Antibiotic resistance in the paediatric population in Pakistan (1996-2025): a systematic review and meta-analysis

Pakistan is facing a severe antimicrobial resistance (AMR) crisis, with the paediatric population at the highest risk. Despite widespread antibiotic use, there has been no long-term synthesis of paediatric-specific AMR data in the country until now.

We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, searching PubMed, Scopus, Web of Science, Embase, and Google Scholar for studies (January 1996-December 2025) reporting antibiotic susceptibility data in children aged 0-18 years in Pakistan. Where three or more studies reported comparable outcomes, proportions were pooled using a DerSimonian-Laird random-effects model with Freeman-Tukey transformation; remaining findings were synthesized narratively.

Twenty-five studies met inclusion criteria (1996-2025). Pooled bacteriologically confirmed sepsis/bloodstream infection positivity was 24.9% (95% confidence interval [CI]: 14.7-36.7%; k = 8), with associated in-hospital mortality of 17.5% (95% CI: 13.9-21.5%; k = 4). Among Salmonella typhi/paratyphi isolates, pooled multi-drug resistance rate was 55.2% (k = 3), rising from 46.5% in 1996 to 92.9% in 2024 across individual studies; pooled ampicillin and meropenem resistance rates were 85.9% and 0.8%, respectively. A dedicated paediatric hospital found 70.5% ceftazidime-avibactam resistance among carbapenem-resistant isolates, and extended-spectrum β-lactamase (ESBL) production reached 67.3% in neonatal sepsis isolates at another centre. Antibiotic use across point prevalence surveys ranged from 82.1% to 97%, with only 2.0% culture-guided prescribing rate in the largest survey.

Published evidence from Pakistan confirms an increasing paediatric AMR crisis spanning carbapenem resistance, extensively drug-resistant typhoid, methicillin-resistant Staphylococcus aureus, and ESBL-producing organisms, combined by near-universal empirical prescribing prescription without culture guidance. Urgent national stewardship, surveillance expansion, and diagnostic investment are imperative.