Antimicrobial resistance (AMR) is a widespread challenge in Syria and among Syrian refugees and migrants, with Syrian clinicians routinely encountering resistant bacterial infections1,2. However, surveillance data from within Syria remain limited, with most available evidence derived from clinical and screening samples in refugee-hosting countries3. These data point to significant AMR prevalence, highlighting the urgent need to strengthen surveillance and control capacities. Syria’s post-conflict setting—characterised by fragmented health systems, governance breakdown, and environmental degradation—further complicates AMR containment. Community and hospital-based transmission of multidrug-resistant organisms (MDROs) threatens the efficacy and outcomes of essential medical interventions such as surgery and intensive care, where such infections prevail. Moreover, population displacement and cross-border movement hinder both diagnosis and tracking of AMR, posing additional challenges for host countries dealing with limited diagnostic resources and undocumented antibiotic histories.

This commentary outlines the drivers of AMR in Syria and emphasises the need for a multisectoral response that goes beyond health sector interventions alone. The conflict has exacerbated pre-existing AMR risks, including weak regulation, unregulated over-the-counter antibiotic use, lack of stewardship programs, and a near absence of treatment guidelines4. As in other contexts, conflict can therefore be seen as an amplifier of existing stressors for AMR.

While not an exhaustive review of MDROs in Syria, we highlight key evidence to underscore the urgency. A 2018 review of data on MDROs in Syria found few robust studies in Syria since the onset of conflict1; authors noted high proportions of extended spectrum beta-lactamase (ESBL) producing Gram negative bacteria and high rates of MDRO Pseudomonas sp.1. They identified studies from the region and Europe, noting that MDRO carriage among Syrian refugees was higher than local populations (83%–33%) with high rates of carbapenem resistant Enterobacteriaceae. Another report analysing 3577 isolates from across Syria found carbapenem resistance in 20% of E. coli and Proteus, 45% of Pseudomonas, and 90% of Acinetobacter5. Similar patterns were reported in Moghnieh et al.‘s review of AMR in fragile Eastern Mediterranean countries, including Syria, though data remained sparse2. Collectively, the evidence—while limited—points to a substantial and under-characterised AMR burden in Syria, necessitating urgent multisectoral action and investment in robust surveillance.

Understanding the context

The collapse of Syria’s long-standing regime in December 2024 exposed the severe degradation of health infrastructure in former regime-held cities such as Damascus, Aleppo, Homs, and Latakia, where major hospitals were found virtually inoperative due to chronic underfunding, corruption, and aid diversion6. Prior to this, over a decade of conflict had fragmented the health system into subnational entities with limited coordination7. For example, the 2019 AMR National Action Plan (NAP), developed with WHO, excluded non-regime areas and suffered from weak implementation even within its intended scope due to insufficient resources and political will. The collapse of governance further undermined regulation, allowing unchecked over-the-counter antimicrobial sales, poor-quality drugs, and unrestricted use of last-resort antibiotics, with minimal enforcement of antimicrobial stewardship (AMS) or treatment guidelines2.

The conflict also displaced over half of Syria’s pre-war population of 22 million8. As of 2024, 7 million remain internally displaced, many in overcrowded camps or shelters lacking clean water, sanitation, and waste management9. Recurrent cholera outbreaks and polio resurgence have underscored systemic gaps in immunisation and WASH infrastructure10. Despite recent returns—over 400,000 refugees and 1 million IDPs—many continue circular migration due to unsafe or uninhabitable home areas11. Currently, 40–60% of healthcare facilities are non- or partially functioning, with poor service quality and limited access12. The decaying infrastructure, overwhelmed healthcare facilities, poor prioritisation and the inadequate supply of required materials have led to neglected infection prevention and control (IPC) measures, a key component of AMR control. A recent study focusing on northeast Syria found that over 90% (30 out of 33) of assessed health facilities did not meet half of the WHO’s minimum IPC requirements, with healthcare-associated infection (HAI) surveillance components almost entirely absent13. Further work to assess the state of IPC across the country and a surveillance system for HCAIs is urgently needed.

Microbiology services are similarly underdeveloped, with outdated equipment, frequent malfunctions, and irregular supply of reagents—particularly in former regime areas. Many labs lack standardised protocols, quality control, and basic infrastructure. These diagnostic deficits contribute to widespread empirical and inappropriate antimicrobial use, often involving over-the-counter or last-line drugs. Misuse is further driven by patient demand and clinicians’ assumptions favouring broad-spectrum or combination therapies, compounded by a lack of public awareness. Studies report high dispensing rates of inappropriate fixed-dose combinations, despite WHO guidance against their use, and raise concerns over drug quality and dosing accuracy. Additionally, there are grave concerns about the quality and appropriate dosing of available antimicrobials14. This combination of poor regulation, limited AMS, weak IPC, and unrestricted access fuels AMR proliferation across both community and healthcare settings. (See Fig. 1)

Fig. 1
Fig. 1
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This figure shows some of the drivers of AMR in Syria, examples of interventions to tackle AMR in Syria and who the key stakeholders for engagement are.

Additional AMR drivers include the high burden of war-related injuries, chronic wounds, and rising non-communicable diseases - all increasing antimicrobial use and healthcare demand. Education and training gaps among healthcare workers persist due to damage to academic institutions, emigration of skilled professionals, weak curricula, and poor adherence to clinical protocols. Regulatory oversight is further undermined by a poorly governed private sector and the influence of pharmaceutical companies, which can distort access and ethical standards. Effective AMR control in Syria must therefore address these intersecting failures across governance, infrastructure, regulation, and education.

Thinking beyond human health

Growing literature highlights the role of environmental, agricultural, and climatic factors in AMR development, particularly in conflict-affected settings15. In Syria, war has severely damaged sectors critical to AMR containment. Repeated attacks on water and energy infrastructure have compromised water quality and access, while contamination from heavy metals, landmines, and unexploded ordnance remains widespread. Though the One Health approach is increasingly endorsed—such as in the May 2024 UN Political Declaration calling for cross-sectoral responses16, Syria’s implementation has been limited and fragmented.

The protracted conflict in Syria has resulted in vast damage to buildings and infrastructure, and altered behaviours and adaptation related to heating and fuel. The toxic remnants of war and pollution, including reliance on diesel generators, open waste incineration, and airborne pollutants from destroyed buildings during bombing campaigns, significantly degraded air and water quality, fostering reservoirs of resistant microbial populations. This results in an increase in particulate matter less than 2.5 micrometres in diameter (PM2.5) from these sources, which worsens respiratory health and serves as a vector for bacteria, while toxic remnants of war and persistent pollution contribute to AMR selection pressures and impact host immunity to infection17. Previous research showed high PM2.5 levels in Syria (averaging 44 µg/m³ annually), highlighting this issue18.

Climate change acts as a critical amplifier of these challenges. Elevated ambient temperatures accelerate bacterial replication rates and enhance the transmission dynamics of resistant pathogens19. Climate change might also affect host susceptibility to infection20. Extreme weather events, particularly flooding, can mobilise and disseminate resistant bacteria through water systems, increasing the spread of AMR across populations19. In Syria, the impacts of climate change, including the extremes of temperature, drought and desertification, are increasingly seen, acting as a further stressor among already vulnerable communities. Though a causality relationship to AMR in Syria needs further exploration, its impacts are evident where climate-induced droughts place additional strains on the already fragile water infrastructure, limiting access to safe water and undermining sanitation efforts, which are crucial in controlling infection spread and mitigating AMR development15. In addition, the severe disruptions to energy supplies can also compromise cold chain systems, which are essential for antibiotic storage, leading to degraded medicines and subtherapeutic dosing, which further accelerates resistance selection.

Political prioritisation and investment

Post-regime Syria faces a health system in disarray, with competing priorities. Addressing AMR requires strong political leadership and cross-sectoral coordination, including Ministries of Health, Agriculture, Higher Education, and Environment. A national AMR committee could facilitate this, engaging stakeholders from government, academia, the diaspora, civil society, and the private sector to drive governance, accountability, coordination and policy coherence. Investment in locally generated, high-quality evidence is essential to guide implementation (see Fig. 1).

Core pillars such as IPC, AMS, diagnostics, and surveillance must be reinforced alongside education, community engagement, and tailored public health messaging. A phased, context-sensitive AMR strategy—building on local initiatives, Syrian diaspora expertise, and international technical support—can enable bottom-up implementation. A robust strategy must move beyond theory into practice and extend beyond human health alone, actively involving different sectors, e.g., environmental, veterinary, and agricultural sectors, in coordinated, financed, and technically supported AMR efforts. Alongside this, the evidence base related to AMR in Syria, understanding its burden, development and transmission (including behavioural factors) must be prioritised in a strategic, coordinated and equitable way. For example, understanding socioeconomic, gendered and healthcare access-related factors, e.g., in rural areas, is key to the generation of contextualised policies which are suited to the sub-contexts within Syria’s borders.

Education across all societal levels—from schoolchildren to healthcare providers and policy makers—is critical to shifting behaviours that sustain AMR. Community-based campaigns using participatory approaches and trusted messengers (e.g., artists, religious leaders, teachers, community health workers) can improve antibiotic literacy and discourage misuse, such as using antibiotics for viral infections21, particularly in settings where traditional health messaging is less effective21. This also includes staggered policies aimed at addressing over-the-counter antibiotic availability or restricting last-line antimicrobials; these require careful consideration to ensure that those with limited healthcare access, particularly in peri-urban or rural areas, are not put at risk. Related to this is the importance of ensuring quality assurance of antibiotics on the market. In a country where pre-conflict, more than 90% of medicines were produced in Syria, re-establishing the devastated pharmaceutical industry with an emphasis on quality and market needs is an intervention that international stakeholders can support as Syria’s borders open up22. While regulation remains important, it cannot substitute for policies grounded in the realities of the local system and resources. Priority must be given to developing coherent, context-sensitive policies that ensure appropriate access to quality antibiotics in all sectors.

Conclusion

AMR is a major healthcare burden in Syria, looming over the population and threatening its economy, calling for an urgent intervention from the relevant Syrian ministries and international organisations. Though further evidence which characterises AMR as well as contextualised transmission pathways and behavioural components is needed, the current evidence base, though weak, suggests the urgency of this issue. In particular, measures which emphasise prevention, e.g., education, vaccination, WASH, IPC, and AMS, are key given the state of the economy and health system. Strengthening laboratory capacity will not only support the clinical care of patients but also AMR surveillance to better understand its burden. Without addressing AMR across sectors, infections caused by MDROs will cause undue morbidity and mortality to the population. Capitalising on existing expertise in these fields within Syria and among the Syrian diaspora and more widely is essential as Syria emerges from decades of oppression and years of protracted conflict and isolation on the international stage.