Antifungal Use and Resistance in a Lower-Middle-Income Country: The Case of Lebanon

Nesrine Hassoun; Issmat I Kassem; Monzer Hamze; Jad El Tom; Nicolas Papon; Marwan Osman

doi:10.3390/antibiotics12091413

Antifungal Use and Resistance in a Lower-Middle-Income Country: The Case of Lebanon

Antibiotics (Basel). 2023 Sep 6;12(9):1413. doi: 10.3390/antibiotics12091413.

Authors

Nesrine Hassoun¹, Issmat I Kassem², Monzer Hamze³, Jad El Tom⁴, Nicolas Papon⁵, Marwan Osman^{6

7}

Affiliations

¹ Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon.
² Center for Food Safety, Department of Food Science and Technology, University of Georgia, 1109 Experiment Street, Griffin, GA 30223, USA.
³ Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli 1300, Lebanon.
⁴ School of Pharmacy, Lebanese American University, Byblos 1401, Lebanon.
⁵ University of Angers, University of Brest, IRF, SFR ICAT, F-49000 Angers, France.
⁶ Cornell Atkinson Center for Sustainability, Cornell University, Ithaca, NY 14853, USA.
⁷ Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.

Abstract

Antimicrobial resistance is a serious threat, particularly in low- and middle-income countries (LMICs). Antifungal resistance is often underestimated in both healthcare and non-clinical settings. In LMICs, it is believed that the inappropriate use of antifungals, limited surveillance systems, and low diagnostic capacities are significant drivers of resistance. Like other LMICs, Lebanon lacks antifungal use and resistance surveillance programs, and the impact of antifungal resistance in the country remains unclear, especially during the unfolding economic crisis that has severely affected medical care and access to safe food and water. Interestingly, the widespread use of antifungals in medicine and agriculture has raised concerns about the development of antifungal resistance in Lebanon. In this light, we aimed to survey available antifungal drugs in the country and evaluate susceptibility patterns of prevalent fungal species to guide empiric treatments and develop antifungal stewardship programs in Lebanon. We noted that the economic crisis resulted in significant increases in antifungal drug prices. Additionally, a comprehensive literature search across PubMed, ScienceDirect, and Google Scholar databases identified 15 studies on fungal infections and antifungal resistance conducted from 1998 to 2023 in Lebanon. While data on antifungal resistance are limited, 87% of available studies in Lebanon focused on candidiasis, while the remaining 13% were on aspergillosis. Overall, we observed a marked antimicrobial resistance among Candida and Aspergillus species. Additionally, incidences of Candida auris infections have increased in Lebanese hospitals during the COVID-19 pandemic, with a uniform resistance to fluconazole and amphotericin-B. Taken together, a One Health approach, reliable diagnostics, and prudent antifungal use are required to control the spread of resistant fungal pathogens in healthcare and agricultural settings.

Keywords: Aspergillus; Candida; Lebanon; One Health; antifungal resistance; epidemiology; surveillance.

Grants and funding

This research received no external funding.