Prevalence, molecular epidemiology and antibiotic resistance of extended-spectrum β-lactamase-producing Enterobacterales (2020–2024): a systematic review and meta-analysis of regional and between-study variation

Abstract

Summary Background Previous reviews of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) focused on specific populations, species or regions, while surveillance platforms omit gene distribution, detection-method variability and species-specific resistance. We synthesised 2020–2024 evidence on ESBL-E prevalence, molecular epidemiology and antibiotic resistance across World Bank regions. Methods Following PRISMA 2020 and PROSPERO registration (CRD420251001467), we searched PubMed, MEDLINE, Scopus and Web of Science on 27 March 2025 for 2020–2024 ESBL-E data from diagnostic specimens or colonisation screening. Random-effects models generated pooled estimates. Heterogeneity was assessed using Cochran’s Q, I² and 95% prediction intervals and explored through pre-specified subgroup analyses and meta-regression. Risk of bias and certainty of evidence were assessed using Joanna Briggs Institute checklists and an adapted GRADE approach. Results Among 140 eligible studies, 120 contributed prevalence data for 18,691 isolates, of which 9,103 were ESBL-positive isolates. Pooled prevalence was 50.37% (95% CI 45.79–54.95; I² = 97.30%; prediction interval 8.00–92.00%), thus making this estimate descriptive rather than generalisable. Certainty was low to very low, driven mainly by very serious inconsistency. Regional estimates ranged from 36.84% in Europe and Central Asia to 55.54% in East Asia and the Pacific, but no regional association was detected in meta-regression ( P = 0.58; R² = 0.00). CTX-M enzymes predominated; bla CTX−M−15 varied by region ( P < 0.001), from 20.11% in East Asia and the Pacific to 89.00% in the Middle East and North Africa. Resistance to fluoroquinolones (55.23–63.27%) and trimethoprim/sulfamethoxazole (74.54%) was common. Detection method was the only significant prevalence moderator ( P = 0.004; genotypic 73.93% versus phenotypic 47.09%); this was an exploratory study-level contrast rather than a paired isolate-level comparison. Klebsiella pneumoniae showed higher pooled resistance than Escherichia coli , including to carbapenems (20.06–37.68% versus 6.17–8.80%), but species were not formally compared. Carbapenem resistance may reflect additional mechanisms, as carbapenemase status was rarely confirmed. Conclusion ESBL production was common in the isolate-level evidence, but extreme heterogeneity limits generalisability. An exploratory regional signal was retained for bla CTX−M−15 , while high co-resistance supports locally interpreted surveillance and context-specific antimicrobial stewardship. These descriptive findings should not be used as stand-alone clinical guidance.