A One Health view of antimicrobial resistance in North Africa: Meta-analysis of ESBL-producing Enterobacteriaceae across sectors

Antimicrobial resistance is a growing global health threat, and extended-spectrum β-lactamase-producing Enterobacterales exemplify a critical challenge. Because these organisms circulate across human, animal, food, and environmental reservoirs, a One Health perspective is essential for understanding their epidemiology. However, comprehensive regional syntheses remain limited in North Africa. This systematic review and meta-analysis synthesized evidence from 182 studies published between 2000 and 2024 on ESBL-producing Enterobacterales across North Africa within a One Health framework. We analyzed epidemiological data from human, animal, food, and environmental sources, as well as reported resistance genes, mobile genetic elements, transferability patterns, and clonal diversity associated with ESBL dissemination in the region In the human sector, the pooled prevalence estimate (PPE) of ESBL-producing Enterobacterales in clinical infections was 32.9%, with a higher burden in healthcare-acquired infections (37.1%) than in community-acquired infections (20.1%). ESBL carriage was also frequent at admission (34.1%) and increased after hospitalization (51.1%). Among non-human sectors, the PPE was 10.9% in animals, 3.73% in food, and 40.7% in environmental sources. bla CTX-M was the predominant β-lactamase gene family, with bla CTX-M-15 as the leading subtype. Non-β-lactam resistance genes were also frequently reported, indicating broader multidrug resistant backgrounds. Genetic drivers of dissemination included insertion sequences, integrons, and diverse plasmid backgrounds, particularly IncF plasmids. Transferability experiments showed frequent horizontal transfer of ESBL associated resistance, often with co-transfer of non-β-lactam resistance determinants. MLST data identified multiple high-risk clones, including Escherichia coli ST131, ST10, ST405, and ST617, and Klebsiella pneumoniae ST101, ST147, and ST15 ESBL-producing Enterobacterales are widely disseminated across interconnected human, animal, food, and environmental compartments in North Africa. Their regional epidemiology is shaped by a high human burden, substantial environmental reservoirs, frequent multidrug resistant backgrounds, mobile genetic elements, horizontal gene transfer, and the circulation of multiple clonal lineages. These findings highlight the need for strengthened and integrated One Health surveillance in North Africa.