Antibiotic resistance in hospital-acquired ESKAPE-E infections in low- and lower-middle-income countries: a systematic review and meta-analysis

Antimicrobial resistance (AMR) and hospital-acquired infections (HAIs) are global health challenges. The burden of antibiotic resistance in HAIs is still unclear in low- and lower-middle-income countries (L-LMICs). This study summarizes recent data on antibiotic resistance in priority HAIs (ESKAPE-E) in L-LMICs and compares them with data from high-income countries (HICs). EMBASE, Web of Science, and Global Index Medicus were searched for studies on AMR patterns in HAIs published from 01/2010 to 10/2020. Random-effects meta-analyses were performed to obtain pooled estimates. In total, 163 eligible studies were included in the review and meta-analysis. The pooled methicillin resistance proportion in Staphylococcus aureus was 48.4% (95% confidence interval [95%CI] 41 center dot 7-55 center dot 2, n = 80). Pooled carbapenem resistance proportions were high in Gram-negative pathogens: Escherichia coli: 16 center dot 6% (95%CI 10 center dot 7-23 center dot 4, n = 60); Klebsiella pneumoniae: 34 center dot 9% (95%CI 24 center dot 6-45 center dot 9, n = 50); Pseudomonas aeruginosa: 37.1% (95%CI 24 center dot 6-45 center dot 9, n = 56); Enterobacter spp.: 51 center dot 2% (95%CI 27 center dot 5-74 center dot 7, n = 7); and Acinetobacter baumannii (complex): 72 center dot 4% (95%CI 62 center dot 1-81 center dot 7%, n = 36). A higher resistance proportions were observed for third-generation cephalosporins: Klebsiella pneumoniae: 78 center dot 7% (95%CI 71 center dot 5-85 center dot 2, n = 46); Escherichia coli: 78 center dot 5% (95%CI 72 center dot 1-84 center dot 2%, n = 58); and Enterobacter spp.: 83 center dot 5% (95%CI 71 center dot 9-92 center dot 8, n = 8). We observed a high between-study heterogeneity (I-2 > 80%), which could not be explained by our set of moderators. Pooled resistance proportions for Gram-negative pathogens were higher in L-LMICs than regional and national estimates from HICs. Patients in resource-constrained regions are particularly affected by AMR. To combat the high resistance to critical antibiotics in L-LMICs, and bridge disparities in health, it is crucial to strengthen local surveillance and the health systems in general.