Etiology, prevalence, and mortality of sepsis among children under five years in Africa: a systematic review and meta-analysis

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BACKGROUND: Sepsis remains a major global health threat, particularly among children under five years in low- and middle-income countries. Africa bears a disproportionate burden of sepsis-related morbidity and mortality. Comprehensive data on the etiology, prevalence, and mortality of pediatric sepsis in Africa remain limited. This systematic review and meta-analysis aimed to determine the causative pathogens, pooled prevalence, mortality, and risk factors of sepsis in African children under five years of age. METHODS: Following PRISMA guidelines, we conducted a systematic search of PubMed, Web of Science, and Scopus for studies published from January 2000 to December 2024. Studies reporting microbiologically confirmed sepsis in children aged 0 to 60 months in Africa were included. Data were managed with Epi Info (version 7.2.7.0) and analyzed in R (version 4.4.2). Pooled prevalence and mortality were estimated using a random-effects model. Heterogeneity was assessed using I2 statistics, and publication bias was evaluated via funnel plots, Egger’s test, and the trim-and-fill method. Subgroup analyses were performed to identify sources of heterogeneity. The quality of original studies was assessed using the National Heart, Lung, and Blood Institute’s Quality Assessment Tools. This review was registered in PROSPERO (CRD42024621969). RESULTS: Forty-six studies from 19 African countries, including 98,651 children and 59,521 pathogens, were analyzed. The most common pathogens were Klebsiella pneumoniae (25%), Acinetobacter baumannii (14.3%), and Staphylococcus aureus (13.2%). Gram-negative bacteria predominated (58.1%), with regional variations. The pooled prevalence of sepsis was 40.2% (95% CI: 26.8–55.4%), decreasing to 27.1% (95% CI: 15.5–43.0%) after adjustment for publication bias. Pooled mortality among clinically suspected cases was 16.3% (95% CI: 10.6–24.4%). Significant risk factors included prolonged rupture of membranes (OR 2.28; 95% CI: 1.30–4.00, p < 0.001), low birth weight (OR 2.16; 95% CI: 1.21–3.87, p < 0.001), and prematurity (OR 3.13; 95% CI: 1.94–5.08, p < 0.001). CONCLUSION: Sepsis in African children under five is highly prevalent and associated with substantial mortality, driven primarily by Gram-negative bacteria. Regional differences in pathogen distribution highlight the need for tailored antimicrobial strategies. These findings underscore the urgency of improving neonatal and pediatric care, enhancing diagnostic capacity, and implementing targeted prevention and management interventions to reduce sepsis burden in Africa. CLINICAL TRIAL NUMBER: Not applicable.

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