Global prevalence of nitrofurantoin-resistant uropathogenic Escherichia coli (UPEC) in humans: a systematic review and meta-analysis.

Background: The global rise in antimicrobial resistance (AMR) is a significant health concern. Nitrofurantoin is used as a first-line antibiotic against many uropathogenic bacterial pathogens, including uropathogenic Escherichia coli (UPEC), and an analysis is required to assess the current global prevalence of nitrofurantoin-resistant UPEC.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search using PubMed and Google Scholar was performed to find studies reporting nitrofurantoin-resistant UPEC in humans. Studies were included/excluded based on predefined criteria and focused only on isolates collected from the urinary tract. The quality of the studies was assessed using the Joanna Briggs Institute's (JBI's) Checklist for Prevalence Studies. Statistical analysis was performed using Metafor and Meta (R packages) to estimate the pooled prevalence, assess publication bias and perform heterogeneity analysis.

Results: Sixty-three studies comprising 774 499 UPEC isolates collected between 1996 and 2024 were analysed and demonstrated a global pooled prevalence of nitrofurantoin-resistant UPEC isolates to be 6.9% (95% CI: 4.8%-9.7%). Continent-wise subgroup analysis showed Europe to have the lowest prevalence, while Asia has the highest prevalence. Decade-wise subgroup analysis showed the global prevalence increased from 2.8% (1996-04) to 8.2% (2005-14) and then decreased to 7.6% in the last decade (2015-24). Substantial heterogeneity was seen among the studies examined, as well as statistically significant publication bias.

Conclusions: The findings show considerable global prevalence of nitrofurantoin-resistant UPEC isolates, with the prevalence being higher in low- and middle-income countries (LMICs). Sufficient education should be provided where possible, and antimicrobial stewardship should be intensified to slow the rate of AMR increase worldwide.