Neonatal sepsis management in Africa: A rapid systematic review and meta-analysis

Neonatal sepsis is a leading cause of morbidity and mortality in Africa. This study aimed to examine neonatal sepsis treatment guidelines in Africa, compare them with WHO recommendations, identify similarities and deviations, and explore the impact of antimicrobial resistance and implementation challenges. A rapid systematic review was conducted following PRISMA-ScR guidelines. Five databases (Science Direct, PubMed, CINAHL, MEDLINE via Ovid, and Scopus) were systematically searched for studies published between 2014 and 2024 that reported national or regional guidelines on neonatal sepsis treatment. Data were extracted on first-line antibiotic selection, route of administration, treatment duration, supportive care measures, multidrug-resistant organisms and alignment with the WHO guidelines. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. Overall, 29 studies were included in the review. Key findings revealed that while ampicillin/gentamicin, a WHO-recommended first-line regimen, was widely adopted, high microbial resistance rates necessitated alternatives such as carbapenems. Gram-negative pathogens, particularly Klebsiella pneumoniae (up to 92 % prevalence) dominated, with multidrug-resistant organisms (MDRO) showing a pooled prevalence of 59 % (95 % CI: 44.4–73.6 %). Regional disparities were evident: Eastern Africa reported 51 % MDRO, while Southern Africa reported 20.3 % MDRO. The high statistical heterogeneity (I² = 99.4 %) in the meta-analysis indicates variation in MDRO prevalence across studies, and the pooled estimate should therefore be interpreted with caution. Common implementation challenges included limited access to second-line antibiotics, inadequate training of healthcare workers and infrastructural constraints. Significant variations existed between neonatal sepsis treatment guidelines in a number of African countries and the WHO recommendations. These were driven by MDRO and healthcare resource limitations. While the WHO guidelines provide a global framework, country-specific adaptations are also necessary. There is a need to strengthen antimicrobial stewardship programs, improve diagnostic capacity, and enhance the training of healthcare workers.