Antimicrobial resistance in Noma control: a costly neglect within existing neglect

Noma is a severe gangrenous orofacial disease affecting malnourished children aged 2–6 years in extreme poverty, with 85–90% mortality if untreated. Recently classified as a Neglected Tropical Disease, it is managed mainly with empirical broad-spectrum antibiotics. Antimicrobial resistance (AMR) threatens to undermine treatment, yet AMR remains largely absent from Noma research and policy. This review examines AMR prevalence and drivers in Noma, identifies knowledge and policy gaps, and proposes recommendations. We reviewed literature on Noma microbiology and documented AMR, plus WHO NTD and AMR policy documents. Community and health system factors and surveillance capacity in Noma-endemic regions, primarily Sub-Saharan Africa, were synthesized. Noma lesions show marked dysbiosis with frequent detection of Fusobacterium necrophorum, Prevotella spp., Staphylococcus aureus, Pseudomonas aeruginosa, and a novel “Treponema sp. A”. A 25-year retrospective analysis found that >92% of patients presented late, requiring prolonged antibiotics. Direct AMR data are scarce. Case reports documented MDR- Escherichia coli in Afghanistan (2012), Vancomycin-resistant Enterococci in South Korea (2022), ESBL E. coli in Mali (2021), Serratia marcescens (Ticarcilline, amoxicillin, and sulfamethoxazole-trimethoprim) and Pseudomonas aeruginosa (Rifampicin) in Chad (2014); and Pseudomonas aeruginosa (penicillins, carbapenems, aminoglycosides, sulfamethoxazole-trimethoprim, and nitrofurantoin) in Italy (2015). A recent metagenomic study reported high β-lactam and metronidazole resistance determinants, especially in Prevotella spp. Drivers include empirical broad-spectrum antibiotic use, self-medication, irrational prescribing, and weak diagnostics, with only a small share of laboratories across 14 SSA countries performing routine bacteriology and susceptibility testing. Policy gaps persist: WHO NTD and AMR strategies are siloed, anaerobes are excluded from GLASS surveillance, and Noma guidelines lack AMR triggers. AMR risks reversing gains in Noma control, and treatment centers may become AMR amplification sites without stewardship. Given limited microbiology data, we recommend adding AMR indicators to WHO and national Noma strategies, integrating anaerobic AMR surveillance at sentinel sites, generating Noma-specific antibiograms, and mandating antimicrobial stewardship in Noma programs. Mainstreaming AMR in Noma research and policy is essential to preserve therapeutic options.