The burden of bacterial antimicrobial resistance in the WHO Eastern Mediterranean Region 1990–2021: a cross-country systematic analysis with forecasts to 2050
Issued Date
2025-11-01
Resource Type
eISSN
24682667
Scopus ID
2-s2.0-105020630884
Pubmed ID
41082884
Journal Title
Lancet Public Health
Volume
10
Issue
11
Start Page
e955
End Page
e970
Rights Holder(s)
SCOPUS
Bibliographic Citation
Lancet Public Health Vol.10 No.11 (2025) , e955-e970
Suggested Citation
Mestrovic T., Naghavi M., Robles Aguilar G., Davis Weaver N., Swetschinski L.R., Wool E.E., Araki D.T., Gershberg Hayoon A., Gray B A., Han C., Ikuta K.S., Rosenblad E., Aalruz H., Abd-Elsalam S., Abedi A., Abolhassani H., Aburuz S., Afzal S., Ahmad A., Ahmadzade A.M., Ahmed A., Ahmed H., Ali A., Ali Z., Ali L., Ali S.S., Al-Marwani S., Almidani O., Al-Rifai R.H., Al-Tawfiq J.A., Alzoubi K.H., Andretta Mendes J., Andrews J.R., Arabloo J., Arafat M., Athari S.S., Atout M.M.W., Azadnajafabad S., Aziz S., Azizian K., Barqawi H.J., Basharat Z., Bedi N., Berkley J.A., Bhattacharjee N.V., Brown C.S., Bustanji Y., Cooper B.S., Dash N.R., Dolecek C., Eckmanns T., Ed-Dra A., El Sayed I., Elhadi M., El-Huneidi W., Elias C., Ellis S., Elsohaby I., Eshrati B., Fahim A., Fatehizadeh A., Koya M.S.F., Feizkhah A., Garrett D.O., Ghazy R.M., Ghoba S., Giannakis K., Haddadi R., Hadei M., Halim S.A., Hamidi S., Hasaballah A.I., Hasan R.S., Hasani H., Haselbeck A.H., Hay B, C S., Hezam K., Hosseinzadeh M., Hsu R.L., Hussein N.R., Imam M.T., Iregbu K.C., Ismail F., Jafarzadeh A., Jalili M., Jalilzadeh Yengejeh R., Jamshidi E., Jomehzadeh N., Kamal Z., Kasraei H., Khamesipour F., Khidri F.F., Khusuwan S., Kuddus M., Kyu H.H., Mahmoud M.A., Makram DE, DF O., Malakan Rad E., Marks F., McManigal B. The burden of bacterial antimicrobial resistance in the WHO Eastern Mediterranean Region 1990–2021: a cross-country systematic analysis with forecasts to 2050. Lancet Public Health Vol.10 No.11 (2025) , e955-e970. e970. doi:10.1016/S2468-2667(25)00201-4 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/113251
Title
The burden of bacterial antimicrobial resistance in the WHO Eastern Mediterranean Region 1990–2021: a cross-country systematic analysis with forecasts to 2050
Author(s)
Mestrovic T.
Naghavi M.
Robles Aguilar G.
Davis Weaver N.
Swetschinski L.R.
Wool E.E.
Araki D.T.
Gershberg Hayoon A.
Gray B A.
Han C.
Ikuta K.S.
Rosenblad E.
Aalruz H.
Abd-Elsalam S.
Abedi A.
Abolhassani H.
Aburuz S.
Afzal S.
Ahmad A.
Ahmadzade A.M.
Ahmed A.
Ahmed H.
Ali A.
Ali Z.
Ali L.
Ali S.S.
Al-Marwani S.
Almidani O.
Al-Rifai R.H.
Al-Tawfiq J.A.
Alzoubi K.H.
Andretta Mendes J.
Andrews J.R.
Arabloo J.
Arafat M.
Athari S.S.
Atout M.M.W.
Azadnajafabad S.
Aziz S.
Azizian K.
Barqawi H.J.
Basharat Z.
Bedi N.
Berkley J.A.
Bhattacharjee N.V.
Brown C.S.
Bustanji Y.
Cooper B.S.
Dash N.R.
Dolecek C.
Eckmanns T.
Ed-Dra A.
El Sayed I.
Elhadi M.
El-Huneidi W.
Elias C.
Ellis S.
Elsohaby I.
Eshrati B.
Fahim A.
Fatehizadeh A.
Koya M.S.F.
Feizkhah A.
Garrett D.O.
Ghazy R.M.
Ghoba S.
Giannakis K.
Haddadi R.
Hadei M.
Halim S.A.
Hamidi S.
Hasaballah A.I.
Hasan R.S.
Hasani H.
Haselbeck A.H.
Hay B, C S.
Hezam K.
Hosseinzadeh M.
Hsu R.L.
Hussein N.R.
Imam M.T.
Iregbu K.C.
Ismail F.
Jafarzadeh A.
Jalili M.
Jalilzadeh Yengejeh R.
Jamshidi E.
Jomehzadeh N.
Kamal Z.
Kasraei H.
Khamesipour F.
Khidri F.F.
Khusuwan S.
Kuddus M.
Kyu H.H.
Mahmoud M.A.
Makram DE, DF O.
Malakan Rad E.
Marks F.
McManigal B.
Naghavi M.
Robles Aguilar G.
Davis Weaver N.
Swetschinski L.R.
Wool E.E.
Araki D.T.
Gershberg Hayoon A.
Gray B A.
Han C.
Ikuta K.S.
Rosenblad E.
Aalruz H.
Abd-Elsalam S.
Abedi A.
Abolhassani H.
Aburuz S.
Afzal S.
Ahmad A.
Ahmadzade A.M.
Ahmed A.
Ahmed H.
Ali A.
Ali Z.
Ali L.
Ali S.S.
Al-Marwani S.
Almidani O.
Al-Rifai R.H.
Al-Tawfiq J.A.
Alzoubi K.H.
Andretta Mendes J.
Andrews J.R.
Arabloo J.
Arafat M.
Athari S.S.
Atout M.M.W.
Azadnajafabad S.
Aziz S.
Azizian K.
Barqawi H.J.
Basharat Z.
Bedi N.
Berkley J.A.
Bhattacharjee N.V.
Brown C.S.
Bustanji Y.
Cooper B.S.
Dash N.R.
Dolecek C.
Eckmanns T.
Ed-Dra A.
El Sayed I.
Elhadi M.
El-Huneidi W.
Elias C.
Ellis S.
Elsohaby I.
Eshrati B.
Fahim A.
Fatehizadeh A.
Koya M.S.F.
Feizkhah A.
Garrett D.O.
Ghazy R.M.
Ghoba S.
Giannakis K.
Haddadi R.
Hadei M.
Halim S.A.
Hamidi S.
Hasaballah A.I.
Hasan R.S.
Hasani H.
Haselbeck A.H.
Hay B, C S.
Hezam K.
Hosseinzadeh M.
Hsu R.L.
Hussein N.R.
Imam M.T.
Iregbu K.C.
Ismail F.
Jafarzadeh A.
Jalili M.
Jalilzadeh Yengejeh R.
Jamshidi E.
Jomehzadeh N.
Kamal Z.
Kasraei H.
Khamesipour F.
Khidri F.F.
Khusuwan S.
Kuddus M.
Kyu H.H.
Mahmoud M.A.
Makram DE, DF O.
Malakan Rad E.
Marks F.
McManigal B.
Author's Affiliation
University of Oxford
Inserm
Stanford University
University of Cambridge
Imperial College London
Johns Hopkins University
VA Medical Center
Karolinska Institutet
Washington University School of Medicine in St. Louis
Chongqing University
University of Washington School of Medicine
City University of Hong Kong
University of Texas Health Science Center at Houston
University of Oxford Medical Sciences Division
Tehran University of Medical Sciences
Indiana University School of Medicine
London School of Hygiene & Tropical Medicine
Alexandria University
Organisation Mondiale de la Santé
King Khalid University
Iran University of Medical Sciences
United Arab Emirates University
Qatar University
Al-Azhar University
CHU de Lyon
The University of Jordan
Mashhad University of Medical Sciences
Prince Sattam Bin Abdulaziz University
Edith Cowan University
Nuffield Department of Medicine
University of Sharjah
Korea University College of Medicine
COMSATS University Islamabad
The Aga Khan University
Folkehelseinstituttet
Houston Methodist Hospital
Jazan University
Ahvaz Jundishapur University of Medical Sciences
Kerman University of Medical Sciences
Duy Tan University
Robert Koch Institute
University of Ha'il
Hamadan University of Medical Sciences
University of Peshawar
Abdul Wali Khan University Mardan
Riphah International University
Galgotias University
Université Sultan Moulay Slimane
National University of Medical Sciences
Guilan University of Medical Sciences
Thailand Ministry of Public Health
The University of Agriculture, Peshawar
Shaqra University
Zanjan University of Medical Sciences (ZUMS)
Faculty of Medicine
Al Ain University
Kurdistan University of Medical Sciences
Al-Zaytoonah University of Jordan
Nankai University School of Medicine
Faculty of Veterinary Medicine
University of Nizwa
Mahidol Oxford Tropical Medicine Research Unit
Wellcome Trust Research Laboratories Nairobi
Islamic Azad University, Ahvaz branch
UK Health Security Agency
Rafsanjan University of Medical Sciences
Institute for Health Metrics and Evaluation
Cleveland Clinic Abu Dhabi
University of Abuja
Liaquat University of Medical & Health Sciences
Taiz University
Philadelphia University
Research Center for Immunodeficiencies
University of Swat
D Y Patil University, Navi Mumbai
University of Zakho
International Vaccine Institute, Seoul
Johns Hopkins Aramco Healthcare
University North
Health Policy Research Center
IUMS Health Management and Economics Research Center
Abadan University of Medical Sciences
National Hospital, Abuja
Hamdan Bin Mohammed Smart University
Institute of Endemic Diseases Sudan
Preventive Medicine and Public Health Research Center
Tobruk University
Iran Food and Drug Administration
Institute of Public Health
Sabin Vaccine Institute
King Edward Memorial Hospital
Global Antibiotic Research and Development Partnership (GARDP)
Shaheed Benazir Bhutto University
National Centre for Disease Control
Alpha Genomics Private Limited
Independent Consultant
Pan-Africa One Health Institute (PAOHI)
Inserm
Stanford University
University of Cambridge
Imperial College London
Johns Hopkins University
VA Medical Center
Karolinska Institutet
Washington University School of Medicine in St. Louis
Chongqing University
University of Washington School of Medicine
City University of Hong Kong
University of Texas Health Science Center at Houston
University of Oxford Medical Sciences Division
Tehran University of Medical Sciences
Indiana University School of Medicine
London School of Hygiene & Tropical Medicine
Alexandria University
Organisation Mondiale de la Santé
King Khalid University
Iran University of Medical Sciences
United Arab Emirates University
Qatar University
Al-Azhar University
CHU de Lyon
The University of Jordan
Mashhad University of Medical Sciences
Prince Sattam Bin Abdulaziz University
Edith Cowan University
Nuffield Department of Medicine
University of Sharjah
Korea University College of Medicine
COMSATS University Islamabad
The Aga Khan University
Folkehelseinstituttet
Houston Methodist Hospital
Jazan University
Ahvaz Jundishapur University of Medical Sciences
Kerman University of Medical Sciences
Duy Tan University
Robert Koch Institute
University of Ha'il
Hamadan University of Medical Sciences
University of Peshawar
Abdul Wali Khan University Mardan
Riphah International University
Galgotias University
Université Sultan Moulay Slimane
National University of Medical Sciences
Guilan University of Medical Sciences
Thailand Ministry of Public Health
The University of Agriculture, Peshawar
Shaqra University
Zanjan University of Medical Sciences (ZUMS)
Faculty of Medicine
Al Ain University
Kurdistan University of Medical Sciences
Al-Zaytoonah University of Jordan
Nankai University School of Medicine
Faculty of Veterinary Medicine
University of Nizwa
Mahidol Oxford Tropical Medicine Research Unit
Wellcome Trust Research Laboratories Nairobi
Islamic Azad University, Ahvaz branch
UK Health Security Agency
Rafsanjan University of Medical Sciences
Institute for Health Metrics and Evaluation
Cleveland Clinic Abu Dhabi
University of Abuja
Liaquat University of Medical & Health Sciences
Taiz University
Philadelphia University
Research Center for Immunodeficiencies
University of Swat
D Y Patil University, Navi Mumbai
University of Zakho
International Vaccine Institute, Seoul
Johns Hopkins Aramco Healthcare
University North
Health Policy Research Center
IUMS Health Management and Economics Research Center
Abadan University of Medical Sciences
National Hospital, Abuja
Hamdan Bin Mohammed Smart University
Institute of Endemic Diseases Sudan
Preventive Medicine and Public Health Research Center
Tobruk University
Iran Food and Drug Administration
Institute of Public Health
Sabin Vaccine Institute
King Edward Memorial Hospital
Global Antibiotic Research and Development Partnership (GARDP)
Shaheed Benazir Bhutto University
National Centre for Disease Control
Alpha Genomics Private Limited
Independent Consultant
Pan-Africa One Health Institute (PAOHI)
Corresponding Author(s)
Other Contributor(s)
Abstract
Background Antimicrobial resistance (AMR) is an urgent global crisis and one of the world's most complex challenges. Although there is increasing evidence of its impact on human mortality and morbidity, precise burden estimation has many challenges, and thus far has been elusive for the Eastern Mediterranean Region. Here, we present a comprehensive time-trend analysis of regional and country-level AMR burden estimates in the WHO Eastern Mediterranean Region (EMR), between 1990 and 2021, with forecasts up to 2050. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 11 infectious syndromes, 22 bacterial pathogens, and 84 pathogen–drug combinations for the WHO EMR and each of its countries from 1990 to 2021. Data were obtained from mortality registries, surveillance systems, hospital records, systematic literature reviews, and other sources. We based our modelling approach on five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths and DALYs attributable to AMR (considering an alternative scenario where drug-resistant infections are replaced with susceptible infections), and deaths and DALYs associated with AMR (considering an alternative scenario where infections would not occur at all). Predictive statistical modelling was applied to generate estimates of AMR burden for each country. We also generated AMR burden forecasts up to 2050. We generated 95% uncertainty intervals (UIs) for the final estimates by taking the 2·5th and 97·5th percentiles across 500 draws through the multistage computational pipeline, and models were cross-validated for out-of-sample predictive validity. Findings We estimated 380 000 deaths (95% UI 332 000–426 000) associated with bacterial AMR and 92 800 deaths (78 300–111 000) attributable to bacterial AMR in the EMR in 2021. In the past 31 years, there was considerable variation in AMR mortality trends across countries of the region and different age groups. Between 1990 and 2021, associated deaths among children younger than 5 years decreased by 50·0% (38·2–62·0), while those among adults aged 70 and older rose by over 85·7% (95% UI 57·0–115·7). Six pathogens were identified as the primary generators of burden: Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Acinetobacter baumannii , and Pseudomonas aeruginosa . A substantial increase in the AMR burden due to S aureus was observed between 1990 (28 200 deaths [21 600–34 000]) and 2021 (49 500 deaths [43 100–56 200]); consequently, in 2021, methicillin-resistant S aureus was a leading pathogen–drug combination for most countries in the region for deaths and DALYs attributable to, and associated with AMR. Somalia had the highest age-standardised mortality rates in the region: for deaths attributable to and associated with AMR per 100 000 population in both 1990 and 2021; conversely, the country with the lowest burden in the EMR was Qatar. By 2050, the number of deaths attributable to AMR in region is forecasted to reach 187 000 (157 000–223 000) and deaths associated with AMR were projected to reach 752 000 (629 000–879 000). Interpretation Our study shows that bacterial AMR has been a serious public health threat in the EMR for more than 30 years, with a substantial fatal and non-fatal burden for priority bacterial pathogens and pathogen–drug combinations. The magnitude of this issue, future projects, and the inadequate response capacity in many countries underscore the need for more stringent regional leadership in this field. The insights gained from this study can direct targeted mitigation strategies for individual countries within the region, aiding in resource allocation and funding decisions, and emphasising the need for collaborative multisectoral endeavours among nations to address this issue. Funding Wellcome Trust, and the UK Department of Health and Social Care using aid funding managed by the Fleming Fund.