Three regional studies show AMR's three fronts: resistance, cost, misuse

Antimicrobial resistance is usually reported as a single number — a resistance rate, a death toll. Three studies in a themed issue of the Eastern Mediterranean Health Journal, the WHO Regional Office for the Eastern Mediterranean's peer-reviewed journal, instead show the problem from three angles that rarely appear together: the resistance itself, the cost of the drugs meant to treat it, and the way those drugs are used [s1][s2][s3].

The resistance

A review of hospital-acquired infections in Saudi Arabia, covering studies published between 2015 and 2025, found Gram-negative pathogens predominant — Klebsiella, E. coli, Pseudomonas and Acinetobacter [s1]. Among those, roughly 41% showed multidrug resistance and about 25% extensive resistance [s1].

The review reported surgical site infections at 1% or below overall, but higher among caesarean-section cohorts, at about 4.7% [s1]. Risk factors included intensive-care stays, invasive devices, diabetes and prolonged procedures [s1]. Prevention-bundle adherence was high, at roughly 94% to 100%, but hand-hygiene compliance lagged, at about 76% [s1]. The review followed PRISMA 2020 guidance and a narrative-synthesis approach, searching several databases for studies published between 2015 and 2025 and appraising their quality with standard tools [s1]. It is a synthesis of existing studies rather than a single prospective surveillance dataset, which limits how precisely those pooled figures can be read [s1]. The gap between near-universal bundle adherence and lagging hand-hygiene compliance is the kind of operational detail such a review can surface: the formal protocols are in place, but the simplest infection-control behaviour is not consistently followed [s1].

The cost

A second study assessed the cost, availability and affordability of antibiotics in Iran using the WHO Access, Watch and Reserve classification, drawing on data for March 2023 to March 2024 [s2]. Its finding was a split by formulation: most injectable antibiotics were unaffordable, while most oral formulations were affordable [s2].

The spread was wide. Among injectables, streptomycin was the cheapest at 15,000 Iranian rials per defined daily dose, while temocillin was the most expensive at 25,828,000 rials per defined daily dose [s2]. Among orals, nitrofurantoin was cheapest at 12,370 rials per defined daily dose and linezolid most expensive at 1,030,558 rials [s2]. Prices and affordability differed significantly across the Access, Watch and Reserve groups, with p-values of 0.007 and 0.035 respectively [s2]. Affordability matters to resistance because when a first-line drug is out of reach, treatment can shift toward whatever is available or be left incomplete [s2].

The misuse

The third study surveyed antibiotic knowledge, attitudes and practices among internally displaced people in conflict-affected north-west Syria, interviewing 630 adults across 12 displacement camps in April 2022 using a WHO-validated questionnaire adapted for the setting [s3]. Two-thirds of participants, 66.5%, had received at least one antibiotic prescription in the past year [s3]. Misuse was common: 62.2% reported using antibiotics without a prescription [s3].

Among the 630 participants — 58.1% female, with a median age of 38 — the study also found differences in who used prescribed antibiotics: women were more likely than men to have used a prescribed course, at an odds ratio of 2.89, while single participants were less likely than married ones, at an odds ratio of 0.29 [s3].

That combination — high antibiotic exposure alongside frequent unprescribed use — is exactly the pattern that accelerates resistance, and the study documents it in a population where health-system oversight is thinnest [s3]. The reliance on a WHO-validated questionnaire, adapted for the Syrian context, is what makes the practices comparable with surveys run elsewhere rather than a one-off snapshot [s3].

Why the three belong together

Each study is limited on its own. The Saudi review pools heterogeneous studies; the Iran analysis prices drugs without tracking how pricing changes prescribing; the Syria survey captures practices at one point in a single displacement setting [s1][s2][s3]. But read across the region they describe a connected system: resistant organisms circulate in hospitals, the drugs to treat them are unevenly affordable, and outside formal care antibiotics are used without prescription. Surveillance of resistance rates alone misses the access and behaviour that shape them. None of the three papers reports a regional death toll, and none is offered here as one — they are descriptive studies of three linked failure points, published together by the region's own health journal [s1][s2][s3].

Sources

• [s1] "A review of the burden, resistance patterns and outcomes of hospital-acquired infections in Saudi Arabia," Eastern Mediterranean Health Journal, 6 June 2026. https://doi.org/10.26719/2026.32.5.333
• [s2] "Cost, availability and affordability of antibiotics in Islamic Republic of Iran," Eastern Mediterranean Health Journal, 6 June 2026. https://doi.org/10.26719/2026.32.5.297
• [s3] "Knowledge, attitudes and practices regarding antibiotic use among internally displaced persons in conflict-affected Syria," Eastern Mediterranean Health Journal, 6 June 2026. https://doi.org/10.26719/2026.32.5.312