Carriage of third-generation cephalosporin-resistant and carbapenem-resistant Enterobacterales among children in sub-Saharan Africa: a systematic review and meta-analysis

Micaela Ruef; Stephane Emonet; Arnaud Merglen; Juan Emmanuel Dewez; Basilice Minka Obama; Gaud Catho; Diego O Andrey; Morgane Kowalski; Stephan Harbarth; Christophe Combescure; Noémie Wagner; Annick Galetto-Lacour

doi:10.1016/j.eclinm.2024.102508

Carriage of third-generation cephalosporin-resistant and carbapenem-resistant Enterobacterales among children in sub-Saharan Africa: a systematic review and meta-analysis

EClinicalMedicine. 2024 Mar 11:70:102508. doi: 10.1016/j.eclinm.2024.102508. eCollection 2024 Apr.

Authors

Affiliations

¹ Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
² Division of Infectious Diseases, Hospital of Valais, Sion, and Faculty of Medicine, Geneva, Switzerland.
³ Division of General Paediatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
⁴ Medical Department, Médecins Sans Frontières, Operational Centre Geneva, Geneva, Switzerland.
⁵ Paediatric Infectious Diseases Unit, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
⁶ Regional Hospital Centre for Ebolowa, Cameroon.
⁷ Infectious Diseases Division, Central Institute, Hospital of Valais, Switzerland.
⁸ Infection Control Division, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
⁹ Division of Infectious Diseases, Department of Medicine and Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
¹⁰ Infection Control Programme and World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
¹¹ Centre for Clinical Research, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
¹² Division of Paediatric Emergency Medicine, Children's Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.

Abstract

Background: The increasing resistance of Enterobacterales to third-generation cephalosporins and carbapenems in sub-Saharan Africa (SSA) is a major public health concern. We did a systematic review and meta-analysis of studies to estimate the carriage prevalence of Enterobacterales not susceptible to third-generation cephalosporins or carbapenems among paediatric populations in SSA.

Methods: We performed a systematic literature review and meta-analysis of cross-sectional and cohort studies to estimate the prevalence of childhood (0-18 years old) carriage of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E) or carbapenem-resistant Enterobacterales (CRE) in SSA. Medline, EMBASE and the Cochrane Library were searched for studies published from 1 January 2005 to 1 June 2022. Studies with <10 occurrences per bacteria, case reports, and meta-analyses were excluded. Quality and risk of bias were assessed using the Newcastle-Ottawa scale. Meta-analyses of prevalences and odds ratios were calculated using generalised linear mixed-effects models. Heterogeneity was assessed using I² statistics. The protocol is available on PROSPERO (CRD42021260157).

Findings: Of 1111 studies examined, 40 met our inclusion criteria, reporting on the carriage prevalence of Enterobacterales in 9408 children. The pooled carriage prevalence of ESCR-E was 32.2% (95% CI: 25.2%-40.2%). Between-study heterogeneity was high (I² = 96%). The main sources of bias pertained to participant selection and the heterogeneity of the microbiological specimens. Carriage proportions were higher among sick children than healthy ones (35.7% vs 16.9%). The pooled proportion of nosocomial acquisition was 53.8% (95% CI: 32.1%-74.1%) among the 922 children without ESCR-E carriage at hospital admission. The pooled odds ratio of ESCR-E carriage after antibiotic treatment within the previous 3 months was 3.20 (95% CI: 2.10-4.88). The proportion of pooled carbapenem-resistant for Enterobacterales was 3.6% (95% CI: 0.7%-16.4%).

Interpretation: This study suggests that ESCR-E carriage among children in SSA is frequent. Microbiology capacity and infection control must be scaled-up to reduce the spread of those multidrug-resistant microorganisms.

Funding: There was no funding source for this study.

Keywords: Carbapenem-resistant Enterobacterales; Carriage; Child; Sub-Saharan Africa; Systematic review and meta-analysis; Third-generation cephalosporin-resistant Enterobacterales.