Increasing trend of antimicrobial resistance in Eastern Mediterranean Region of World Health Organization

By Shanet Susan AlexMar 9 2022Reviewed by Aimee Molineux

In a recent study published in the Emerging Infectious Diseases journal, researchers investigated the rising antimicrobial resistance (AMR) in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) from 2017 to 2019.

AMR is a worldwide catastrophe and one of the most complicated health challenges the world has ever faced, jeopardizing a century of medical progress. Animal and human health are both impacted by AMR. Each year, 700,000 people die from drug-resistant infections across the globe, and if no concerted measures are made to combat AMR, the mortality rates are predicted to rise to 10 million by 2050.

The WHO's EMR includes 21 nations and the occupied Palestinian territories. The region is socioeconomically and demographically diverse. Wars, population displacement, and conflicts affect around two-thirds of the EMR countries, posing tremendous health risks and disrupting health systems. The emergence and transmission of AMR in the EMR nations were influenced by the weak health surveillance system, a high burden of infectious diseases, insufficient regulatory frameworks, and limited antimicrobial stewardship (AMS) and infection prevention and control (IPC) programs.

About the study

In the present study, the scientists reported the AMR burden over time in the nations of the EMR to better inform the regional response to AMR. The team evaluated the national AMS and IPC programs in the EMR countries.

For this, they assessed information on bloodstream infections (BSIs) documented in the Global Antimicrobial Resistance Surveillance System (GLASS) from 2017 to 2019, data from seven nations on nationally representative antimicrobial prescriptions surveys, and information from two surveys conducted regionally. 

Results and discussions

The results show that 20 of the 22 EMR nations constructed their national AMR action plans in synchronization with the global plan. Various countries in the EMR have been collecting data on AMR and antimicrobials usage after 2017. Thus, the AMR detection and monitoring potential and awareness of the complexity and scope of AMR improved in many EMR countries. 

The median proportion of individuals with carbapenem-resistant Acinetobacter spp. (CRAsp)-induced BSIs were the highest at 70.3% in the EMR nations. This proportion is exceptionally higher than the United States (US), where 33.9% of healthcare-related infections were caused by CRAsp. In addition, 32.6% of Acinetobacter spp. isolates found in cerebrospinal fluid (CSF) or blood were carbapenem-resistant in European Union (EU) nations. This indicates that the CRAsp was a high-risk bacterium circulating in healthcare facilities in the EMR countries. The transmission of CRAsp was accentuated by the lack of proper execution of IPC. Carbapenem-resistant Enterobacteriaceae (CRE) and CRAsp have developed resistance to practically all antimicrobial medicines available now, resulting in case-fatality and patient mortality rates of more than 50%.

The analysis of inpatient prescriptions of antimicrobials revealed a significant usage of carbapenems and third-generation cephalosporin (3GC), which might explain why these medicines have such high levels of resistance among pathogens. For instance, K. pneumoniae was resistant to carbapenems and 3GC.

The total prevalence of antimicrobial medication usage in the seven nations of the EMR that conducted the point-prevalence survey was lower than certain African countries, comparable to Latin America but higher than European countries, respectively. Treatment of community-acquired infections was the most prevalent reason for prescribing antimicrobials in the EMR and several European and African countries. However, 3GCs were the most prescribed antimicrobial medication in the EMR, whereas penicillins with β-lactamase inhibitors were the most generally prescribed antimicrobial drugs in Europe.

AMS initiatives prevent the emergence of resistance. Only five nations in the EMR enforce a prescription-only antimicrobial drug sale policy in pharmacies. Two countries have adopted the watch or reserve (AWaRe) classification to the national Essential Medicines List to boost the use of the access group of antimicrobials as a first or second empirical choice in common infections. Legislation enforcing this objective must be accompanied by comprehensive universal health care. 

Despite the substantial burden of AMR, the EMR has significant impediments to AMS deployment. These barriers include limited availability of clinical pharmacy and infectious disease experts in many nations, restrictions in the microbiological diagnostic breadths, absence of national-level AMR management, and knowledge gaps about the optimum usage of antimicrobials among healthcare professionals.

Following the emergence of resistant pathogens, IPC programs were crucial to limit their transmission. Unfortunately, IPC has never been an integrated part of healthcare systems, unlike other curative and preventive strategies. IPC programs were developed primarily to deal with national or global infectious disease pandemics or epidemics such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Middle East respiratory syndrome CoV (MERS-CoV).

Although IPC has progressed in many high-income countries, its deployment and adherence in the middle- and low-income nations was still limited. The coronavirus disease 2019 (COVID-19) pandemic revealed the necessity of IPC, but various nations in the EMR have yet to induct or improve their national IPC programs. Further, although investing in IPC requires resources, the COVID-19 pandemic revealed that it was immensely cost-effective in minimizing infection transmission among patients and healthcare staff and lowering infections associated with drug-resistant strains. 

Conclusions

The study findings demonstrate that the occurrence of AMR in EMR nations was significant, and its continuous rise poses a threat to the region's health security. AMS initiatives to prevent AMR emergence and IPC strategies to minimize spread are still in the early stages of development in the EMR nations, with different capacities in various countries.

This predicament warrants the need for political participation and leadership. The EMR nations must speed up the execution of their national AMR strategies by establishing effective national AMR governance structures consisting of adequate financing, highly specialized human resources, and the training of accountable staff at every level.