https://orcid.org/0000-0003-0241-8809
Figures
Abstract
Introduction
The growing challenge of antimicrobial resistance in Ethiopia and itsprogression towards XDR and PDR has become a critical public health concern. Therefore, thisreview determined the current state of emerging XDR and PDR bacteria, including pre-XDR and XDR-TB, their contributing factors, advancements, and future perspectives against drug-resistant bacteria, as well as their implications for public health and insights for future research.
Methodology
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A systematic search of all available literature was conducted using PubMed/Medline, Scopus, EMBASE, Google Scholar, Hinari, Web of Science, ScienceDirect, Cochrane Library, and African Journals Online databases.This study included original articles published in English that reported XDR and PDR bacteria, Pre-XDR-TB, and XDR-TBb without limit on the study period and publication year. Descriptive statistics were used to summarize the findings.
Results
Twenty-five studies published between 2010 and 2025 were included in this review. Among 5620 bacterial isolates identified,1289 were XDR (22.9%), with the prevalence ranging from 5.7% to 43.2%. A total of 440 bacterial isolates were PDR (9.1%), with its prevalence in individual studies ranged from 0.8% to 19.1%. The most common XDR bacteria identified were Klebsiella species; 26.7% (2.8%-84.6%), followed by E. coli; 26.4%(14.6%-35.7%), Acinetobacter species; 24.9%(10.1%-58.3%), and P. aeruginosa; 18.7% (2.8%-44.4%). The most frequently identified PDR bacteria were Acinetobacter species; 17.3% (7.9%-50.0%), followed by Klebsiella species; 13.7%(2.7%-25.8%), E. coli; 10.2%(2.4%-22.6%), and P. aeruginosa; 5.7%(4.3%-33.3%). Additionally, from 1419 MDR-TB and 160 TB confirmed cases, Pre-XDR-TB was 3.4% (2.4%-5.7%) and XDR-TB was 1.5%(0.6%-10.0%). These isolates were identified from different clinical specimens, which represents a significant concern in community and hospital settings.
Conclusion
The emergence of XDR and PDR represents a major threat to Ethiopian public health, resulting in increased morbidity, mortality, prolonged hospitalizations, high healthcare costs, and challenged treatment options. Urgent national surveillance and genomic detection of resistance mechanisms are needed to better track the spread of drug-resistant bacteria, promote antimicrobial stewardship, and enhance drug and vaccine trials.
Author summary
This systematic scoping review addresses the critical public health concern of antimicrobial resistance in Ethiopia, specifically focusing on the emergence of XDR and PDR bacteria, including Pre-XDR and XDR-TB. The review, adhering to PRISMA-ScR guidelines, synthesized findings from 25 studies published between 2010 and 2025. Results indicate that among 5620 bacterial isolates, 22.9% were XDR and 9.1% were PDR. Klebsiella species, E. coli, Acinetobacter species, and P. aeruginosa were the most common XDR and PDR bacteria identified. Additionally, pre-XDR-TB was found in 3.4% and XDR-TB in 1.5% of TB confirmed cases. Inappropriate antibiotic use, inadequate sanitation, and agricultural antibiotic use are key contributing factors. The emergence of these highly resistant strains poses a significant threat, leading to increased morbidity, mortality, and healthcare costs in Ethiopia. The authors highlight the urgent need for national surveillance, genomic detection of resistance mechanisms, and strengthened antimicrobial stewardship programs to combat this escalating crisis and inform future research and policy development.
Citation: Assefa M, Tigabie M, Amare A, Girmay G, Geteneh A, Ayalew G, et al. (2025) Emergence of extensively and pan-drug resistance in clinical bacterial isolates: A systematic scoping review from Ethiopian public health perspective. PLoS Negl Trop Dis 19(8): e0013363. https://doi.org/10.1371/journal.pntd.0013363
Editor: Yunn-Hwen Gan, National University of Singapore, SINGAPORE
Received: April 28, 2025; Accepted: July 15, 2025; Published: August 28, 2025
Copyright: © 2025 Assefa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All the necessary data are available in the article and Supporting information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist
1. Introduction
The global rise of antimicrobial resistance (AMR) poses a significant threat to public health, undermining decades of progress in infectious disease management [1]. The most alarming developments within this crisis are the emergence of extensively drug-resistant (XDR) bacterial strains, which are non-susceptibility to at least one agent in all but two or fewer antimicrobial categories, and pan drug-resistant (PDR) strains, defined as isolates resistant to all available antimicrobial agents [2]. Studies conducted in Ethiopia reveal a concerning rise in antimicrobial resistance, with a notable prevalence of multidrug-resistant (MDR), XDR, and even PDR bacteria. The common bacteria reported were Klebsiella pneumoniae, Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli, which exhibit increasing resistance to a broad spectrum of antibiotics, including carbapenems [3–5].
An increased burden of antibiotic-resistant bacteria is related to a complex interplay of resistance mechanisms. The production of enzymes, such as carbapenemases and extended-spectrum beta-lactamases, which inactivate a broad range of antibiotics, alterations in bacterial cell membrane permeability, the action of efflux pumps, and the acquisition of resistance genes through horizontal gene transfer, often facilitated by plasmids, further contributes to the rapid dissemination of resistance [6]. Research indicates that these resistant strains are particularly prevalent in hospital settings, especially in intensive care units, and also within environmental samples such as those taken from water sources and waste disposal sites [7,8].
The issue of extensive drug resistance in Ethiopia extends to Mycobacterium tuberculosis (MTB), the causative agent of tuberculosis (TB). Ethiopia is recognized as a country with a high burden of both MDR and rifampicin-resistant TB [9]. The definition of pre-extensively drug-resistant TB (Pre-XDR-TB) refers to MDR-TB with resistance to any fluoroquinolone, whereas extensively drug-resistant TB (XDR-TB) is defined as MDR-TB with additional resistance to any fluoroquinolone and at least one Group A drug [10].
While existing research highlights the growing prevalence of MDR bacteria within the country, the progression towards XDR and PDR represents a critical public health problem. It is valuable to determine the current state of knowledge regarding the emergence and dissemination of XDR and PDR bacterial strains in Ethiopia. Therefore, this review focused on the documented cases of XDR and PDR bacterial infections, including Pre-XDR and XDR-TB,the potential factors contributing to their emergence, the current targets for AMR,their implications for public health, and insights for future research in Ethiopia.
2. Methodology
2.1. Study design
This scoping review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [11] (S1 File). The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO), with identification number CRD420251084786 and link https://www.crd.york.ac.uk/PROSPERO/view/CRD420251084786.
2.2. Research questions
- What is the current state of XDR and PDR Gram-positive and Gram-negative bacterial infections?
- Are Pre-XDR and XDR-TB existing in the country of high TB burden?
- What are the possible contributing factors for the emergence of XDR and PDR bacteria in the Ethiopian context?
- What are current advancements and future perspectives forfighting AMR in the country?
- What will be their implications for Ethiopian public health for the implementation of preventive strategies and future research?
2.3. Literature search strategy
This scoping review used the Population–Concept–Context (PCC) paradigms to determine the suitability of the studies. It included studies on any patient population (“Population”) in Ethiopia (“Context”) that reported on XDR or PDR bacteria (including Pre-XDR/XDR-TB) as the main outcomes (“Concept”). The search included all available articles published; the last search was performed between March 10 and 20, 2025. The following electronic databases were used: PubMed/Medline, Scopus, EMBASE, Google Scholar, Hinari, Web of Science, Science Direct, Cochrane Library, and African Journals Online. The search terms were used alone or in combination with Boolean operators such as “OR” or “AND”. An example of a PubMed search strategy used was as follows: ((((((((antimicrobial resistance) OR (pre-extensively drug-resistant)) OR (extensively drug-resistant)) OR (pandrug-resistant)) OR (XDR)) OR (Pre-XDR)) OR (PDR)) AND (((((((((bacteria) OR (organism)) OR (infection*)) OR (Mycobacterium)) OR (Mycobacterium tuberculosis)) OR (M. tuberculosis)) OR (MTB)) OR (tuberculosis)) OR (TB))) AND (Ethiopia). A manual search of the references of the included studies and other reviews was conducted. The articles retrieved were imported into EndNote X9 bibliographic software manager (Clarivate Analytics, Philadelphia, PA, USA).
2.4. Study selection and eligibility criteria
The titles and abstracts of the studies were screened by four authors (MA, MT, WTA, and AA) independently. The full-text articles were then assessed for eligibility, and any disagreements between the authors were resolved through discussion with the fifth author (SB). Original research articles published in English that reported XDR and PDR, Pre-XDR-TB, and XDR-TB, conducted in Ethiopia only, and without limit on the study period and publication year were eligible for the study. Additionally, primary studies on clinical isolates were included except one study from environmental isolates.Case reports, communications, letters to editors, opinions, reviews, and meta-analysis studies were excluded.
2.5. Data extraction and synthesis
Data from individual studies were extracted using the designed extraction tool in Microsoft Excel 2019 (Microsoft Corp., Redmond, WA, USA) by four authors (MA, MT, AA, and GG). The type of information collected from eligible studies was author name, year of publication, area in which the study was conducted, study period, sample size, source of specimen,number of bacterial isolates, number of XDR/PDR bacteria, type of bacterial isolate, number of MTB/MDR-TB, Pre-XDR-TB, and XDR-TB.Because of the nature of the study design (scoping review), data were synthesized manually without using software. The overall prevalence was calculated using the following formula:
and
The minimum and maximum prevalence from studies was taken as a range value. Descriptive statistics were used to summarize the individual study’s findings.The results were presented in tables and figures.
3. Results
3.1. Literature search results
In this review, 1540 potentially relevant articles were identified. Depending on the evaluation of the eligibility criteria, 25full-text articles were included in the review [12–37] (Fig 1).
3.2. Study demographics
Twenty-five studies (8 for TB and 17 for other bacteria) published between 2010 and 2025 were included in this review. Among seventeen studies, most of the single-centered studies were conducted in Addis Ababa (n = 8), followed by Bahir Dar (n = 2), one study each for Harar, Sidama, Jimma, and Arba Minch. Multi-center studies were also conducted; such as one each for (Addis Ababa, Harar, Jimma, and Hawassa), (Addis Ababa, Jimma, and Hawassa), and (Addis Ababa and Adama) (Table 1). On the other hand, eight studies were included for TB (3 from Addis Ababa,1 each from Amhara, Tigray, and Oromia regions, 2 from multiple regions of Ethiopia) (Table 2).
3.3. Extensively drug-resistant bacterial isolates
Among a total of 5620 bacterial isolates identified,1289 were XDR (22.9%; 1289/5620), with the prevalence ranging from 5.7% to 43.2%. The most common XDR bacteria identified were Klebsiella species; 26.7% (2.8%-84.6%), followed by E. coli; 26.4% (14.6%-35.7%), Acinetobacter species; 24.9%(10.1%-58.3%), and P. aeruginosa; 18.7% (2.8%-44.4%) (Table 1). The least common isolates reported were S. aureus, Coagulase-negative Staphylococcus, Enterococcus, Citrobacter species., Enterobacter species, Proteus species., S. enterica sub. enterica, M. morganii, Providencia species, and Serratia species (S2 File). The presence of Gram-negative XDR bacteria across the studies within different sources of specimens and environments represents a significant concern in community and hospital settings.
3.4. Pandrug-resistant bacterial isolates
According to recent studies in Ethiopia, a total of 440 bacterial isolates were PDR (9.1%; 440/4864 total isolates), with its prevalence in individual studies ranging from 0.8% to 19.1%. The most frequently identified PDR bacteria were Acinetobacter species; 17.3% (7.9%-50.0%), followed by Klebsiella species; 13.7%(2.7%-25.8%), E. coli; 10.2% (2.4%-22.6%), and P. aeruginosa; 5.7%(4.3%-33.3%) (Table 1).While seemingly less prevalent than XDR, the identification of PDR bacteria in multiple studies across Ethiopia signifies a critical and advanced stage in antibiotic resistance within the country.
3.5. Pre-extensively and extensively drug-resistant tuberculosis
A total of eight studies [29–36] comprising, 1419 MDR-TB and 160 TB confirmed cases were included. The varying prevalence rates of Pre-XDR-TB; 3.4% (2.4%-5.7%) and XDR-TB; 1.5% (0.6%-10.0%) have been reported. The emergence of XDR in MTB alongside other bacterial species given a broader underlying issue in Ethiopia (Table 2).
4. Discussion
This review is the first to describe the findings of original research articles on the currently emerging XDR and PDR bacterial strains in Ethiopia. The comprehensive summary of findings from different regions of Ethiopia showed an overall prevalence of XDR (22.9%; 1289 XDR bacteria divided by 5620 total bacterial isolates) and PDR (9.1%; 440 PDR bacteria divided by 4864 total bacterial isolates), with highly prevalent Gram-negative bacteria. In a systemic review of the current epidemiology and prognosis of PDR Gram-negative bacteria, a total of 526 PDR isolates were reported with P. aeruginosa (33.3%), A. baumannii (32.7%) and K. pneumoniae (23.8%). The majority of PDR strains were isolated from intensive care units, with the potential to cause hospital outbreaks and dissemination between hospitals and long-term facilities. Pan-drug-resistant infections were associated with excess mortality, mounting up to 71.0%, and were independently high regardless of the infection source [38]. Thus, this review described the burden of XDR and PDR, and their mechanism of resistance on frequently reported bacteria such as Klebsiella species, Acinetobacter species, E. coli, and P. aeruginosa from an Ethiopian perspective.
4.1. Emergence of XDR and PDR Klebsiella species
Antibiotic resistance usually emerges among Gram-negative bacilli, especially Entero bacteriaceae because of their prevalence in hospital settings and the spectrum of resistance to antibiotics by K. pneumoniae is gradually increasing. This review found that Klebsiella species were the most commonly identified bacteria with XDR; 26.8% and PDR; 13.7%.This finding is comparable with a study by Usman et al, which reported the XDR (31.3%) and PDR (9.4%) prevalence of K.pneumoniae [39]. A study in India also reported an 18.0% prevalence of XDR Klebsiella species [40].In recent years, the AMR problem of Klebsiella species has become increasingly severe. In the case of K. pneumoniae, genes like bla-KPC and bla-NDM confer resistance to β-lactams including carbapenems; mcr-1 leads to colist in resistance; K.oxytoca, bla-CTX-M causes resistance to multiple β-lactams, and aac(3)-II results in aminoglycoside resistance; K. granulomatis may have tet genes, making it resistant to tetracycline [41]. Since the virulence potential of this pathogen is increasing, further research should be conducted on hypervirulent strains to compare virulence with resistance patterns for the development of treatment targets.
4.2. Emergence of XDR and PDR Acinetobacter species
Globally,Acinetobacter species have been a leading cause of nosocomial infections, causing significant morbidity and mortality.In this review,the burden of their XDR and PDR patterns showed 24.9% and 17.3%, respectively. A five-year antimicrobial resistance trend analysis showed increasing carbapenem non-susceptible and MDR rates in Acinetobacter species, with 56.7% and 71.6%, respectively [42]. A study in Bangladesh found moderate to high levels of resistance against aminoglycosides (45–53%), cephalosporins (28–45%), fluoroquinolones (28–39%), and carbapenems (17–19%), as well as XDR (13.64%) and PDR (2.3%) isolates of Acinetobacter species [43]. According to virulence-associated phenotypic assays, XDR isolates were more virulent to G. mellonella larvae, had a better capacity for iron uptake, and produced more capsules. Furthermore, virulence genes (tonB, hemO, abaI, and ptk) were more prevalent in XDR isolates, whereas pld and ompA genes were more prevalent in non-MDR isolates [44]. The most important features of A. baumannii are its ability to persist in hospital settings and rapidly develop resistance to a wide variety of antibiotics. Compared with other bacteria, A.baumannii has a highly sophisticated resistance mechanism including various antimicrobial-inactivating enzymes, efflux pump over expression, alterations in antibiotic target location, and outer membrane protein permeability [45].
4.3. Emergence of XDR and PDR E. coli
The prevalence of XDR and PDR E. coli isolates was 26.3% and 10.2%, respectively. This finding is supported by a study in Iraq that reported XDR strains (25.4%) [46]. The key resistance mechanisms in E. coli include efflux pumps and porin mutations that mediate resistance to a broad spectrum of antibiotics, biofilm formation, persister cell formation, the activation of stress response systems, to withstand antibiotic pressure, and the acquisition of resistance genes through horizontal gene transfer, facilitated by mobile genetic elements such as plasmids and transposons [47]. The presence of transferable plasmids is responsible for the XDR phenotype of E. coli W60; NDM-5 confers high resistance to β-lactam/BLI combinations; co-expression of ble-MBL enhances the resistance caused by NDM-5; and the secretion and function of TEM type β-lactamases depend on their signal peptides [48].
4.4. Emergence of XDR and PDR P. aeruginosa
P. aeruginosa is one of the most common antibiotic-resistant bacteria causing nosocomial infections, especially in burn units and patients with cystic fibrosis [49,50]. The combined report of this review showed an XDR; 18.7% (2.8%-44.4%) and PDR; 5.7% (4.3%-33.3%) prevalence of P. aeruginosa. The antibiotic resistance profile of P. aeruginosa in intensive care units revealed that 50% were MDR, and 2.3% were XDR phenotype [51]. Another study on burn patients showed an 87.5% XDR prevalence [52]. Major resistance mechanisms are intrinsic, acquired, and adaptive, which include biofilm-mediated resistance and the formation of multidrug-tolerant persister cells [53,54]. The intrinsic resistance occurs through restricted outer membrane permeability, the presence of efflux systems, and the production of antibiotic-inactivating enzymes. Whereas acquired resistance occurs either through horizontal gene transfer (acquisition of aminoglycoside-modifying enzymes and β-lactamases) or mutational events that result in the overexpression of efflux pumps or β-lactamases or the decreased expression or modification of target sites and porins [55].
4.5. The Burden of Pre-XDR and XDR-TB in Ethiopia
According to the studies report, there were varying prevalence rates of Pre-XDR-TB; 3.4% (2.4%-5.7%) and XDR-TB; 1.5% (0.6%-10.0%). Compared to our review finding, a higher prevalence of Pre-XDR and XDR-TB was reported from India, with 55.9% and 4.9%, respectively [56]. A systematic review and meta-analysis in Latin America and the Caribbean showed that the pooled prevalence of pre-XDR-TB was 10.0%, being higher in Brazil (16.0%) and Peru (13.0%), whereas the pooled prevalence of XDR-TB in was 5.0%, being higher in Cuba and Peru, 6.0% each [57].Another study from Bangladesh reported 16.18% of Pre-XDR-TB cases, with 81.82% fluoroquinolone-resistant Pre-XDR-TB and 18.18% of second-line injectable agent-resistant Pre-XDR-TB [58]. Moreover, Daniel et al reported a Pre-XDR TB prevalence rate of 16.7%, with 80.0% resistance to ofloxacin and 20.0% resistance to Kanamycin [59]. A study determined the role of DNA gyrase mutations in Pre-XDR AND XDR-TB clinical isolates revealed that all Pre-XDR-TB and XDR-TB isolates carried at least one mutation within the quinolone resistance-determining region of DNA gyrase [60].Thisvariation could be due to the meta-analysis nature of the study based on diverse patient populations in various settings, geographic differences, methods of detection, and epidemiological factors that contribute to drug resistance. This review finding provides insight into the current issue of Pre-XDR and XDR-TB strains in different regions of Ethiopia, which requires strengthening the national drug-resistance surveillance and TB programs, and continued efforts in TB control and management.
5. Factors contributing to XDR and PDR in the Ethiopian context
Antibiotic usage patterns are a major factor in the emergence and spread of XDR and PDR bacteria in Ethiopia. The inappropriate use of antimicrobials includes the overuse of antibiotics, their misuse for non-bacterial infections, their availability over the counter without a prescription, and the common practice of empirical prescribing based on clinical syndromes rather than definitive microbiological diagnosis [61]. Additionally, incomplete courses of antibiotic therapy and prolonged treatment durations also contribute to the selection and propagation of antibiotic-resistant strains [62]. A study on antibiotic consumption and prescribing patterns in Ethiopia reveals high usage of certain antibiotics like doxycycline, amoxicillin, and ciprofloxacin, alongside reports of irrational prescribing practices involving incorrect doses, frequencies, and durations [63]. This resulted in a significant selective pressure, favoring the survival and proliferation of bacteria that have developed resistance mechanisms, ultimately leading to the emergence of XDR and PDR strains.
Inadequate sanitation and hygiene infrastructure, limited access to clean water, inadequate management of waste in both healthcare facilities and communities, and insufficient adherence to infection prevention and control guidelines all contribute to the dissemination of drug-resistant microorganisms [61].A study has documented that suboptimal water, sanitation, and hygiene facilities, as well as low rates of hand-hygiene compliance within healthcare settings, are risk factors for antibiotic-resistant infections [64]. Moreover, the presence of antibiotic-resistant bacteria and resistance genes in healthcare wastewater and municipal solid waste highlights the environmental dimension of this challenge [65].
The use of antibiotics in agriculture and animals is another recognized contributing factor to the rise of AMR in Ethiopia. The practice of administering antimicrobials to farm animals for prophylactic purposes and to promote growth can lead to the development of resistant bacteria in animals, which can then potentially transfer to humans through the food chain or environmental contamination [66]. This interconnectedness between human and animal health, often referred to as the “One Health” approach, underscores the need to consider antibiotic use across all sectors. While Ethiopia has established national action plans for AMR, challenges persist in ensuring their effective implementation, coordination among different stakeholders, and adequate allocation of financial resources [62].
6. Current solutions and future perspectives for tackling AMR in Ethiopia
Ethiopia has recognized the growing threat of AMR and has developed a National Action Plan for Antimicrobial Resistance (NAP-AMR) from 2021 to 2025 [67]. This plan adopts a “One Health” approach, acknowledging the interconnectedness of human, animal, and environmental health in the context of AMR. The challenges of AMR in Ethiopia require alternative treatment strategies beyond conventional antibiotics. Given the limitations of existing antibiotics, recent research into phage therapy, which utilizes bacteriophages to target and destroy specific bacteria, holds significant promise. A study by Hailemichael et alreported that virulent phages were active against 42% of MDR A. baumannii, 40% of both biofilm-producing and MDR A. baumannii, and 35.3% of the biofilm-producing isolates [68].The promising effect of the Myoviridae-like phages, Podoviridae, and Siphoviridae phages against drug-resistant pathogenic E. coli has raised the possibility of their use in the future treatment of E. coli infections [69]. Another study also suggested that phages (ΦJHS-PA1139 and ΦSMK-PA1139) have great potential to serve the dual purpose as surface coating agents for preventing MDR P. aeruginosa colonization in medical implants and as biofilm removal agents in implant-associated infections [70].
Additionally, investigating the potential of traditional Ethiopian medicinal practices, particularly those involving plant-derived compounds with antimicrobial properties, could yield valuable insights to hinder challenges associated with emerging antimicrobial resistance. An in-vitro experimental study conducted by Gadisa and Tadesse showed that the extracts obtained from C.englerianum and E. depauperate had potent antibacterial activity on MDR bacteria such as Methicillin-resistant S. aureus, E. faecalis, E. coli, and K. pneumoniae [71].Strengthening infection prevention and control measures within healthcare settings is paramount to minimize the spread of resistant bacteria. Moreover, improving the laboratory capacity in Ethiopia for proper identification of resistant bacteria and sensitivity testing of detection methods could be valuable. This will help to reduce the inappropriate use of antibiotics, which is a major contributor to the growing problem of antibiotic resistance.
7. Implications for public health and research
The emergence of XDR and PDR bacterial infections in Ethiopia has a significant impact on public health, causing high morbidity and mortality. Because of their resistance to most or all conventional antibiotics, the presence of XDR and PDR bacteria also presents a significant treatment challenge and severely limits therapeutic options The healthcare system in Ethiopia is facing a dwindling arsenal of effective antimicrobial agents to combat these life-threatening infections [72]. This scarcity of treatment choices can lead to treatment failures, prolonged periods of illness, and an increased reliance on potentially more harmful medications. Vulnerable populations such as newborns and immune-compromised patients within Ethiopia are at a higher risk of drug-resistant bacterial infections. Studies have specifically highlighted the high prevalence of MDR bacteria among HIV-positive individuals [73] and the significant impact of drug-resistant bacteria among hospitalized neonates for clinical bloodstream infections [74].
The genomic epidemiology of β-lactamases, carbapenemases, colistin-resistance, and other resistance genes in Ethiopia reveals a concerning landscape of rapidly evolving AMR, significantly compromising the effectiveness of last-resort antibiotics. This detailed genetic understanding highlights the prevalence and diverse types of carbapenemase genes, particularly bla-NDM variants, and their presence across various clinically relevant bacteria like K. pneumoniae, A. baumannii, and E. coli, often co-harboring multiple resistance mechanisms [75,76]. It signals a heightened risk of untreatable infections, leading to increased patient morbidity, mortality, prolonged hospital stays, and escalating healthcare costs in an already resource-constrained setting. Identifying the specific mobile genetic elements (like plasmids) carrying these resistance genes underscores the high potential for horizontal gene transfer, facilitating their rapid spread not only within healthcare settings but also across human, animal, and environmental reservoirs, demanding a robust “One Health” approach to surveillance and intervention strategies. This genomic insight is vital for informing targeted infection control, guiding antimicrobial stewardship programs, and accelerating the development of novel diagnostics and therapeutic approaches to combat this escalating public health crisis in Ethiopia.It is important to strengthen laboratory capacity and surveillance networks in line with WHO recommendations for AMR containment.
The identification of XDR-TB in Ethiopia is a challenge to effective TB management, which limits treatment options, leading to higher rates of treatment failure, relapse, and mortality. This poses a significant burden on Ethiopia’s healthcare system, which requires an increased cost of specialized drugs, prolonged treatment durations, and the need for more intensive patient monitoring and support, all within a resource-limited setting. Furthermore, the presence of XDR-TB resulted in the risk of widespread transmission, particularly in crowded urban areas and within vulnerable populations. Strengthening rapid and accurate drug susceptibility testing, ensuring strict adherence to directly observed treatment for all TB patients, innovating new and effective anti-TB drugs, and implementing comprehensive contact tracing and investigation to identify and manage new cases swiftly are strategies to curb its spread.
8. Strengths and limitations
Although the researchers provided valuable input regarding the recently emerging XDR and PDR bacterial strains, it is important to note that the true burden of XDR and PDR bacteria in Ethiopia might be underestimated due to inherent challenges in their phenotypic detection (disk-diffusion method) and reporting variation. As highlighted by Global Antibiotic Research and Development Partnership (GARDP) Revive, the prevalence of PDR bacteria is difficult to accurately assess because isolates are often not tested against all possible antibiotics. This limitation in comprehensive testing, potentially due to resource constraints, suggests that the reported prevalence rates may not fully reflect the actual extent of XDR and PDR in the country.
9. Conclusion
In Ethiopia, the emergence of XDR and PDR bacteria represents a significant and growing threat to public health. These highly resistant bacteria pose a serious challenge to the healthcare system, leading to increased morbidity, mortality, prolonged hospitalizations, and high healthcare costs. Sustained and intensified implementation of Ethiopia’s NAP-AMR, with adequate funding and strong multisectoral coordination, is crucial. Strengthening surveillance systems to better track the emergence and spread of resistant bacteria, promoting antimicrobial stewardship programs to optimize antibiotic use, and enhancing infection prevention and control measures are mandatory.
9.1. Significance of the review
This review provides evidence for recently emerging XDR and PDR bacterial strains, as well as Pre-XDR and XDR-TB in Ethiopia. Additionally, it explored the significant contributors of resistance, recent advancements in the treatment of drug-resistant bacteria in Ethiopia, and their implications for public health. It highlights the need for urgent nationwide surveillance and antimicrobial stewardship programs. The findings also serve as baseline data for future research and healthcare policy development at the national level.
Supporting information
S2 File. The detailed information of included articles for this review.
https://doi.org/10.1371/journal.pntd.0013363.s002
(XLSX)
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