Umeå University's logo

Background: The health and well-being of refugees are critically compromised by harsh living conditions, which foster the emergence of infectious diseases and the misuse of antimicrobial agents. This multi-centre, cross-sectional, community-based study investigated the prevalence of urine carriage of bacteria and the associated antimicrobial resistance patterns of the isolates among Syrian refugees living in makeshift camps in Lebanon, an East Mediterranean country.

Methods: We used multi-variable logistic regression models to identify the risk factors associated with bacteriuria in this vulnerable population. Mid-stream urine samples were collected aseptically from 79 Syrian refugees; regardless of whether they exhibited symptoms of urinary tract infections. Samples were inoculated onto UriSelect™ 4 chromogenic agar, and bacterial isolates were identified using MALDI-TOF-MS. Antibiotic susceptibility testing was assessed using the Kirby–Bauer disk diffusion assay.

Findings: The prevalence of bacteriuria was 30.8% (95% confidence interval: 21.6–41.7), and the aetiologic agents were primarily Escherichia coli (80%), Klebsiella pneumoniae (12%) and Enterobacter cloacae complex (8%). The Enterobacterales isolates exhibited high resistance to penicillins (64%), cephalosporins (20–48%), and quinolones (28%), with 56% showing multi-drug resistance. While the female sex and rubbish accumulation were risk factors, tea consumption, reduced chicken intake, and economic support were protective against bacteriuria.

Conclusions: This report corroborates prior anecdotal evidence regarding underdiagnosed bacteriuria among Syrian refugees in Lebanon. The data highlight the pressing need for monitoring and awareness programmes to curb the spread of infectious diseases and antimicrobial resistance in both refugee and host communities.

Infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) are of great concern, as mortality is high, and treatment options are very limited. Despite having among the highest rates reported worldwide, scarce genomic data are available on CRAB strains from the Middle East. Here, we report the global emergence of a novel International Clone (IC), designated IC12, based on the epidemiological, phenotypic and genome sequencing data (short reads and long reads) of a set of 60 A. baumannii isolates belonging to multilocus sequence type 158 (Pasteur scheme). IC12, prevailing in the Middle East since 2007, has also been found in Europe, Asia and South America. Alleles OXA-65 and ADC-117, coded by the blaOXA-51-like and blaADCA. baumannii-intrinsic genes, respectively, were hallmarks shared by all the isolates. Plasmid pIC12-2 (80,000 bp), which carries a repAci6 replication initiator (RP-T1) and a type IV conjugative transfer system, played a major role in the antimicrobial resistance profile of 54/60 of the IC12 isolates. This resistance was mediated by three mobile genetic elements, namely Tn2008, MITEAb-IC12 and TnaphA6. All four Peruvian IC12 isolates lacked pIC12-2 and carried a different set of plasmids. Two of the Peruvian isolates carried a chromosomal resistance island of 79,396 bp long (designated IC12-RI) marked by the occurrence of tet(X3). The global spread of IC12 is worrying and calls for further studies on the virulence features and clinical impact of this clone.

Background: Armed conflict contributes to the development and spread of antimicrobial resistance (AMR). Understanding healthcare providers’ perceptions is essential for identifying key determinants and developing contextualised recommendations. This study explored perceptions of AMR among healthcare providers in northwest Syria - a conflict-affected area- before the fall of the Syrian regime in December 2024.

Methods: A qualitative study was conducted using semi-structured interviews with healthcare providers who had worked in northwest Syria within the previous five years. Seventeen interviews were conducted remotely in Arabic in July–August 2023. Participants were identified through purposive and snowball sampling. Transcriptions were analysed using deductive thematic analysis.

Results: Of the 17 key informants, (11 doctors, 6 pharmacists); most were from Idlib governorate. Emerging themes included healthcare professionals’ understanding of AMR, perceived drivers, conflict- and disaster-related influences, and examples of good practice. Frequently cited drivers of AMR were over-the-counter availability of antimicrobials, pharmacy-led dispensing, and community insistence on antibiotics. Inadequate microbiology diagnostic capacity was also highlighted as a key factor.

Conclusion: Interviews highlighted perceived contributors to AMR in northwest Syria, including ineffective or absent policies regulating antibiotic dispensing, lack of antimicrobial guidelines or poor enforcement, and limited access to diagnostics. These findings support the development of contextualised recommendations during the transition of Syria’s health system.

The genus Acinetobacter is widely distributed in nature. A key step in the evolutionary trajectory of Acinetobacter is the diversification of species that are well adapted to human-made environments, particularly hospitals, including those capable of causing infection outbreaks. The temporal dynamics, routes and mechanisms of such nosocomial adaptations remain to be elucidated. This review provides a comprehensive description of 162 Acinetobacter isolates collected between 1910 and 1970 under various taxonomic names, which may facilitate a more detailed exploration of the pathogenic and nosocomial shifts of Acinetobacter. Genomic analysis of these isolates can help reveal the earliest traits of antimicrobial resistance and detect initial genetic events, thereby allowing hypotheses on driving factors that may have preceded the extensive use of modern antimicrobials. Through comparison with contemporary isolates, the evolutionary events and ecological processes that have shaped the phylogeny of today's highly successful Acinetobacter strains can be mapped, and their arsenals of antimicrobial resistance determinants and virulence factors can be tracked chronologically.

Carbapenem-resistant Acinetobacter baumannii causes one of the most difficult-to-treat nosocomial infections. Polycationic drugs like polymyxin B or colistin and tetracycline drugs such as doxycycline or minocycline are commonly used to treat infections caused by carbapenem-resistant A. baumannii. Here, we show that a subpopulation of cells associated with the opaque/translucent colony phase variation by A. baumannii AB5075 displays differential tolerance to subinhibitory concentrations of colistin and tetracycline. Using a variety of microscopic techniques, we demonstrate that extracellular polysaccharide moieties mediate colistin tolerance to opaque A. baumannii at single-cell level and that mushroom-shaped biofilm structures protect opaque bacteria at the community level. The colony switch phenotype is found to alter several traits of A. baumannii, including long-term survival under desiccation, tolerance to ethanol, competition with Escherichia coli, and intracellular survival in the environmental model host Acanthamoeba castellanii. Additionally, our findings suggest that extracellular DNA associated with membrane vesicles can promote colony switching in a DNA recombinase-dependent manner.

Importance: As a WHO top-priority drug-resistant microbe, Acinetobacter baumannii significantly contributes to hospital-associated infections worldwide. One particularly intriguing aspect is its ability to reversibly switch its colony morphotype on agar plates, which has been remarkably underexplored. In this study, we employed various microscopic techniques and phenotypic assays to investigate the colony phase variation switch under different clinically and environmentally relevant conditions. Our findings reveal that the presence of a poly N-acetylglucosamine-positive extracellular matrix layer contributes to the protection of bacteria from the bactericidal effects of colistin. Furthermore, we provide intriguing insights into the multicellular lifestyle of A. baumannii, specifically in the context of colony switch variation within its predatory host, Acanthamoeba castellanii.

Objectives: The contamination of fresh surface waters poses a significant burden on human health and prosperity, especially in marginalized communities with limited resources and inadequate infrastructure. Here, we performed in-depth genomic analyses of multidrug-resistant bacteria (MDR-B) isolated from Al-Oueik river water that is used for irrigation of agricultural fields in a disenfranchised area that also hosts a makeshift Syrian refugee camp.

Methods: A composite freshwater sample was filtered. Faecal coliforms were counted and extended spectrum cephalosporins and/or ertapenem resistant bacteria were screened. Isolates were identified using MALDI-TOF-MS and analysed using whole-genome sequencing (WGS) to identify the resistome, sequence types, plasmid types, and virulence genes.

Results: Approximately 106 CFU/100 mL of faecal coliforms were detected in the water. Four drug-resistant Gram-negative bacteria were identified, namely Escherichia coli, Klebsiella pneumoniae, Enterobacter hormaechei, and Pseudomonas otitidis. Notably, the E. coli isolate harboured blaNDM-5 and a YRIN-inserted PBP3, representing an emerging public health challenge. The K. pneumoniae isolate carried blaSHV-187 as well as mutations in the gene encoding the OmpK37 porin. Enterobacter hormaechei and P. otitidis harboured blaACT-16 and blaPOM-1, respectively.

Conclusion: This report provides comprehensive genomic analyses of MDR-B in irrigation water in Lebanon. Our results further support that irrigation water contaminated with faecal material can be a reservoir of important MDR-B, which can spread to adjacent agricultural fields and other water bodies, posing both public health and food safety issues. Therefore, there is an urgent need to implement effective water quality monitoring and management programs to control the proliferation of antibiotic-resistant pathogens in irrigation water in Lebanon.

The earthquakes in Türkiye and Syria in February, 2023, have caused further devastation in northwest Syria—an area already affected by protracted armed conflict, mass forced displacement, and inadequate health and humanitarian provision. The earthquake damaged infrastructure supporting water, sanitation, and hygiene, and health-care facilities. The disruptions to epidemiological surveillance and ongoing disease control measures resulting from the earthquake will accelerate and expand ongoing and new outbreaks of many communicable diseases including measles, cholera, tuberculosis, and leishmaniasis. Investing in existing early warning and response network activities in the area is essential. Antimicrobial resistance, which had already been an increasing concern in Syria before the earthquake, will also be exacerbated given the high number of traumatic injuries and breakdown of antimicrobial stewardship, and the collapse of infection prevention and control measures. Tackling communicable diseases in this setting requires multisectoral collaboration at the human–animal–environment nexus given the effect of the earthquakes on all these sectors. Without this collaboration, communicable disease outbreaks will further strain the already overburdened health system and cause further harm to the population.

Background: In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates.

Methods: We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence.

Results: The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p < 0.001), but downwards trends for acute jaundice syndrome, suspected typhoid fever and acute bloody diarrhoea. For the major disruption of the Alouk water plant, an interrupted time series analysis did not find a strong correlation between the disruption and changes in disease incidence in the weeks following the incident, but long-term increases in WBD were observed.

Conclusions: While no strong immediate correlation could be established between disruptions to WASH and WBDs in northeast Syria, further research is essential to explore the impact of conflict-associated damage to civil infrastructure including WASH. This is vital though challenging given confounding factors which affect both WASH and WBDs in contexts like northeast Syria. As such, research which includes exploration of mitigation after damage to WASH is essential to improve understanding of impacts on quantity and quality of WASH. More granular research which explores the origin of cases of WBDs and how such communities are affected by challenges to WASH is needed. One step towards research on this, is the implementation of adequate reporting mechanisms for real time tracking of the WASH attacks, damages, direct effects, and likely impact in conjunction with environmental and public health bodies and surveillance systems.

As a result of the COVID-19 pandemic, as well as other outbreaks, such as SARS and Ebola, bats are recognized as a critical species for mediating zoonotic infectious disease spillover events. While there is a growing concern of increased antimicrobial resistance (AMR) globally during this pandemic, knowledge of AMR circulating between bats and humans is limited. In this paper, we have reviewed the evidence of AMR in bats and discussed the planetary health aspect of AMR to elucidate how this is associated with the emergence, spread, and persistence of AMR at the human–animal interface. The presence of clinically significant resistant bacteria in bats and wildlife has important implications for zoonotic pandemic surveillance, disease transmission, and treatment modalities. We searched MEDLINE through PubMed and Google Scholar to retrieve relevant studies (n = 38) that provided data on resistant bacteria in bats prior to 30 September 2022. There is substantial variability in the results from studies measuring the prevalence of AMR based on geographic location, bat types, and time. We found all major groups of Gram-positive and Gram-negative bacteria in bats, which are resistant to commonly used antibiotics. The most alarming issue is that recent studies have increasingly identified clinically significant multi-drug resistant bacteria such as Methicillin Resistant Staphylococcus aureus (MRSA), ESBL producing, and Colistin resistant Enterobacterales in samples from bats. This evidence of superbugs abundant in both humans and wild mammals, such as bats, could facilitate a greater understanding of which specific pathways of exposure should be targeted. We believe that these data will also facilitate future pandemic preparedness as well as global AMR containment during pandemic events and beyond.

Since the late 1930s, resistance to sulfonamides has been accumulating across bacterial species including Acinetobacter baumannii, an opportunistic pathogen increasingly implicated the spread of antimicrobial resistance worldwide. Our study aimed to explore events involved in the acquisition of sulfonamide resistance genes, particularly sul2, among the earliest available isolates of A. baumannii. The study utilized the genomic data of 19 strains of A. baumannii isolated before 1985. The whole genomes of 5 clinical isolates obtained from the Culture Collection University of Göteborg (CCUG), Sweden, were sequenced using the Illumina MiSeq system. Acquired resistance genes, insertion sequence elements and plasmids were detected using ResFinder, ISfinder and Plasmidseeker, respectively, while sequence types (STs) were assigned using the PubMLST Pasteur scheme. BLASTn was used to verify the occurrence of sul genes and to map their genetic surroundings. The sul1 and sul2 genes were detected in 4 and 9 isolates, respectively. Interestingly, sul2 appeared thirty years earlier than sul1. The sul2 gene was first located in the genomic island GIsul2 located on a plasmid, hereafter called NCTC7364p. With the emergence of international clone 1, the genetic context of sul2 evolved toward transposon Tn6172, which was also plasmid-mediated. Sulfonamide resistance in A. baumannii was efficiently acquired and transferred vertically, e.g., among the ST52 and ST1 isolates, as well as horizontally among non-related strains by means of a few efficient transposons and plasmids. Timely acquisition of the sul genes has probably contributed to the survival skill of A. baumannii under the high antimicrobial stress of hospital settings.