Rising antimicrobial resistance in urinary tract infections across low- and middle-income countries: a systematic review

Abstract Background Urinary tract infections (UTIs) are common worldwide, and rising antimicrobial resistance (AMR) threatens effective empirical treatment, particularly in low- and middle-income countries (LMICs), where diagnostic and stewardship capacity may be limited. We synthesized evidence on uropathogen distribution and resistance patterns in LMICs and translated the findings into an implementation-oriented public health roadmap. Methods We conducted a systematic review in accordance with PRISMA and MOOSE guidance and registered the protocol in PROSPERO (ID: 1267531). PubMed, Embase, and Scopus were searched through December 1, 2025, for observational studies reporting culture-confirmed UTIs and antimicrobial susceptibility outcomes in LMICs. Because of methodological and clinical heterogeneity, findings were synthesized descriptively without meta-analysis. Results Twelve studies from Sub-Saharan Africa, South Asia, Southeast Asia, and the Caribbean met the inclusion criteria. Escherichia coli was the predominant uropathogen, accounting for 26.7%–62.4% of isolates in studies reporting organism-level data. Resistance to commonly used oral agents was frequently high: trimethoprim–sulfamethoxazole resistance ranged from 19 to 87%, and fluoroquinolone resistance exceeded 70% in several cohorts. Nitrofurantoin resistance was comparatively lower where reported. Multidrug-resistant and extended-spectrum β-lactamase-producing organisms were identified in hospital, community, and antenatal settings, although definitions and potential overlap between these phenotypes varied across studies. Conclusions Evidence from the included LMIC studies indicates that resistance to widely used empirical UTI treatments may constrain routine management. The predominance of hospital-based surveillance and heterogeneity in susceptibility reporting highlight the need to expand access to culture and antimicrobial susceptibility testing, standardize reporting, and extend antimicrobial stewardship beyond tertiary care. We propose a structured roadmap linking identified evidence gaps to feasible interventions that support locally informed empirical therapy and strengthened surveillance.