Comparison of the global prevalence and trend of human intestinal carriage of ESBL-producing Escherichia coli between healthcare and community settings: a systematic review and meta-analysis

Abstract

Objectives: The widespread intestinal carriage of ESBL-producing Escherichia coli (ESBL E. coli) among both patients and healthy individuals is alarming. However, the global prevalence and trend of this MDR bacterium in healthcare settings remains undetermined. To address this knowledge gap, we performed a comparative meta-analysis of the prevalence in community and healthcare settings.

Methods: Our systematic review included 133 articles published between 1 January 2000 and 22 April 2021 and indexed in PubMed, EMBASE or Google Scholar. A random-effects meta-analysis was performed to obtain the global pooled prevalence (community and healthcare settings). Subgroup meta-analyses were performed by grouping studies using the WHO regions and 5 year intervals of the study period.

Results: We found that 21.1% (95% CI, 19.1%-23.2%) of inpatients in healthcare settings and 17.6% (95% CI, 15.3%-19.8%) of healthy individuals worldwide carried ESBL E. coli in their intestine. The global carriage rate in healthcare settings increased 3-fold from 7% (95% CI, 3.7%-10.3%) in 2001-05 to 25.7% (95% CI, 19.5%-32.0%) in 2016-20, whereas in community settings it increased 10-fold from 2.6% (95% CI, 1.2%-4.0%) to 26.4% (95% CI, 17.0%-35.9%) over the same period.

Conclusions: The global and regional human intestinal ESBL E. coli carriage is increasing in both community and healthcare settings. Carriage rates were generally higher in healthcare than in community settings. Key relevant health organizations should perform surveillance and implement preventive measures to address the spread of ESBL E. coli in both settings.

Figure 1.

Selection of articles for the meta-analysis. Note: studies reporting the prevalence in both the community and healthcare settings were not discarded.

Figure 2.

Number of studies included by WHO region and study setting. The absolute numbers of participants (ESBL E. coli positive/total screened) in the community settings were (by region): Africa (270/1786), America (109/1242), South-East Asia (494/1502), Europe (887/15168), Eastern Mediterranean (479/2084) and West Pacific (1713/8851). The absolute numbers of participants (ESBL E. coli positive/total screened) in the healthcare settings were (by region): Africa (682/2206), America (107/2236), South-East Asia (304/1494), Europe (3370/32464), Eastern Mediterranean (218/711) and West Pacific (1040/3574).

Figure 3.

The global and regional prevalence of human intestinal ESBL E. coli carriage. (a) The global pooled prevalence of faecal ESBL E. coli carriage in community and healthcare settings (forest plot in Figure S1). (b) Regional pooled prevalence of faecal ESBL E. coli carriage in the six WHO regions (forest plot in Figures S2 and S3). (c) A summary of global and regional human intestinal ESBL E. coli carriage with 95% CI as obtained from forest plots in Figures S1–S3. P values are the P values for heterogeneity.

Figure 4.

The global and regional trends in the prevalence of faecal ESBL E. coli carriage. (a) Linear regression plots showing the global trend in the carriage rate in the community (1.5% yearly increase, P = 0.027) and healthcare settings (1.3% annual rise, P = 0.003). (b) A bar graph depicting pooled prevalence by 5 year intervals of the study period (forest plots in Figures S4 and S5). In (c), studies of both community and healthcare settings were combined to show the regional trend in the six WHO regions (P values were not significant (>0.05) for all the regions). (d) A summary of global trend in human intestinal ESBL E. coli carriage with 95% CI as obtained from forest plots in Figures S4 and S5. P values are the P values for heterogeneity. Note: in (b) and (d), for the year interval 2001–05 there were only two studies for community setting and this might result in underestimation of the real prevalence.

Figure 5.

Comparison of faecal ESBL E. coli carriage rate between healthy individuals and inpatients in Europe. Carriage rates among inpatients increased with increasing duration of stay in healthcare settings. Summary table (a) and bar graph (b) were based on the meta-analysis forest plot in Figure S6. P values are the P values for heterogeneity. In this subgroup analysis, the absolute numbers of participants (ESBL E. coli positive/total screened) in Europe were: community setting (887/15168), admitted <48 h (1254/11983), admitted ≥48 h (1445/16589) and nursing care (671/3892).