Burden and global distribution of antimicrobial resistance in non-bloodstream infections among adults with cirrhosis: A systematic review and proportional meta-analysis

OBJECTIVES: To systematically characterise the global distribution of bacterial pathogens, antimicrobial resistance patterns, and resistance determinants in non-bloodstream infections among adults with cirrhosis. METHODS: We performed a systematic review and proportional meta-analysis of studies reporting AMR in non-bloodstream bacterial infections among patients with cirrhosis. PubMed, Embase, Scopus and Web of Science were searched up to 15 September 2025. Pooled proportion estimates of multidrug-resistance (MDR) and the etiological bacterial pathogens were calculated using random-effects models. Subgroup analyses were performed by country income, continent, and bacterial species. RESULTS: Thirty-one studies contributed data from 2781 clinical infections and 381 colonisation observations. Spontaneous bacterial peritonitis predominated (89%), followed by urinary tract infections (7%). Gram-negative bacteria accounted for 60% of isolates (Escherichia coli 29%, Klebsiella pneumoniae 11%), while Gram-positive pathogens represented 39% (Enterococcus spp. 14%, Staphylococcus aureus 6%). The overall pooled MDR proportion was 23% (95% CI: 13-37), with higher burdens in lower-middle-income countries (MDR 56% vs. 15%-41%; ESBL 24% vs. 8%-10%; VRE 23% vs. 2%; CRE 32% vs. 1%). Genotypic data identified 436 resistance genes with marked continental differences. CONCLUSION: In cirrhosis-associated non-bloodstream infections, Gram-negative bacteria predominate and are associated with high levels of MDR, particularly in lower-middle-income countries. These findings highlight the need for integrated phenotypic and genomic surveillance of resistance patterns to inform empiric antimicrobial therapy.