The socioeconomic burden of antibiotic resistance in conflict-affected settings and refugee hosting countries: a systematic scoping review

Antibiotic consumption in hospitals in humanitarian settings in Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia and South Sudan

BACKGROUND

Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs.

METHODS

Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days.

RESULTS

Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan.

CONCLUSIONS

This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.

Resistome in a changing environment: Hotspots and vectors of spreading with a focus on the Russian-Ukrainian War

This work aims to shed light on the key factors contributing to the development of environmental resistance and the urgent need to address the growing problem of antibiotic resistance (AR) under the Russian-Ukrainian conflict. The article provides an overview of the main mechanisms involved in AR development and dissemination globally and the challenges posed by the ongoing war in Ukraine. The work outlines various international initiatives to reduce AR, including the concept of "One Health" and the strategies established, which are the key to reducing the effects on public health. Addressing AR globally and in conflict areas requires a comprehensive approach. This involves implementing monitoring of the microorganism's resistance levels to antibiotics, controlling the use of antimicrobial drugs, increasing public awareness of the AR, introducing educational programs to prevent the improper use of antibiotics, and adopting environmentally safe methods for the disposal of waste from medical, food, and other industries that produce or use antibiotics. Such initiatives are essential for promoting the responsible use of antibiotics, preventing the spread of AR infections, and preserving the effectiveness of existing antimicrobial drugs.

Characterization of wound infections among patients injured during the Ruso-Ukrainian war in a Role 4 hospital

INTRODUCTION

The management of infections in war wounds is a problem aggravated by the presence of multiresistant bacteria and requires a combined approach with surgery. Literature has identified the risks and patterns of antibiotic resistance in previous armed conflicts, but the Russian-Ukrainian conflict has required the study of specific bacterial resistance patterns.

METHODS

We included war-injured patients from the Russian-Ukrainian conflict transferred for treatment to the General Defense Hospital of Zaragoza from May 2022 to October 2023. Epidemiological data, factors related to the injury, presence of infection and microbiological results were collected; These data were subsequently analyzed statistically.

RESULTS

Fifty-three patients were included in the study, with a mean age of 35.6 years; 83% were injured by an explosive mechanism and all received antibiotic therapy prior to transfer. Seventeen patients had skin, soft tissue or joint infection. Correlation was demonstrated with the presence of bone lesion (p 0.03), skin coverage defect (p 0.000) and presence of foreign bodies (p 0.006). Nine patients had monomicrobial cultures, and the most frequently isolated microorganisms were Gram negative bacilli (GNB) and Staphylococcus aureus. Virtually all GNB presented some resistance mechanism.

CONCLUSION

Our work shows the correlation of war wound infection with the presence of foreign bodies and affected tissues. Likewise, the presence of polymicrobial wounds is emphasized, with a predominance of GNB and multidrug-resistant S. aureus.

Bullet-related bacterial wound infections among injured personnel at emergency site hospitals in Bahir Dar: prevalence, antimicrobial susceptibility and associated factors

BACKGROUND

Bullet-related bacterial wound infection can be caused by high-velocity bullets and shrapnel injuries. In Ethiopia, significant injuries were reported that may cause severe wound infections, persistent systemic infections and may lead to amputation and mortality. The magnitude, antimicrobial susceptibility profiles, and factors associated with bacterial wound infections among patients with bullet-related injuries are not yet studied particularly at health facilities in Bahir Dar, Northwest Ethiopia. Therefore, this study was aimed to determine the prevalence, bacterial profiles, antimicrobial susceptibility profiles, and factors associated with bacterial infections among patients with bullet-related injuries at referral health facilities in Bahir Dar, Northwest Ethiopia.

METHODS

A Hospital-based cross-sectional study was conducted among patients with bullet-related injuries at three referral health facilities in Bahir Dar from May 25 to July 27, 2022. A total of 384 patients with bullet-related injuries were included in the study. Sociodemographic and clinical data were collected using a structured questionnaire. Wound swabs were collected aseptically and cultured on Blood and MacConkey agar following bacteriological standards. Biochemical tests were performed to differentiate bacteria for positive cultivation and antimicrobial susceptibility profiles of the isolates were done on Muller Hinton agar using the Kirby-Bauer disk diffusion technique according to the 2021 Clinical Laboratory Standard Institute (CLSI) guideline. The data were entered using Epi-Info version 7.3 and analyzed using SPSS version 25. Descriptive data were presented using frequency, percentages, figures, and charts. Logistic regression was carried out to identify factors associated with bacterial wound infections. P-value < 0.05 was considered statistically significant.

RESULTS

The prevalence of bullet-related bacterial wound infection among three referral hospitals in Bahir Dar city was 54.7%. The most commonly isolated Gram-negative organism was Klebsiella spps 49 (23.3%) while among Gram-positive organism, Staphylococcus aureus 58 (27.6%) and coagulase-negative staphylococci (CONS) 18 (8.6%). Contamination, hospitalization and smoking habit were significantly associated with the presence of bullet-related bacterial wound infections. Over 97% multidrug resistant (MDR) bacterial isolates were identified and of theses, E. coli, Proteus species, Citrobactor, and Staphylococcus aureus were highly drug resistant.

CONCLUSION

Increased prevalence of bullet-related bacterial wound infection was noticed in this study. S. aureus followed by Klebsiella species were most commonly isolated bacteria. High frequency of resistance to Ampicillin, Oxacillin, Cefepime, Ceftriaxone, Ceftazidime, Vancomycin, and Norfloxacin was observed. Therefore, proper handling of bullet injuries, prompt investigation of bacterial infections, monitoring of drug sensitivity patterns and antibiotic usage are critical.

Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now

Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.

Bacterial resistance to antibacterial agents: Mechanisms, control strategies, and implications for global health

The spread of bacterial drug resistance has posed a severe threat to public health globally. Here, we cover bacterial resistance to current antibacterial drugs, including traditional herbal medicines, conventional antibiotics, and antimicrobial peptides. We summarize the influence of bacterial drug resistance on global health and its economic burden while highlighting the resistance mechanisms developed by bacteria. Based on the One Health concept, we propose 4A strategies to combat bacterial resistance, including prudent Application of antibacterial agents, Administration, Assays, and Alternatives to antibiotics. Finally, we identify several opportunities and unsolved questions warranting future exploration for combating bacterial resistance, such as predicting genetic bacterial resistance through the use of more effective techniques, surveying both genetic determinants of bacterial resistance and the transmission dynamics of antibiotic resistance genes (ARGs).

Heavy metal co-resistance with antibiotics amongst bacteria isolates from an open dumpsite soil

Heavy metal co-resistance with antibiotics appears to be synergistic in bacterial isolates via similar mechanisms. This synergy has the potential to amplify antibiotics resistance genes in the environment which can be transferred into clinical settings. The aim of this study was to assess the co-resistance of heavy metals with antibiotics in bacteria from dumpsite in addition to physicochemical analysis. Sample collection, physicochemical analysis, and enumeration of total heterotrophic bacteria counts (THBC) were all carried out using standard existing protocols. Identified bacteria isolates were subjected to antibiotics sensitivity test using the Kirby Bauer disc diffusion technique and the resulting multidrug resistant (MDR) isolates were subjected to heavy metal tolerance test using agar dilution technique with increasing concentrations (50, 100, 150, 200 and to 250 μg/ml) of our study heavy metals. THBC ranged from 6.68 to 7.92 × 105 cfu/g. Out of the 20 isolates subjected to antibiotics sensitivity, 50% (n = 10) showed multiple drug resistance and these were B. subtilis, B. cereus, C. freundii, P. aeruginosa, Enterobacter sp, and E. coli (n = 5). At the lowest concentration (50 μg/ml), all the MDR isolates tolerated all the heavy metals, but at 250 μg/ml, apart from cadmium and lead, all test isolates were 100% sensitive to chromium, vanadium and cobalt. The control isolate was only resistant to cobalt and chromium at 50 μg/ml, but sensitive to other heavy metals at all concentrations The level of co-resistance shown by these isolates is a call for concern.

The lived experience of patients with conflict associated injuries whose wounds are affected by antimicrobial resistant organisms: a qualitative study from northwest Syria

INTRODUCTION

For those with severe conflict-associated wounds which are affected by antimicrobial resistant (AMR) organisms, health systems during protracted conflict are often ill-equipped to respond to their needs. In this study, our aim is to explore the experiences of those with conflict-associated wounds whose wounds have been infected with AMR bacteria and who reside in northwest Syria (NWS). This is with a view to understanding the challenges they face and how the health and humanitarian system can better respond to their needs.

METHODS

A qualitative research methodology where in-depth interviews were conducted with patients who are known to have AMR organisms infecting conflict-associated wounds was used. Patients were recruited from Bab Al-Hawa hospital in NWS based on pre-set inclusion criteria. They were invited to participate in remote interviews due to the ongoing COVID-19 pandemic. Interviews were conducted during January and February 2021 and transcribed in Arabic before thematic analysis was undertaken to identify key themes and subthemes.

RESULTS

14 in-depth interviews were conducted of which 12 were with men. The age range was 20-49 years. We categorised the findings into 6 themes: i. those related to the mechanism of injury, ii, the impact of the conflict on health system accessibility, iii. experiences of immediate inpatient management, iv. the experience of outpatient and home management, v. the current impact of the injury on participants, and vi. participant perspectives around improving healthcare access for those with conflict-related wounds affected by AMR organisms. Important findings relate to the quality and capacity for both immediate and longer-term care and the psychosocial and socioeconomic impacts of the injuries which many of the participants continue to grapple with.

CONCLUSION

This is the first exploration through qualitative research of the experiences of those with conflict-affected wounds which are infected with AMR organisms in NWS. Emerging themes as told by participants can help stakeholders, including policy makers, humanitarian organisations and those involved with health system planning in NWS consider gaps in current and future care needs (including livelihood opportunities) for this vulnerable group.

Prevalence of Multidrug-Resistant Bacteria (Enteropathogens) Recovered from a Blend of Pig Manure and Pinewood Saw Dust during Anaerobic Co-Digestion in a Steel Biodigester

South Africa adopts intensive livestock farming, embracing the employment of huge quantities of antibiotics to meet the increased demand for meat. Therefore, bacteria occurring in the animal products and manure might develop antibiotic resistance, a scenario which threatens public health. The study investigated the occurrence of Gram-negative bacteria from eighteen pooled samples withdrawn from a single-stage steel biodigester co-digesting pig manure (75%) and pine wood saw dust (25%). The viable counts for each bacterium were determined using the spread plate technique. The bacterial isolates were characterised based on cultural, morphological and biochemical characteristics, using the Analytical Profile Index 20 e test kit. In addition, isolates were characterised based on susceptibility to 14 conventional antibiotics via the disc diffusion method. The MAR index was calculated for each bacterial isolate. The bacterial counts ranged from 104 to 106 cfu/mL, indicating manure as a potential source of contamination. Overall, 159 bacterial isolates were recovered, which displayed diverse susceptibility patterns with marked sensitivity to amoxicillin (100% E. coli), streptomycin (96.15% for Yersinia spp.; 93.33% for Salmonella spp.) and 75% Campylobacter spp. to nitrofurantoin. Varying resistance rates were equally observed, but a common resistance was demonstrated to erythromycin (100% of Salmonella and Yersinia spp.), 90.63% of E. coli and 78.57% of Campylobacter spp. A total of 91.19% of the bacterial isolates had a MAR index > 0.2, represented by 94 MAR phenotypes. The findings revealed multidrug resistance in bacteria from the piggery source, suggesting they can contribute immensely to the spread of multidrug resistance; thus, it serves as a pointer to the need for the enforcement of regulatory antibiotic use in piggery farms. Therefore, to curb the level of multidrug resistance, the piggery farm should implement control measures in the study area.

Antimicrobial use and resistance in Democratic Republic of Congo: Implications and recommendations; A mini review

Antimicrobial resistance is a public health problem in the Democratic Republic of Congo and it occurs when pathogens (bacteria, viruses and parasites) no longer respond to antimicrobial drugs. So, their treatment becomes ineffective and complex increasing the risk the spread of infectious and opportunistic diseases and producing serious forms of these infections leading to a high number of deaths. It is important to put in place effective methods and materials for the prevention and treatment of infections resistant to antimicrobial drugs, to provide improved access to quality antimicrobials and to reduce the number of treatment failures. Increasing levels of resistance have significant economic consequences and third-line treatments become much more expensive than first- and second-line treatments. As antimicrobial resistance is a complex health problem that requires a coordinated multisector approach, it is important to intensify innovation in operational research and the development of new antimicrobial drugs. Surveillance remains a valuable tool in the fight against antimicrobial resistance in the Democratic Republic of Congo, as it helps to detect resistant infections and allows corrective decisions to be made, this surveillance guides policy recommendations and the monitoring of use and treatment and abuse of antibiotics.

Our study aimed to show the importance of establishment of national plans for the fight against antimicrobial resistance by installing laboratories and monitoring sites in order to reduce the risk and rate of deaths due to antimicrobial resistance in the Demographic republic of Congo.

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Antimicrobial resistance is a public health problem worldwide and in the Democratic Republic of Congo in particular.

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Currently in the Democratic Republic of Congo, there is a high rate of infections that do not respond to treatment, which increases the spread of certain diseases and the occurrence of serious forms.

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Surveillance of this resistance is valuable in the fight against antibiotic resistance because it helps to detect resistant infections and will allow the government to make decisions and put in place recommendations on the use of antibiotics.

Antimicrobial, antibiofilm, and anticancer potential of silver nanoparticles synthesized using pigment-producing Micromonospora sp. SH121

Silver nanoparticles (AgNPs) have gained interest as an alternative pharmaceutical agent because of antimicrobial resistance and drug toxicity. Considering the increasing request, eco-friendly, sustainable, and cost-effective synthesis of versatile AgNPs has become necessary. In this study, green-made AgNPs were successfully synthesized using Micromonospora sp. SH121 (Mm-AgNPs). Synthesis was verified by surface plasmon resonance (SPR) peak at 402 nm wavelength in the UV-Visible (UV-Vis) absorption spectrum. Scanning electron microscopy (SEM) analysis depicted that Mm-AgNPs were in the size range of 10-30 nm and spherical. Fourier transform infrared spectroscopy (FTIR) confirmed the existence of bioactive molecules on the surface of nanoparticles. The X-ray diffraction (XRD) analysis revealed the face-centered cubic (fcc) structure of the Mm-AgNPs. Their polydispersity index (PDI) and zeta potential were 0. 284 and -35.3 mV, respectively. Mm-AgNPs (4-32 µg/mL) exhibited strong antimicrobial activity against Bacillus cereus, Enterococcus faecalis, Enterococcus hirae, Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas putida, Staphylococcus epidermidis, Streptococcus pneumoniae, and Aspergillus flavus. Mm-AgNPs partially inhibited the biofilm formation in Acinetobacter baumannii, E. coli, K. pneumoniae, and Pseudomonas aeruginosa. Furthermore, results showed that low concentrations of Mm-AgNPs (1 and 10 µg/mL) caused higher cytotoxicity and apoptosis in DU 145 cells than human fibroblast cells. Based on the results, Mm-AgNPs have an excellent potential for treating infectious diseases and prostate cancer.

The challenge of antibiotic resistance in post-war Mosul, Iraq: An analysis of 20 months microbiological samples from a tertiary orthopaedic care centre

BACKGROUND

Iraq has suffered unrest and conflicts in the past decades leaving behind a weakened healthcare system. In 2018, Médecins Sans Frontières (MSF) opened a tertiary orthopaedic care centre in Mosul providing reconstructive surgery with access to microbiological analysis.

METHODS

A retrospective cross-sectional analysis of microbiological and clinical data of patients admitted between April 2018 - December 2019.

RESULTS

There were 174 patients who were included in this study; there were more males than females (135 to 38 respectively), and the mean age was 32.6 years. Of the 174 patients, the majority had more than one bacterial isolate detected (n= 122, 70.1%); 141 (81.0%) had at least one multi-drug resistant (MDR) isolate detected during their hospital stay. Staphylococcus aureus (n=197, 48.2%) was the most common organism isolated. Overall, most isolates detected were MDR (n=352, 86%), mostly MRSA (n=186, 52.8%) or ESBL-producing Enterobacterales (n=117, 33.2%). Among patients admitted to the Operating Department (n=111, 63.7%), 81.1% (n=90) were admitted for violent trauma injuries. Patients who had more than one procedure performed per surgery had significantly increased odds of having at least one MDR organism isolated (OR 8.66, CI 1.10-68.20, p=0.03).

CONCLUSION

This study describes a high prevalence of antibiotic resistance in patients with trauma-related wounds in Mosul, Iraq. It highlights the importance of microbiological analysis and ongoing surveillance to provide optimal treatment. Additionally, it underscores the importance of infection prevention and control measures and antibiotic stewardship.

Antibiotic resistance among bacteria isolated from war-wounded patients at the Weapon Traumatology Training Center of the International Committee of the Red Cross from 2016 to 2019: a secondary analysis of WHONET surveillance data

Background

A substantial body of evidence has recently emphasized the risks associated with antibiotic resistance (ABR) in conflicts in the Middle East. War-related, and more specifically weapon-related wounds can be an important breeding ground for multidrug resistant (MDR) organisms. However, the majority of available evidence comes from the military literature focused on risks and patterns of ABR in infections from combat-related injuries among military personnel. The overall aim of this study is to contribute to the scarce existing evidence on the burden of ABR among patients, including civilians with war-related wounds in the Middle East, in order to help inform the revision of empirical antibiotic prophylaxis and treatment protocols adopted in these settings. The primary objectives of this study are to: 1) describe the microbiology and the corresponding resistance profiles of the clinically relevant bacteria most commonly isolated from skin, soft tissue and bone biopsies in patients admitted to the WTTC; and 2) describe the association of the identified bacteria and corresponding resistance profiles with sociodemographic and specimen characteristics.

Methods

We retrospectively evaluated the antibiograms of all consecutive, non-duplicate isolates from samples taken from patients admitted to the ICRC WTTC between 2016 and 2019, limited to skin and soft tissue samples and bone biopsies. We collected data on socio-demographic characteristics from patient files and data on specimens from the WHONET database. We ran univariate and multivariable logistic regression models to test the association between bacterial and resistance profiles with sociodemographic and specimen characteristics.

Results

Patients who were admitted with war-related trauma to the ICRC reconstructive surgical project in Tripoli, Lebanon, from 2016 to 2019, presented with high proportion of MDR in the samples taken from skin and soft tissues and bones, particularly Enterobacterales (44.6%), MRSA (44.6%) and P. aeruginosa (7.6%). The multivariable analysis shows that the odds of MDR isolates were higher in Iraqi patients (compared to Syrian patients) and in Enterobacterales isolates (compared to S. aureus isolates).

Conclusions

Our findings stress the importance of regularly screening patients who present with complex war-related injuries for colonization with MDR bacteria, and of ensuring an antibiotic-sensitivity testing-guided antimicrobial therapeutic approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07253-1.

Impact of Selected Behavioral and Environmental Factors on the Antibiotic Therapy in Polish Children With Upper Respiratory Tract Infections

Antibiotic therapy must be carried out consistently and according to the guidelines. Viruses are the dominant cause of upper respiratory tract infections (URTIs) in children, as has been shown in many previous studies. Unnecessary antibiotic therapy should be avoided so that it does not affect patients' health and lead to the development of resistant bacterial strains. Here we report a national survey conducted in a group of 4,389 children to assess the impact of selected behavioral and environmental factors on antibiotic therapy in patients with URTIs. We found that selected environmental factors influenced the type of treatment. The place of residence, having siblings, an absence of vaccinations, the presence of allergies, and attendance at educational institutions were conducive to antibiotic therapy. These factors also influenced the frequency of hospitalization of children and their absence from nurseries, kindergartens, and schools, as well as the absence of their guardians from work.