Antimicrobial Resistance Patterns and Clinical Outcomes of Gram-Negative Bloodstream Infections in Saudi Arabian Hospitals: A Systematic Review and Meta-Analysis

This study aimed to review the evidence systematically and quantify the association between antimicrobial resistance (AMR) in gram-negative bloodstream infections (GNBSI) and all-cause mortality in hospitals in Saudi Arabia. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a PROSPERO protocol (CRD420251167703), databases (December 2010-October 2025) for observational studies comparing mortality in resistant versus susceptible GNBSI were searched. Risk of bias assessment using Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) was performed. Data pooling was achieved using a random-effects meta-analysis (Mantel-Haenszel method) incorporating the Hartung-Knapp adjustment to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Of 1,297 initial records, three retrospective cohort studies representing 19,056 patients satisfied the inclusion criteria. Risk of bias ranged from low to serious. Patients infected with resistant gram-negative pathogens demonstrated significantly higher odds of mortality compared to those with susceptible infections (pooled OR: 2.35; 95% CI: 2.30-2.41; p < 0.0001). Statistical heterogeneity was negligible (I² = 0.0%), but the small number of studies limits this finding. In this first systematic review and meta-analysis from Saudi Arabia, AMR in GNBSI was associated with a greater than twofold increase in the mortality odds. Although with limited and heterogeneous evidence, findings underscore the clinical burden, highlighting the need for antimicrobial stewardship, enhanced infection control measures, and large-scale prospective research to inform public health policies.