Burden of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae among Cancer Patients in Africa: A Systematic Review and Meta-Analysis
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Background : Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) exacerbate infections in cancer patients, in settings where antimicrobial resistance threatens health outcomes. This study estimated the prevalence of ESBL-PE among cancer patients in Africa from 2010 to 2024. Methods: We searched PubMed, Embase, Web of Science, CINAHL, and Global Health for observational studies reporting ESBL-PE prevalence in cancer patients. Studies published in English from 2010 to 2024 were included. Two reviewers independently screened studies, extracted data using standardized forms, and assessed quality using the Newcastle-Ottawa Scale. Pooled prevalence was calculated using a random-effects model in RStudio v4.4.2, with heterogeneity assessed by I² statistics and publication bias by funnel plots and Egger’s test. Results: Twelve studies from nine African countries, involving 565 patients (305 events) and 687 samples (338 events), were included. The pooled prevalence was 49.9% (95% CI: 23.1%-76.9%, I² = 91.8%, p < 0.001) at the patient level and 48.1% (95% CI: 31.7%-65.0%, I² = 84.0%, p < 0.001) at the sample level. Escherichia coli and Klebsiella pneumoniae predominated, with high resistance to cephalosporins (median: 89.5%-90%) and fluoroquinolones but preserved carbapenem efficacy. Publication bias was evident, and heterogeneity persisted after sensitivity analysis. Conclusions: The high ESBL-PE prevalence in African cancer patients signals a critical public health issue, necessitating enhanced surveillance, antimicrobial stewardship, and intentional infection control measures.
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The paper has now been assessed by two independent expert reviwers, bot of which provided positive feedbacks. Yet, both reviewers suggested minor changes in the manuscript, mostly related to structural and grammatical changes. Please address the reviewers' comments and resubmit your manuscript for further consideration. When resubmitting your work, please include a point by point response to reviewers' comments and a tracked version, as well as a clean version, of the manuscript.
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Comments to Author
It is interesting that the authors report resistance rates to antibiotics other than β‑lactams. However, regarding carbapenem resistance—given that this is an ESBL-producing scenario—was carbapenemase production ruled out as the underlying mechanism? Could the carbapenem resistance described instead be mediated by ESBL production combined with additional mechanisms such as porin loss or efflux pump overexpression? In several sections, the bacterial names are not written in italics.
Please rate the manuscript for methodological rigour
Good
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible …
Comments to Author
It is interesting that the authors report resistance rates to antibiotics other than β‑lactams. However, regarding carbapenem resistance—given that this is an ESBL-producing scenario—was carbapenemase production ruled out as the underlying mechanism? Could the carbapenem resistance described instead be mediated by ESBL production combined with additional mechanisms such as porin loss or efflux pump overexpression? In several sections, the bacterial names are not written in italics.
Please rate the manuscript for methodological rigour
Good
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
The authors perform a much-needed review and mate-analysis of ESBL-PE in cancer patient. The research is informative and could be important in treatment of cancer patients suffering from infection and inform the use of antibiotics. The manuscript need some improvement and clarification as indicated below. More details could be given on the methodology to those not familiar with he field. It recommend the working on the comment below: Line 28: the sentence that begins with "The pool prevalence was 49.9% ….." should be clear what prevalence is it. Line 110: Figure 1: PRISMA, this need more details of what was done and explain the figure to make it independent of the main text. 162: Figure: Pooled prevalence at the patient level; again, explain the figure in details beyond just the title. And there …
Comments to Author
The authors perform a much-needed review and mate-analysis of ESBL-PE in cancer patient. The research is informative and could be important in treatment of cancer patients suffering from infection and inform the use of antibiotics. The manuscript need some improvement and clarification as indicated below. More details could be given on the methodology to those not familiar with he field. It recommend the working on the comment below: Line 28: the sentence that begins with "The pool prevalence was 49.9% ….." should be clear what prevalence is it. Line 110: Figure 1: PRISMA, this need more details of what was done and explain the figure to make it independent of the main text. 162: Figure: Pooled prevalence at the patient level; again, explain the figure in details beyond just the title. And there were 12 studies in total but only six are listed here what happen to rest of the others, this should be explain and justified both in the figure and the main text. It would also help to indicate which regions are the studies from in the figure. 167: Figure: Pooled prevalence of at sample level. Same as above for figure 2. 187: Figure 4: Funnel plot of Pooled prevalence among cancer patients. Same for figures above, give a bit more detail of what was done and what does this mean. And its appears only 6 studies are included here too, why and what happen to the others should be explained. 188: Figure 5, same as figure 4 above. Line 194; Sentence beginning with " These figures significantly exceed global estimate….. quoting the figure of the global estimate would support the claimed being made. Line 205 E.coli and Klebsiella pneumonia should be italicise 233 Limitation of the study is written like a shopping list. This should be written in an academic format. The supplementary file has 20 studies but also 12 are discussed in the paper. An explanation is needed for the reason of adding the other studies in there.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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It is really difficult to follow the data in the tables, as the columns are quite narrow for the amount of text in them. It would probably be best to insert the tables in landscape orientation.
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