Accepted for/Published in: JMIR Public Health and Surveillance
Date Submitted: Mar 1, 2026
Date Accepted: Jul 19, 2026
Multicentre Antimicrobial Resistance Surveillance Across Four Iraqi Governorates: Implications for Stewardship Policy and WHO AWaRe–Aligned Public Health Strategies
ABSTRACT
Background:
Antimicrobial resistance (AMR) is a major public health threat globally, with disproportionate impact in low- and middle-income countries where surveillance systems are often fragmented. In Iraq, nationally integrated, multicentre resistance data to support stewardship policy and WHO AWaRe–aligned interventions remain limited.
Objective:
To characterise multicentre antimicrobial resistance patterns across hospital and community settings in Iraq and evaluate their implications for national surveillance strengthening and antimicrobial stewardship policy
Methods:
We performed a multicentre cross-sectional analysis of routine microbiology data from four Iraqi governorates representing approximately 10% of the national population. De-duplicated isolates (first isolate per patient per specimen type) were included. Multidrug resistance (MDR) was defined as non-susceptibility to at least one agent in three or more antimicrobial classes. Resistance proportions with 95% confidence intervals were calculated and compared by clinical setting and specimen type.
Results:
Among 846 isolates, Escherichia coli (27.8%), Staphylococcus aureus (17.9%), Pseudomonas aeruginosa (7.7%), and Klebsiella pneumoniae (7.0%) predominated. Overall MDR prevalence was 57.3% (95% CI 53.9–60.6) and was significantly higher among inpatients (p=0.044). Third-generation cephalosporin resistance was detected in 69.3% of E. coli and 44.4% of K. pneumoniae isolates. Carbapenem resistance was present in 12.4% of E. coli, 11.1% of K. pneumoniae, and 29.4% of P. aeruginosa. Methicillin resistance was identified in 89.8% of S. aureus isolates.
Conclusions:
High MDR prevalence and substantial resistance among priority pathogens highlight urgent needs for strengthened national surveillance integration, routine antibiogram reporting, and stewardship interventions aligned with WHO AWaRe targets. These findings provide operationally relevant evidence to support public health policy reform and structured AMR surveillance expansion in Iraq.
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