Background: The burden of antimicrobial resistance (AMR) has been estimated to be the highest in sub-Saharan Africa (SSA). The current study estimated the proportion of drug-resistant Enterobacterales causing infections in SSA children.

Methods: We searched MEDLINE/PubMed, Embase and the Cochrane Library to identify retrospective and prospective studies published from 01/01/2005 to 01/06/2022 reporting AMR of Enterobacterales causing infections in sub-Saharan children (0-18 years old). Studies were excluded if they had unclear documentation of antimicrobial susceptibility testing methods or fewer than ten observations per bacteria. Data extraction and quality appraisal were conducted by two authors independently. The primary outcome was the proportion of Enterobacterales resistant to antibiotics commonly used in paediatrics. Proportions were combined across studies using mixed-effects logistic regression models per bacteria and per antibiotic. Between-study heterogeneity was assessed using the I²statistic. The protocol was registered with PROSPERO (CRD42021260157).

Findings: After screening 1111 records, 122 relevant studies were included, providing data on more than 30,000 blood, urine and stool isolates.Escherichia coliandKlebsiellaspp. were the predominant species, both presenting high proportions of resistance to third-generation cephalosporins, especially in blood cultures: 40.6% (95% CI: 27.7%-55%; I²: 85.7%, number of isolates (n): 1032) and 84.9% (72.8%-92.2%; I²: 94.1%, n: 2067), respectively. High proportions of resistance to other commonly used antibiotics were also observed.E. colihad high proportions of resistance, especially for ampicillin (92.5%; 95% CI: 76.4%-97.9%; I²: 89.8%, n: 888) and gentamicin (42.7%; 95% CI: 30%-56.5%; I²: 71.9%, n: 968). Gentamicin-resistantKlebsiellaspp. were also frequently reported (77.6%; 95% CI: 65.5%-86.3%; I²: 91.6%, n: 1886).

Interpretation: High proportions of resistance to antibiotics commonly used for empirical treatment of infectious syndromes were found for Enterobacterales in sub-Saharan children. There is a critical need to better identify local patterns of AMR to inform and update clinical guidelines for better treatment outcomes.