Background: Carbapenemase-producing Klebsiella pneumoniae (CPKP) is a major antimicrobial resistance threat, while hospital wastewater represents an important reservoir and potential pathway for environmental dissemination. Genomic surveillance can reveal resistance determinants, genetic lineages, and transmission patterns, but evidence from Sub-Saharan Africa remains fragmented. Objective: This systematic review evaluated genomic evidence on CPKP in hospital wastewater across Sub-Saharan Africa, focusing on carbapenemase determinants, genomic lineages, mobile genetic elements, and surveillance approaches. Methods: Major electronic databases were systematically searched using predefined eligibility criteria and the PRISMA 2020 framework. Eligible studies investigated CPKP recovered from hospital wastewater or associated effluents in Sub-Saharan African countries. Data on detection methods, carbapenemase genes, resistance determinants, sequence types, plasmids, genomic approaches, and epidemiological findings were extracted and narratively evaluated. Results: Hospital wastewater harboured genetically diverse CPKP carrying clinically important carbapenemase determinants and mobile genetic elements. Reported isolates exhibited diverse sequence types and plasmid-associated resistance profiles, indicating both clonal and potentially horizontal dissemination. However, genomic evidence was geographically uneven and concentrated in relatively few countries. Targeted molecular methods predominated, whereas whole-genome and metagenomic approaches were less frequently applied, limiting resolution of genomic relatedness and transmission pathways. Conclusion: Hospital wastewater represents an important but underutilized genomic surveillance interface for CPKP in Sub-Saharan Africa. Standardized wastewater surveillance, expanded genomic sequencing and bioinformatics capacity, and integration of environmental and clinical genomic data are needed to strengthen early detection, track resistance dissemination, and support coordinated One Health antimicrobial-resistance control.
