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However, no comprehensive review has evaluated the burden of bacterial co-infections, antibiotic resistance (AR), and multi-drug resistance (MDR) across both hospitalized and non-hospitalized Iranian COVID-19 patients. This systematic review and meta-analysis aimed to determine the prevalence of bacterial infections, AR, and MDR during the COVID-19 era in Iran.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Following PRISMA 2020 guidelines, we systematically searched MEDLINE (PubMed), Embase, Scopus, Web of Science, and Iranian regional databases for studies published from January 2020 to March 2025. The review protocol was registered with the Open Science Framework (OSF;\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"10.17605\/OSF.IO\/SCBRX\" ext-link-type=\"doi\">https:\/\/doi.org\/10.17605\/OSF.IO\/SCBRX<\/jats:ext-link>\n                      ). Fifteen studies comprising 36,403 COVID-19 patients\u201433,989 inpatients (including 22,875 treated in intensive-care units) and 2,414 outpatients\u2014met the inclusion criteria. We combined results from multiple studies to determine overall rates of bacterial infections, antibiotic resistance, and multi-drug resistance, using methods that account for differences between studies.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The pooled prevalence of bacterial co-infection among Iranian COVID-19 patients was 19.6% (95% CI: 17.8\u201321.4%) across hospitalized and non-hospitalized settings. Among hospitalized patients, secondary bacterial infections were predominantly caused by Gram-negative pathogens:\n                      <jats:italic>Klebsiella pneumoniae<\/jats:italic>\n                      (36.2%),\n                      <jats:italic>Acinetobacter baumannii<\/jats:italic>\n                      (28.4%),\n                      <jats:italic>Escherichia coli<\/jats:italic>\n                      (24.8%), and\n                      <jats:italic>Pseudomonas aeruginosa<\/jats:italic>\n                      (11.7%). High heterogeneity (I\u00b2 &gt;90%) was observed across most pooled estimates. Critical antimicrobial resistance rates were observed particularly in hospitalized settings, with carbapenem resistance reaching 91% for imipenem and 88% for meropenem in A. baumannii. Given that 63% of the cohort were ICU patients, the high secondary bacterial infection and resistance rates likely reflect risk factors such as mechanical ventilation and prolonged hospitalization.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Iran\u2019s AMR crisis during the COVID-19 era affects both hospitalized and non-hospitalized patients, with particularly concerning rates in healthcare settings. The predominance of hospitalized cases in available literature (ICU-heavy cohorts) reflects the urgent need for antimicrobial stewardship programs targeting hospital-based carbapenem-sparing regimens, while highlighting the need for improved surveillance across all COVID-19 care settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12879-025-11643-6","type":"journal-article","created":{"date-parts":[[2025,9,29]],"date-time":"2025-09-29T19:10:14Z","timestamp":1759173014000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Antibiotic resistance and bacterial co-infections in COVID-19 patients in Iran: a systematic review and meta-analysis of hospitalized and non-hospitalized cases"],"prefix":"10.1186","volume":"25","author":[{"given":"Zahra","family":"Najafi-Olya","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zahra","family":"Heydarifard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mehdi Azizmohammad","family":"Looha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akram Sadat","family":"Ahmadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neda","family":"Yarhamadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moslem","family":"Safaei","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,9,29]]},"reference":[{"issue":"7","key":"11643_CR1","doi-asserted-by":"publisher","first-page":"442","DOI":"10.2471\/BLT.20.268573","volume":"98","author":"H Getahun","year":"2020","unstructured":"Getahun H, Smith I, Trivedi K, Paulin S, Balkhy HH. 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