When First‐Line Therapies Fail: Surgical Site Infections and the Declining Antimicrobial Utility in a Resource‐Limited Nation

Antimicrobial resistance (AMR) poses a critical threat to surgical care in resource-limited settings. This study describes the epidemiology of AMR in surgical site and wound infections in Belize from 2018 to 2024. METHODS: A retrospective analysis of national laboratory data focused on Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus from surgical and wound specimens. Resistance phenotypes (ESBL, MRSA), susceptibility profiles, and temporal-spatial trends were analyzed. RESULTS: Among 850 isolates, ESBL production among Enterobacteriaceae more than doubled from 25% to > 45% over 7 years, while MRSA remained persistently elevated (55%-65%). Critical treatment gaps emerged: over one-third of ESBL isolates showed resistance to both oral (ciprofloxacin) and intravenous (gentamicin) options. ESBL infections clustered in central Belize and following cesarean sections; MRSA predominated in diabetic amputations. Antibiotic consumption preceded resistance by approximately 6 months. Sentinel carbapenem-resistant Enterobacteriaceae and vancomycin-resistant Enterococcus were detected. CONCLUSION: AMR is prevalent in Belize, with rapidly expanding ESBL rates and significant therapeutic limitations. Urgent interventions are needed, including updated treatment guidelines, targeted antimicrobial stewardship, and enhanced infection control in high-burden areas.