Epidemiology and risk factors of multidrug-resistant tuberculosis in Saudi Arabia: a systematic review and meta-analysis.

BACKGROUND

Tuberculosis (TB), a major global health challenge, has been further complicated by the emergence of multidrug-resistant TB (MDR-TB), defined as resistance to at least isoniazid and rifampicin. In Saudi Arabia, TB management continues to face challenges related to population migration, demographic shifts, and comorbidities such as diabetes. Despite multiple local studies, the overall prevalence and risk factors of MDR-TB are not well established. This study aims to estimate the prevalence of MDR-TB in Saudi Arabia and identify its key risk factors.

METHODS

A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were conducted in the following databases: MEDLINE, Scopus, Web of Science, Cochrane Library, and Google Scholar. Studies published in English since 2000, involving adult TB patients tested for isoniazid and rifampicin resistance, were included. Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Appraisal Tool for Cross-Sectional Studies (AXIS) tools. RStudio (v2024.09.1) was used to perform the analysis with a random-effects model, estimating pooled prevalence and odds ratios (ORs). Heterogeneity was evaluated through I 2, and publication bias was assessed using funnel plots.

RESULTS

Sixteen studies conducted in Saudi Arabia were included, encompassing 4,238 TB cases. The pooled prevalence of isoniazid and rifampicin resistance was 15% [95% confidence interval (CI): 7-28%] and 6% (95% CI: 3-9), respectively. MDR-TB was observed in 8% (95% CI: 4-16) of cases. Previous TB treatment was significantly associated with MDR-TB (OR = 7.34, 95% CI: 2.84-18.98, p < 0.001). In unadjusted analyses, male sex, Saudi nationality, smoking, diabetes, and pulmonary TB site were not significantly associated with MDR-TB; however, adjusted pooled analyses suggested significant associations for Saudi nationality and smoking, while diabetes remained non-significant.

CONCLUSION

MDR-TB remains a significant challenge in Saudi Arabia. Standardized diagnostic protocols, enhanced treatment monitoring, and targeted preventive strategies are essential to curb resistance and improve outcomes.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/search, identifier CRD420251078514 (PROSPERO).