Burden of fecal colonization with extended-spectrum beta-lactamase producing enterobacteriaceae among food handlers in Africa: A systematic review and meta-analysis

Abstract

Abstract Background Antimicrobial resistance particularly from extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) is a critical global public health threat, contributing significantly to infection-related mortality. The human intestinal tract is a key reservoir for ESBL-PE, and exposure to antibiotics can disrupt the gut microbiota, thereby making it easier for these pathogens to colonize the intestine. Colonized individuals are at risk of developing subsequent infections and can silently transmit these resistant bacteria to others. This transmission risk is particularly significant in food handlers, who can inadvertently spread pathogens to consumers, posing a substantial food safety hazard. In Africa, the rapid spread of ESBL-PE is exacerbated by a lack of regular surveillance and antibiotic stewardship programs. While primary studies on ESBL-PE exist, a comprehensive synthesis of data specific to the food handler population is lacking. Therefore, this systematic review and meta-analysis aimed to determine the pooled fecal colonization rate of ESBL-PE among food handlers in Africa to inform public health interventions. Materials and Methods This review was conducted according to a protocol registered in PROSPERO (ID: CRD420251075141). A systematic search was performed from September 5 to 15, 2025 in PubMed, Google Scholar, and Hinari/Research4Life to identify relevant studies. The methodological quality of the included studies was appraised using the Joanna Briggs Institute (JBI) critical appraisal tool. Data were extracted into Microsoft Excel 2019 and analyzed with Stata software version 17. Given significant heterogeneity among the studies (I² = 98.3%, p < 0.001), a random-effects meta-analysis model (DerSimonian and Laird) was used to calculate the pooled prevalence. To investigate the substantial heterogeneity, we performed subgroup analysis. Furthermore, sensitivity analysis was conducted to assess the influence of individual studies on the overall results. The potential for publication bias was assessed visually with a funnel plot and statistically using Egger’s test. Finally, results were presented via text, figures, and tables. Results The meta-analysis incorporated nine studies with publication year ranged between 2012 and 2023, involving 4,061 participants. The pooled fecal colonization rate of ESBL-PE among food handlers in Africa was 23.64% (95% CI: 15.3, 31.94%). A high degree of heterogeneity was observed (I² = 98.3%, p < 0.001). The most prevalent ESBL-PE species identified was E. coli , with a pooled prevalence of 85.83% (95% CI: 79.97, 91.69%, I 2 = 95.56%, p <0.001), followed by Klebsiella species at 23.92% (95% CI: 18.48, 29.35%, I 2 = 0.00%, p = 0.65) Conclusion and recommendations This meta-analysis establishes that approximately one in four food handlers in Africa are colonized with ESBL-PE, indicating a substantial reservoir for community transmission. This colonization risk facilitates the spread of antimicrobial resistance and can lead to severe, hard-to-treat infections. We therefore recommend implementing targeted public health measures, including routine screening, antimicrobial stewardship, and strict infection control protocols for food handlers to mitigate this threat.