Risk factors for neonatal sepsis in Sub-Saharan Africa: a systematic review with meta-analysis

Christine Manich Bech; Christina Nadia Stensgaard; Stine Lund; Charlotte Holm-Hansen; Jesper Sune Brok; Ulrikka Nygaard; Anja Poulsen

doi:10.1136/bmjopen-2021-054491

Risk factors for neonatal sepsis in Sub-Saharan Africa: a systematic review with meta-analysis

Christine Manich Bech^*, Christina Nadia Stensgaard, Stine Lund, Charlotte Holm-Hansen, Jesper Sune Brok, Ulrikka Nygaard, Anja Poulsen

^*Corresponding author for this work

Department of Paediatrics and Adolescent Medicine

30 Citations (Scopus)

Abstract

OBJECTIVES: To identify the risk factors for neonatal sepsis in Sub-Saharan Africa.

DESIGN: Systematic review and meta-analysis.

DATA SOURCES: PubMed, Embase, Web of Science, African Index Medicus and ClinicalTrials.gov were searched for observational studies from January 2010 to August 2020.

SETTING: Sub-Saharan Africa, at all levels of healthcare facilities.

PARTICIPANTS: 'Neonates' (<28 days of age) at risk of developing either clinical and/or laboratory-dependent diagnosis of sepsis.

OUTCOME MEASURES: Identification of any risk factors for neonatal sepsis.

RESULTS: A total of 36 studies with 23 605 patients from secondary or tertiary level of care facilities in 10 countries were included. Six studies were rated as good quality, 8 as fair and 22 as poor. Four studies were omitted in the meta-analysis due to insufficient data. The significant risk factors were resuscitation (OR 2.70, 95% CI 1.36 to 5.35), low birth weight <1.5 kg (OR 3.37, 95% CI 1.59 to 7.13) and 1.5-2.5 kg (OR 1.36, 95% CI 1.01 to 1.83), low Apgar score at the first minute (OR 3.69, 95% CI 2.34 to 5.81) and fifth minute (OR 2.55, 95% CI 1.46 to 4.45), prematurity <37 weeks (OR 1.91, 95% CI 1.27 to 2.86), no crying at birth (OR 3.49, 95% CI 1.42 to 8.55), male sex (OR 1.30, 95% CI 1.01 to 1.67), prolonged labour (OR 1.57, 95% CI 1.08 to 2.27), premature rupture of membranes (OR 2.15, 95% CI 1.34 to 3.47), multiple digital vaginal examinations (OR 2.22, 95% CI 1.27 to 3.89), meconium-stained amniotic fluid (OR 2.72, 95% CI 1.58 to 4.69), intrapartum maternal fever (OR 2.28, 95% CI 1.18 to 4.39), foul-smelling vaginal discharge (OR 3.31, 95% CI 2.16 to 5.09) and low socioeconomic status (OR 1.93, 95% CI 1.11 to 3.35). We found considerable heterogeneity in the meta-analysis of 11 out of 15 identified risk factors.

CONCLUSION: Multiple risk factors for neonatal sepsis in Sub-Saharan Africa were identified. We revealed risk factors not listed by the WHO guidelines. The included studies overall had high risk of bias and high heterogeneity and thus, additional research of high quality is needed.

PROSPERO REGISTRATION NUMBER: CRD42020191067.

Original language	English
Article number	e054491
Journal	BMJ Open
Volume	12
Issue number	9
Number of pages	15
ISSN	2044-6055
DOIs	https://doi.org/10.1136/bmjopen-2021-054491
Publication status	Published - 1 Sept 2022

Keywords

Female
Humans
Infant, Low Birth Weight
Infant, Newborn
Infant, Newborn, Diseases
Male
Neonatal Sepsis/complications
Risk Factors
Sepsis/epidemiology
PAEDIATRICS
NEONATOLOGY
Paediatric infectious disease & immunisation
OBSTETRICS

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10.1136/bmjopen-2021-054491

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@article{e294d3fbae2e40819031327b492a718f,

title = "Risk factors for neonatal sepsis in Sub-Saharan Africa: a systematic review with meta-analysis",

abstract = "OBJECTIVES: To identify the risk factors for neonatal sepsis in Sub-Saharan Africa.DESIGN: Systematic review and meta-analysis.DATA SOURCES: PubMed, Embase, Web of Science, African Index Medicus and ClinicalTrials.gov were searched for observational studies from January 2010 to August 2020.SETTING: Sub-Saharan Africa, at all levels of healthcare facilities.PARTICIPANTS: 'Neonates' (<28 days of age) at risk of developing either clinical and/or laboratory-dependent diagnosis of sepsis.OUTCOME MEASURES: Identification of any risk factors for neonatal sepsis.RESULTS: A total of 36 studies with 23 605 patients from secondary or tertiary level of care facilities in 10 countries were included. Six studies were rated as good quality, 8 as fair and 22 as poor. Four studies were omitted in the meta-analysis due to insufficient data. The significant risk factors were resuscitation (OR 2.70, 95\% CI 1.36 to 5.35), low birth weight <1.5 kg (OR 3.37, 95\% CI 1.59 to 7.13) and 1.5-2.5 kg (OR 1.36, 95\% CI 1.01 to 1.83), low Apgar score at the first minute (OR 3.69, 95\% CI 2.34 to 5.81) and fifth minute (OR 2.55, 95\% CI 1.46 to 4.45), prematurity <37 weeks (OR 1.91, 95\% CI 1.27 to 2.86), no crying at birth (OR 3.49, 95\% CI 1.42 to 8.55), male sex (OR 1.30, 95\% CI 1.01 to 1.67), prolonged labour (OR 1.57, 95\% CI 1.08 to 2.27), premature rupture of membranes (OR 2.15, 95\% CI 1.34 to 3.47), multiple digital vaginal examinations (OR 2.22, 95\% CI 1.27 to 3.89), meconium-stained amniotic fluid (OR 2.72, 95\% CI 1.58 to 4.69), intrapartum maternal fever (OR 2.28, 95\% CI 1.18 to 4.39), foul-smelling vaginal discharge (OR 3.31, 95\% CI 2.16 to 5.09) and low socioeconomic status (OR 1.93, 95\% CI 1.11 to 3.35). We found considerable heterogeneity in the meta-analysis of 11 out of 15 identified risk factors.CONCLUSION: Multiple risk factors for neonatal sepsis in Sub-Saharan Africa were identified. We revealed risk factors not listed by the WHO guidelines. The included studies overall had high risk of bias and high heterogeneity and thus, additional research of high quality is needed.PROSPERO REGISTRATION NUMBER: CRD42020191067.",

keywords = "Female, Humans, Infant, Low Birth Weight, Infant, Newborn, Infant, Newborn, Diseases, Male, Neonatal Sepsis/complications, Risk Factors, Sepsis/epidemiology, PAEDIATRICS, NEONATOLOGY, Paediatric infectious disease \& immunisation, OBSTETRICS",

author = "Bech, \{Christine Manich\} and Stensgaard, \{Christina Nadia\} and Stine Lund and Charlotte Holm-Hansen and Brok, \{Jesper Sune\} and Ulrikka Nygaard and Anja Poulsen",

note = "{\textcopyright} Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.",

year = "2022",

month = sep,

day = "1",

doi = "10.1136/bmjopen-2021-054491",

language = "English",

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TY - JOUR

T1 - Risk factors for neonatal sepsis in Sub-Saharan Africa

T2 - a systematic review with meta-analysis

AU - Bech, Christine Manich

AU - Stensgaard, Christina Nadia

AU - Lund, Stine

AU - Holm-Hansen, Charlotte

AU - Brok, Jesper Sune

AU - Nygaard, Ulrikka

AU - Poulsen, Anja

N1 - © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

PY - 2022/9/1

Y1 - 2022/9/1

N2 - OBJECTIVES: To identify the risk factors for neonatal sepsis in Sub-Saharan Africa.DESIGN: Systematic review and meta-analysis.DATA SOURCES: PubMed, Embase, Web of Science, African Index Medicus and ClinicalTrials.gov were searched for observational studies from January 2010 to August 2020.SETTING: Sub-Saharan Africa, at all levels of healthcare facilities.PARTICIPANTS: 'Neonates' (<28 days of age) at risk of developing either clinical and/or laboratory-dependent diagnosis of sepsis.OUTCOME MEASURES: Identification of any risk factors for neonatal sepsis.RESULTS: A total of 36 studies with 23 605 patients from secondary or tertiary level of care facilities in 10 countries were included. Six studies were rated as good quality, 8 as fair and 22 as poor. Four studies were omitted in the meta-analysis due to insufficient data. The significant risk factors were resuscitation (OR 2.70, 95% CI 1.36 to 5.35), low birth weight <1.5 kg (OR 3.37, 95% CI 1.59 to 7.13) and 1.5-2.5 kg (OR 1.36, 95% CI 1.01 to 1.83), low Apgar score at the first minute (OR 3.69, 95% CI 2.34 to 5.81) and fifth minute (OR 2.55, 95% CI 1.46 to 4.45), prematurity <37 weeks (OR 1.91, 95% CI 1.27 to 2.86), no crying at birth (OR 3.49, 95% CI 1.42 to 8.55), male sex (OR 1.30, 95% CI 1.01 to 1.67), prolonged labour (OR 1.57, 95% CI 1.08 to 2.27), premature rupture of membranes (OR 2.15, 95% CI 1.34 to 3.47), multiple digital vaginal examinations (OR 2.22, 95% CI 1.27 to 3.89), meconium-stained amniotic fluid (OR 2.72, 95% CI 1.58 to 4.69), intrapartum maternal fever (OR 2.28, 95% CI 1.18 to 4.39), foul-smelling vaginal discharge (OR 3.31, 95% CI 2.16 to 5.09) and low socioeconomic status (OR 1.93, 95% CI 1.11 to 3.35). We found considerable heterogeneity in the meta-analysis of 11 out of 15 identified risk factors.CONCLUSION: Multiple risk factors for neonatal sepsis in Sub-Saharan Africa were identified. We revealed risk factors not listed by the WHO guidelines. The included studies overall had high risk of bias and high heterogeneity and thus, additional research of high quality is needed.PROSPERO REGISTRATION NUMBER: CRD42020191067.

AB - OBJECTIVES: To identify the risk factors for neonatal sepsis in Sub-Saharan Africa.DESIGN: Systematic review and meta-analysis.DATA SOURCES: PubMed, Embase, Web of Science, African Index Medicus and ClinicalTrials.gov were searched for observational studies from January 2010 to August 2020.SETTING: Sub-Saharan Africa, at all levels of healthcare facilities.PARTICIPANTS: 'Neonates' (<28 days of age) at risk of developing either clinical and/or laboratory-dependent diagnosis of sepsis.OUTCOME MEASURES: Identification of any risk factors for neonatal sepsis.RESULTS: A total of 36 studies with 23 605 patients from secondary or tertiary level of care facilities in 10 countries were included. Six studies were rated as good quality, 8 as fair and 22 as poor. Four studies were omitted in the meta-analysis due to insufficient data. The significant risk factors were resuscitation (OR 2.70, 95% CI 1.36 to 5.35), low birth weight <1.5 kg (OR 3.37, 95% CI 1.59 to 7.13) and 1.5-2.5 kg (OR 1.36, 95% CI 1.01 to 1.83), low Apgar score at the first minute (OR 3.69, 95% CI 2.34 to 5.81) and fifth minute (OR 2.55, 95% CI 1.46 to 4.45), prematurity <37 weeks (OR 1.91, 95% CI 1.27 to 2.86), no crying at birth (OR 3.49, 95% CI 1.42 to 8.55), male sex (OR 1.30, 95% CI 1.01 to 1.67), prolonged labour (OR 1.57, 95% CI 1.08 to 2.27), premature rupture of membranes (OR 2.15, 95% CI 1.34 to 3.47), multiple digital vaginal examinations (OR 2.22, 95% CI 1.27 to 3.89), meconium-stained amniotic fluid (OR 2.72, 95% CI 1.58 to 4.69), intrapartum maternal fever (OR 2.28, 95% CI 1.18 to 4.39), foul-smelling vaginal discharge (OR 3.31, 95% CI 2.16 to 5.09) and low socioeconomic status (OR 1.93, 95% CI 1.11 to 3.35). We found considerable heterogeneity in the meta-analysis of 11 out of 15 identified risk factors.CONCLUSION: Multiple risk factors for neonatal sepsis in Sub-Saharan Africa were identified. We revealed risk factors not listed by the WHO guidelines. The included studies overall had high risk of bias and high heterogeneity and thus, additional research of high quality is needed.PROSPERO REGISTRATION NUMBER: CRD42020191067.

KW - Female

KW - Humans

KW - Infant, Low Birth Weight

KW - Infant, Newborn

KW - Infant, Newborn, Diseases

KW - Male

KW - Neonatal Sepsis/complications

KW - Risk Factors

KW - Sepsis/epidemiology

KW - PAEDIATRICS

KW - NEONATOLOGY

KW - Paediatric infectious disease & immunisation

KW - OBSTETRICS

UR - https://www.scopus.com/pages/publications/85137917361

U2 - 10.1136/bmjopen-2021-054491

DO - 10.1136/bmjopen-2021-054491

M3 - Review

C2 - 36253895

SN - 2044-6055

VL - 12

JO - BMJ Open

JF - BMJ Open

IS - 9

M1 - e054491

ER -

Risk factors for neonatal sepsis in Sub-Saharan Africa: a systematic review with meta-analysis

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