Non-tuberculous mycobacterial infections in mainland China and Taiwan: a systematic review and meta-analysis of epidemiology, species distribution, and drug resistance (2013-2024)

Introduction Non-tuberculous mycobacteria (NTM) represent an emerging public health threat in China. Despite evidence of rising NTM prevalence and significant regional variation, comprehensive and up-to-date nationwide data on epidemiology, species distribution, and drug resistance patterns have been lacking. This study aimed to systematically evaluate the prevalence, geographical and temporal trends, species composition, and antimicrobial resistance of NTM in mainland China and Taiwan from 2013 to 2024. Methods Adhering to PRISMA guidelines, this systematic review and meta-analysis (PROSPERO: CRD42024540102) included 43 studies (2013-2024) encompassing 17,959 NTM isolates from 225,733 suspected TB patients. Stata software was used for meta-analysis with a random-effects model; publication bias was assessed via Egger's test and funnel plots. Results The pooled NTM prevalence among suspected tuberculosis patients was 11.27% (95% CI: 9.89-12.65%), with marked geographic variation: highest in northeast (24.18%) and southeast coastal regions (12.83%), and lowest in southwest (2.30%). Slowly growing mycobacteria accounted for 68.07% of isolates, dominated by Mycobacterium avium complex (especially M. intracellulare ); rapidly growing mycobacteria (26.57%) were more prevalent in southern provinces, with M. abscessus predominant. An overall upward trend in NTM isolation was observed from 2009-2021, followed by a decline in 2022-2023. Widespread resistance to first-line antituberculosis drugs was universal, whereas clarithromycin, amikacin, linezolid, and clofazimine retained good activity. Conclusion NTM prevalence in China has continued to rise over the past decade and now exceeds many global estimates, with pronounced coastal-southern predominance. The persistently high resistance to standard antituberculosis drugs underscores the urgent need for standardized diagnostic protocols, mandatory NTM reporting, enhanced surveillance networks, and region-tailored treatment guidelines. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42024540102.