Burden and distribution of multidrug-resistant bacteria among hospitalized patients with cirrhosis: A systematic review and meta-analysis.

BACKGROUND/

OBJECTIVES

Bacterial infections are major precipitants of decompensation and death in cirrhosis. Multidrug-resistant (MDR) bacteria are increasingly recognized in this population, but their burden across infection sites and healthcare settings remains uncertain. We aimed to estimate the prevalence and distribution of MDR bacterial infections among hospitalized patients with cirrhosis and culture-proven infections.

METHODS

PubMed, Embase, and Scopus were searched through November 2025 for observational studies reporting patient-level MDR prevalence among hospitalized patients with cirrhosis and culture-positive infections. A proportional meta-analysis was conducted using 95% confidence intervals (CI), and heterogeneity was assessed with the I² statistic. Stratified analyses were performed based on epidemiological and clinical factors.

RESULTS

Twenty-nine studies including 13,361 patients were analyzed. Across heterogeneous hospitalized cirrhosis cohorts, the prevalence of patients with MDR bacterial infections was 36.73% (95% CI: 32.23-41.35%; I² = 92.9%). Asia had the highest estimate, at 41.95% (95% CI: 34.36-49.74%; I² = 90.6%). Europe had a prevalence of 31.75% (95% CI: 27.37-36.29%; I² = 66.3%), Latin America of 31.10% (95% CI: 23.77-38.94%; I² = 74.9%), and North America of 23.33% (95% CI: 13.07-35.50%; I² = 82.9%). Data from Oceania and Africa were limited. Acinetobacter spp. showed the strongest association with MDR, at 85.06% (95% CI: 54.39-99.73%; I² = 77.2%), whereas Escherichia coli was the most common MDR bacteria, at 42.39% (95% CI: 31.57-53.59%; I² = 90.7%).

CONCLUSION

MDR bacteria are common among hospitalized patients with cirrhosis and culture-proven infections. Gram-negative organisms predominate, with E. coli accounting for the largest absolute MDR burden, while Acinetobacter spp. showed the highest pathogen-specific probability of MDR.