One health perspective of antibiotic resistance in enterobacterales from Southeast Asia: a systematic review and meta-analysis

Antimicrobial resistance (AMR) in Enterobacterales poses serious public health, agricultural, and environmental threats. In Southeast Asia, a coordinated "One Health" approach is lacking, and fragmented evidence hampers targeted interventions. This study systematically quantify and analyse AMR prevalence across human, animal, and environmental sectors in Southeast Asia by conducting a meta-analysis of 137 observational studies from 2013 to 2023. We found that Ceftriaxone resistance in E. coli was highest in human samples (49.3%, 95% CI: 37.3-61.3; N = 2,640), followed by environmental (37.1%, 95% CI: 8.4-72.2; N = 288) and animal sources (11.2%, 95% CI: 1.6-27.9; N = 923). In humans, meropenem resistance was 13.0% in K. pneumoniae (95% CI: 2.0-31.3; N = 7,803) and 1.4% in E. coli (95% CI: 0.1-4.4; N = 13,696). Resistance increased over time in human (p = 0.009) and animal sectors (p = 0.004). blaCTX-M and blaTEM were reported across all sectors. This synthesis also highlights a critical evidence gap: most studies focused on Thailand (67) and Vietnam (42). Samples came mostly from animals (62) and humans (59), with limited multi-sector studies. Only one study assessed all four sectors (human, animal, environment, food). Our study reveals an escalating AMR crisis alongside critical research gaps across Southeast Asia. Future efforts must therefore strengthen both integrated surveillance to understand transmission and regional health systems to implement effective One Health action.