Burden and Genomic Landscape of Antimicrobial Resistance in Non-Bloodstream Infections Among Patients with Cirrhosis: A Systematic Review and Meta-Analysis

BackgroundPatients with cirrhosis are highly susceptible to infections due to immune dysfunction and gut barrier impairment. Non-bloodstream infections frequently trigger decompensation and mortality, yet the global distribution of antimicrobial resistance (AMR) in these infections is poorly characterized. MethodsWe performed a systematic review and meta-analysis of studies reporting AMR in non-bloodstream bacterial infections among patients with cirrhosis. PubMed, Embase, and Web of Science were searched up to 15 September 2025. Pooled prevalence estimates of multidrug-resistant (MDR) and key resistant pathogens were calculated using random-effects models. Subgroup analyses were performed by country income, continent, and bacterial species. ResultsThirty-one studies including 3,162 infections were analysed. Spontaneous bacterial peritonitis predominated (79%), followed by colonisation (12%) and urinary tract infections (7%). Gram-negative bacteria accounted for 60% of infections (Escherichia coli 29%, Klebsiella pneumoniae 11%), while Gram-positive pathogens represented 39% (Enterococcus spp. 14%, Staphylococcus aureus 6%). Overall pooled MDR prevalence was 29%, with higher burdens in lower-middle-income countries (MDR 47% vs. 22-41%; ESBL 24% vs. 10%; VRE 21% vs. 3%; CRE 32% vs. 1%). Genotypic data identified 436 resistance genes with marked continental differences. ConclusionCirrhosis-associated non-bloodstream infections are dominated by Gram-negative bacteria and show high MDR, particularly in lower-middle-income countries. These findings highlight the need for integrated phenotypic and genomic surveillance of resistance patterns in these settings to guide empiric therapy.