The prevalence of neonatal sepsis caused by gram-negative bacteria and their antibiotic resistance patterns in Pakistan: a systematic review and meta-analysis

Neonatal sepsis is a significant cause of morbidity and mortality in infants, particularly those caused by Gram-negative bacteria. Antibiotic resistance makes this problem more challenging for medical experts. The study aims to determine the pooled prevalence of Gram-negative bacteria in neonates with sepsis and their antibiotic resistance patterns across different regions in Pakistan. A comprehensive literature search was conducted in electronic databases, including PubMed, Embase, and Google Scholar, to identify studies published between 2016 and 2025 for the systematic review. A meta-analysis was conducted using RStudio. The pooled prevalence was estimated using both fixed-effect and random-effects models. Publication bias was assessed using Egger’s and Begg’s tests and further evaluated through visual inspection of a funnel plot. Based on 54 studies comprising 9,039 neonates, the pooled prevalence of Gram-negative bacteria among neonates with sepsis in Pakistan was 57% (95% CI: 50–64). Most studies were cross-sectional, with the remainder comprising prospective, retrospective, and descriptive. Escherichia coli , Klebsiella spp, and Acinetobacter spp., were the most frequently reported Gram-negative pathogens across all provinces. The highest levels of antimicrobial resistance were observed for ampicillin (61.3%), amoxicillin (50.8%), gentamicin (45.8%), and cefotaxime (42.4%). Subgroup meta-analysis by study period demonstrated significant temporal variation in pooled prevalence, ranging from 35% in 2017 to 75% in 2018. The study revealed that Gram-negative bacteria, particularly E. coli , and Klebsiella spp , were the primary cause of neonatal sepsis in Pakistan.