Antimicrobial Resistance in Syria

Background Antimicrobial resistance is one of the important and serious public health problems worldwide. Syria has a severe lack of data regarding this problem, especially after war. We aimed from this study to provide a unique snapshot on antimicrobial resistance in Syria. Methods This is a multi-centric cross-sectional in-vitro study. The results of routine antimicrobial susceptibility tests were collected and analyzes from ve major hospitals during the period from 1st March 2018 through 31th October 2018. Results Final analysis included 2861 isolates. We noticed extremely high rates of antimicrobial resistance among all the species studied. Gram negatives have high resistance rates for cephalosporins. 77% of E.coli, 73% of Klebsiella and 82% of pseudomonas are resistant for ceftriaxone. We also noticed minimal effect of macrolides on gram negatives. 25% of Salmonella typhi strains were resistant to ciprooxacin. High resistance rates to nitrofurantoin is seen among uropathogenic bacteria. Most gram positive bacteria still have a low resistance rate to vancomycin and linezolid. 54% of staphylococcus aureus and 38% of streptococcus pyogens are resistant to amoxicillin-clavulanate. Resistance rates to Colistin are minimal. The comparison with resistance rates before war reveals the great impact of war on antimicrobial resistance problem. Conclusion Antimicrobial resistance rates in Syria are worrying. We recommend that the Syrian health authorities apply a policy to restrict the irrational use of antibiotics, and to increase awareness toward antimicrobials use.

. Antimicrobial resistance rates of the studied bacteria. The first number is the absolute number of resistant isolates of the studied bacterium against the studied antibiotic , the second number is the total number of isolates tested against the antibiotic, the third number is the percentage of the resistant strains. ND: No Data.

Discussion
In this study, we report the frequencies of drug resistance of the key bacterial pathogens using the routine results of 5 major centers, that give a considerable representation the Syrian population.
This is the first large, geographically-comprehensive, pathogen-comprehensive study about antimicrobial resistance in Syria.
We notice an extremely high rate of antimicrobial resistance among all the species studied, for most studied antibiotics.
It is important to notice that Acinetobacter spp. Resistance rate was 100% for Amoxicillin-clavulinic acid, cefadroxil, cefotaxime, and tetracyclin. Resistance rate to the tested antibiotics was more than 70%, except for cotrimoxazole (36%) and Colistin (6%), making Colistin the most in-vitro effective for Acinetobacter spp. In Syria, followed by cotrimoxazole.
Cephalosporins have an extremely high rate of resistance, especially in G-bacteria. For example, 77% of E.coli, 73% of Klebsiella and 82% of pseudomonas are resistant for ceftriaxone, a widely used antibiotic for all kinds of infections in Syria. However, Ceftriaxone with sulbactam has lower resistance rates but these rates are still high (table1).
The effect of macrolides on G-bacteria is minimal. 87% and 100% of E.coli strains are resistant to azithromycin and erythromycin, respectively. 86% and 100% of Klebsiella spp. strains are resistant to azithromycin and erythromycin, respectively.
Fortunately, G+ bacteria still have a proportionally low resistance rate to vancomycin. Linezolid is still effective too (table 1). However, resistance rate to linezolid was 23% in streptococcus pyogens and 20% in streptococcus pneumoniae.
Unfortunately, 54% of staphylococcus aureus and 38% of streptococcus pyogens are resistant to amoxicillin with clavulanic acid.
We notice an extremely high rates of resistance to nitrofurantoin among urinary tract infection-related species. For example, 45% of E.coli, 60% of Enterobacter, 79% of Kleibsella, 100% of proteus and 79% of Pseudomonas isolates are resistant to Nitrofurantoin.
Salmonella typhi, a key pathogen in the developing countries, has a high resistance rates to the studied antibiotics, including ciprofloxacin (25%). However, piperacillin with tazobactam and cefepime have the least resistance rate: 13% for piperacillin with tazobactam and 20% for cefepime.
It is worthy to note that resistance rates to Colistin are minimal.
A quick look at table 1 reveals that most bacteria, especially E.coli spp., Enterobacter spp., Klebsiella, Pseudomonas spp. And staphylococcus aureus Have become "superbugs" in Syria.
To better understand the impact of the Syrian war on antimicrobial resistance, we should compare the current data with the pre-conflict data. For example, Al-Omar reported in that the prevalence of Staphylococcus aureus resistance to ampicillin in Misiaf (Tartous Countryside) during 2004 is 69%, and to amoxicillin-Clavulanate is 37% (7), while we found in our study that the prevalence of Staphylococcus aureus resistance to ampicillin is 92%, and to amoxicillin-Clavulanate is 54%.
Obied and Obied in 2005 found that 64% of Streptococcus pneumonia strains in Damascus isolated from CSF were resistant to penicillin, 16% to erythromycin, and 16% to tetracycline, and None resistant to ceftriaxone, cefotaxime, amoxicillin-Clavulanate (8), While we found in our study that that 64% of Streptococcus pneumonia strains were resistant to penicillin, 78% to erythromycin, and 35% to tetracycline, and 10% resistant to ceftriaxone, 15% resistant to cefotaxime and 23% amoxicillin-Clavulanate.
Hussein and Nizzam studied the antimicrobial resistance of bacteria isolated from Otitis media in children of Qamishli in North-eastern Syria, during 2008 and 2009 (9). 0% of Pseudomonas spp. and staphylococcus aureus isolates were resistant for imipenem, but in the current study 41% of Pseudomonas and 15% of Staphylococcus aureus isolates were resistant to Imipenem. In the same study 31% of Pseudomonas isolates and 20% of Klebsiella isolates were resistant to levofloxacin, while in our study 62% of Pseudomonas isolates and 63% of Kleibsella isolates were resistant to levofloxacin Hamzeh et al. conducted a retrospective review of 260 Acinetobacter baumannii isolates from 2008 to 2011 in Aleppo (10). Resistance to specific antibiotics in the latter study was: 65% imipenem, 87% piperacillintazobactam,74% cotrimoxazole, 7% Colistin. In our study, Resistance of Acinetobacter spp. strains to the same antibiotics was: 83% imipenem, 82% piperacillin-tazobactam, 36% cotrimoxazole, 6% Colistin. These were just examples of the dramatic growing of the antimicrobial resistance in Syria.
The main reasons for this antimicrobial resistance trend in Syria is the irrational use of antibiotics in Syria. Antibiotics are easily available for people without prescription (11). In addition, the Syrian people do not have enough awareness of antimicrobials use (12) (13). Also, the lack of the diagnostic tests during war urged healthcare providers to treat infections arbitrarily using wide spectrum antibiotics.
During war, healthcare services are damaged, sanitation is poor, health professionals migrate, and exposure in compromised healthcare centers is dramatically increased. War further disrupts the administrative bodies that regularly tackle the drivers of AMR (6).
Although Abbara et al. (6) provided a comprehensive review of the existing evidence of antimicrobial resistance in the Syria, We found by electronic search some additional publications that address antimicrobial resistance state in Syria before and after war (9) (15) (16) (17) (18) (19) (20). We mentioned them to make future researchers aware of them. However, an extensive hand-search should be held if we wanted to do a systematic review about antimicrobial resistance in Syria, as most Syrian journals are not indexed in databases, and much research projects in the universities are not published in journals, but indexed in the university library.
This study has major limitations. some valuable information was incomplete, such as: sample type, clinical complaint, wards where the patients were hospitalized in, gender and age of the patients. therefore, we decided to analyze the variables for which we had complete information. In addition, some important bacteria are not included in our study like anaerobes, Shigella, H.pylori,…etc, because : They are usually diagnosed clinically and treated arbitrarily and they need special media and conditions that are not available in our labs, especially during war. In General, there is a lack in the literature reporting the antimicrobial resistance in Syria before and after war, especially fastidious organisms like H.pylori. Another limitation is that much antibiotics are not reported sufficiently, because of the limited availability during war. We have experienced the significant disadvantages of the use of routine results, and of the multi-centric design.

Materials And Methods
This is a multi-centric cross-sectional in-vitro study. The results of routine antimicrobial susceptibility tests were collected from participating centers during the period from 1 st March 2018 through 31th October 2018. Data were collected from the following central hospitals: Aleppo University Hospital (Aleppo), Aleppo University Hospital of Obstetrics and Gynecology (Aleppo), Alassad University Hospital (Damascus), Damascus University Hospital of Obstetrics and Gynecology (Damascus). Albassel General Hospital (Tartous). The majority of Syrian patients usually admit to these major hospitals in these major cities, which gives our data a considerable representivity of Syria.
Our target sample was Bacteria isolated from any pathologic sample, on any culture medium, and tested for antimicrobial susceptibility by disc diffusion method.
We excluded duplicate isolates from the same patient, and isolates tested for antimicrobial susceptibility by other methods, like automated methods.
The results were scored as susceptible, intermediate, or resistant according to CLSI criteria (2017) in all collaborating laboratories.
We did statistical analysis using SPSS (version 20.0) . Intermediate results were considered as resistant. For every studied pathogen, We calculated the absolute number of resistant isolates, total number of isolates, and the percentage of resistant isolates tested for every antibiotic. We only reported pathogens with 10 or more isolates tested for the studied antibiotic.

Conclusions
Despite all limitations, our report reflects a unique snapshot of the drug resistance in Syria with information from 5 major centers that would be useful to define better strategies to control drug resistance, and direct current health care and future research in Syria.
We recommend an antibiotics restriction policy to be applied by the health care system in Syria. Health care providers should eliminate or at least restrict antibiotics in which high resistance is observed, and replace them with equivalent antibiotics with low resistance potential. This report may help with directing this replacement procedure. We recommend further well-designed and well-controlled studies to examine the antimicrobial resistance of all pathogenic bacteria to all relevant antibiotics. Finally, This National report should be updated periodically.

Declarations
Page 12/13 Ethics approval and consent to participate: This study was approved by the ethical committee of the Faculty of Medicine in University of Damascus and University of Aleppo. The ethical approval was also gained from Albassel Hospital, Tartous city.
Consent for publication: not applicable. Our manuscript does not contain any individual person's data in any form.
Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Competing Interests: Nothing to declare Funding: There is no funding.
Authors Contributions: SH and ZS: Study design, data collection and critical review.
A Alhamid: Data collection, study design, statistical analysis, results interpretation and draft writing. All authors have read and approved the final manuscript.