Background:
Antimicrobial resistance represents a major global public health challenge and poses a particular threat to pediatric populations, who are frequently exposed to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalization. Understanding the burden, pathogen profile, and determinants of multidrug-resistant (MDR) bacterial infections among pediatric inpatients is essential for informing targeted prevention and control strategies.

Objective:
To systematically review and synthesize evidence on the prevalence of multidrug-resistant (MDR) bacterial infections, distribution of MDR pathogens, and associated risk factors among pediatric inpatients in Saudi Arabia.

Methods:
This systematic review and meta-analysis was conducted in accordance with PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, Web of Science, Google Scholar, and relevant registers were searched from inception to December 2025. Observational studies reporting MDR bacterial infections among pediatric inpatients (0–18 years) in Saudi Arabia were included. Study quality was assessed using the Newcastle–Ottawa Scale (NOS). A random-effects meta-analysis with Freeman–Tukey double arcsine transformation was used to estimate pooled prevalence. Subgroup analyses were conducted by age group, healthcare setting, geographic region, study design, and study period.

Results:
Seventeen studies comprising 3,512 pediatric inpatients met the inclusion criteria, of which 16 studies were included in the meta-analysis. The pooled prevalence of MDR bacterial infections was 36.0% (95% CI: 22.2%–51.1%), with substantial heterogeneity (I² = 98.6%). Gram-negative bacteria predominated, particularly Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, and Pseudomonas aeruginosa, frequently exhibiting ESBL production and carbapenem resistance. Consistently reported risk factors included prior and broad-spectrum antibiotic exposure, ICU/NICU admission, mechanical ventilation, central venous catheter use, prolonged hospitalization, and underlying comorbidities. Subgroup analyses revealed significant regional variation in MDR prevalence, while differences by age group, healthcare setting, and study period were not statistically significant under random-effects models. Overall study quality was moderate to high, with no studies rated as high risk of bias.

Conclusions:
Multidrug-resistant bacterial infections constitute a substantial burden among pediatric inpatients in Saudi Arabia, driven by antimicrobial exposure, intensive care environments, and patient vulnerability. These findings underscore the need for strengthened antimicrobial stewardship, infection prevention and control measures, and coordinated national surveillance systems targeting pediatric healthcare settings.

Keywords: Multidrug resistance; pediatric inpatients; antimicrobial resistance; Saudi Arabia; systematic review; meta-analysis