Antibiotic Resistance in the Middle East and Southern Asia: A Growing Crisis, Hampered by Data Gaps

A sweeping new meta-analysis conducted by Médecins Sans Frontières (MSF) has revealed alarming levels of antibiotic resistance (ABR) across the Middle East and Southern Asia, particularly in countries impacted by conflict or strained health systems.

Despite efforts to contain antimicrobial resistance globally, this study highlights just how uneven and fragile those efforts remain—especially in low- and middle-income countries (LMICs) where surveillance capacity is inconsistent, and clinical decision-making often occurs in the absence of actionable local data.

The review spans nine countries—Iran, Türkiye, Pakistan, Iraq, Syria, Yemen, Lebanon, Palestine, and Afghanistan—and draws on more than 200 peer-reviewed studies reporting resistance in bloodstream, burn, and wound-related infections. Its findings paint a stark picture: resistance to first-line antibiotics is not only widespread, it frequently exceeds 30%, including near-universal resistance to carbapenems among Acinetobacter baumannii isolates in Türkiye and Iran. In Pakistan, colistin resistance in Klebsiella pneumoniae reached a staggering 81%, a troubling development given colistin’s status as a last-resort antibiotic.

Bloodstream infections, including sepsis, yielded some of the most concerning figures. Methicillin-resistant Staphylococcus aureus (MRSA) rates approached 94% in non-paediatric patients in Iran, while third-generation cephalosporin resistance was high among Escherichia coli and K. pneumoniae isolates in both Pakistan and Türkiye. Ciprofloxacin resistance in Salmonella Typhi, particularly in Pakistan, often surpassed 70%, suggesting that even oral therapies traditionally used for typhoid fever are becoming less effective in some populations.

For burn and wound infections, the dominant pathogens—Pseudomonas aeruginosa, A. baumannii, and S. aureus—demonstrated resistance across nearly all commonly used antibiotic classes. While vancomycin resistance remained low, particularly in Iran and Türkiye, gentamicin and amikacin resistance frequently crossed critical thresholds, limiting the range of empiric options available to clinicians working in acute care and surgical settings.

Yet, while the resistance patterns themselves are striking, perhaps more revealing is the variability and often poor quality of the underlying data. Using the JBI Critical Appraisal Checklist for Prevalence Studies, the researchers found that only about one in ten studies met all eight quality criteria. Key clinical and methodological details—such as the patient’s age group, inpatient or outpatient status, or the antibiotic susceptibility testing method used—were frequently missing or vaguely described. Even basic distinctions like community-acquired versus hospital-acquired infection were absent in the vast majority of studies.

This lack of clarity limits the clinical utility of the data. For example, in sepsis cases, knowing whether A. baumannii is hospital-acquired dramatically changes its likely resistance profile—and, thus, appropriate empirical therapy. Without that context, even accurate resistance rates become difficult to apply meaningfully in patient care.

The implications extend beyond MSF’s operations. The reviewed countries all participate in the World Health Organization’s Global Antimicrobial Resistance Surveillance System (GLASS), yet the study found no clear evidence that this participation had led to higher-quality or more consistent reporting. This disconnect underscores the limitations of surveillance systems that rely heavily on national laboratories or health ministries but are under-resourced and unevenly implemented in fragile or conflict-affected states.

Among the more sobering insights is that published literature—a vital stopgap in settings where national antibiograms are unavailable—is an imperfect substitute for systematic, coordinated surveillance. The review suggests that countries with more stable research environments, such as Iran and Türkiye, tend to be overrepresented in the literature, while others, like Syria or Yemen, remain under-documented despite high ABR burdens. This skews the broader understanding of resistance patterns and potentially diverts resources or attention away from the most urgent settings.

Moreover, methodological inconsistencies further undermine confidence in individual study findings. For example, vancomycin resistance in S. aureus—typically assessed via minimum inhibitory concentration methods—was sometimes evaluated using less reliable disc diffusion tests. Similarly, resistance to ceftriaxone was occasionally reported in organisms inherently resistant to it, like P. aeruginosa, calling into question the microbiological validity of some results.

Despite these limitations, the overall trends are impossible to ignore. ABR in this region is widespread, evolving rapidly, and frequently outpaces the tools clinicians have available to respond. And while MSF’s review does not seek to offer definitive, guideline-changing data, it does point to practical next steps.

First, there is an urgent need to standardize how ABR data are collected and reported in the peer-reviewed literature—especially in LMICs. Developing a reporting framework akin to the CONSORT or PRISMA guidelines for resistance studies could dramatically improve data quality, comparability, and clinical relevance. Detailed metadata on patient demographics, infection site, sample source, and susceptibility methods should become routine.

Second, countries where high-quality data are currently lacking—particularly in active conflict zones—should be prioritized for investment in microbiological capacity. Even modest support to local laboratories could yield disproportionate returns by informing empiric therapy, preventing overuse of last-resort antibiotics, and shaping future stewardship policies.

Finally, the findings reinforce the need for practical, scalable stewardship interventions. While surveillance and data-sharing are critical, they must be paired with targeted programs to guide appropriate antibiotic use at the bedside. For MSF and other humanitarian organizations, this could mean creating simplified, locally adapted treatment protocols that account for regional resistance patterns, even when full antibiograms are not available.

Antibiotic resistance in the Middle East and Southern Asia is not a looming threat—it is a current, entrenched reality. This review offers one of the clearest syntheses yet of how the crisis is unfolding on the ground and what gaps must be addressed to combat it. The data may be imperfect, but the message is unmistakable: more rigorous research, smarter policy, and a commitment to equity in global health surveillance are all essential if we are to prevent the erosion of one of modern medicine’s most foundational tools.