Understanding the Epidemiology of Multi-Drug Resistant Gram-Negative Bacilli in the Middle East Using a One Health Approach

Abstract

In the last decade, extended-spectrum cephalosporin and carbapenem resistant Gram-negative bacilli (GNB) have been extensively reported in the literature as being disseminated in humans but also in animals and the environment. These resistant organisms often cause treatment challenges due to their wide spectrum of antibiotic resistance. With the emergence of colistin resistance in animals and its subsequent detection in humans, the situation has worsened. Several studies reported the transmission of resistant organisms from animals to humans. Studies from the middle east highlight the spread of resistant organisms in hospitals and to a lesser extent in livestock and the environment. In view of the recent socio-economical conflicts that these countries are facing in addition to the constant population mobilization; we attempt in this review to highlight the gaps of the prevalence of resistance, antibiotic consumption reports, infection control measures and other risk factors contributing in particular to the spread of resistance in these countries. In hospitals, carbapenemases producers appear to be dominant. In contrast, extended spectrum beta lactamases (ESBL) and colistin resistance are becoming a serious problem in animals. This is mainly due to the continuous use of colistin in veterinary medicine even though it is now abandoned in the human sphere. In the environment, despite the small number of reports, ESBL and carbapenemases producers were both detected. This highlights the importance of the latter as a bridge between humans and animals in the transmission chain. In this review, we note that in the majority of the Middle Eastern area, little is known about the level of antibiotic consumption especially in the community and animal farms. Furthermore, some countries are currently facing issues with immigrants, poverty and poor living conditions which has been imposed by the civil war crisis. This all greatly facilitates the dissemination of resistance in all environments. In the one health concept, this work re-emphasizes the need to have global intervention measures to avoid dissemination of antibiotic resistance in humans, animals and the environment in Middle Eastern countries.

Clinical and Economic Impact of Antimicrobial Stewardship Interventions Reported Among Hospital Inpatients in The Middle East: a Systematic Review Protocol

“…The Middle East includes 15 strategically, politically and economically diverse countries: Bahrain, Egypt, Iraq, Iran, Jordan, the Kingdom of Saudi Arabia (KSA), Kuwait, Lebanon, Palestine, Qatar, Sultanate Oman, Syria, Turkey, the United Arab Emirates (UAE), and Yemen (43). Conversely, Middle East has its own share of antibiotic-resistance issues that stems from a wide range of problems, including selfprescribing (44,45), misuse of antimicrobials (35,45) over the counter sales (46,47), poor infection control measures, poor understanding and unrealistic expectations among patients (48,49), and most notably due to the recent population mobilization due to socio-economic developments, con icts and multiple war crises (50). A recent report from the WHO has also highlighted that, due to poor economic status and lack of health care insurance, patients often approach pharmacists for their medications to avoid consultations costs (50).…”

“…Conversely, Middle East has its own share of antibiotic-resistance issues that stems from a wide range of problems, including selfprescribing (44,45), misuse of antimicrobials (35,45) over the counter sales (46,47), poor infection control measures, poor understanding and unrealistic expectations among patients (48,49), and most notably due to the recent population mobilization due to socio-economic developments, con icts and multiple war crises (50). A recent report from the WHO has also highlighted that, due to poor economic status and lack of health care insurance, patients often approach pharmacists for their medications to avoid consultations costs (50). Moreover, the overall public awareness about the use of antimicrobials and its resistance in this region is reported to be poor (48,49,(51)(52)(53)(54)(55).…”

Antimicrobial-resistant genes among Klebsiella pneumoniae in the Arabian Gulf Countries: A systemic review and meta-analysis

“…Even, inappropriate use of antibiotics is also another added reason for the dissemination of MDROs in the Arabian Gulf countries. (10) Conclusion:…”

“…A study from Saudi Arabia reported OXA and NDM carbapenemases (17). Studies from the United Arab Emirates reported NDM, OXA-48, and, to a lesser degree KPC, as the predominant carbapenemases in clinical isolates of K. pneumoniae (10). A meta-analysis study in East Africa reported CTX-M, TEM, SHV, and OXA genes predominance among Enterobacteriaceae isolates (18).…”

“…They have reported multiple factors that might be contributing to the increasing antimicrobial resistance rates (9). An interplay of antibiotics overuse/misuse in humans and animals, inappropriate infection control measures and continuous mobility of the people due to socio-economic con icts and multiple war crises has to lead to a dissemination of antimicrobial resistance (10).…”