Methicillin-resistant Staphylococcus aureus (MRSA): a systematic review and meta-analysis of prevalence and antibiotic resistance patterns in clinical isolates at health-care settings of South Asia

A growing clinical concern and threat has arisen from methicillin-resistant Staphylococcus aureus (MRSA) in South Asia. This study investigated and evaluated the prevalence of MRSA and the antibiotic resistance pattern in clinical specimens analyzed from South Asian patients. The systematic review and meta-analysis were conducted by extracting data from published reports from the last 25 years (2001–2025) on MRSA prevalence and antibiotic resistance patterns from clinical samples isolated from South Asian patients, following the standard PRISMA-220 procedure for study selection. Meta-analyses were performed using MedCalc 19.5.1 (MedCalc Software Ltd., Ostend, Belgium) and the CMA (Comprehensive Meta-Analysis) software version 3.0 (Biostat Inc., Englewood, NJ, USA). A standard extraction procedure was used to import the datasets into Microsoft Excel. DerSimonian-Laird random-effects model was used to calculate the pooled MRSA prevalence through Forest plot analysis. Publication bias, subgroup, and heterogeneity analyses were also used by funnel plot analysis, Egger’s regression, and I² statistics. Pearson correlation analysis, hierarchical clustering, and heat map visualization were carried out using R software (version 4.3.2; R Foundation for Statistical Computing, Vienna, Austria). 31,029 S. aureus isolates were identified from 75 included clinical studies, with 12,160 MRSA isolates. The pooled proportion of MRSA among clinical S. aureus isolates was 44.3% (95% CI: 40.2–48.4), with significant heterogeneity (I²=96.7%; p < 0.001). Minor publication bias was observed via funnel plot analysis; however, no publication bias ( p = 0.106) was observed with Egger’s test. Subgroup analysis indicated a small-study effect for Pakistan ( p = 0.015). Diversified pooled prevalence of MRSA was reported from various South Asian countries, with the highest pooled prevalence in Bangladesh (52.9%) and the lowest in Pakistan (37.8%). A temporal rise in the MRSA burden has been reported over the last decade. Penicillin and ampicillin exhibited low susceptibility (< 10%) against MRSA, whereas vancomycin demonstrated the highest pooled susceptibility (98.0%). However, overall vancomycin susceptibility remained high; reports of mitigated vancomycin susceptibility and vancomycin-resistant S. aureus (VRSA) underscore the importance of judicious antimicrobial utilization and continued antimicrobial surveillance. A higher prevalence of MRSA was observed in South Asian clinical settings. Distinct prevalence of MRSA was reported in different countries of South Asia, which indicates regional variation in diagnosis, treatment regimen, and management. However, these outcomes must be elucidated very carefully because of the extensive heterogeneity between reports across the included studies. A high pooled prevalence of MRSA was observed in South Asian health-care settings, with extensive heterogeneity across reports and remarkable regional variation. Vancomycin exhibited the highest pooled susceptibility (98.0%) among the assessed antibiotics; although reports of decreased susceptibility and VRSA support the urgent need for judicious antimicrobial use and continued antimicrobial surveillance. These findings must be evaluated very carefully because of the extensive heterogeneity among the included reports.