The proliferation of AR pathogens is a serious worry for physicians and scientists.3 In Saudi Arabia, the easy accessibility of antimicrobials without a prescription, coupled with self-medication practices and incomplete antibiotic courses, fuels the emergence of AR bacteria.^16,17 A 2014 study demonstrated that approximately 78% of people in Saudi Arabia had self-medicated with antimicrobial drugs at some point in their lives.¹⁷ Another study conducted in 2015 revealed that antimicrobial misuse is prevalent in Saudi Arabia, with almost 64% of individuals consuming antimicrobials without a prescription and approximately 71% failing to complete prescribed antibiotic regimens.¹⁶ The absence of programs to monitor AR has caused healthcare staff and patients using antibiotics inappropriately.¹⁸ This enables bacteria to transfer AR genes and resistance-boosting factors, contributing to the spread of MRSA and MDR bacteria. These infections can be more difficult to treat and can lead to higher mortality rates.^19-21 Additionally, the introduction of effective antimicrobial drugs has slowed down, and the options for overcoming AR are limited.^19,20

This study aimed to determine the levels of AR, including MRSA and MDR, in major Gram-positive bacterial pathogens found in patients at a private Saudi Arabian hospital. From January 2017 through December 2021, a total of 6,271 Gram-positive bacteria isolates were accumulated for analysis. This study found a high prevalence of Strep. agalactiae (3,377/6,271; 53.85%), similar to the 76.2% reported by Atif Asghar in Hera General Hospital in Makkah, Saudi Arabia.²¹ Interestingly, this study deviates from those of Aldawsari et al. and Al Mutair et al., who reported Staph. aureus as the leading Gram-positive bacteria in their Saudi Arabian studies.^22,23

From 2017 to 2019, the study observed a general decrease in AR in all studied bacteria. This is consistent with findings from other studies, such as those by Aldawsarie et al. and Wang et al., which were conducted after the implementation of a national action plan to combat AR.^22,24 MSSA exhibited the dramatic drop with the antibiotic CIP (-8%), while for MRSA had DA (-35%), and Enterococcus species had VA (-4%). Contrary to this study, an Iranian study, absent systematic antibiotic guidelines, reported continuous increases in AR against most antibiotics. In particular, from 2015 to 2018, the study found that the resistance of Staph. aureus to CIP increased by 46%, the resistance of Enterococcus species to AMP increased by 13%, and CoNS to CN increased by 14%.²⁵ The contrast between the findings of this study and the study conducted in Iran emphasizes the importance of monitoring AR. This research identified instances where specific bacterial strains completely overcame their resistance to certain antimicrobials within a three-year period. Similarly, MRSA treated with LZD exhibited a significant decline in resistance, transitioning from 49/149 isolates in 2017 to 0/116 isolates in 2019 (a decrease from 33% to 0%).

The results of this study suggest that monitoring AR is crucial in the fight against potentially devastating infections, its benefits are undeniable. This approach helps track drug resistance in bacteria, leading to better antimicrobial choices, shorter hospital stays, and ultimately, saving lives.²⁶ In addition, SNAP tackles the treat of drug-resistant infections head-on, both by closely monitoring their spread through sentinel sites and by safeguarding critically important antibiotics from overuse in animal agriculture.¹⁰ While the long-term effects of these two recently implemented strategies are promising, more data is needed to fully understand their impact.

In March 2017, SNAP took a big step in tackling antimicrobial resistance by adapting and implementing the WHO’s global surveillance system, GLASS. This powerful tool, designed to track drug-resistant bacteria, prioritized monitoring MRSA and MDR strains. In addition, recognizing the looming threat of MRSA and MDR bacteria, the Saudi Arabia Health Ministry, in April 2017, requested a stewardship program key performance indicator (KPI). This KPI, would monitor the effectiveness of interventions against these drug-resistant superbugs, ensuring they stay under control.¹⁰ After implementing these strategies, the data revealed a significant decrease in the prevalence of MRSA and MDR isolate (p < 0.05). This decrease is consistent with findings from other studies, such as those by US Centers for Disease Control and Prevention (CDC) and Majumder et al.^27,28 The decline of MRSA and MDR unlocks a double win; treatment success rates rise, reducing complications and hospital stays, while healthcare systems face less strain from these stubborn infections.^6,29,30

In early 2020, the first case of COVID-19 was reported in Saudi Arabia.³¹ Since then, scientists have cautioned against the misuse of antimicrobial drugs, even though there is clinical evidence that suggests that bacterial co-infections can occur during viral epidemics.^31,32 Antimicrobial use is expected to be high in Saudi Arabian Hospitals due to the severity of the diseases treated and the number of interventions given to patients.^32,33 A recent study found that, during the COVID-19 outbreak, there was an increase in the sale of non-prescription antimicrobial drugs by Saudi pharmacies. In 2020, a study showed a reduction in the total number of isolated pathogens in the hospital, as well as a reduction in AR, MRSA, and MDR. This was likely due to COVID-19 control measures such as school closures, and lockdowns. However, in 2021, another study displayed that AR increased for most isolated Gram-positive bacteria and significantly increased for MRSA (p < 0.05) compared to all previous years. In addition, all isolated pathogens showed a significant increase for MDR in 2021 compared to other years. These findings are consistent with other studies that have shown that the misuse of antibiotics during COVID-19 can lead to an increase in AR bacteria and MDR.^6,32,33 A systemic review estimated that a staggering 88% of people engaged in self-medication with antimicrobials and other drugs during the pandemic.³⁴ Another study from India found that approximately of 216 million doses of antibiotics were sold in 2020 alone.³⁵

While this study demonstrates the effectiveness of SNAP’s strategies in reducing AR from 2017 to 2019, it’s important to acknowledge some limitations that may influence the interpretation of this study: 1) missing clinical data: the study lacked access to vital information like treatment outcomes and mortality rates linked to Gram-positive bacteria, limiting the study analysis scope; 2) incomplete control groups: for some variables, this study couldn’t establish appropriate control groups, potentially impacting the strength of the study comparisons; 3) Enterococcus genus: we couldn’t identify specific Enterococcus species, hampering the study ability to pinpoint AR and infection rates within this genus; 4) policy dynamics ignored: the analysis didn’t factor in potential annual changes in hospital policies driven by COVID-19, physician recommendations, and antibiotic availability; 5) Gram-negative exclusion: the study focused solely on Gram-positive bacteria, excluding a major category relevant to AR trends; 6) Variable sample sizes: year-to-year disparities in the number of tested isolates could introduce inconsistencies in the data. However, during COVID-19, the misuse of antibiotics led to an increase in AR for most isolated pathogens. Therefore, to reach a significate AR reduction and a 50% reduction in MRSA by 2025 as indicated in SNAP, more work needs to be done to implement the SNAP strategies and increase the public’s awareness about AR. To truly solidify the impact of SNAP’s plan, future studies encompassing more hospitals and a wider timeframe are crucial.