Meta-analysis finds high fluoroquinolone resistance in E. coli causing UTIs globally

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Frontiers in Medicine Published May 25, 2026 Medically reviewed May 25, 2026 DOI ↗ By Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

Key Takeaway

Consider local resistance patterns when prescribing fluoroquinolones for UTIs, as pooled prevalence is high.

This systematic review and meta-analysis pooled data from 36 studies worldwide to estimate the prevalence of fluoroquinolone resistance in Escherichia coli isolated from urinary tract infections. The analysis used a random-effects model and assessed heterogeneity, with sensitivity analyses showing stable estimates.

The overall pooled prevalence of fluoroquinolone resistance was 31.09% (95% CI, 24.89%–38.05%). By specific agent, ciprofloxacin resistance was 30.32% (95% CI, 22.60%–39.34%), levofloxacin resistance was 27.57% (95% CI, 9.01%–59.40%), and pefloxacin resistance was 68.75% (95% CI, 55.94%–79.76%). These are prevalence estimates and do not imply causation.

Limitations include restriction to English-language studies, geographic heterogeneity, and one study contributing modestly to heterogeneity. The authors call for enhanced antimicrobial stewardship, improved resistance surveillance, harmonized reporting standards, and further investigation into resistance mechanisms and data gaps in underrepresented regions.

Clinicians should interpret these pooled estimates cautiously given the wide confidence intervals for some agents and the heterogeneity across settings. The findings reinforce the importance of local resistance data to guide empiric therapy for UTIs.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedMay 2026

View Original Abstract ↓

BackgroundFluoroquinolone resistance in Escherichia coli isolated from urinary tract infections (UTIs) is an increasing global concern, with marked variation across regions and specific agents. Estimating resistance prevalence is essential to guide empirical therapy and strengthen antimicrobial stewardship programs.MethodsA systematic review and meta-analysis was conducted in accordance with PRISMA guidelines, including English-language observational studies published through December 2025. PubMed, Embase, and Web of Science were searched for reports on fluoroquinolone-resistant E. coli in UTIs. Study quality was evaluated using the modified Newcastle-Ottawa Scale. Pooled prevalence estimates were calculated using a random-effects model, and heterogeneity was assessed with the I² statistic. Subgroup analyses were performed by fluoroquinolone agent. Robustness was examined through sensitivity analyses, while meta-regression explored associations between sample size and resistance prevalence. Publication bias and influential studies were evaluated using DOI and Baujat plots.ResultsAmong 9,033 identified records, 36 studies met the inclusion criteria. The overall pooled prevalence of fluoroquinolone resistance in E. coli was 31.09% (95% CI, 24.89%–38.05%). Resistance estimates were 30.32% (95% CI, 22.60%–39.34%) for ciprofloxacin, 27.57% (95% CI, 9.01%–59.40%) for levofloxacin, and 68.75% (95% CI, 55.94%–79.76%) for pefloxacin. Sensitivity analyses demonstrated stable pooled estimates ranging from 30% to 32%. Meta-regression suggested an inverse association between study sample size and reported resistance rates. One study contributed modestly to heterogeneity.ConclusionThis analysis demonstrates substantial and geographically heterogeneous fluoroquinolone resistance in E. coli causing UTIs, with particularly high rates reported in China, Iran, and Bangladesh. While ciprofloxacin resistance was considerable, pefloxacin exhibited the highest prevalence. These findings reinforce the importance of enhanced stewardship initiatives, improved resistance surveillance, harmonized reporting standards, and further investigation into resistance mechanisms and data gaps in underrepresented regions.