The Public Health Burden of Antimicrobial Resistance in Yemen: A Narrative Review

ABSTRACT

Background and Aim

Antimicrobial resistance is a global health crisis, with its impact magnified in conflict settings like Yemen, where a decimated health system and humanitarian emergency create ideal conditions for the proliferation of resistant pathogens. A clear understanding of the antimicrobial resistance landscape is essential for effective public health interventions. This communication synthesizes and critically appraises peer‐reviewed studies and strategic reports published between 2019 and 2025 to delineate the status of antimicrobial resistance and antibiotic stewardship in Yemen, identify evidence gaps, and propose context‐specific recommendations.

Methods

A systematic search of PubMed, Google Scholar, Dimensions.ai, Semantic Scholar, and WHO regional publications was conducted for relevant literature from 2019 to 2025. Key data on study design, resistance patterns, antibiotic consumption, and knowledge, attitude, and practice were extracted and thematically synthesized. This review critically assesses the evidence base without introducing new primary data.

Results

Localized surveillance indicates concerning resistance rates among key pathogens. Investigations conducted in Aden and Al‐Bayda demonstrate elevated resistance to first‐line antimicrobial agents, including trimethoprim–sulfamethoxazole and amoxicillin–clavulanate. Antibiotic utilization is notably excessive, particularly within intensive care units, with substantial dependence on “Watch” category antibiotics like ceftriaxone and last‐resort drugs such as meropenem. A significant knowledge–practice discrepancy persists; although there is sufficient awareness regarding antimicrobial resistance, self‐medication remains widespread (62.7% of the population), facilitated by the availability of non‐prescription dispensing. The primary obstacle to the rational use of antibiotics is the high cost of diagnostic testing.

Conclusion

Antimicrobial resistance in Yemen is a crisis driven by systemic collapse, not merely knowledge deficits. Effective interventions must be conflict‐adapted, prioritizing subsidized diagnostics, redesigning awareness campaigns to address behavioral drivers, and integrating AMR containment into all humanitarian health responses.

1. Background

Antimicrobial resistance (AMR) is a leading global public health threat, directly causing an estimated 1.27 million deaths and associated with nearly 5 million deaths in 2019 [1, 2, 3]. Projections suggest that without intervention, AMR could cause 39.1 million deaths between 2025 and 2050 [4]. The burden falls disproportionately on low‐ and middle‐income countries (LMICs), where weak health systems and a high prevalence of infectious diseases accelerate the emergence of resistant pathogens [5, 6].

The mechanisms fueling this crisis in conflict zones are multifaceted. The breakdown of health infrastructure leads to a collapse in infection prevention and control (IPC) measures, while disrupted supply chains can increase the prevalence of substandard and falsified medicines [7]. Overburdened healthcare systems, combined with the mass displacement of populations and a rise in malnutrition and war‐related injuries, create a surge in infectious diseases and a corresponding demand for antibiotics [8]. This pressure often forces clinicians into empirical prescribing without the guidance of diagnostic tests, a situation exacerbated in regions like the WHO Eastern Mediterranean Region, which already reports the highest per capita antibiotic consumption globally [7, 9]. These factors converge to create a perfect storm where resistance can emerge and spread rapidly.

Conflict zones like Yemen represent a dangerous incubator for AMR [10, 11]. Since 2015, the ongoing conflict has devastated Yemen's health system, leaving only half of its facilities fully functional [12]. The destruction of water, sanitation, and hygiene (WASH) infrastructure, coupled with widespread malnutrition and displacement, increases susceptibility to infections and drives antibiotic demand [12]. In this environment, war wounds, cholera outbreaks, and other diseases create intense pressure for antimicrobial use, often in an unregulated manner, turning treatable infections into life‐threatening conditions [11].

1.1. Objectives

Despite the clear danger, the AMR landscape in Yemen is poorly defined due to significant surveillance gaps. This narrative review aims to address this by:

Overviewing and critically evaluating the existing peer‐reviewed literature and strategic reports on AMR and antibiotic stewardship (AMS) in Yemen, published from 2019 to 2025. Identifying key trends in resistance, antibiotic consumption, and socio‐behavioral drivers, while highlighting evidence gaps and offering context‐specific recommendations to inform both national and international efforts in combating AMR within this challenging environment.

2. Methods

This manuscript is structured as a critical narrative review of the existing evidence base on the antimicrobial resistance (AMR) crisis in Yemen. The primary objectives were to review and critically evaluate the existing peer‐reviewed literature and strategic reports on AMR and antibiotic stewardship (AMS) in Yemen, published within a defined period. The scope focused on identifying key trends in resistance patterns, antibiotic consumption, and socio‐behavioral drivers, while simultaneously highlighting critical evidence gaps.

• –Literature Search Strategy and Data Sources

A comprehensive literature search was conducted across major electronic repositories and databases: PubMed, Google Scholar, Dimensions.ai, and Semantic Scholar. This was complemented by searches of gray literature sources, including WHO–EMRO publications and Yemeni Ministry of Public Health and Population (MoPHP) reports.

The search was restricted to studies published between January 2019 and July 2025. This timeframe was selected to capture the most recent evidence following the escalation of the conflict and disruption of health services, extending to July 2025 to intentionally capture preliminary findings and accepted manuscripts made available ahead of formal publication.

• –Advanced Search Protocol:

To ensure the rigor and transparency required for this assessment, specific advanced search strategies utilizing Boolean operators were employed across the selected databases and repositories. Given the diversity of the repositories (structured database vs. broad academic search engines), the search strings were adapted to maximize retrieval sensitivity, combining the geographic focus with all relevant subject areas:

1. Conceptual Search Terms: The search focused on combining the core keywords: “antimicrobial resistance,” “antibiotic stewardship,” “antibiotic use,” and “KAP survey.”

2. Comprehensive Search String (Applied via Boolean Logic): The primary search strings combined the geographic term (Yemen) with all conceptual terms: (Yemen) AND (“antimicrobial resistance” OR AMR OR “antibiotic stewardship” OR “antibiotic use” OR “KAP survey”).

3. Database‐Specific Implementation:

• ◦For PubMed, relevant Medical Subject Headings (MeSH) terms were also incorporated to broaden the search beyond basic keyword matching.
• ◦For Google Scholar, Dimensions.ai, and Semantic Scholar, the search utilized quotation marks (“”) to mandate phrase matching and employed the Boolean operators (AND, OR) to precisely link the conceptual terms with the geographic location, maximizing relevance despite the varied indexing methods of these platforms.

4. Gray Literature Acquisition: Reports from the WHO–EMRO and the MoPHP were searched manually using the listed keywords within the organizations' internal document repositories and via targeted external searches focusing on official publications and national action plans published within the specified timeframe. This step was crucial for retrieving official documents, such as the National Action Plan (NAP) for AMR (2022–2026).

• –Study Selection Process

Following the execution of the search protocols, all identified records were screened against predefined inclusion criteria.

Inclusion Criteria:

1. Original research or official reports.

2. Studies focused explicitly on Yemen.

3. Content addressing antibiotic use, resistance surveillance, Knowledge, Attitude, and Practice (KAP) surveys, or stewardship interventions.

The study inclusion process, detailing the systematic reduction from the initial number of identified records to the final set of included studies, is visually represented in the accompanying flowchart (Figure 1). This chart specifies the number of records identified initially, those remaining after title/abstract screening, and the final number of studies included after full‐text assessment, providing full transparency regarding selection decisions.

• –Data Extraction and Synthesis

FIGURE 1.

Flow diagram of the search and selection process for included studies. *Google Scholar search yielded 973 results; first 200 results screened to identify gray literature and additional sources (n = 200 included in screening).

For each high‐quality publication selected, key data—including authors, year, design, setting, sample size, findings, and limitations—were systematically extracted. Furthermore, the included studies, as detailed in Table 1, rely almost exclusively on cross‐sectional designs and are geographically fragmented, with a heavy concentration in urban centers such as Aden and Sana'a.

TABLE 1.

Synthesis of key evidence on antimicrobial resistance patterns, consumption, and socio‐behavioral drivers in Yemen (2019–2025).

Authors & year	Study design & setting	Sample & population	Key findings	Main limitation
Badulla et al., 2020 [1]	Cross‐sectional; Hospitals & labs in Aden	412 clinical specimens	High overall resistance to TMP–SMX (73.1%) and Amoxicillin–clavulanate (65.2%). Key pathogens: Staphylococcus spp. (41.7%), E. coli (39.8%).	Limited by cross‐sectional design and reliance on localized data primarily from urban centers (Aden), reducing generalizability across the conflict‐affected region.
Orubu et al., 2021 [7]	Mixed‐methods; Yemen	54 healthcare workers (HCWs)	Eighty‐one percent of cases lack AST due to cost. Sixty‐seven percent of pharmacists sell antibiotics without a prescription. Seventy‐four percent of physicians feel pressure to prescribe broad‐spectrum agents.	Exploratory design utilizing a relatively small sample size (54 HCWs), potentially limiting the representativeness of quantitative findings across diverse healthcare facilities.
Hussien et al., 2025 [13]	Cross‐sectional; Wound infections in Al‐Bayda	139 patients	“Alarming” resistance to first‐line antibiotics. Key pathogens: E. coli (20.4%), P. aeruginosa (19.4%), S. aureus (17.6%).	Cross‐sectional design focusing specifically on resistance patterns in wound infections within a single governorate (Al‐Bayda), potentially skewing resistance profiles compared to other infection types.
Al‐Tahish & Alyahawi, 2024 [14]	Retrospective; 5 ICUs in Sana'a	1970 ICU patients	Extremely high consumption (18,017.91 DDD/1000 patient‐days). Seventy‐five percent of antibiotics used were from the WHO “Watch” group (Ceftriaxone, Vancomycin, Meropenem).	Data is limited to consumption patterns exclusively within Intensive Care Units (ICUs) in Sana'a, which are inherently prone to extremely high antibiotic use; it does not reflect general in‐patient or community use.
Alshakka et al., 2023 [15]	Cross‐sectional; General public in Aden	400 members of the public	High knowledge–practice gap. Notably, 81.5% know overuse causes resistance, but 62.7% self‐medicated with non‐prescription antibiotics.	A cross‐sectional design provides a single snapshot in time and is geographically limited to an urban population in Aden, potentially failing to accurately reflect KAP among rural populations.
Al‐Haifi et al., 2025 [16]	Cross‐sectional; University in Thamar	1000 medical students	Good awareness of AMR, but poor practice. Notably, 70.7% admitted to taking antibiotics based on a pharmacist's recommendation without a prescription.	Focuses solely on medical students—a highly specific, educated demographic—limiting the generalizability of the KAP findings to the broader healthcare workforce or the public.
Lassalle, F., et al., 2023 [17]	Genomic surveillance; Yemen	260 V. cholerae samples	Emergence of a multidrug‐resistant Vibrio cholerae strain carrying a new plasmid, which became dominant after 2018.	Limited in scope to genomic surveillance of a single, epidemic‐driven pathogen (Vibrio cholerae), and does not provide insight into resistance trends across the full spectrum of common bacterial infections.

The synthesized evidence was then grouped thematically to describe patterns of antibiotic consumption, prevalent resistance profiles, and documented stewardship efforts. The overall evidence base was critically evaluated to identify consistencies, contradictions, methodological limitations, and data gaps, and then contextualized within the operational realities of Yemen.

• –Quality Assessment and Risk of Bias

In accordance with the aims of a critical narrative overview, a formal, quantitative risk‐of‐bias assessment using standardized tools (such as PRISMA checklists or the Newcastle–Ottawa Scale) was not conducted. This approach was justified by the extreme methodological heterogeneity of the included evidence, which encompasses official governmental reports, microbiological surveillance data, and diverse cross‐sectional KAP surveys. Imposing a single quantitative metric on such disparate study types would obscure the critical evaluation.

Instead, the quality and potential sources of bias in the evidence base were critically evaluated and narratively described during the data synthesis. This process ensured that the resulting synthesis accounted for known methodological limitations, including localized sampling, small sample sizes, and the inherent potential for reporting bias in self‐reported KAP data. These limitations emphasize that conclusions about resistance profiles must be interpreted through the lens of the localized, non‐generalizable findings identified in the source literature.

3. Results

3.1. Resistance Patterns From Localized Surveillance

The available data, though fragmented and primarily from urban centers, indicate widespread resistance across multiple bacterial species (Table 1). A 2020 study in Aden analyzing 412 clinical specimens identified Staphylococcus spp. (41.7%), E. coli (39.8%), Pseudomonas spp. (9.0%), Klebsiella pneumoniae (4.4%) was the most common isolate [1]. The study revealed exceptionally high overall resistance to common oral antibiotics, including trimethoprim–sulfamethoxazole (73.1%) and amoxicillin–clavulanate (65.2%) [1]. Similarly, a 2025 study of 139 patients with wound infections in Al‐Bayda Governorate found the predominant pathogens to be E. coli (20.4%), Pseudomonas aeruginosa (19.4%), Staphylococcus aureus (17.6%), and Citrobacter freundii (16.7%) [13]. The authors reported an “alarming” level of resistance to first‐line antibiotics among most isolates [13]. Genomic surveillance of the cholera epidemic has also revealed the emergence of a multidrug‐resistant Vibrio cholerae strain, driven by a new plasmid that became dominant after 2018 [17].

3.2. Antibiotic Consumption and Stewardship

Antibiotic consumption is extremely high across all levels of healthcare. In the community, self‐medication rates are as high as 78%, with 62.7% of the public in Aden obtaining antibiotics without a prescription [18]. Pharmacists enable this, 67% of whom admit to dispensing antibiotics without a prescription, and physicians, 74% of whom report pressure to prescribe broad‐spectrum agents empirically [7]. In hospitals, a retrospective study in five Sana'a ICUs measured consumption at 18,017.91 Defined Daily Doses (DDD) per 1000 patient‐days—an exceptionally high rate. Critically, about 75% of these antibiotics belonged to the WHO “Watch” group, with ceftriaxone, vancomycin, and the last‐resort carbapenem, meropenem, being the most consumed [14]. Effective stewardship is virtually nonexistent, with the primary barrier being the cost of Antimicrobial Susceptibility Testing (AST), which was not performed in 81% of indicated cases because patients could not afford it [7].

3.3. Knowledge, Attitude, and Practice (KAP)

A profound knowledge–practice gap exists across society. A 2023 survey in Aden found that while 81.5% of the public knew overuse causes resistance, 62.7% had recently self‐medicated [15]. Even among medical students, who demonstrate good knowledge, high rates of non‐prescription antibiotic use persist (70.7%) [16]. This indicates that knowledge alone is insufficient to drive rational behavior when economic necessity and systemic barriers override it.

4. Discussion

The synthesized evidence, while limited by its reliance on cross‐sectional studies from a few urban centers, paints a coherent and alarming picture of AMR in Yemen. The crisis is not one of ignorance but of systemic failure [19]. However, a rigorous scholarly analysis demands that we critically qualify these findings by acknowledging the profound methodological constraints inherent in studies conducted during conflict. The documented resistance profiles, while concerning, must be contextualized by the inherent limitations in their collection. Current data is fragmented and predominantly derived from urban centers, thereby restricting the generalizability of resistance patterns throughout Yemen [1, 13, 17]. For instance, the notably high overall resistance observed in Aden to commonly used oral antibiotics, such as trimethoprim–sulfamethoxazole (73.1%) and amoxicillin–clavulanate (65.2%), primarily reflects findings from specific hospitals and laboratories. Similarly, the emphasis on clinical presentations such as wound infections in Al‐Bayda Governorate introduces selection bias; consequently, the reported resistance profiles may not accurately represent resistance rates in other prevalent infection types, including respiratory or urinary tract infections. Although genomic surveillance, demonstrating the emergence of a multidrug‐resistant Vibrio cholerae strain, provides valuable insights, its limited scope precludes comprehensive conclusions regarding the broader spectrum of bacterial threats. Ultimately, reliance on localized, cross‐sectional data yields mere snapshots, impeding the ability to track temporal trends or establish causal relationships between underlying drivers and resistance development. This emphasizes the near‐total absence of longitudinal surveillance data.

This pattern of limited, localized surveillance is paralleled by the severe methodological constraints impacting the consumption data. The reported antibiotic consumption rates in Yemen are exceptionally high. However, the methodology employed in the key consumption study introduces significant bias, which must be considered when interpreting the findings. Specifically, the measurement of 18,017.91 Defined Daily Doses (DDD) per 1000 patient‐days, with 75% of antibiotics classified within the WHO “Watch” group—including Meropenem—stems exclusively from retrospective data collected across five Intensive Care Units (ICUs) in Sana'a [14]. ICUs inherently involve high patient acuity levels and correspondingly elevated use of broad‐spectrum and last‐resort antibiotics. While this data highlights a critical area requiring immediate Antibiotic Stewardship (AMS) intervention within high‐acuity settings, its confinement to ICU environments limits its applicability for estimating antibiotic use among the general inpatient population or in the community. This methodological limitation warrants caution when formulating national hospital consumption policies; nonetheless, it confirms that last‐resort antibiotics are under substantial pressure.

Finally, while the study setting constrains the consumption findings, the socio‐behavioral evidence is similarly constrained by its demographic sampling. The evidence indicates a significant gap between knowledge and practice. For example, 81.5% of the public in Aden are aware that overuse of antibiotics contributes to resistance; however, 62.7% engage in self‐medication [15]. This observation, primarily derived from cross‐sectional studies confined to urban areas such as Aden, suggests regional limitations. Further, studies focusing on highly educated urban populations, including the survey of 1000 medical students at Thamar University, may overestimate the level of antimicrobial awareness relative to the general population or marginalized groups in rural areas [16]. These demographic and geographic constraints reinforce the review's core argument: that the issue is fundamentally systemic and economic, rather than solely rooted in ignorance. These critical methodological constraints notwithstanding, the synthesized evidence points to a single, overriding conclusion regarding the drivers of AMR. The key drivers—unregulated dispensing, empirical prescribing, and public self‐medication—are rational adaptations to a collapsed health and economic system where diagnostics are an unaffordable luxury [7]. The finding that healthcare workers rank AST as the least important solution to AMR is a pragmatic acknowledgment of this reality, not a rejection of its clinical value and the fact that even medical students—a highly informed demographic—admit to poor practices (70.7% taking antibiotics based on pharmacists' recommendations without prescriptions) confirms that systemic factors, such as limited access to diagnostic testing due to cost, drive behaviors across society.

This systemic reality—where economic constraints override clinical best practice—creates a significant gap between the ambitious goals of Yemen's NAP 2022–2026 and the on‐the‐ground capacity for implementation [20]. The NAP's objectives—such as establishing nationwide surveillance and implementing hospital AMS programs—are technically sound but face monumental hurdles [20]. International partners are providing crucial support for capacity‐building, including training clinicians and assessing laboratories [21, 22]. However, for these top‐down efforts to succeed, they must be paired with bottom‐up solutions that address the immediate barriers faced by patients and providers.

5. Conclusion

AMR in Yemen is a crisis‐within‐a‐crisis, a direct consequence of protracted conflict. It is defined by high‐level resistance to essential antibiotics, driven by systemic factors that make irrational antibiotic use an economic necessity. The pervasive knowledge–practice gap demonstrates that conventional awareness campaigns are insufficient. To be effective, the national and international response must shift from ideal‐world stewardship models to pragmatic, high‐impact strategies tailored for a humanitarian emergency. The most critical and urgent intervention is to neutralize cost as a barrier to diagnostics by subsidizing or providing free rapid diagnostic and susceptibility tests. Without addressing the fundamental economic and structural drivers of irrational use, the silent pandemic of AMR will continue its devastating advance through Yemen, threatening to undermine all other life‐saving health interventions.

Author Contributions

Gamal Esam Ahmed Alsakkaf: writing – review and editing, writing – original draft, methodology, conceptualization, visualization.

Funding

The author received no specific funding for this work.

Disclosure

The lead author Gamal Esam Ahmed Alsakkaf affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Ethics Statement

The author has nothing to report.

Conflicts of Interest

The author declares no conflicts of interest.

Policy on Using ChatGPT and Similar AI Tools

Information collection: We used Dimensions.ai and Semantic Scholar to find relevant journal articles and other sources. Writing – review & editing: We used Google Gemini Pro 2.5 to improve the grammar of the draft sentences into clearer, more academic ones, with human intervention.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.