Prevalence of antimicrobial resistance in acute community-acquired urinary tract infections in Sub-Saharan Africa: a systematic review.

BACKGROUND: In Sub-Saharan Africa, over-the-counter antibiotic dispensing and limited resources drive high antimicrobial resistance (AMR), yet data on community-acquired urinary tract infections (UTIs) remain scarce. This review synthesizes available AMR evidence in this population. METHODS: We searched MEDLINE, Embase and Global Health (January 2000-April 2026) for studies evaluating AMR in acute community-acquired UTIs across Sub-Saharan Africa. Random-effects meta-analyses evaluated resistance of Escherichia coli and Klebsiella spp. against five commonly prescribed antibiotics. RESULTS: From 3099 screened articles, 42 studies (19 countries) were analysed. Pooled AMR prevalence was high for E. coli and Klebsiella spp., respectively: trimethoprim-sulfamethoxazole [62.2% (95% CI: 51.9%-72.5%) versus 66.4% (95% CI: 46.7%-86.2%)]; amoxicillin-clavulanic acid [48.9% (95% CI: 39.8%-58.0%) versus 47.5% (95% CI: 31.0%-63.2%)]; ceftriaxone [40.8% (95% CI: 19.4%-62.2%) versus 44.6% (95% CI: 28.6%-60.7%)]; ciprofloxacin [32.8% (95% CI: 25.1%-40.4%) versus 35.8% (95% CI: 20.3%-51.4%)] and nitrofurantoin [18.2% (95% CI: 9.2%-27.2%) versus 28.3% (95% CI: 12.1%-44.5%)]. All estimates showed very high heterogeneity (I 2 > 96%), unresolved by subgroup analysis. E. coli resistance to amoxicillin-clavulanic acid increased significantly over time (P = 0.028). Resistance did not differ significantly by pathogen or geographic region. CONCLUSIONS: Community-acquired UTIs in Sub-Saharan Africa exhibit high rates of AMR. Addressing this burden requires targeted community antimicrobial stewardship, rapid diagnostic tools to guide empiric therapy and standardized laboratory reporting to enable accurate global surveillance.