Molecular Epidemiology of Diarrhoeagenic Escherichia coli in Africa: A Systematic Review and Meta-Analysis

Introduction Diarrhoeagenic Escherichia coli (DEC) persistently challenges public health in Africa, contributing substantially to the diarrhoeal disease burden. This systematic review and meta-analysis illuminate the distribution and antimicrobial resistance (AMR) patterns of DEC pathotypes across the continent. Methods The review selectively focused on studies reporting prevalence and/or AMR of human-derived DEC pathotypes from African nations, excluding data from extra-intestinal, animal, and environmental sources, and studies focused on drug and mechanism experiments. Employing a robust search strategy, pertinent studies were retrieved from SCOPUS, PubMed, and EBSCOhost, processed with Covidence, and screened in alignment with PRISMA guidelines. Results The reviewed studies were predominantly hospital-based (80%) and paediatric-focused (91%), with a meagre 4.4% documenting DEC outbreaks. Seven DEC pathotypes were discerned, with Enteroaggregative E. coli (EAEC) being notably prevalent (43%, 95% CI: 30% – 55%) and Enteroinvasive E. coli (EIEC) least prevalent (24%, 95%CI: 17% – 32%). Identified non-susceptibilities were noted against essential antibiotics, including ciprofloxacin, ceftriaxone, and ampicillin, while instances of carbapenem and Extended-Spectrum Beta-Lactamase (ESBL) resistance were scarce. Conclusion Despite sporadic data on DEC prevalence and AMR in Africa, particularly in community settings, a palpable gap remains in real-time outbreak surveillance and comprehensive data documentation. Augmenting surveillance and embracing advancements in molecular/genomic characterisation techniques are crucial to precisely discerning the actual impact and resistance continuum of DEC in Africa. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The systematic review, writing workshops and in-person meetings for the FBD expert group members were funded by the Bill & Melinda Gates Foundation grant INV-033857. The authors wish to express their profound gratitude to the Africa PGI of Africa CDC for their unwavering support throughout this systematic review. Additionally, we extend our heartfelt thanks to Professor Kathryn E. Holt for dedicating her valuable time and providing insightful feedback on the draft manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript