Neonatal Colonization With Antibiotic-Resistant Pathogens in Low- and Middle-Income Countries : A Systematic Review and Meta-Analysis

Abstract

This systematic review and meta-analysis investigates the prevalence of colonization with antibiotic-resistant bacterial pathogens in the first 3 months of life in low- and middle-income countries (LMICs).

Key Points

Question

What are the prevalence of and factors associated with colonization with third-generation cephalosporin–resistant Enterobacterales (3GCRE), carbapenem-resistant Enterobacterales (CRE), and methicillin-resistant Staphylococcus aureus (MRSA) during the first 3 months of life in low- and middle-income countries (LMICs)?

Findings

In this systematic review and meta-analysis of 67 studies including 17 152 individuals, the pooled prevalence of 3GCRE colonization was 30% compared with 3% for CRE and 3% for MRSA colonization. Hospital birth, previous neonatal antibiotic use, and prolonged rupture of membranes were associated with increased risk of 3GCRE colonization.

Meaning

The findings suggest substantial prevalence of antibiotic-resistant pathogen carriage in neonates and infants in LMICs.

Abstract

Importance

In low- and middle-income countries (LMICs), neonatal bacterial infections are mainly caused by Enterobacterales species and Staphylococcus aureus, which are also the leading causes of mortality directly attributable to antimicrobial resistance. As bacterial colonization often precedes infection, better knowledge of colonization is crucial to prevent antibiotic-resistant neonatal sepsis.

Objective

To synthesize current evidence on the prevalence of and factors associated with colonization with third-generation cephalosporin–resistant Enterobacterales (3GCRE), carbapenem-resistant Enterobacterales (CRE), and methicillin-resistant S aureus (MRSA) during the first 3 months of life in LMICs.

Data Sources

PubMed, Scopus, Web of Science, and the World Health Organization Global Index Medicus were searched for articles published from January 1, 2000, through July 29, 2024.

Study Selection

Included studies were conducted in LMICs and reported prevalence rates or factors associated with colonization with 3GCRE, CRE, or MRSA in neonates and infants up to 3 months of age. Outbreak reports were excluded.

Data Extraction and Synthesis

Data extraction and risk-of-bias assessment using a Joanna Briggs Institute tool were performed by 2 independent reviewers. Pooled prevalence for each pathogen was computed using a random-effects model. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Main Outcomes and Measures

Prevalence of and factors associated with 3GCRE, CRE, and MRSA colonization.

Results

Of the 3147 articles identified in the search, 67 studies (51 for 3GCRE and CRE and 16 for MRSA) including 17 152 individuals were eligible. The pooled prevalence of 3GCRE colonization was 30.2% (95% CI, 21.4%-40.7%; τ ² = 1.48; I ² = 95.1%), varying from 18.2% (95% CI, 10.8%-29.1%) in nonhospitalized individuals to 48.2% (95% CI, 36.4%-60.2%) in hospitalized individuals. The prevalence of CRE colonization was 2.6% (95% CI, 0.7%-8.8%; τ ² = 7.79; I ² = 95.6%), while it was 2.7% (95% CI, 1.0%-6.7%; τ ² = 2.58; I ² = 93.5%) for MRSA. Increased risk of colonization with 3GCRE was associated with hospital birth (odds ratio [OR], 1.87; 95% CI, 1.33-2.64), neonatal antibiotic use (OR, 2.96; 95% CI, 1.43-6.11), and prolonged rupture of membranes (OR, 3.86; 95% CI, 2.19-6.84).

Conclusions and Relevance

In this systematic review and meta-analysis of antibiotic-resistant pathogen carriage in individuals aged 0 to 3 months, the pooled prevalence was substantial despite a limited exposure period. Although high heterogeneity between studies limited extrapolation of results, the findings highlight the need for further investigation to identify transmission routes and to design targeted and effective preventive measures.