Antimicrobial Resistance Across Four Iraqi Governorates: A Multicenter Cross-Sectional Surveillance Analysis With Implications for Antimicrobial Stewardship Policy and WHO AWaRe-Aligned Public Health Strategies

Background: Antimicrobial resistance is a major public health threat globally, with disproportionate impact in low- and middle-income countries, where surveillance systems are often fragmented. In Iraq, nationally integrated multicenter resistance data to support stewardship policy and World Health Organization Access Watch Reserve (WHO AWaRe)-aligned interventions remain limited. Objective: The objective of this study is to characterize multicenter antimicrobial resistance patterns across inpatient and outpatient laboratory settings in selected Iraqi governorates, and evaluate their implications for surveillance strengthening and antimicrobial stewardship policy. Methods: We performed a multicenter cross-sectional surveillance analysis of routine microbiology data from four Iraqi governorates, representing approximately 10% of Iraq's population. Deduplicated isolates (first isolate per patient per specimen type) were included. Multidrug resistance was defined as non-susceptibility to at least one agent in three or more antimicrobial classes. Resistance proportions with 95% CI were calculated and compared by clinical setting and specimen type. Results: Among 846 isolates, Escherichia coli (n=235/846, 27.8%), Staphylococcus aureus (n=151/846, 17.9%), Pseudomonas aeruginosa (n=65/846, 7.7%), and Klebsiella pneumoniae (n=59/846, 7.0%) predominated. Overall multidrug resistance prevalence was 57.3% (95% CI 53.9-60.6) and was significantly higher among inpatients (P=.04). Third-generation cephalosporin resistance was detected in 69.3% (106/153) of Escherichia coli and 44.4% (8/18) of Klebsiella pneumoniae isolates. Carbapenem resistance was present in 12.4% (20/161) of Escherichia coli, 11.1% (2/18) of Klebsiella pneumoniae, and 29.4% (5/17) of Pseudomonas aeruginosa. Methicillin resistance was identified in 89.8% (136/151) of Staphylococcus aureus isolates. Conclusions: High multidrug resistance prevalence and substantial resistance among priority pathogens highlight urgent needs for strengthened surveillance integration, routine antibiogram reporting, and antimicrobial stewardship interventions aligned with WHO AWaRe targets. These findings provide multicenter subnational evidence to support surveillance strengthening, routine antibiogram reporting, and antimicrobial stewardship policy refinement in Iraq.