Third-generation Cephalosporin resistance in Sub-Saharan Africa: a systematic review and meta-analysis

Antimicrobial resistance is a critical global health threat, with Sub-Saharan Africa disproportionately affected. Third-generation cephalosporins are widely used for severe infections due to their safety, broad spectrum, and effectiveness. However, resistance to third-generation cephalosporins undermines treatment and exacerbates poor outcomes in regions with limited alternative therapies. This systematic review and meta-analysis evaluated the prevalence, temporal trends, and geographical variations of resistant pathogens in Sub-Saharan Africa.

We searched three databases from the inception until 16^th August 2024 for observational studies reporting third-generation cephalosporin resistant infections in Sub-Saharan Africa. Eligible studies reported prevalence data for confirmed infections in SSA. Pooled prevalence estimates with 95% confidence intervals (CIs) were calculated using random-effects meta-analysis, with subgroup analyses by pathogen, region, clinical setting, and publication year.

Here we show a total of 200 studies involving 355,136 patients. The pooled prevalence of third-generation cephalosporin resistant pathogens is 45.3% (95% CI: 36.7-54.4%). Resistance rates are highest for Klebsiella pneumoniae (57.7%) and Enterobacter spp. (54.2%). Temporal trends show an increase in resistance, with prevalence rising from 22.8% before 2009 to 42.0% in 2020-2024. Geographical disparities are evident, with higher prevalence in East (59.7%) and West Africa (49.8%) compared to Central Africa (27.0%). High-risk settings include neonatal intensive care units, surgical wards, and rural or mixed-care facilities.

Third-generation cephalosporin resistant pathogens represent an escalating global health crisis in SSA, exacerbated by regional disparities and rising resistance rates over time. Immediate interventions are needed, including enhanced surveillance and antimicrobial stewardship programs.