Antimicrobial Resistance in Intensive Care Units in Somalia: A Commentary on Measurement Gaps and Facility-Level Priorities for Infection Prevention and Stewardship

Antimicrobial resistance (AMR) is increasingly shaping intensive care unit (ICU) care, where high antibiotic exposure, invasive devices, and prolonged hospitalization create favorable conditions for resistant pathogens to emerge and spread. Somalia is expanding emergency and critical care capacity, yet many facilities still face gaps in infection prevention and control (IPC), routine microbiology, unit-level antibiograms, and structured antimicrobial stewardship (AMS). This commentary integrates frontline ICU experience in Mogadishu, targeted non-systematic selection of Somali hospital studies, and operational guidance from the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) to discuss pragmatic priorities for ICU AMR response. The aim is not to estimate national prevalence or demonstrate intervention effectiveness. Available studies from Mogadishu suggest substantial multidrug-resistant organism burdens in adult ICU, pediatric ICU, and hospital-acquired infections, while national IPC assessment findings and local stewardship evidence indicate important systems constraints. We argue that a realistic starting point is a minimum facility-level ICU AMR starter package consisting of six linked actions: defined accountability, audited IPC essentials, useful microbiology outputs including quarterly antibiograms, 48-72-hour antibiotic review, planned durations with stop dates, and protection of selected last-line agents using the WHO AWaRe framework. This package is presented as a pragmatic checklist for piloting and local adaptation rather than as a validated national framework. Strengthening measurement, IPC, and stewardship in sentinel hospitals may help generate the local data needed for future policy, quality improvement, and implementation research.