Drug resistance could be behind twice as many Asian hospital deaths as we thought
The largest study of its kind followed 10,000 patients across 19 Asian countries, and found that resistance accounts for a far greater share of deaths from severe hospital infections than population-level modelling had estimated.
- 27 August 2026
- 5 min read
- by Priya Joi
At a glance
- In a landmark study across 41 hospitals, almost three-quarters of the hospital infections analysed involved drug-resistant bacteria.
- Resistance accounted for 19.8% of deaths from these infections, close to double the 10.5% derived from earlier modelling.
- The burden fell hardest on lower-middle-income countries, children and younger adults.
Drug resistance is responsible for around twice as many deaths from severe hospital infections in Asia as global modelling has estimated, a large new study in The Lancet Infectious Diseases has found.
Two infectious disease specialists, writing in an accompanying commentary, called the findings “sobering”.
Researchers followed nearly 10,000 patients with hospital-acquired bloodstream infections or ventilator-associated pneumonia across 41 hospitals in Asia and found that almost three quarters of the infections involved drug-resistant bacteria.
The burden was not shared evenly, however, as resistance raised the risk of dying most in lower-middle-income countries. In high-income hospitals within the same region, the researchers found little or no difference in mortality between resistant and susceptible infections.
The authors say this suggests that modelling has been underestimating the toll of hospital-acquired resistant infections, and that the gap is likely to be widest in poorer countries.
The study is the first of this scale in Asia that moved beyond using estimates to gathering clinical data on infections, drug treatment success rates and mortality.
The authors say their findings suggest modelling may have been severely underestimating the burden of hospital-acquired resistant infections, particularly in poorer countries, and argue for surveillance that follows patients rather than estimates from national statistics.
75% of infections were resistant
The ACORN-HAI network, led by Yin Mo at the National University of Singapore, enrolled patients between September 2022 and February 2025. Sites ranged from high-income Singapore, Japan and Brunei to lower-middle-income Pakistan, Nepal, Bangladesh, Timor-Leste and Viet Nam.
Patients of any age were included if they had a microbiologically confirmed bloodstream infection acquired in hospital or ventilator-associated pneumonia.
These are two of the most severe infections a patient can pick up while being treated for something else.
After exclusions, 9,496 patients and 9,642 infection episodes were analysed, each followed for 28 days. Of those episodes, 7,102, or 73.7%, involved drug-resistant bacteria.
Gram-negative organisms dominated, accounting for 78.8% of infections, and more than half of those were resistant to multiple drug classes.
Within 28 days, 37.7% of patients with a resistant infection had died, against 30.0% of those with a susceptible one.
Mortality was higher still for the two pathogens the World Health Organization ranks as critical priorities: 51.3% for carbapenem-resistant Acinetobacter and 48.4% for carbapenem-resistant Enterobacterales.
Separating resistance from severity
Mortlity alone can’t indicate what percentage of deaths were due to resistant infections.
To determine this, the researchers compared patients with resistant infections against patients with susceptible infections caused by the same type of organism, adjusting for age, sex, income setting, underlying illness, severity of disease and intensive care admission. What remains after that adjustment is the mortality attributable to resistance.
By that measure, resistance accounted for 19.4% of deaths in carbapenem-resistant Acinetobacter infections and 16.2% in carbapenem-resistant Enterobacterales. Both findings held up when the researchers restricted the analysis to patients infected with a single organism.
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Attributable mortality reached 16.9% in ventilator-associated pneumonia and 10.7% in lower-middle-income countries. In high-income settings within the same region, the researchers found little or no difference in mortality between resistant and susceptible infections at all.
Attributable mortality was 11.7% among children aged 5 to 14 and 11.2% among people aged 15 to 49, higher than among the oldest patients.
Double the numbers
The death toll from resistant infections in Asia was previously estimated to be around 130,000, but this study puts it at roughly 250,000.
The difference lies in how much of the dying is blamed on resistance. Earlier modelled estimates attributed about one in ten of these deaths to resistant bacteria. Measured in patients, it was closer to one in five.
The authors say this suggests that modelling has been underestimating the toll of hospital-acquired resistant infections, and that the gap is likely to be widest in poorer countries.
They are clear about the limits, however. The 41 hospitals were picked because they could run a standardised protocol, so they are not a cross-section of Asian hospitals. And the death toll figures rest on extrapolation, so the true range of uncertainty may be wider than the study reports.
Ineffective drugs
The study found that patients were often being given older drugs that are now known not to be effective.
For instance, among infections caused by carbapenem-resistant gram-negative bacteria, 57.8% were treated with carbapenems, the very drugs the bacteria resist, and 35.6% with polymyxins, an older class associated with kidney toxicity.
Newer agents developed for exactly these pathogens were almost entirely absent. Across 1,605 carbapenem-resistant Acinetobacter episodes, neither sulbactam-durlobactam nor cefiderocol was prescribed once. For carbapenem-resistant Enterobacterales, ceftazidime-avibactam appeared in 166 prescriptions, and no other newer agent was used at all.
In their accompanying commentary, Amy Mathers, an infectious disease physician at the University of Virginia School of Medicine, and Jose Munita of Universidad del Desarrollo in Chile, argue this is unlikely to reflect what doctors would choose. They read the prescribing patterns as a marker of therapeutic scarcity, meaning the drugs simply were not there to prescribe.
They conclude “Better patient-level data produce better models, and better models can support better policy. 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.”
