Geographic and genomic determinants of antimicrobial resistance in indian children: a systematic review and meta-analysis

Antimicrobial resistance (AMR) is a major public health challenge, especially in the pediatric population in low- and middle-income countries, particularly India, where the burden of pediatric infections is high. However, nationally representative, pediatric-specific estimates of AMR with geographic stratification remain lacking. We conducted a systematic review and meta-analysis to define the magnitude and regional variation of AMR among Indian children. We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 and the Joanna Briggs Institute guidelines. PubMed/MEDLINE, Scopus, and the Cochrane Library were searched from inception to December 2025 for studies reporting antimicrobial resistance in bacterial isolates from children (≤ 18 years) in India. Given substantial clinical and methodological heterogeneity across pathogens, antibiotic classes, and settings, we conducted stratified random-effects meta-analyses by geographic zone for key resistance phenotypes. Forty-seven studies met the inclusion criteria, of which 23 contributed to the quantitative synthesis. Pronounced geographic heterogeneity in AMR was observed across India. The number of studies contributing to each pooled estimate ranged from 2 to 8, and heterogeneity (I²) ranged from 19% to 79%. Carbapenem resistance among neonatal intensive care unit isolates ranged from 12% (95% CI 8–18) in Central India to 80% (70–88) in North India. Extended-spectrum β-lactamase production was consistently high (60–80%) across most regions, but lower in Central India (38%). Methicillin-resistant Staphylococcus aureus prevalence ranged from 35% (26–44) to 61% (49–72). Fluoroquinolone resistance exceeded 85% in North, South, and East/Northeast regions, whereas colistin resistance remained ≤ 8% nationally. Genomic data demonstrated widespread dissemination of bla CTX-M-15 and regional clustering of carbapenemase genes ( bla NDM, bla OXA), supporting both clonal spread and horizontal gene transfer. Antimicrobial resistance in Indian children is highly prevalent and geographically heterogeneous, with up to five-fold regional differences in carbapenem resistance. In high-burden regions, these resistance levels are likely to compromise the effectiveness of standard empirical therapies, particularly in neonatal and critical care settings. These findings support the urgent need for region-specific empirical treatment guidelines, pediatric-focused antimicrobial stewardship, and integrated phenotypic–genomic surveillance systems.