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%), 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.

Keywords: Antibiotic resistance; Antimicrobial resistance; Conflict; Middle East.

Fig. 1

Map of countries included in this systematic review on AMR and conflict in the Middle East (the identification as fragile and conflict affected and non-conflict affected is based on the World Bank classification, 2011–2018)

Fig. 2

PRISMA flow diagram of the selection of articles for this review

Fig. 3

Temporal trends in the proportion of resistance to five classes of antibiotics by year of publication among studies including E. coli, K. pneumoniae, Acinetobacter spp. and S. aureus

Fig. 4

Funnel plots for publication bias in ten studies reporting the proportion of ESBL producers among E. coli isolated from urinary samples: a) All studies (Eggers regression test p = 0.52), b) Studies in conflict settings (Eggers regression test p = 0.78), c) Studies in non-conflict settings (Eggers regression test p = 0.07)