Antimicrobial resistance (AMR) in ventilator-associated pneumonia and bloodstream infections in Asia is common and associated with high mortality rates and reduced quality of life, as shown in the ACORN-HAI study.
In a large cohort of patients enrolled from 41 hospitals across 19 countries in Asia, 73.7 percent of the 9,642 infection episodes documented between 2022 and 2025 were associated with AMR bacteria, reported first author Dr Yin Mo from the National University of Singapore, Singapore, and colleagues. [Lancet Infect Dis 2026;doi:10.1016/S1473-3099(26)00357-9]
Gram-negative bacteria were the most common, with carbapenem-resistant Acinetobacter spp (CRA; 36.5 percent) predominating in ventilator-associated pneumonia and third-generation cephalosporin-resistant Escherichia coli (9.1 percent) in bloodstream infections.
Crude 28-day mortality was 37.7 percent among AMR infection episodes and 40.6 percent among multidrug-resistant infection episodes. The median days to death were 7 for both.
The attributable mortality for AMR infections was the highest in ventilator-associated pneumonia (16.9 percent), among children ages 5–14 years (11.7 percent), among young adults ages 15–49 years (11.2 percent), and in lower-middle income countries (LMICs; 10.7 percent).
Among resistant pathogens, CRA and carbapenem-resistant Enterobacterales (CRE) were associated with the highest crude and attributable mortality. Crude 28-day mortality exceeded 40 percent for both pathogens, while attributable mortality was approximately 19.4 percent for CRA and 16.2 percent for CRE.
As for quality of life, CRA- and CRE-related infections resulted in the worst functional outcomes in LMICs and in the upper-middle income countries (UMICs), respectively.
“Antibiotic treatment data revealed widespread reliance on carbapenems, polymyxins, and anti-pseudomonal penicillin-β-lactamase inhibitor combinations, which are often ineffective against [CRA and CRE] and associated with substantial toxicity,” Mo and colleagues noted. “[This prescribing pattern] likely reflects restricted access to newer antibiotics, including their complete unavailability in many settings.”
High mortality
Overall, the estimated deaths attributable to AMR bacterial ventilator-associated pneumonia and hospital-acquired and healthcare-associated bloodstream infections were 0.25 million (95 percent confidence interval [CI], 0.17–0.36) in Asia, nearly double the 0.13 million estimated from the 2019 Global Research on Antimicrobial Resistance (GRAM) study.
“Although our estimates were derived from selected hospitals and might not be nationally representative, these differences suggest that modelling approaches relying on assumptions to link microbiology and patient outcome data might underestimate the burden of healthcare-associated AMR, particularly in LMIC settings,” the authors said.
“Nevertheless, these burden estimates should be interpreted cautiously because they rely on several assumptions and extrapolations beyond the study population,” they added.
ACORN-HAI enrolled 10,111 patients between 2022 and 2025, among whom 9,496 (median age 60 years, 60.2 percent male, 53.9 percent from UMICs) were included in the final analysis. Of the 9,642 index infection episodes, 6,597 (68.4 percent) were bloodstream infections and 3,045 (31.6 percent) were ventilator-associated pneumonia.
Moving beyond measuring AMR burden
“The greatest contribution of this study is its accurate measurement of the real toll of AMR across a vast and diverse group of countries and settings,” linking microbiological data, antimicrobial treatment, attributable mortality, and patient-centred functional and quality-of-life outcomes, wrote Dr Amy Mathers from the University of Virginia, Charlottesville, Virginia, US, and Dr Jose Munita from Universidad del Desarrollo, Santiago, Chile, in an accompanying editorial. [Lancet Infect Dis 2026;doi:10.1016/S1473-3099(26)00417-2]
Mathers and Munita described the findings as “sobering” and highlighted two issues that merit particular attention.
“First, the authors report a strikingly uneven distribution of AMR-related mortality, which disproportionally affected children, younger adults, and patients from LMICs. Second, beyond mortality, quality-of-life analyses highlight that survival after a severe healthcare-associated infection is often not equivalent to recovery, particularly among patients with carbapenem-resistant infections,” they said.
“The next challenge is to move past measuring the burden of AMR and determine whether closing the diagnostic and therapeutic gap improves survival of resistant infections. The task now is not only to count deaths from AMR more accurately, but to decrease their number, especially across regions bearing the greatest burden,” Mathers and Munita concluded.