Barw Barw Medical Journal 2960-1959 2026 11 01 Resistance Patterns of Gram-Negative Bacteria and Surgical Site Infections Across the Middle East: A Systematic Review and Meta-Analysis 10.58742/bmj.v4i2.245 eng Mee Kamal Department of Scientific Affairs, Smart Hospital, Madam Mitterrand Street, Sulaymaniyah, Iraq.. meeraspot01@gmail.com Mohammad Al-Tamimi Department of Microbiology, Pathology and Forensic Medicine, Faculty of Medicine, The Hashemite University, Zarqa, Jordan.. mohammad.altamimi@hu.edu.jo Ayman D. Alsheikh Department of Medical Laboratory Sciences, Faculty of Allied Medical Sciences, Zarqa University, Zarqa, Jordan.. ayman.alsheikh74@gmail.com Imdat Kilbas Dental Prosthesis Technology Program, Vocational School of Health Services, Fenerbahce University, Istanbul, Türkiye.. imdtklbs@gmail.com Khaled M. Aboshanab Department of Microbiology and Immunology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.. aboshanab2012@pharma.asu.edu.eg Muhammad Yasir Pathological Sciences Department-MBBS Program, Fakeeh College for Medical Sciences, and Fakeeh Care Group, Jeddah, Saudi Arabia.. yasirkhattak.mrl@gmail.com Mutasim E. Ibrahim Department of Microbiology and Clinical Parasitology, College of Medicine, University of Bisha, Bisha, Saudi Arabia.. meibrahim7@gmail.com Shnya R. Hamalaw College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Iraq.. Shnya.05001750@univsul.edu.iq Suhaib H. Kakamad Department of Medical Laboratory Technology, Faculty of Health Sciences, Qaiwan International University, Sulaymaniyah, Iraq.. kakamad.suhaib@outlook.com Hussein M. Hamasalih Department of Quality, Smart Hospital, Madam Mitterrand Street, Sulaymaniyah, Iraq.. hussainhamasalh@gmail.com Hawdang A. Sidiq Department of Quality, Smart Hospital, Madam Mitterrand Street, Sulaymaniyah, Iraq.. hawdangsidiq@gmail.com Shvan L. Ezzat Department of Laboratory, Smart Hospital, Madam Mitterrand Street, Sulaymaniyah, Iraq.. ShvanEzzat1@protonmail.com Yasemin Çağ Department of Infectious Diseases and Clinical Microbiology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Türkiye.. dryasemincag@gmail.com Berun Anwar Abdalla Department of Scientific Affairs, Smart Hospital, Madam Mitterrand Street, Sulaymaniyah, Iraq. | Kscien Organization for Scientific Research (Middle East Office), Azadi Mall, Hamdi Street, Sulaymaniyah, Iraq.. berun.anwer95@gmail.com 2026 09 10 Introduction Surgical site infections (SSIs) are a leading healthcare-associated infection, driven by multidrug-resistant Gram-negative bacteria. Regional data from the Middle East remain limited. This meta-analysis aimed to estimate pooled antimicrobial resistance (AMR) profiles of Gram-negative isolates (GNI) recovered from SSIs.. Methods PubMed/MEDLINE and Google Scholar were searched in January 2026 for studies reporting AMR in SSI GNI.  Eligible studies were English-language reports from the Middle East presenting AMR patterns of Gram-negative bacteria recovered from SSIs. Case reports, laboratory and animal studies, conference papers, and abstract-only publications were ineligible. Proportions were pooled using DerSimonian-Laird random-effects models with Freeman-Tukey double-arcsine transformation, heterogeneity assessed by I². Results Twenty-three studies from 8 countries were included. GNI comprised 71.9% (95% CI 60.5-82.2) of all culture-positive isolates and, when restricted to SSI-confirmed specimens, 86.4% (95% CI 63.6-99.3). Escherichia coli was most frequent (27.9%), followed by Pseudomonas aeruginosa (25.8%) and Klebsiella pneumoniae (21.3%). Resistance exceeded 65% for ampicillin in E. coli and for ceftriaxone in both E. coli and K. pneumoniae, with resistance to the remaining third-generation cephalosporins (cefotaxime, ceftazidime) ranging from 46.5% to 85.9%. Conclusion Gram-negative SSI isolates in the Middle East showed high resistance across many agent classes, with substantial multidrug resistance, carbapenem resistance, and ESBL production. This regional resistance profile reinforces the need for local, SSI-specific surveillance and antimicrobial stewardship.