Antimicrobial resistance of Enterobacterales in Central Africa: a systematic review and meta-analysis

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Antimicrobial resistance (AMR) in Enterobacterales is a growing concern in sub-Saharan Africa, yet data remain scarce for Central Africa. We conducted a systematic review and meta-analysis (2008–2024) to estimate the prevalence of extended spectrum ß-lactamase-producing Enterobacterales (ESBL-EB) and AMR frequency across nine Central African countries. Systematic searching strategy and risk of bias assessment followed PRISMA guidelines. Prevalence or frequencies and 95% confidence intervals were estimated using a random effects meta-model with the Der Simonian and Laird method. Here we show an ESBL-EB pooled prevalence of 22% (41% for carriage and 10% in clinical samples) for the 24 selected articles assessing ESBL-EB. For the 26 selected articles assessing AMR frequency, we find it is high for cotrimoxazole (63–81%), amoxicillin/clavulanic acid (43–63%), ciprofloxacin (24–33%), and remains lower for nitrofurantoin (12–18%) and amikacin (13–19%). We provide pooled estimates for alternative agents and highlight the near-total absence of data for WHO Reserve antibiotics, including carbapenems, newer β-lactam/β-lactamase inhibitors, and fosfomycin. Significant heterogeneity and high exclusion rate due to risk of bias reflect major diagnostic limitations in the region. The high prevalence of AMR in Central Africa underscores the urgent need to strengthen antimicrobial susceptibility testing capacities, restrict empirical use of key antibiotics, and ensure equitable access to effective antimicrobials. Without coordinated investments for microbiology capacities scale-up, prescription regulation, strategies for water, sanitation and hygiene, and infection prevention and control, patient outcomes and regional AMR containment will be jeopardized. Antibiotic resistance occurs when bacteria are not killed by the antibiotic usually being used as treatment. It can lead to untreatable infections and is expected to be the leading cause of death by 2050. Antibiotic resistant bacteria hosted in the gut are responsible for most of this burden. It is unclear how much antibiotic resistance occurs in Central Africa as surveillance systems are not fully operational. We looked at scientific publications on antibiotic resistance of gut bacteria in this region. We found high resistance levels in healthy people as well as individuals with infections, especially for antibiotics used as first treatment option. This could be explained by the lack of access to hygiene and sanitation, affordable healthcare services and alternative antibiotics. Our work suggests coordinated investment is required to limit antibiotic resistance in Central Africa. Garé et al. systematically review the prevalence of antimicrobial resistance (AMR) in Enterobacterales in Central Africa, focusing on Extended-Spectrum β-Lactamase. Data is of heterogenous quality and shows high levels of AMR in clinical and carriage samples. Peer Review: Communications Medicine thanks Olga Perovic, Mecky Matee for their contribution to the peer review of this work. [A peer review file is available.]

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