key: cord-0050755-0tlpt77f
authors: Karamya, Alabedeen; Youssef, Alexey; Adra, Ali; Karah, Nabil; Kanj, Souha S.; Elamin, Wael; Nahas, Rabiea Al; Shaddood, Ali; Saleh, Ali; Althiab, Esraa; Abbara, Aula
title: High Rates of Antimicrobial Resistance among Clinical Isolates from Microbiology Laboratories in Syria.
date: 2020-09-28
journal: J Infect
DOI: 10.1016/j.jinf.2020.09.026
sha: a34fd829658ed254e2d36bb51460e78b096ff213
doc_id: 50755
cord_uid: 0tlpt77f

nan

stewardship program [6] . Data in such conflict affected countries is limited with little reliable data available for Syria [7] .

The few published studies are limited by the small number of samples or patients, lack of generalizability, and mostly originated from the major cities, particularly Damascus and Aleppo [7] .

Here we report data from 5 public hospitals and 4 private laboratories in 4 to determine the genus and/or species of the isolates. Results of antibiotic susceptibility tests were collected for up to 100 isolates of each bacterium in each location. For antibiotic susceptibility testing, 7 labs used the agar disk diffusion method while the remaining 2 labs used the VITEK® 2 method (BioMérieux, France). Susceptibility reports were provided in paper format. Diameters of inhibition zones and MIC values were extracted to Excel™ sheets, and assigned R, I or S where R=resistant, I=intermediate and S=susceptible, following the Clinical and Laboratory Standards Institute (CLSI) guidelines [8] . An antibiogram was assigned to each clinical isolate, and the number/percentage of susceptible isolates of each bacterium was calculated against each antibiotic.

Rates of susceptibility were then calculated and compared per facility, city, or species/genus. Multidrug resistance (MDR) bacteria were defined as microorganisms that are resistant to one or more agents in at least three separate classes.

Data for 3577 bacterial isolates were provided. The susceptibilities and resistance patterns are detailed in table 1. A notable finding from this study is the absence of standard operating procedures and guidelines among laboratories; this was noted from discussions with the microbiologists as well as the array of antibiotic discs used and reported for isolates. It is notable that antibiotic discs were used for bacterial isolates even when the bacteria are known to be intrinsically resistant, when no CLSI MIC break point exists or when the antibiotic tested is not used in clinical practice to treat the infection. Some of these discrepancies are underlined in the table. A key example are the antibiotic sensitivities performed for Pseudomonas spp. where co-amoxiclav and cefixime are tested. On direct questioning, microbiologists reported a locally devised criteria for interpreting the results e.g. a zone of >21mm as suggestive of Pseudomonas being sensitive to co-amoxiclav.

For Gram-negatives (excluding Acinetobacter, which is intrinsically resistant to most antibiotics tested), high proportions of resistance to co-amoxiclav are reported with a range of 75% to 89% for Klebsiella spp., Proteus spp., E. coli and Enterobacter spp. For ciprofloxacin, the range is 43% to 57%; for amikacin, it is 12% to 50% and for meropenem, it is 8 to 45%. The resistance patterns for the Pseudomonas isolates are concerning with resistance of 43% and over reported for antibiotics that should be effective (piperacillin-tazobactam, meropenem, ciprofloxacin, and amikacin). For carbapenem resistance (suggested here by meropenem resistance,) 20% of E. coli and Proteus isolates and 45% of Pseudomonas isolates were resistant.

For Acinetobacter, 90% of isolates were reported as resistant to meropenem and 85% were resistant to amikacin which is very concerning. Acinetobacter is a bacterium that has increasingly been seen in clinical settings. It has intrinsic resistance to a number of commonly used antibiotics, and multi-or pan-resistant strains have been known to cause infection among those injured during conflict (so called "Iraqibacter") [9] or nosocomial transmission, particularly in intensive care units. As such, this is of particular concern in Syria where protracted conflict and humanitarian crisis continue. Verbal communication to ZAK reported that two patients died in one centre during the summer of 2017, both harbouring pan-drug resistant isolates of Acinetobacter baumannii (Personal communication).

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