BYBLOS & BEIRUT—Arab countries have become breeding grounds for bacteria that can’t be controlled by the usual antibiotics. A handful of researchers are trying to track this problem—and wish they could put a stop to it.
The danger seems abstract to much of the public, but not to researchers in the field. “A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century,” said a World Health Organization report issued in April.
In Lebanon, for example, antibiotic resistance is more widespread than in Western countries, says George Araj, the director of the clinical microbiology department at the American University of Beirut Medical Center. This is in large part due, he says, to the misuse of antibiotics and a lagging effort to keep tabs on which strains of bacteria are resistant to which drugs. Araj has been doing this in his own lab since 1992, but he acknowledges a regional network is needed.
It’s hard to say exactly how bad the situation is in Lebanon compared to Europe and the United States, he says. It all depends on the type of bacteria. “With some strains we’re better, but in general we’re much worse,” says Araj. He estimates that Lebanon may be facing a problem 40 to 50 percent worse than the West.
Despite this, Lebanon is still doing better than most other Arab countries, says Araj.
Other experts agree. “The misuse of antibiotics is rife across the Arab world,” says Sima T. Tokajian, an associate professor of molecular microbiology at the Lebanese American University’s Byblos campus.
Both Tokajian and Araj say one of the main causes of resistance in the region is driven by the ease of acquiring antibiotics—a doctor’s prescription is not usually required. “Over-the-counter sales need to stop,” says Tokajian.
Tokajian tracks the geographical distribution and dispersal of bacteria strains using different techniques. The data collected from this research may prove invaluable for mapping the spread of resistance. Tokajian says her lab is one of the only accredited facilities outside of Europe and North America to conduct some of these tests.
In Lebanon two years ago, Tokajian and her colleagues noticed one of the most serious methods of antibiotic resistance. The samples were collected in Tripoli from Syrian civilians injured during the ongoing war. Tokajian is now checking the genetic details of these bacteria—a strain called Acinetobacter baumannii. The strain has adapted so that it can break down an important and powerful class of antibiotics called carbapenems. These are known as “last resort antibiotics” because they kill most strains of bacteria. They’re often the last drug on the shelf after doctors have tried to kill infections with other antibiotics.
Araj says it’s commonplace for resistant bacteria to be brought to Lebanon by patients from other Arab countries. People come from around the region to the hospital where Araj works believing it offers some of the best medical care in the area. In these other countries, mistreatment and misdiagnosis are even more commonplace. Iraq and Syria in particular are frequent offenders, says Araj. The confined quarters and conditions in refugee camps across the region are likely to enable the spread of both infections and resistance.
He recalls analyzing cultures of E-coli and Klebsiella bacteria that were resistant to many different forms of antibiotics. “I enquired about the patients and they turned out to be Iraqi,” say Araj, “Most of the new kinds of resistance are imported.”
In addition to the introduction of new forms of resistance, Tokajian says more and more strains of bacteria are picking up pre-existing types of resistance. The parts of bacterial that code for resistance easily move from bacteria to bacteria. In this process, known as gene transfer, bacteria exchange genetic material. Three years ago, a group of scientists showed this doesn’t only happen within the same species, but also between highly different strains.
Araj acknowledges the situation is threatening and concedes that the public health researchers are fighting a losing battle. In addition, he says some reports of resistance may be inaccurate: “Some hospitals don’t know how to test for resistance and can give you false resistance.”
Earlier this year, the World Health Organization released a report on antimicrobial resistance, which highlighted the extensive prevalence of resistance in the Middle East and Arab countries. The agency added that the situation is worsened by humanitarian crises in the region.
Because a doctor’s prescription is not required to get antibiotics in most Arab countries, patients without medical expertise may be seeking antibiotics for illnesses that can’t be cured by them, including viral infections. Taking the antibiotics still exposes their body’s bacteria to the drugs and gives the bacteria the chance to develop resistance.
Araj says that both doctors and patients are to blame. Doctors too often cave into pressure from patients demanding inappropriate or unnecessary antibiotics and pharmacists almost never question a request for the drugs, he says.
This situation seems unlikely to change without the introduction of new laws. “’No political will’ would be putting it politely,” says Araj. Tokajian also doubts that laws demanding prescriptions for antibiotics will come along any time in the near future. “We have so many other issues in the region demanding attention, it’s hard to compete,” she says.
The World Health Organization report cited a need for better surveillance of which strains are resistant to which drugs in which countries. Araj produces a chart each year, which matches bacteria with antibiotics to show the resistance patterns observed in his lab. An ideal response to the worsening resistance problem in the Arab world would be a larger version of Araj’s efforts in an online database drawing on labs throughout the region, says Tokajian.
As for the way things stand at the moment, there is very little collaboration between institutions on tracking resistance, she says: “We’re just not talking to each other.”