Measles in conflict-affected northern Syria: results from an ongoing outbreak surveillance program

Predictors of antibiogram performance and antibiotic resistance patterns in the northern Syrian region: A cross-sectional investigation

Introduction

Antibiogram use is crucial in the fight against antibiotic resistance in Syria, helping to guide treatment decisions, monitor resistance trends, and implement measures to mitigate this global health threat. This study explores the predictors of antibiogram performance and antibiotic resistance patterns in hospital settings in the Northern Syrian region.

Methods

An observational cross-sectional study was performed over six months, from the beginning of September 2022 to February 2023, targeting patients admitted to two hospitals in Syria with susceptibility to infection. The study excluded patients who did not consent or were unwilling to participate, while all individuals admitted due to infectious diseases, regardless of age, sex, or race, were included in the research. Data were collected prospectively, and antimicrobial susceptibility evaluations were performed using the disc diffusion method (the Kirby-Bauer test). Statistical analyses, including the analysis of the results, were conducted utilizing the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois) Version 29.

Results

Of 300 hospitalized patients taking antibiotics, an antibiogram was performed for 200 individuals (cases), while 100 patients (controls) received direct treatment. One-hundred eighty-five cases had a positive culture (69.7% Gram-negative and 30.3% Gram-positive) and subsequently underwent assessment for antibiotic resistance. Cases comprised more females (56.0%) than controls (48.0%), with no statistically significant differences (p > 0.05). Significantly more patients between 25 and 63 were cases (63.8%) than controls (51.0%), while older ages were notably higher among controls (31.7%; p = 0.044), history of cardiovascular diseases was higher among controls (59.0%) than cases (47.0%; p = 0.050). Escherichia coli (N = 60; 30%), Klebsiella (N = 37; 18.5%), and Streptococcus (N = 32; 16%) were the most common bacteria. The study explored antibiotic resistance patterns among identified germs, emphasizing the high sensitivity of all identified germs for broad-spectrum antibiotics, including meropenem, amikacin, gentamicin, and fluoroquinolones (levofloxacin, ciprofloxacin). High resistance (%Sensitivity below 60%) was noted for Sulfamethoxazole, nalidixic acid, amoxiclav, lincomycin cefotaxime, ceftriaxone, and cefixime. Specifically, Escherichia coli exhibited robust sensitivity to meropenem (100%), amikacin (93.2%), and ciprofloxacin (92.7%). However, notable resistance was observed against sulfamethoxazole (68.8%), amoxicillin-clavulanate (78.3%), and cefotaxime (88.3%). For Klebsiella, resistance rates were prominent, particularly against sulfamethoxazole (69.4%), amoxicillin (83.8%), and nalidixic acid (100%). Among Gram-positive bacteria, Staphylococcus demonstrated significant resistance to sulfamethoxazole (95.2%) and ceftriaxone (78.3%) while maintaining high sensitivity to meropenem (100%) and vancomycin (100%). Streptococcus exhibited notable resistance against sulfamethoxazole (87.5%) and cefotaxime (90.6%).

Conclusion

The increase in resistance to penicillins, sulfonamides, and cephalosporins, along with continued sensitivity to broad-spectrum antibiotics, including aminoglycosides, carbapenems, and fluoroquinolones, emphasizes the importance of promoting antibiogram use and antibiotic stewardship programs. The limited availability of new antibiotics reinforces the need for urgent efforts to optimize antibiotic use and improve clinical outcomes in Northern Syria.

Communicable diseases in northwest Syria in the context of protracted armed conflict and earthquakes

The earthquakes in Türkiye and Syria in February, 2023, have caused further devastation in northwest Syria-an area already affected by protracted armed conflict, mass forced displacement, and inadequate health and humanitarian provision. The earthquake damaged infrastructure supporting water, sanitation, and hygiene, and health-care facilities. The disruptions to epidemiological surveillance and ongoing disease control measures resulting from the earthquake will accelerate and expand ongoing and new outbreaks of many communicable diseases including measles, cholera, tuberculosis, and leishmaniasis. Investing in existing early warning and response network activities in the area is essential. Antimicrobial resistance, which had already been an increasing concern in Syria before the earthquake, will also be exacerbated given the high number of traumatic injuries and breakdown of antimicrobial stewardship, and the collapse of infection prevention and control measures. Tackling communicable diseases in this setting requires multisectoral collaboration at the human-animal-environment nexus given the effect of the earthquakes on all these sectors. Without this collaboration, communicable disease outbreaks will further strain the already overburdened health system and cause further harm to the population.

An Emerging Health Crisis in Turkey and Syria after the Earthquake Disaster on 6 February 2023: Risk Factors, Prevention and Management of Infectious Diseases

On 6 February 2023, Turkey and Syria were hit by two major earthquakes that caused extremely heavy structural damage to buildings and infrastructure in one of the most densely populated areas of Anatolia. The authors visited the devastated area shortly after the earthquakes in the frame of search and rescue and scientific missions in order to check whether the newly formed conditions have the potential to further affect public health. Based on the collected disaster-related field data, it is revealed that risk factors associated with and favoring emergence of infectious diseases are present in the affected residential areas from the first hours of the emergency state. The coexistence and synergy of many collapsed health facilities, cold winter conditions, destruction of lifeline infrastructures, overcrowding in emergency shelters, poor sanitation and adverse socio-economic conditions along with evolving crises and disasters (conflicts, pandemic and epidemics) may further aggravate the already fragile public health situation and cause considerable delays in the recovery process. Efficient disease surveillance at local and regional levels is a crucial requirement for early warning and protection against emerging infectious diseases in the earthquake-affected areas among other proposed measures for prevention and management of infectious diseases.

Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

Wars have hidden repercussions beyond the immediate losses of life, well-being, and prosperity. Those that flee wars and seek refuge in safer locations are not immune to the tragic impacts. Of particular concern is the susceptibility of the refugee populations to infectious diseases and antimicrobial-resistant pathogens. This poses a detrimental risk to these disenfranchised populations, who often have limited access to medical care, sanitation, and nutritious and safe food. Furthermore, antimicrobial-resistant pathogens in refugees can be both transmitted to and acquired from their hosting communities. The latter is particularly problematic when the host countries suffer from serious challenges such as limited resources, pollution, and widespread antimicrobial resistance (AMR). Here, we discuss AMR in refugees of the ongoing Syrian war, a conflict that resulted in the largest population displacement in recent history. We argue that Syrian refugees and their hosting communities are at an elevated risk of complicated and life-threatening AMR infections. We also call on the international community to address this grievous problem that threatens the disenfranchised refugee populations and can spill over across geographic borders to affect multiple countries.