Epidemiology of clinical antimicrobial-resistant Enterobacterales in Togo over three decades: a systematic review and meta-analysis, with recommendations and alternative solutions.

Abstract

Background: According to the World Health Organization (WHO), surveillance programs have become essential at national, regional, and global levels to adjust empirical treatments and target interventions to prevent and control the emergence of antimicrobial resistance (AMR). Therefore, this study aimed to conduct the first systematic review and meta-analysis of clinical Enterobacterales resistance to 11 representative antimicrobials from the WHO AWaRe (Access, Watch, Reserve) list, and to provide recommendations to tackle AMR more efficiently in Togo.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (The PRISMA 2020) were used to conduct this study and the protocol was registered with PROSPERO (CRD42024606897). Keywords were used to conduct a systematic literature review of electronic databases. Data analysis was conducted using Stata software version 17.0.

Results: Twenty research articles reporting 9,327 clinical Enterobacterales isolates obtained from 1991 to 2020 were included in this review and were mainly Escherichia coli (6,639; 71.2%), and Klebsiella spp. (2,542; 27.3%), mainly isolated from urine (14 studies; 70%), and pus/wounds (12; 60%). The pooled Enterobacterales resistance rates ranged from 1% (95% CI: 0, 2) imipenem, 3% (95% CI: 1, 5) amikacin, 4% (95% CI: 2, 7) fosfomycin, 50% (95% CI: 40, 60) chloramphenicol, 55% (95% CI: 45, 64) gentamicin, 68% (95% CI: 59, 76) ciprofloxacin, 73% (95% CI: 66, 80) amoxicillin/clavulanic acid (AMC), 79% (95% CI: 71, 86) third-generation cephalosporins (3GC), to 90% (95% CI: 86, 93) sulfamethoxazole/trimethoprim (SXT). The most significant upward trend over 30 years was reported for SXT (R² = 73.24%, p < 0.001), ciprofloxacin (R² = 61.44%, p < 0.001), and 3GC (R² = 18.49%, p < 0.001). Klebsiella spp. strains were significantly more resistant to chloramphenicol (p = 0.03) than E. coli isolates, whereas E. coli isolates were significantly more resistant to amikacin (p = 0.04) than Klebsiella spp. isolates.

Conclusion: This study revealed high first-line AMR rates with drastic upward trends in clinical Enterobacterales isolated in Togo over the past 30 years. Thus, the adjustment of empirical antimicrobial treatments in Togo becomes crucial. Moreover, the implementation of prevention policies, whole-genome sequencing approaches, and the promotion of antibiotic stewardship must be enhanced. Finally, alternative therapeutic approaches, such as phytotherapy and phage therapy, were discussed.

Clinical trial: Not applicable.