We read with interest this recently published study in the Journal by Kwok et al. describing antimicrobial resistance (AMR).1 Protracted conflicts have triggered large waves of internal displacement and cross-national forced displacement of millions of people across the Middle East and North Africa region, stretching already overburdened healthcare systems across the region.2 An important public health challenge facing such contexts is AMR where the melee of conflict, overuse of antibiotics, lack of antimicrobial stewardship, weak laboratory infrastructure and insufficient quality and quantity of relevant human resources provide particular drivers for AMR.3 Nosocomial and community transmission is exacerbated by poor infection control practices and inadequate shelter or sanitation leading to increases in AMR which increases the economic burden on patients and the health system.4 ^, 5 This is becoming increasingly pertinent during the COVID-19 pandemic where antimicrobials are overused alongside a weakened antimicrobial stewardship program.6 Data in such conflict affected countries is limited with little reliable data available for Syria.

The few published studies are limited by the small number of samples or patients, lack of generalizability, and mostly originated from the major cities, particularly Damascus and Aleppo.7 Here we report data from 5 public hospitals and 4 private laboratories in 4 major cities across Syria including Damascus, Homs, Latakia, and Tartous. Minimum inhibitory concentrations (MICs) for 1463 out of 3577 isolates (41%) were provided. For the rest, only disc diffusion data was reported with results as sensitive, intermediate, or resistant. The results were obtained after requests were sent to the laboratories by one of the authors. A survey in which available equipment, protocols and training was performed with the participating laboratories. Reports were retrieved for a variety of clinical samples including blood, sputum, urine, and wounds. All samples were collected between June 2016 and March 2018. Methods used by the laboratories included a description of the morphological characteristics of the colonies, biochemical tests and API tests (BioMérieux, France) to determine the genus and/or species of the isolates. Results of antibiotic susceptibility tests were collected for up to 100 isolates of each bacterium in each location. For antibiotic susceptibility testing, 7 labs used the agar disk diffusion method while the remaining 2 labs used the VITEK^Ⓡ 2 method (BioMérieux, France). Susceptibility reports were provided in paper format. Diameters of inhibition zones and MIC values were extracted to Excel™ sheets, and assigned R, I or S where R=resistant, I=intermediate and S=susceptible, following the Clinical and Laboratory Standards Institute (CLSI) guidelines.

Data for 3577 bacterial isolates were provided. The susceptibilities and resistance patterns are detailed in