Antimicrobial resistance reaches 33.3% in cirrhosis patients with bacterial infections across global settings

BACKGROUND & AIMS: The global epidemiology of bacterial infections in cirrhosis remains inadequately characterised. We aimed to delineate temporal trends and geographical variations in the microbiological profiles, antimicrobial resistance (AMR) patterns, and clinical outcomes of bacterial infections in cirrhosis. METHODS: In this systematic review and meta-analysis (PROSPERO: CRD42024593473), we searched Embase, MEDLINE and Web of Science from inception to Nov 27, 2024, without language restrictions, for cross-sectional and cohort studies reporting microbiological characteristics, AMR patterns, and/or mortality of bacterial infections in adult patients with cirrhosis. The primary outcome was the proportion of AMR among positive bacterial cultures. Secondary outcomes included bacterial distribution and mortality following bacterial infections. Pooled proportions were estimated using random-effects models, with subgroup analyses stratified by time period, World Health Organization region, World Bank income group, infection type and site. RESULTS: Of 3,891 records identified, 169 studies (35,180 infected patients) were included. Gram-positive bacteria accounted for 32.9% (95% CI 30.3-35.5) of all positive cultures, with an increasing trend over time and higher proportion observed in high-income countries and Europe. Multidrug-resistant bacteria were identified in 33.3% (95% CI 28.6-38.3) of positive cultures, with a rising temporal trend. The highest multidrug-resistant bacteria proportions were observed in low or lower-middle-income countries and in South-East Asia, and the lowest in high-income countries and the Americas. A temporal declining trend in in-hospital, 30-day, and 90-day mortality rates was observed, but the reduction was less pronounced for long-term mortality. CONCLUSION: The increase of Gram-positive and AMR-related infections may inform future empirical antibiotic strategies. Pronounced regional and economic disparities in infection patterns highlight the need for region-specific efforts to mitigate AMR. Persistent challenges remain in reducing long-term mortality. IMPACT AND IMPLICATIONS: The epidemiology of bacterial infections is critical to guide clinical and public health decision-making, yet comprehensive global data remain limited. This systematic review and meta-analysis offer a detailed global overview of microbiological profiles, antimicrobial resistance patterns, and clinical outcomes associated with bacterial infections in cirrhosis, revealing substantial temporal and geographical variations. The high proportion and growing global burden of antimicrobial resistance among patients with cirrhosis underscore the urgent need for both international collaboration and context-specific national strategies. PROSPERO REGISTRATION NUMBER: CRD42024593473.