19 November 2024 - In the wards of Dr Muhammad Waasim Maaz Hospital, also known as Bab al Salama Surgical Hospital in Azaz, northwestern Syria, healthcare workers face a complex challenge every day: treating patients suffering from infections complicated by antimicrobial resistance (AMR). Despite limited resources, they continue to provide care to their community, encountering stories that reflect both the vulnerabilities and resilience of those they treat. 

Zeina’s journey to recovery

Zeina Saleh, along with her mother, at the Bab al Salama Surgical Hospital in Azaz, northwestern Syria. Photo credit: WHO/Mrinalini Santhanam

Six-year-old Zeina Saleh arrived at Bab al Salama Surgical Hospital with a persistent high fever, vomiting and other alarming symptoms. “Even the fever medicine didn’t help,” her mother recalls as she sits in the hospital’s isolation ward. Zeina was lethargic and unresponsive to light or sound, leaving her family deeply worried. 

Dr Anas Al-Dhaher, a pediatrician specializing in neonatology, diagnosed bacterial meningitis after conducting a thorough examination and cerebrospinal fluid analysis. “It’s a serious infection, but we initiated treatment immediately,” he explains.

The Independent Doctors Association (IDA)-managed Bab al Salama Surgical Hospital’s testing lab within the main hospital. Photo credit: WHO/Mrinalini Santhanam 

Despite their swift action, there were warning signs that the infection might be complicated by antibiotic resistance. “We noticed that after starting the standard antibiotics, there wasn’t the expected rapid response in her symptoms,” Dr Anas shares. “This delay made us suspect resistance might be a factor.” 

Unfortunately, without access to culture testing at the hospital, confirming resistance was not an option. Families in Azaz often cannot afford private lab fees, leaving doctors to rely on clinical observations and standardized protocols. “Our emergency protocols always include culturing, but it is not available in our hospital. It’s only available in private labs, but it’s expensive. Also, it’s often inaccurate,” says Dr Anas. 

The medical team adjusted Zeina’s treatment to include broader-spectrum antibiotics to ensure coverage for resistant strains, guided by WHO recommendations. 

Over the next two days, Zeina’s condition improved noticeably—her fever subsided, and she began to eat and engage with her surroundings again. “She completed the full 14-day course and was discharged in good health,” Dr Anas adds. 

Left to right: Dr Husam Abob Alward, Dr Naser El Yousef and Dr Fares Al Shadidy, who work at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

Zeina’s case underscores the challenges healthcare workers face in managing infections in northwest Syria. Antimicrobial resistance complicates these situations, as doctors often must use broad-spectrum antibiotics due to the lack of diagnostic tools. This approach, while necessary, increases the risk of resistance in the long term. 

For Zeina’s mother, the experience was eye-opening. “I learned not to give antibiotics without consulting a doctor. It’s something I want other parents to know,” she says. 

In Azaz and similar communities, misuse of antibiotics is a common problem. Many people bypass doctors altogether and purchase antibiotics directly from pharmacies without prescriptions. Others start antibiotics at the first sign of illness but stop as soon as they feel better, failing to complete the full course. Such practices allow bacteria to survive and evolve, making future infections harder to treat. 

Facing complications head-on

Layal Sheikh, with her mother Azab and father Abdullah, at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

Fifteen-year-old Layal Sheikh’s story highlights the strain antimicrobial resistance places on health care systems. Layal underwent emergency surgery for a suspected abdominal tumor, but her recovery took a complicated turn. Post-surgery, she developed a severe infection. 

“The initial antibiotics didn’t work, likely due to resistance,” explains Dr Naser El Yousef, the lead surgeon who managed her case. The medical team recommended a culture test to identify the most effective antibiotics.  

While waiting for the results the team adjusted Layal’s treatment, cautiously introducing higher-generation antibiotics. This approach was paired with strict infection control measures to ensure that resistance did not worsen. “We took a careful, stepwise approach, escalating antibiotics only when absolutely necessary,” says Dr Naser. 

Over the course of several weeks Layal’s infection began to subside. Her condition stabilized and she was eventually discharged in good health, much to her family’s relief. 

For Layal’s father, the ordeal was a lesson in the importance of timely medical care. 

“We tried home remedies at first, but they didn’t help. The doctors here were thorough and supportive and I’m grateful for their efforts,” he says. 

Dr Naser reflects on the challenges healthcare workers face in managing antimicrobial resistance. “Without access to adequate resources like culture tests and referral systems, we are often navigating in the dark. It’s critical to have the right tools to provide timely and effective care,” he says. 

WHO monitors the distribution of antibiotics and advocates for responsible use while in discussion with the pharmacist at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

WHO monitors the distribution of antibiotics and advocates for responsible use while in discussion with the pharmacist at the Bab al Salama Surgical  

WHO has been instrumental in addressing these gaps by training healthcare workers like Dr Naser and Dr Anas to effectively manage resistant infections, enhance infection control practices across healthcare facilities, and educate patients. With support from USAID’s Bureau for Humanitarian Assistance (BHA), WHO trained over 600 healthcare professionals in 2024 alone and plans to continue advocating for responsible antibiotic use, patient education, and regular testing to ensure that patients like Layal and Zeina can access quality, specialized care when needed. 

The human cost of antimicrobial resistance 

Each patient’s experience sheds light on the growing challenge of antimicrobial resistance in conflict-affected areas like northwestern Syria. Limited resources and the misuse of antibiotics complicate efforts to manage infections effectively. 

Healthcare workers like Dr Anas and Dr Naser do more than treat illnesses – they educate families and promote practices that help prevent resistance. 

“We make a point of explaining the importance of completing medication courses and seeking medical help early,” says Dr Anas. 

For patients and families, these lessons are invaluable. 

“I’ve learned to trust the doctors and follow their advice,” says Layal’s father. “It’s the best way to protect our children.”

Dr. Rajab Bek underlined the urgent need for collective action to face the growing menace of AMR17 November 2024, –World Antimicrobial Awareness Week (WAAW) is held annually between 18 to 24 November. As this year’s WAAW approaches, Syrian health professionals are highlighting the threat of antimicrobial resistance (AMR).

Dr Mohammad Wahid Rajab Bek, Head of the Syrian Association of Infectious Diseases and of the Infectious Diseases Department at Al-Mouwasat University Hospital in Damascus, underlined the urgent need for collective action to face the growing menace of AMR.

"Antibiotics are lifesaving when used properly, but misuse has become widespread," he warned.

"People often turn to antibiotics for common colds and fevers without a prescription, obtaining them from pharmacies or using medications leftover at home. This misuse leads to antibiotic resistance, where bacteria evolve to withstand the effects of antibiotics, putting lives at risk and complicating treatments."

In his medical practice, Dr Bek has observed a troubling increase in antibiotic-resistant urinary tract infections: "Infections once easily treatable now require stronger, more expensive drugs. Costs can escalate from US$ 15–US$ 20 to US$ 500–US$ 1000, burdening health systems and patients. The majority of people can't afford such costs."

The consequences extend beyond financial strain. Antibiotic-resistant infections lead to prolonged illnesses and weaken immune systems. "Even minor infections can escalate into severe complications or death if unresponsive to antibiotics," warns Dr Bek.

To combat AMR at the national level, hospitals have implemented strict antibiotic controls. "Awareness is key," stresses Dr Bek. "Antibiotics are dispensed through a controlled system with specialist consultation. We also focus on preventive measures, like administering specific antibiotics before surgeries."

He underlined the importance of patient responsibility: "Stopping antibiotics early can contribute to resistance. Patients must complete their prescribed course, even if they feel better, and consult their doctor before making any changes."

"Every hour matters. An hour delay in providing the correct antibiotic increases the risk of death by 8%. Appropriate use of antibiotics saves lives. Misuse accelerates resistance."

WAAW is a global campaign to raise awareness about AMR and promote responsible antimicrobial use. This year’s theme, "Educate. Advocate. Act now", underscores the urgency of better antimicrobial stewardship.

This year, the World Health Organization (WHO), in partnership with the Food and Agriculture Organization (FAO), the UN Environment Programme (UNEP) and the World Organization for Animal Health (WOAH), has developed a campaign guide to support WAAW activities. The collaboration highlights the importance of developing a united front against AMR and encouraging all sectors to participate.

Photo caption: WHO staff following up with beneficiaries at one of the WHO-supported health centers in rural Aleppo, Syria. Photo credit: @WHO Syria.

13 November 2024, – In collaboration with the Syrian Ministry of Health (MoH) and partners, WHO has mobilized healthcare services to address the urgent needs of over 510,000 displaced individuals who have crossed from Lebanon into Syria since September 24, 2024. With needs increasing daily and basic services under strain, WHO’s coordinated health interventions support both displaced individuals and host communities, at border crossings, community centers, and shelters, particularly in underserved rural areas.

WHO leads and coordinates the health response to ensure access to essential health services and to mitigate risk of disease outbreaks among new arrivals and host communities. Services include primary healthcare, disease surveillance, mental health and psychosocial support (MPHSS), and water quality monitoring. Mobile medical teams provide integrated clinical care, including nutrition, routine immunization and Psychological First Aid on-site. Additionally, 24/7 mental health hotlines in Aleppo and Damascus, coupled with WHO outreach teams, offer specialize support to the most vulnerable, including survivors of gender-based violence.

To strengthen disease surveillance, WHO supports the MoH’s Early Warning, Alert, and Response System (EWARS) with operational resources and rapid response teams. EWARS data collection and response activities are being bolstered through WHO-supported field assistants, particularly in high-risk areas like Aleppo, Lattakia, Tartous, Homs, and Rural Damascus.

Children under 5, including new arrivals, are benefiting from expanded immunization services – most recently during the third round of the Big Catch-Up activity from 13 to 17 October. More than 10,000 children displaced from Lebanon were screened. WHO also provided vitamin A supplements to over 750,000 children and extended vaccinations to hosting centers through community outreach.

“Syria is facing a crisis within a crisis. The number of people in need is growing daily while the country’s capacity to absorb additional pressures is increasingly strained at time when the humanitarian response is critically underfunded. Guided by our commitment to leaving no one behind, WHO is supporting health partners, including the Ministry of Health, to deliver lifesaving health services to those most vulnerable need,” said Christina Bethke, WHO Representative, a.i. to Syria.

In addition to clinical care, WHO is conducting nutrition screenings at hosting centers and host communities, monitoring water quality for safe drinking water, and disseminating health messages to prevent waterborne and respiratory diseases. In October, WHO dispatched over 118 tons of essential medical supplies to support displaced populations and local health facilities. Oxygen concentrators and assistive devices were distributed in Homs, along with 100 First Aid Kits to the MoH across various governorates.

The generosity and flexibility of WHO’s existing humanitarian donors has enabled the response to date. Over the next six months, WHO will need an additional US$17.2 million to sustain these efforts and calls upon international donors to support the response, ensuring that lifesaving care reaches vulnerable populations and strengthens Syria’s long-term healthcare resilience.