Treatment gaps and risk factors for multidrug-resistant Enterobacterales in Belize: a 6-year (2018–2023) nationwide retrospective analysis

Background: Antimicrobial resistance (AMR) in Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae is a global threat, yet data from Belize and the wider Caribbean are scarce. Understanding local resistance patterns is critical for effective treatment and stewardship. Objectives: To determine antibiotic susceptibility patterns, quantify multidrug resistance (MDR) in outpatient and inpatient settings, identify predictors of empirical treatment failure for urinary tract infections (UTIs), and analyze temporal and geographic trends. Design: Nationwide retrospective analysis of clinical isolates from Belize’s public health system (2018–2023). Methods: We analyzed 4591 clinical isolates. MDR was defined as non-susceptibility to ⩾3 drug categories. Multivariable logistic regression identified predictors of the risk of empirical treatment failure for UTIs. Joinpoint regression analyzed temporal trends. Geospatial analysis mapped hotspots of incidence and resistance. Results: E. coli was predominant (68%). Among 3005 urinary isolates, 1247 (41.5%) were resistant to both first-line oral antibiotics (ciprofloxacin and trimethoprim-sulfamethoxazole). Extended-spectrum β-lactamase (ESBL) production (adjusted odds ratio (aOR) 8.91, 95% CI 7.40–10.73), infection with K. pneumoniae (aOR 2.85, 95% CI 2.32–3.51) or E. cloacae (aOR 4.12, 95% CI 2.78–6.11), and older age were key predictors. Ciprofloxacin resistance in E. coli increased significantly post-2020 (Annual Percent Change 9.8%, p = 0.02). MDR was prevalent in outpatient settings (42.1% for E. coli, 61.2% for K. pneumoniae). Geospatial analysis revealed the Belize District as the incidence hotspot, while the Toledo District was the ESBL prevalence hotspot (29.5%). Conclusion: Belize faces a notable AMR crisis characterized by a high community burden of MDR Enterobacterales, a critical empirical treatment gap for UTIs, and accelerating resistance trends.