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

ABSTRACT

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] 41·7-55·2, n = 80). Pooled carbapenem resistance proportions were high in Gram-negative pathogens: Escherichia coli: 16·6% (95%CI 10·7-23·4, n = 60); Klebsiella pneumoniae: 34·9% (95%CI 24·6-45·9, n = 50); Pseudomonas aeruginosa: 37.1% (95%CI 24·6-45·9, n = 56); Enterobacter spp.: 51·2% (95%CI 27·5-74·7, n = 7); and Acinetobacter baumannii (complex): 72·4% (95%CI 62·1-81·7%, n = 36). A higher resistance proportions were observed for third-generation cephalosporins: Klebsiella pneumoniae: 78·7% (95%CI 71·5-85·2, n = 46); Escherichia coli: 78·5% (95%CI 72·1-84·2%, n = 58); and Enterobacter spp.: 83·5% (95%CI 71·9-92·8, n = 8). We observed a high between-study heterogeneity (I²  >  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.

KEYWORDS:

• Antibiotic resistance
• hospital-acquired infections
• low-resource countries
• Health equity

Acknowledgments

We thank Ines Noll and Hans-Peter Blank from the Robert Koch Institute for providing data from the German Antibiotic-Resistance-Surveillance (ARS). We also thank Marieke Gerstmann, Elsa Rabe and Sina Wallenfels (data management support), and Nina Schöpf from the Robert Koch Institute for proofreading assistance. Authors Contributions: OA, SB, TE, and RM designed the study. OA, SB, and RM performed literature screening, study selection, data extraction, and assessed of risk of bias. RM conducted the statistical analyses. OA, SB, and RM wrote the first draft of the manuscript with critical input of TE. OA, SB and RM have accessed and verified the data. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by internal funds of the Robert Koch Institute (OA, SB, TE, RM) and the Global Health Protection Program (OA), both through the German Ministry of Health. The funder has no role in the design of the study; collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.