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Burkholderia Infections and Melioidosis · Review
One Health · July 31, 2026
Well-designed and adequately powered for the question it asks.
This systematic review and meta-analysis of 15,514 Salmonella isolates found a global pooled prevalence of azithromycin resistance of 9.12% (95% CI: 6.53–12.07), with substantial proportions of multidrug-resistant and extensively drug-resistant strains among resistant isolates. The analysis identified multiple resistance mechanisms and significant geographical variation, supporting the characterization of azithromycin-resistant Salmonella as an emerging global public health concern warranting coordinated surveillance and stewardship interventions.
Systematic review and meta-analysis. Salmonella isolates with genetic and phenotypic characterization data; analysis included studies stratified by geography, isolate source (human, animal, food), and serovar.. n = 15,514. Global; analysis identified high prevalence in Southern Asia and Eastern Europe..
Pooled prevalence of azithromycin resistance among Salmonella isolates was 9.12% (95% CI: 6.53–12.07) Among azithromycin-resistant isolates, multidrug-resistant (MDR) serovars accounted for 31.10% (95% CI: 18.82–44.86) Among azithromycin-resistant isolates, extensively drug-resistant (XDR) serovars accounted for 19.30% (95% CI: 6.90–35.75)
Clinical outcomes (treatment failure, mortality) are not addressed; this is epidemiological surveillance data only
Clinicians treating invasive salmonellosis should be aware of rising azithromycin resistance rates, particularly in strains originating from Southern Asia and Eastern Europe, and the high proportion of resistant isolates that are multidrug resistant, which may limit therapeutic options and inform empiric therapy selection. Laboratory surveillance and local resistance epidemiology should guide clinical decision-making.
Systematic review and meta-analysis of 15,514 isolates with prespecified protocol registration and formal heterogeneity assessment, providing robust pooled prevalence estimates for a public health surveillance question, though observational in nature and not measuring clinical intervention outcomes.
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Clinicians treating invasive salmonellosis should be aware of rising azithromycin resistance rates, particularly in strains originating from Southern Asia and Eastern Europe, and the high proportion of resistant isolates that are multidrug resistant, which may limit therapeutic options and inform empiric therapy selection. Laboratory surveillance and local resistance epidemiology should guide clinical decision-making.
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Introduction Salmonella infections pose a significant public health challenge, affecting both social and economic dimensions across various countries. Different animal species serve as reservoirs for Salmonella and contribute to drug resistance in human isolates. The improper use of antimicrobials in livestock, companion animals, and humans has led to the rise of multidrug-resistant (MDR), extensively drug-resistant (XDR), and azithromycin-resistant Salmonella serovars globally. This systematic review and meta-analysis aim to evaluate heterogeneity, estimate pooled proportions, and outline the molecular epidemiology of these resistant Salmonella serovars worldwide. Methods We analyzed data from 15,514 Salmonella isolates, focusing on their genetic and phenotypic characteristics. Our analysis included meta-analyses and frequency analyses based on the studies' geographical locations, the types of isolates, and potential biases. We employed a random-effects model, specifically the DerSimonian-Laird method, to evaluate heterogeneity and estimate pooled proportions. The result is presented as a proportion and confidence interval after the inverse of the Freeman-Tukey transformation; otherwise, all the calculations were made using the Freeman–Tukey double arcsine transformation. Results The pooled prevalence of azithromycin resistance among Salmonella isolates was 9.12% (95% CI: 6.53–12.07). Among azithromycin-resistant isolates, multidrug-resistant (MDR) and extensively drug-resistant (XDR) serovars accounted for 31.10% (95% CI: 18.82–44.86) and 19.30% (95% CI: 6.90–35.75), respectively. Resistance mechanisms involved multiple genetic factors, including efflux pumps ( mefA, acrB gene mutation), enzymatic phosphorylation ( mphA ), and class 1 integrons gene cassettes. Notably, resistance rates varied by region and serovar, with high prevalence in Southern Asia and Eastern Europe. Conclusion Azithromycin resistance in Salmonella is a growing global health concern, complicated by the presence of MDR and XDR strains and diverse resistance mechanisms. Urgent, coordinated efforts encompassing enhanced surveillance, antimicrobial stewardship, and research are critical to controlling resistance and preserving azithromycin’s efficacy in treating invasive salmonellosis through a One Health approach. Additionally, addressing antimicrobial use in the agriculture and veterinary sectors is critical to safeguarding public health. Registration We conducted a systematic review and meta-analysis after registering the protocol with PROSPERO (CRD420251047985), following the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) guidelines.
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