Antimicrobial Resistance in Urinary Tract Infection: A Quantitative Review of Recent Global Data

Abstract

Urinary tract infections (UTIs) are among the most common bacterial infections worldwide and a major driver of antibiotic use. This quantitative systematic review and meta-analysis evaluated global antimicrobial resistance (AMR) patterns in UTI isolates collected between January 2018 and October 2025. Secondary data were extracted from 16 peer-reviewed studies encompassing approximately 1.7 million urine isolates, primarily Escherichia coli and Klebsiella pneumoniae, across six WHO regions. Random-effects (logit-transformed) meta-analyses were conducted in R to estimate pooled resistance prevalences and subgroup differences by pathogen, setting, region, and income level. The pooled resistance rates were 52.4% for ciprofloxacin, 49.1% for third-generation cephalosporins, 33.6% for trimethoprim-sulfamethoxazole, 6.8% for nitrofurantoin, 3.9% for fosfomycin, and 1.8% for carbapenems. Resistance was consistently higher in Klebsiella than E. coli and in hospital versus community isolates, while pediatric isolates showed lower resistance. Regional disparities were pronounced, with the highest resistance observed in Africa and South Asia and the lowest in Europe and North America. Meta-regression indicated a modest decline in fluoroquinolone resistance since 2018 and significantly lower rates in higher-income countries. These findings reveal persistently high resistance to ciprofloxacin and cephalosporins, undermining their empirical use for uncomplicated cystitis. Nitrofurantoin and fosfomycin remain highly effective and should be prioritized for first-line therapy. Strengthened antimicrobial stewardship, routine culture confirmation, rapid diagnostics, and improved surveillance particularly in low- and middle-income settings are essential to reduce resistance and guide evidence-based UTI management.