Global in vitro antimicrobial susceptibility profiles of Mycobacterium abscessus: a systematic review and meta-analysis

Mycobacterium abscessus (MAB) exhibits extensive antimicrobial resistance, contributing to major treatment challenges and frequent therapeutic failure. This systematic review and meta-analysis aimed to assess the global in vitro susceptibility of antimicrobial agents against clinical MAB isolates. Relevant studies reporting antimicrobial susceptibility data according to the Clinical and Laboratory Standards Institute (CLSI) guidelines were systematically identified through searches of PubMed, Scopus, and Embase up to 31 May 2025. The pooled in vitro resistance rates of antimicrobial agents in clinical MAB isolates were estimated using a random-effects model. Publication bias was assessed using Egger’s test. A total of 114 studies met the inclusion criteria, comprising 47 studies eligible for systematic review only, 38 for meta-analysis only, and 29 for both systematic review and meta-analysis. Among isolates with subspecies identification, M. abscessus subsp. abscessus (MAB-A) and M. abscessus subsp. massiliense (MAB-M) were more frequently identified than M. abscessus subsp. bolletii (MAB-B). Overall, MAB demonstrated resistance to most drugs commonly used in treatment regimens, including amikacin (2.8%, 95% CI 2.1–3.5%), clarithromycin (9.9%, 95% CI 7.4–12.5%), cefoxitin (14.6%, 95% CI 9.3–19.9%), imipenem (34.5%, 95% CI 26.1–43.0%), and linezolid (24.2%, 95% CI 18.2–30.2%). For other agents, resistance rates ranged from 67.7% for tobramycin to 94.5% for doxycycline. Substantial heterogeneity across studies was observed, as indicated by the I 2 statistic (I 2 = 65.51–99.65%). Publication bias was detected for most drugs ( p < 0.05), except for inducible clarithromycin resistance, imipenem, meropenem, and tobramycin. The systematic review of MIC50 and MIC90 data for novel agents proposed for the treatment of MAB demonstrated that clofazimine, bedaquiline, tedizolid, eravacycline, and omadacycline consistently exhibited lower MIC50 and MIC90 values than sarecycline. This study provides a comprehensive overview of global antimicrobial susceptibility patterns of MAB and indicates that several agents included in current treatment regimens retain in vitro activity against MAB. Strengthened global laboratory-based surveillance is essential to inform antimicrobial stewardship and to optimize clinical management of MAB infections.