Antimicrobial resistance in community-acquired enteric pathogens amongst children ≤10-years-old in low-and middleincome settings: a systematic review and meta-analysis

Noah O. Okumu ^1* Dishon M. Muloi ¹ Arshnee Moodley ¹ Julie Watson ² Alice Kiarie ¹ Linnet Ochien'g ¹ Joseph O. Wasonga ¹ Christine Mutisya ¹ Lorren Alumasa ¹ Joseph J. N. Ngeranwa ³ Oliver Cumming ² Elizabeth Anne Jessie Cook ¹

• ¹ International Livestock Research Institute (ILRI), Nairobi, Kenya
• ² Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
• ³ Kenyatta University, Nairobi, Kenya

Introduction: Antimicrobial resistance (AMR) is a global health priority. This systematic review summarizes the prevalence of AMR in enteric pathogens of community origin amongst ≤10-year-old children in low- and middle-income countries (LMICs). This study reports proportions of pooled resistance in Campylobacter sp., Escherichia coli, Shigella sp. and Salmonella sp. (CESS) to clinically relevant antibiotics. Methods: Six online repositories (PubMed, Medline, Web of Science, Cochrane Library, CABI, and EMBASE) were searched for articles published between January 2005 - September 2024. Random effects meta-analyses models were conducted to estimate the pooled AMR proportions for CESS pathogens, and subgroup analysis done by region. Results: Sixty-four publications from 23 LMICs met our inclusion criteria. Pooled E. coli AMR estimates were sulfamethoxazole/trimethoprim (SXT) 71% [95%CI:57-82%]; ampicillin (AMP) 56% [95%CI: 44-67%]; ciprofloxacin (CIP) 10% [95%CI: 5-20%]; and ceftriaxone (CRO) 8% [95%CI:2-31%]. The proportions of AMR detected in Shigella sp. were AMP 76% [95%CI: 60-87%]; nalidixic acid (NA) 9% [95%CI:2-31%]; CIP 3% [95%CI:0-15%]; and CRO 2% [95%CI:0-19%]. Salmonella sp. AMR proportions were AMP 55% [95%CI:35-73%] and SXT 25% [95%CI:15-38%]. Campylobacter spp. AMR proportions by antibiotic were: erythromycin (ERY) 33% [95%CI:12-64%] and CIP 27% [95%CI:8-61%]. There was high variability in regional subgroup analysis with high inter-study and region heterogeneity I2 ≥75%. Conclusions: Our results summarize drug-resistant enteric bacterial pathogens in young children, providing evidence that CESS pathogens are increasingly becoming insensitive to clinically important antimicrobials. Regional differences in resistance patterns amongst these community isolates highlight the need for strong national and regional surveillance to detect regional variation and to inform treatment and appropriate antibiotic stewardship programs. The limitations of our findings include high regional variability, significant inter-study heterogeneity, and underrepresentation of certain LMICs.