289 Towards precision medicine in sepsis In tropical settings, artemisinin drug resistance in falciparum malaria is an emerging problem and is spreading westward in Southeast Asia. Proportions of extended-spectrum beta-lactamase (ESBL) producing Gram-negative bacteria have been reported to be as high as 50% in India and 80% in China in healthcare associated infections. Methicillin-resistant Staphylococcus aureus rates have been reported to range from 50% to 85% in Sri Lanka, Thailand and India [27, 28]. Carbapenem-producing Enterobacteriaceae and Acinetobacter baumannii are an increasing problem in LMIC, with antimicrobial-resistant A. baumannii being the most common cause of MDR hospitalacquired infections in LMIC, surviving for prolonged periods in the environment. Moreover, fluoroquinolone resistance in Salmonella typhi is high in Asia and rising in Africa [29]. Spread of highly resistant bacteria is an increasing problem, facilitated by the high connectivity through overseas flights. Antimicrobial stewardship should be promoted. A setting-adapted pharmacistdriven program across 47 South African Hospitals resulted in large reduction of antimicrobial use [30]. Local resistance patterns should be monitored by sentinel sites and data should be reportedas recommended by the WHO Global Antimicrobial Resistance Surveillance System [31]. Understaffing is common, with low staff-patient ratios, resulting in multiple breaks in infection control, increasing the risks of cross-infection. It often mandates the implication of the relatives in patients’ care, which may contribute to dissemination of MDR pathogens. It may have specific considerations among refugees [32]. Finally, the lack of laboratory capacity for diagnosis represents a restriction for implementation of RDT, complicates the identification of MDR and limits de-escalation. In summary, the majority of the world population is living in LMICs and there is a high burden of critical illnesses with unacceptably high mortality due to lack of resources. The knowledge and awareness of sepsis in LMICs should be improved by training programmes and epidemiological studies in collaboration with HICs’ sepsis experts. The current sepsis definitions and guidelines should be modified based on epidemiological data and available resources in LMICs for the improvement in timely resuscitation of septic patients [1, 9, 33]. During these improvement programmes in sepsis management, recent advances in personalized medicine in HICs should be customized to LMICs and require a different paradigm. 11
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