Title: race and ethnicity and the risk of community-acquired third-generation cephalosporin-resistant uropathogens: a systematic review and meta-analysis.

Objective: The objective of this systematic review and meta-analysis (SRMA) was to synthesize literature on the differences in risk of community-acquired third-generation cephalosporin resistant (3GC-R) uropathogens across racial and ethnic groups. Methods: This SRMA builds on a completed scoping review of the association between race, ethnicity, and risk of colonization or community-acquired infection with ESKAPE pathogens. A literature search was conducted for the earlier scoping review in January 2022 and updated in March 2024. Following PRISMA guidelines, titles and abstracts were screened before advancing to full-text review and data extraction. A customized extraction form in Covidence captured relevant information from each study. For this SRMA, studies identified in the scoping review that reported case counts or effect measures related to colonization or community-acquired infection with 3GC-R uropathogens across distinct identities were included. Separate random effects meta-analyses assessed differences in risk of 3GC-R uropathogens between each minority racial/ethnic group and White/Caucasian persons. Results: Five studies comprising 13,527 subjects were included in the SRMA, among which there was generally a higher risk of 3GC-R uropathogens among Hispanic/Latinx and Asian persons compared to White persons. Only the meta-analysis of Hispanic/Latinx versus White/Caucasian persons yielded a statistically significant pooled risk ratio; specifically, Hispanic/Latinx persons had a 27% higher risk of harboring 3GC-R uropathogens (95% CI: 1.04, 1.55). Conclusions: As antibiotic resistance rises in community settings, our findings support the need to understand the structural issues that underpin differential risk of 3GC-R uropathogens across race and ethnicity.