Penicillin remains an effective agent against Group A Streptococcus in low- and middle-income countries: A systematic review and meta-analysis of antibiotic resistance and associated genes
DOI:
https://doi.org/10.7196/SAMJ.2025.v115i7.2837Keywords:
Group A Streptococcus, antimicrobial resistance, Antimicrobial resistance genes, LMICAbstract
Background. Driven by the extensive use of antibiotics, antibiotic resistance has become an issue globally, in both hospital and community settings. Limited access to laboratory diagnostic testing often results in undetected resistance, which may only be detected once empiric treatment fails. There have been numerous reports on the increase of antibiotic resistance in group A Streptococcus (Strep A), particularly macrolide resistance.
Objectives. To document the prevalence of antibiotic resistance in Strep A in low- and middle-income countries (LMICs) to the most widely used antibiotics. Where possible, resistance data were correlated with emm typing data.
Methods. We employed an extensive search strategy to identify studies in LMICs reporting on Strep A susceptibility to commonly prescribed antibiotics. Inclusion criteria required that isolates underwent emm typing. Two reviewers independently extracted data and assessed quality; statistical analyses, including meta-analysis using Stata software, evaluated the association between AMR and emm subtypes, and heterogeneity was assessed with Cochrane’s Q and I2 statistics.
Results. Fifty studies met the eligibility criteria and were included in this review. A range of phenotypic resistance testing methods was employed across the studies, the most common being disc diffusion. Three studies exclusively used molecular testing. For the Strep A antimicrobial resistance (AMR) quantitative synthesis, 23 commonly used antibiotics were included in the meta-analysis. Increased resistance was observed among the macrolides (erythromycin, clindamycin, azithromycin), clarithromycin and tetracycline. Differences were observed in resistance patterns across emm types, with emm1, emm12 and emm60 showing higher resistance rates to tetracycline and erythromycin. The ermB (57.60%) and tetM (52.18%) genes were the most prevalent AMR genes among the studies. No resistance to penicillin, amoxicillin/clavulanic acid, cefotaxime, cefuroxime, linezolid, ofloxacin or teicoplanin was reported.
Conclusion. This review comprehensively characterises the latest evidence on the prevalence of antibiotic resistance in Strep A in LMICs. Strep A in LMICs continues to be highly susceptible to antibiotics in vitro, primarily to penicillins. Strep A macrolide resistance patterns in LMICs are similar to those observed in high-income countries. The findings of this review may serve to inform effective treatment decisions and public health interventions.
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