<p>Forest plot of subgroup analysis.</p>

Background

Antimicrobial resistance caused by extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE) has emerged as a major threat to global public health. The human gastrointestinal tract represents a critical ecological niche for these organisms, enabling silent carriage and onward transmission. Food handlers are of particular concern because they can facilitate indirect transmission of resistant bacteria through food preparation and handling. Despite the availability of primary studies, evidence focusing specifically on food handlers in Africa remains fragmented. This systematic review and meta-analysis therefore aimed to estimate the pooled prevalence of fecal colonization with ESBL-PE among food handlers in Africa.

Methods

This review was conducted according to a protocol registered in PROSPERO (ID: CRD420251075141). A systematic search was performed from September 5–15, 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 model (DerSimonian and Laird) was used to calculate the pooled prevalence. To investigate the substantial heterogeneity, we performed subgroup and sensitivity analysis. The potential for publication bias was assessed using funnel plot and Egger’s test.

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%, I² = 95.56%, p < 0.001), followed by Klebsiella species at 23.92% (95% CI: 18.48, 29.35%, I² = 0.00%, p = 0.65).

Conclusion and recommendations

This meta-analysis demonstrates that approximately one in four food handlers were identified as ESBL-PE carriers in Africa based on pooled estimates. These findings highlight the need for strengthened food safety regulations, routine screening of high-risk occupational groups, and enhanced antimicrobial stewardship programs to limit the spread of resistant Enterobacteriaceae.