Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: A systematic review

Abstract

Background: In spite of the evident general negative effects of armed conflict on countries’ health systems and populations’ health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe:1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization;2. Differences in proportions of AMR isolates between conflict and non-conflict countries. Methods: A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for “antimicrobial resistances” and “Middle East”, to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale. Results: A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following:1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%: range), and both carbapenem resistance (median 8.1% and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3% and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.Conclusions: There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

Antimicrobial Resistance Among GLASS Pathogens In Morocco: An Epidemiological Scoping Review

“…They have been described in most of selected papers. Other systematic reviews, conducted on AMR in the Middle East [77] and Africa [78], have reported the same results.…”

“…Such infections might require hospitalization and intravenous injection of carbapenem antibiotics. In this review, the carbapenem-resistance proportion among GLASS Enterobacteriaceae appears like other reports from Africa [78] and the Middle East [77], but higher than those described in most European countries [84]. In this context, the prevalence of carbapenemase-producing K. pneumoniae and E. coli, per 10 000 hospital admissions, presents an average of 1.3 (6.0 in Italy, 0.02 in Norway).…”

“…In a recent systematic review conducted in the MENA region [77], it was shown that the lack of consistency and harmonization in the regional surveillance system is not a prerogative of the Middle East, as is the case in developed countries.…”

Surveillance strategies using routine microbiology for antimicrobial resistance in low- and middle-income countries

“…Alternatively, a less preferable approach, is the utilization of microbiology data alone (laboratory-based surveillance) without clinical and epidemiological data. Most national and supranational AMR networks rely solely on laboratory data to trace changes of antimicrobial susceptibility in space and time [7,[19][20][21][22]. A recent review on supranational networks performing AMR surveillance in LMICs showed the heterogeneity of data due to lack of standards on the composition and activities of surveillance networks [7], and the majority (80%; 39/49) describe AMR based on samples sent to laboratory for clinical purposes (Table 2).…”

Pediatric Infectious Diseases Encountered During Wartime Part II: Infectious Diseases Complications in the Individual Pediatric Patient

“…Just recently, the first review specifically addressing the antimicrobial resistance evidence gaps in the Middle East was published. Not surprisingly, the authors found no data available for children from conflict-affect settings [57]. Common infections worldwide are becoming more difficult to treat; however, children injured during armed conflict are also inevitably at risk for acquiring MDRO.…”