BACKGROUND
While the relationship between conflict-associated injuries and antimicrobial resistance is increasingly being elucidated, data concerning civilian casualties is sparse. This systematic review assesses literature focused on Global Antimicrobial Resistance Surveillance System (GLASS) Priority Pathogens causing infections in civilian wounds and burns in conflict-affected countries within the World Health Organisation's Eastern Mediterranean Region Office (EMRO)
METHODS
A systematic literature review was conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Five databases and grey literature were searched, identifying studies published from January 2010 to June 2024. Search terms included "wounds", "burns," "antimicrobial resistance", and the twelve countries of interest. Included studies reported resistance of GLASS pathogens. Two reviewers used Covidence to assess papers for inclusion. Data were extracted into a spreadsheet for analysis. Where quantitative data were available, medians, interquartile ranges and percentages were calculated by pathogen and country.
RESULTS
621 records were identified; 19 studies met inclusion criteria. Nine of the papers were from Iraq, three from Libya, three from Lebanon, one each from Yemen and Gaza; two reported on conflict affected refugees in Jordan. A total of 1,942 distinct microbiological isolates were reported, representing all four critical and high priority GLASS pathogen categories. Among the isolates, Staphylococcus aureus was the most prevalent (36.3%). Median resistances identified: Methicillin resistant Staphylococcus aureus (n = 680): 55.6% (IQR:49.65-90.3%); carbapenem resistant Pseudomonas aeruginosa (n = 372): 22.14% (7.43-52.22%); carbapenem resistant Acinetobacter baumannii (n = 366): 60.3% (32.1-85%); carbapenem resistant Klebsiella pneumoniae (n = 75): 12.65% (9.73-34.25%); ceftriaxone resistant Escherichia coli (n = 63): 76% (69-84.65%); ceftriaxone resistant Klebsiella pneumoniae (n = 40): 81.45% (76.73-86.18%). Only three studies had a low risk of bias.
DISCUSSION
Findings imply high rates of GLASS priority pathogens among wounded civilians in conflict-affected EMRO countries. However, evidence was heterogeneous, low quality and sparse in certain countries, highlighting the necessity of effective surveillance including standardised data collection. Improving primary data will facilitate the production of large, high-quality studies throughout the EMRO, including under-represented countries.
Conclusion: Laboratory diagnostic capacity building and improved surveillance in conflict-affected settings in the Eastern Mediterranean Region are required to assess the burden of GLASS priority pathogens in vulnerable non-combatant populations.
To evaluate and compare the prevalence, reasons, sources and factors associated with self-medication with antibiotics (SMA) within Africa.
METHODS
Systematic review and meta-analysis. An electronic search of PubMed and Google Scholar databases was performed for observational studies conducted between January 2005 and February 2020. Two reviewers independently screened abstracts and full texts using the PRISMA flowchart and performed quality assessment of eligible studies. Both qualitative and quantitative syntheses were carried out.
RESULTS
Forty studies from 19 countries were eligible for qualitative synthesis. The prevalence of SMA in Africa ranged from 12.1% to 93.9% with a median prevalence of 55.7% (IQR 41-75%). Western Africa was the sub-region with the highest reported prevalence of 70.1% (IQR 48.3-82.1%), followed by Northern Africa with 48.1% (IQR 41.1-64.3%). We identified 27 antibiotics used for self-medication from 13 different antibiotic classes. Most frequently used antibiotics were penicillins (31 studies), tetracyclines (25 studies) and fluoroquinolones (23 studies). 41% of these antibiotics belong to the WHO Watch Group. The most frequent indications for SMA were upper respiratory tract infections (27 studies), gastrointestinal tract symptoms (25 studies) and febrile illnesses (18 studies). Common sources of antibiotics used for self-medication were community pharmacies (31 studies), family/friends (20 studies), leftover antibiotics (19 studies) and patent medicine stores (18 studies). The most frequently reported factor associated with SMA was no education/low educational status (nine studies).
CONCLUSION
The prevalence of SMA is high in Africa and varies across sub-regions with the highest prevalence reported in Western Africa. Drivers of SMA are complex, comprising of socio-economic factors and insufficient access to health care coupled with poorly implemented policies regulating antibiotic sales.
