should be noted that 
penicillin and cephalosporin susceptibility is no longer 
universal for GBS, particularly in Asia29,30. More data on 
GBS epidemiology in Mongolia is currently being 
assimilated and molecular testing will become part of the 
NCMCH’s laboratory strategy by the end of 2019. Once 
in place, a guideline for risk stratification of fetomaternal 
and neonatal management will be introduced. 

Enterococcal identification was introduced in 
2016, and universal testing for aminopenicillin, 
gentamicin, and vancomycin susceptibility is currently 
being introduced. The increase in enterococcal 
identification underscores the significant impact of 
improved diagnostics on the accuracy of institutional 
species composition and treatment considerations. 

In previous years, limited data available on S. 
aureus in Mongolia identified a rate of 9% of methicillin 
resistance and of 28% of multidrug resistance in 2007 
and 201131. Sample origin was only known for 21% of 
isolates in this study. Our data shows a much higher rate 
of MRSA, possibly as a result of a greater number of 
sterile samples from hospitalized patients, though a 
comparison of the two studies is difficult. Our findings 
may also be indicative of a significant rise in the 
proportion of MRSA among S. aureus isolates in 
Mongolia over time.  Comparison with a similar 
institution in the neighboring nation of Kazakhstan 
shows that rates of MRSA in Mongolia are strikingly 
higher. In Kazakhstan, 95 to 100% of S aureus isolates 
were reported as oxacillin susceptible32, of our isolates, 
one third were methicillin resistant. In Russian Siberia, 
nosocomial MRSA rates among S. aureus are more 
comparable at a rate of 22%, though community rates of 
MRSA in Siberia were reportedy much lower (2.9%) 
than we identified in outpatients attending the NCMCH.   

In relation to the community acquired 
infections, Mongolia’s unique position as country where 
animal husbandry and nomadic herders’ lifestyle applies 
to much of the population remains to be investigated. 
Over 700 drugs are registered and commonly used in 
livestock production. AMR monitoring in the livestock 
and food supply is critical in order to control AMR 
development. Laboratories routinely examine food for 
food borne pathogens, however AMR testing is not yet 
systematically conducted throughout the food chain32. A 
Mongolian Food Chain AMR monitoring system piloted 
in 2016 with WHO support revealed that food borne 
pathogens found in animal products and animal 
production facilities were commonly resistant to 
antimicrobials with a high proportion of multidrug-
resistance. In another study, almost half of food items 
tested MRSA positive33. This highlights that in addition 
to infection control in the hospital environment, AMR is 
an issue that requires an integrative and collaborative 
approach of multiple agencies34. Susceptibility testing for 
gram positive isolates at NCMCH is now performed 

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following a more standardized approach, and staff 
training is ongoing. Cefoxitin disk testing for MRSA 
identification has been introduced at NCMCH and 
follow-up data is being collected. Vancomycin 
susceptibility testing has been included from 2016. Of the 
six S. aureus isolates exhibiting non-reliable vancomycin 
susceptibility, all but one were methicillin susceptible, 
contrasting the fact that most studies have identified that 
the majority of vanA or vanB positive S. aureus isolates 
to be also methicillin resistant. VanA/B/C acquisition is 
increasingly recognized to occur irrespective of 
methicillin susceptibility33,35. In the future, isolates found 
to be vancomycin resistant will be tested for extended 
antimicrobial susceptibilities. Susceptibility testing will 
aim to include vancomycin susceptibility by MIC into 
testing of all invasive S. aureus isolates, with an 
implementation deadline by the end of 2019. 

Our study constitutes the largest published 
record of clinical gram positive isolates in Mongolia. The 
results emphasize the importance of consequent 
surveillance and urgent attention to strategies that that 
allow rapid diagnosis of gram positive infections; a 
difficult task Mongolia shares with other countries in the 
area experiencing rapid and profound societal and 
economic change. Compared with studies from 
neighboring nations, the rates of AMR among gram 
positive isolates at NCMCH, particularly S. aureus and 
S. pneumoniae, were much higher. As a nation with 
significant livestock populations, AMR monitoring must 
be embedded in an approach that involves both the public 
and veterinary sector as well as healthcare facilities. 
International collaboration is critical to address these 
issues. 

 

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	Microbiological and Susceptibility Profile of Clinical Gram Positive Isolates at a Tertiary Pediatric and Maternity Hospital in Ulaanbaatar, Mongolia
	Microbiological and Susceptibility Profile of Clinical Gram Positive Isolates at a Tertiary Pediatric and Maternity Hospital in Ulaanbaatar, Mongolia
	Abstract
	Abstract
	Keywords: Child Health; Women Health; Communicable Diseases; Epidemiology; Maternal and Child Health; Mongolia
	Keywords: Child Health; Women Health; Communicable Diseases; Epidemiology; Maternal and Child Health; Mongolia
	Microbiological and Susceptibility Profile of Clinical Gram Positive Isolates at a Tertiary Pediatric and Maternity Hospital in Ulaanbaatar, Mongolia
	Microbiological and Susceptibility Profile of Clinical Gram Positive Isolates at a Tertiary Pediatric and Maternity Hospital in Ulaanbaatar, Mongolia
	Research
	Research

