Antimicrobial Resistance in the Arab Region

  • Tala Ballouz
  • Nesrine Rizk
  • Souha S KanjEmail author
Living reference work entry


A few decades after the discovery of the first antibiotic, the widespread overuse and misuse of antibiotics across human and nonhuman sectors have led to the development and spread of antimicrobial resistance (AMR). AMR is now a threat to public health worldwide not only for its effect on population health but also for the significant associated economic burden. Several governments and organizations, including the World Health Organization (WHO), have emphasized the need to control this problem and called for the development and implementation of national policies and strategies to limit its spread.

In this chapter, we will provide a broad overview of the global epidemiology of AMR with emphasis on the current situation in countries of the Arab world. We will also explore the causes behind its evident increase. Finally, we will end with specific recommendations for the implementation of multifaceted strategies and action policies structured around the Global Action Plan launched by the WHO.


Antimicrobial resistance Antimicrobial stewardship Arab countries Multidrug resistance Surveillance Antibiotics Infection control 


  1. Abbara A, Rawson TM, Karah N, El-Amin W, Hatcher J, Tajaldin B, Dar O, Dewachi O, Abu Sitta G, Uhlin BE, Sparrow A (2018a) Antimicrobial resistance in the context of the Syrian conflict: drivers before and after the onset of conflict and key recommendations. Int J Infect Dis 73:1–6PubMedCrossRefGoogle Scholar
  2. Abbara A, Rawson TM, Karah N, El-Amin W, Hatcher J, Tajaldin B, Dar O, Dewachi O, Abu Sitta G, Uhlin BE, Sparrow A (2018b) A summary and appraisal of existing evidence of antimicrobial resistance in the Syrian conflict. Int J Infect Dis 75:26–33PubMedCrossRefGoogle Scholar
  3. Abdelaziz A, Tawfik A, Rabie K, Omran M, Hussein M, Abou-Ali A, Ahmed A-S (2019) Quality of community pharmacy practice in antibiotic self-medication encounters: a simulated patient study in upper Egypt. Antibiotics 8:35PubMedCentralCrossRefPubMedGoogle Scholar
  4. Al Jarousha AMK, Jadba AHNE, Afifi ASA, Qouqa IAE (2009) Nosocomial multidrug-resistant Acinetobacter baumannii in the neonatal intensive care unit in Gaza City, Palestine. Int J Infect Dis 13:623–628PubMedCrossRefGoogle Scholar
  5. Al-Ghamdi M (2001) Empirical treatment of uncomplicated urinary tract infection by community pharmacist in the eastern province of Saudi Arabia. Saudi Med J 22:1105–1108PubMedGoogle Scholar
  6. Alghamdi S, Shebl NA, Aslanpour Z, Shibl A, Berrou I (2018) Hospital adoption of antimicrobial stewardship programmes in gulf cooperation council countries: a review of existing evidence. J Glob Antimicrob Resist 15:196–209. Scholar
  7. Al-Ghamdi S, Gedebou M, Bilal NE (2002) Nosocomial infections and misuse of antibiotics in a provincial community hospital, Saudi Arabia. J Hosp Infect 50:115–121PubMedCrossRefGoogle Scholar
  8. Alhomoud F, Aljamea Z, Almahasnah R, Alkhalifah K, Basalelah L, Alhomoud FK (2017) Self-medication and self-prescription with antibiotics in the Middle East—do they really happen? A systematic review of the prevalence, possible reasons, and outcomes. Int J Infect Dis 57:3–12. Scholar
  9. Al-Mazeedi HM, Abbas AB, Alomirah HF, Al-Jouhar WY, Al-Mufty SA, Ezzelregal MM, Al-Owaish RA (2010) Screening for tetracycline residues in food products of animal origin in the State of Kuwait using charm II radio-immunoassay and LC/MS/MS methods. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 27:291–301PubMedCrossRefGoogle Scholar
  10. Almohammed RA, Bird EL (2019) Public knowledge and behaviours relating to antibiotic use in gulf cooperation council countries: a systematic review. J Infect Public Health 12:159–166. Scholar
  11. Al-Mustafa ZH, Al-Ghamdi MS (2002) Use of antibiotics in the poultry industry in Saudi Arabia: implications for public health. Ann Saudi Med 22:4–7PubMedCrossRefGoogle Scholar
  12. Alnemri AR, Almaghrabi RH, Alonazi N, Alfrayh AR (2016) Misuse of antibiotic: a systemic review of Saudi published studies. Curr Pediatr Res 20:169–173Google Scholar
  13. Aly NY, Omar AA, Badawy DA, Al-Mousa HH, Sadek AA (2012) Audit of physicians’ adherence to the antibiotic policy guidelines in Kuwait. Med Princ Pract 21:310–317PubMedCrossRefGoogle Scholar
  14. Arzanlou M, Chai WC, Venter H (2017) Intrinsic, adaptive and acquired antimicrobial resistance in Gram-negative bacteria. Essays Biochem 61:49–59PubMedCrossRefGoogle Scholar
  15. Aslam B, Wang W, Arshad MI, Khurshid M, Muzammil S, Rasool MH, Nisar MA, Alvi RF, Aslam MA, Qamar MU, Salamat MKF, Baloch Z (2018) Antibiotic resistance: a rundown of a global crisis. Infect Drug Resist 11:1645–1658PubMedPubMedCentralCrossRefGoogle Scholar
  16. Ayyad S, Al-Owaisheer A, Al-Banwan F, Al-Mejalli A, Shukkur M, Thalib L (2010) Evidence-based practice in the use of antibiotics for respiratory tract infections in primary health centers in Kuwait. Med Princ Pract 19:339–343PubMedCrossRefGoogle Scholar
  17. Barlam TF, Cosgrove SE, Abbo LM, Macdougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK (2016) Implementing an antibiotic stewardship program: guidelines by the infectious diseases society of America and the society for healthcare epidemiology of America. Clin Infect Dis 62:1197–1202PubMedCrossRefGoogle Scholar
  18. Blair JMA, Webber MA, Baylay AJ, Ogbolu DO, Piddock LJV (2015) Molecular mechanisms of antibiotic resistance. Nat Rev Microbiol 13:42–51. Scholar
  19. Camacho A, Bouhenia M, Alyusfi R, Alkohlani A, Naji MAM, de Radiguès X, Abubakar AM, Almoalmi A, Seguin C, Sagrado MJ, Poncin M, McRae M, Musoke M, Rakesh A, Porten K, Haskew C, Atkins KE, Eggo RM, Azman AS, Broekhuijsen M, Saatcioglu MA, Pezzoli L, Quilici ML, Al-Mesbahy AR, Zagaria N, Luquero FJ (2018) Cholera epidemic in Yemen, 2016–18: an analysis of surveillance data. Lancet Glob Heal 6:e680–e690CrossRefGoogle Scholar
  20. Cassini A, Högberg LD, Plachouras D, Quattrocchi A, Hoxha A, Simonsen GS, Colomb-Cotinat M, Kretzschmar ME, Devleesschauwer B, Cecchini M, Ouakrim DA, Oliveira TC, Struelens MJ, Suetens C, Monnet DL, Strauss R, Mertens K, Struyf T, Catry B, Latour K, Ivanov IN, Dobreva EG, Tambic Andraševic A, Soprek S, Budimir A, Paphitou N, Žemlicková H, Schytte Olsen S, Wolff Sönksen U, Märtin P, Ivanova M, Lyytikäinen O, Jalava J, Coignard B, Eckmanns T, Abu Sin M, Haller S, Daikos GL, Gikas A, Tsiodras S, Kontopidou F, Tóth Á, Hajdu Á, Guólaugsson Ó, Kristinsson KG, Murchan S, Burns K, Pezzotti P, Gagliotti C, Dumpis U, Liuimiene A, Perrin M, Borg MA, de Greeff SC, Monen JC, Koek MB, Elstrøm P, Zabicka D, Deptula A, Hryniewicz W, Caniça M, Nogueira PJ, Fernandes PA, Manageiro V, Popescu GA, Serban RI, Schréterová E, Litvová S, Štefkovicová M, Kolman J, Klavs I, Korošec A, Aracil B, Asensio A, Pérez-Vázquez M, Billström H, Larsson S, Reilly JS, Johnson A, Hopkins S (2019) Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis 19:56–66PubMedPubMedCentralCrossRefGoogle Scholar
  21. Centers for Disease Control and Prevention (2014) Core elements of hospital antibiotic stewardship programs. US Department of Health and Human Services, CDC, AtlantaGoogle Scholar
  22. Centers for Disease Prevention and Control (2019) Antibiotic Prescribing and Use. Accessed 15 Aug 2019
  23. CLSI (2019) CLSI M100-ED29: 2019 performance standards for antimicrobial susceptibility testing, 29th edn. M100 ED29:2019&scope=user
  24. Cooke J, Butler C, Hopstaken R, Dryden MS, McNulty C, Hurding S, Moore M, Livermore DM (2015) Narrative review of primary care point of- care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Respir Res 2:1–10. Scholar
  25. Daoud Z, Farah J, Sokhn ES, El Kfoury K, Dahdouh E, Masri K, Afif C, Abdel-Massih RM, Matar GM (2017) Multidrug-resistant Enterobacteriaceae in Lebanese hospital wastewater: implication in the. One Health Concept Microb Drug Resist 24:166–174PubMedCrossRefGoogle Scholar
  26. Davey P, Marwick C, Scott C, Charani E, McNeil K, Brown E, Gould M, Ramsay C, Michie S (2017) Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2:CD003543Google Scholar
  27. Davies J, Davies D (2010) Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev 74:417–433PubMedPubMedCentralCrossRefGoogle Scholar
  28. Diab M, Hamze M, Bonnet R, Saras E, Madec JY, Haenni M (2018) Extended-spectrum beta-lactamase (ESBL)- and carbapenemase-producing Enterobacteriaceae in water sources in Lebanon. Vet Microbiol 217:97–103PubMedCrossRefGoogle Scholar
  29. Dib JG, Al-Tawfiq JA, Al Abdulmohsin S, Mohammed K, Jenden PD (2009) Improvement in vancomycin utilization in adults in a Saudi Arabian medical center using the hospital infection control practices advisory committee guidelines and simple educational activity. J Infect Public Health 2:141–146PubMedCrossRefGoogle Scholar
  30. EUCAST (2019) Clinical breakpoints and dosing of antibiotics.
  31. European Centre for Disease Prevention and Control (2018) Surveillance of antimicrobial resistance in Europe (2017)Google Scholar
  32. European Commission Directorate-General for Health and Food Safety (2017) EU Guidelines for the prudent use of antimicrobials in human healthGoogle Scholar
  33. Forsberg KJ, Reyes A, Wang B, Selleck EM, Sommer MOA, Dantas G (2012) The shared antibiotic resistome of soil bacteria and human pathogens. Science 337:1107–1111. (80- )PubMedPubMedCentralCrossRefGoogle Scholar
  34. Gayer M, Legros D, Formenty P, Connolly MA (2007) Conflict and emerging infectious diseases. Emerg Infect Dis 13:1625–1631PubMedPubMedCentralCrossRefGoogle Scholar
  35. Haddad N, Kanj SS, Awad LS, Abdallah DI, Moghnieh RA (2019) The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance. BMC Infect Dis 19:293PubMedPubMedCentralCrossRefGoogle Scholar
  36. Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJV (2016) Understanding the mechanisms and drivers of antimicrobial resistance. Lancet 387:176–187PubMedCrossRefGoogle Scholar
  37. Husni R, Atoui R, Choucair J, Moghnieh R, Mokhbat J, Tabbarah Z, Bizri AE, Tayyar R, Jradeh M, Yared N, Musharrafieh U, Al-Awar G, Helou Z, Dakdouki G, Farra A, Hammoud J, Aoun N, Kanj SS (2017) The Lebanese society of infectious diseases and clinical microbiology guidelines for the treatment of urinary tract infections. Leban Med J 65:208–219CrossRefGoogle Scholar
  38. Khalifeh MM, Moore ND, Salameh PR (2017) Self-medication misuse in the Middle East: a systematic literature review. Pharmacol Res Perspect 5:1–13CrossRefGoogle Scholar
  39. Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, Goossens H, Laxminarayan R (2018) Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci U S A 115:E3463–E3470PubMedPubMedCentralCrossRefGoogle Scholar
  40. KPMG (2014) The global economic impact of anti-microbial resistance. KPMG, LondonGoogle Scholar
  41. Laxminarayan R, Sridhar D, Blaser M, Wang M, Woolhouse M (2016) Achieving global targets for antimicrobial resistance. Science 353:874–875. (80- )PubMedCrossRefGoogle Scholar
  42. Leangapichart T, Dia NM, Olaitan AO, Gautret P, Brouqui P, Rolain J-M (2016a) Acquisition of Extended-Spectrum ␤-lactamases by Escherichia coli and Klebsiella pneumoniae in gut microbiota of pilgrims during the hajj pilgrimage of 2013. Antimicrob Agents Chemother 60:3222–3226PubMedPubMedCentralCrossRefGoogle Scholar
  43. Leangapichart T, Gautret P, Griffiths K, Belhouchat K, Memish Z, Raoult D, Rolain J-M (2016b) Acquisition of a High Diversity of Bacteria during the hajj pilgrimage, including Acinetobacter baumannii with Bla OXA-72 and Escherichia coli with Bla NDM-5 Carbapenemase genes. Antimicrob Agents Chemother 60:5942–5948PubMedPubMedCentralCrossRefGoogle Scholar
  44. Llewelyn MJ, Fitzpatrick JM, Darwin E, SarahTonkin-Crine GC, Paul J, Peto TEA, Yardley L, Hopkins S, Walker AS (2017) The antibiotic course has had its day. BMJ 358:j3418. Scholar
  45. MacGowan AP (2008) Clinical implications of antimicrobial resistance for therapy. J Antimicrob Chemother 62:ii105–ii114PubMedCrossRefGoogle Scholar
  46. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, Harbarth S, Hindler JF, Kahlmeter G, Olsson-Liljequist B, Paterson DL, Rice LB, Stelling J, Struelens MJ, Vatopoulos A, Weber JT, Monnet DL (2012) Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 18:268–281CrossRefGoogle Scholar
  47. McEwen SA, Collignon PJ (2017) Antimicrobial resistance: a one health colloquium. Microbiol Spectr 6:1–26Google Scholar
  48. Memish ZA, Venkatesh S, Shibl AM (2003) Impact of travel on international spread of antimicrobial resistance. Int J Antimicrob Agents 21:135–142PubMedCrossRefGoogle Scholar
  49. Moghnieh R, Yared Sakr N, Kanj SS, Musharrafieh U, Husni R, Jradeh M, Al-Awar G, Matar M, Jureij W, Saad A, Azar E, Abi Hanna P, Minari A, Hammoud J, Kfoury J, Mahfouz T, Abou Chakra D, Zaatari M, Tabbarah ZA (2014) The Lebanese Society for Infectious Diseases and Clinical Microbiology (LSIDCM) guidelines for adult Community-Acquired Pneumonia (CAP) in Lebanon. Leban Med J 62:40–47. Scholar
  50. Moghnieh R, Kanafani Z, Abi Hanna P, Matar MJ, Mokhbat J, Jradeh M, Yared N, Husni R, Abdallah D, Atoui R, Choucair J, Al-Awar G, Dakdouki G, Farra A, El Helou G, Hammoud J, Aoun N, Kanj SS (2017) 2016 Lebanese Society of Infectious Diseases & clinical microbiology guidelines on the management of febrile neutropenia in adult cancer patients in the era of growing antimicrobial resistance. Leban Med J 65:63–82. Scholar
  51. Moghnieh RA, Kanafani ZA, Tabaja HZ, Sharara SL, Awad LS, Kanj SS (2018) Epidemiology of common resistant bacterial pathogens in the countries of the Arab League. Lancet Infect Dis 18:e379–e394PubMedCrossRefGoogle Scholar
  52. Levy S, (2012) Molecular Biology Pathogenicity and Ecology of Bacterial Plasmids. Springer, Boston, p 679-682Google Scholar
  53. Mouhieddine TH, Olleik Z, Itani MM, Kawtharani S, Nassar H, Hassoun R, Houmani Z, El ZZ, Fakih R, Mortada IK, Mohsen Y, Kanafani Z, Tamim H (2015) Assessing the Lebanese population for their knowledge, attitudes and practices of antibiotic usage. J Infect Public Health 8:20–31PubMedCrossRefGoogle Scholar
  54. Mund MD, Khan UH, Tahir U, Mustafa BE, Fayyaz A (2017) Antimicrobial drug residues in poultry products and implications on public health: a review. Int J Food Prop 20:1433–1446CrossRefGoogle Scholar
  55. Nasr Z, Paravattil B, Wilby KJ (2017) The impact of antimicrobial stewardship strategies on antibiotic appropriateness and prescribing behaviours in selected countries in the Middle East: a systematic review. East Mediterr Heal J 23:430–440CrossRefGoogle Scholar
  56. National Quality Forum, National Quality Partners, Antibiotic Stewardship Action Team (2018) National Quality Partners Playbook: Antibiotic Stewardship in Acute CareGoogle Scholar
  57. Nazer LH, Kharabsheh A, Rimawi D, Mubarak S, Hawari F (2015) Characteristics and outcomes of Acinetobacter baumannii infections in critically ill patients with Cancer: a matched case–control study. Microb Drug Resist 21:556–561. Scholar
  58. Nhung N, Cuong N, Thwaites G, Carrique-Mas J (2016) Antimicrobial usage and antimicrobial resistance in animal production in Southeast Asia: a review. Antibiotics 5:37PubMedCentralCrossRefPubMedGoogle Scholar
  59. Nixon J, Ulmann P (2006) The relationship between health care expenditure and health outcomes: evidence and caveats for a causal link. Eur J Health Econ 7:7–18PubMedCrossRefGoogle Scholar
  60. OECD (2018) Stemming the superbug tide: just a few dollars more. OECD Publishing, ParisCrossRefGoogle Scholar
  61. Pehrsson E, Tsukayama P, Patel S, Mejia-Bautista M, Sosa-Soto G, Navarrete K, Calderon M, Cabrera L, Hoyos-Arango W, Bertoli MT, Berg DE, Gilman RH, Dantas G (2016) Interconnected microbiomes and resistomes in low-income human habitats. Nature 533:212–2016PubMedPubMedCentralCrossRefGoogle Scholar
  62. Roy K, Groom K, Knight M (2018) Point of care respiratory viral testing (POCT): a novel service to target appropriate antimicrobial prescription and improve antibiotic stewardship. Eur Respir J 52:PA2032. Scholar
  63. Saga T, Yamaguchi K (2009) History of antimicrobial agents and resistant bacteria. Japan Med Assoc J 52:103–108Google Scholar
  64. Shehadeh M, Suaifan G, Darwish RM, Wazaify M, Zaru L, Alja’fari S (2012) Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharm J 20:125–133. Scholar
  65. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society (2012) Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 33:322–327CrossRefGoogle Scholar
  66. Tacconelli E, Carrara E, Savoldi A, Harbarth S, Mendelson M, Monnet DL, Pulcini C, Kahlmeter G, Kluytmans J, Carmeli Y, Ouellette M, Outterson K, Patel J, Cavaleri M, Cox EM, Houchens CR, Grayson ML, Hansen P, Singh N, Theuretzbacher U, Magrini N, Aboderin AO, Al-Abri SS, Awang Jalil N, Benzonana N, Bhattacharya S, Brink AJ, Burkert FR, Cars O, Cornaglia G, Dyar OJ, Friedrich AW, Gales AC, Gandra S, Giske CG, Goff DA, Goossens H, Gottlieb T, Guzman Blanco M, Hryniewicz W, Kattula D, Jinks T, Kanj SS, Kerr L, Kieny MP, Kim YS, Kozlov RS, Labarca J, Laxminarayan R, Leder K, Leibovici L, Levy-Hara G, Littman J, Malhotra-Kumar S, Manchanda V, Moja L, Ndoye B, Pan A, Paterson DL, Paul M, Qiu H, Ramon-Pardo P, Rodríguez-Baño J, Sanguinetti M, Sengupta S, Sharland M, Si-Mehand M, Silver LL, Song W, Steinbakk M, Thomsen J, Thwaites GE, van der Meer JW, Van Kinh N, Vega S, Villegas MV, Wechsler-Fördös A, Wertheim HFL, Wesangula E, Woodford N, Yilmaz FO, Zorzet A (2018) Discovery, research, and development of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and tuberculosis. Lancet Infect Dis 18:318–327. Scholar
  67. Taylor J, Hafner M, Yerushalmi E, Smith R, Bellasio J, Vardavas R, Bienkowska-gibbs T, Rubin J (2014) Estimating the economic costs of antimicrobial resistance: model and results. RAND Eur:1–113Google Scholar
  68. The Review on Antimicrobial Resistance (2016) Tackling drug-resistant infections globally: final report and recommendations. Wellcome Trust, HM Government, LondonGoogle Scholar
  69. World Bank (2016) Drug-resistant infections: a threat to our economic future. World Bank Rep 2:1–132Google Scholar
  70. World Health Organisation (2018) Monitoring global Progress on addressing antimicrobial resistance: analysis report of the second round of results of AMR country self-assessment survey 2018Google Scholar
  71. World Health Organization (2001) WHO global strategy for containment of antimicrobial resistance. World Health Organization, GenevaGoogle Scholar
  72. World Health Organization (2014) Antimicrobial resistance. Global report on surveillanceGoogle Scholar
  73. World Health Organization (2015) Global action plan on antimicrobial resistanceGoogle Scholar
  74. World Health Organization (2017a) Global priority list of antibiotic-resistant bacteria to guide research, discovery, and development of new antibiotics. World Heal Organ. Scholar
  75. World Health Organization (2017b) Global antimicrobial resistance surveillance system (GLASS) reportGoogle Scholar
  76. Yaacoub SG, Lahoud NA, Francis NJ, Rahme DW, Murr TH, Maison PF, Saleh NG (2019) Antibiotic prescribing rate in Lebanese community pharmacies: a Nationwide patient-simulated study of acute bacterial rhinosinusitis. J Epidemiol Glob Health 9:44PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Infectious diseases, Department of Internal MedicineAmerican University of Beirut Medical CenterBeirutLebanon

Section editors and affiliations

  • Amal Saad-Hussein
    • 1
  1. 1.Environmental Research Division, Environmental & Occupational Medicine DepartmentNational Research CentreCairoEgypt

Personalised recommendations