Sex-related disparities in sepsis in western Europe: A systematic review and meta-analysis

Hagar L Mowafy; Nicolas Garin; Antonios Katsounas; Pere Castellvi; Jordi Rello; ESGIE/ESGCIP study group investigators

doi:10.1016/j.ejim.2026.106900

Sex-related disparities in sepsis in western Europe: A systematic review and meta-analysis

Eur J Intern Med. 2026 May 11:106900. doi: 10.1016/j.ejim.2026.106900. Online ahead of print.

Authors

Hagar L Mowafy¹, Nicolas Garin², Antonios Katsounas³, Pere Castellvi⁴, Jordi Rello⁵; ESGIE/ESGCIP study group investigators

Collaborators

ESGIE/ESGCIP study group investigators:
Despoina Koulenti⁶, Claire Roger⁷, Emine Alp⁸, Joan R Rello⁹, Paraskevi C Fragkou¹⁰, Demosthenes Makris¹¹

Affiliations

¹ Medical Microbiology and Immunology department, Faculty of Medicine, Cairo University, Egypt; Department of Medical Microbiology and Immunology, Faculty of Medicine, October 6 University, Egypt. Electronic address: hagarmowafy@kasralainy.edu.eg.
² Division of Internal Medicine, Riviera Chablais Hospital, Rennaz, Switzerland; Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland; University of Geneva, Switzerland.
³ Division of Clinical Infectious Diseases and Internal Critical Care, Department of Medicine, Knappschaft-Kliniken University Hospital Bochum, In der Schornau 23-25, Bochum 44892, Germany.
⁴ Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain; Department of Clinical and Health Psychology, Universitat Autonoma de Barcelona (UAB), Bellaterra, Spain.
⁵ Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain; Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERes), Instituto de Salud Carlos III, Madrid, Spain; UR-UM 103 IMAGE, University Montpellier, Division of Anesthesia Critical Care Pain and Emergency Medicine, CHU Nîmes, Nîmes, France.
⁶ Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom.
⁷ Division of Anesthesia and Critical Care, Pain and Emergency Medicine, University of Montpellier, Nîmes University Hospital, Nîmes, France.
⁸ Department of Infectious Diseases and Clinical Microbiology, Ankara Bilkent City Hospital, Yıldırım Beyazıt University, Ankara, Türkiye.
⁹ Faculty of Pharmacy and Food Sciences, Universitat de Barcelona, Barcelona, Spain.
¹⁰ Internal Medicine Department, Aegli Medical Clinic, Athens, Greece.
¹¹ Department of Intensive Care, School of Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.

PMID: 42115064
DOI: 10.1016/j.ejim.2026.106900

Abstract

Background: Whether biological sex independently influences sepsis outcomes remains uncertain and historical data show heterogeneous findings.

Methods: We conducted this systematic review and meta-analysis according to PRISMA guidelines. PubMed, Scopus, and Web of Science were searched (January 2020 to April 2025) for studies reporting mortality outcomes in adult sepsis patients stratified by sex in Western Europe. We assessed studies' quality using the QUIPS tool. Report followed the Sex and Gender Equity in Research (SAGER) guidelines.

Results: From 3445 records, 18 studies comprising 671,861 participants were included. Pneumonia was the most common infection in both sexes-significantly more frequent among men-whereas urinary tract infections predominated in women. Men consistently exhibited higher baseline severity scores, but the difference was not statistically significant. The pooled analysis showed a significant lower odds ratio (OR) of short-term mortality in males compared with females (pooled OR = 0.96, 95% CI 0.94-0.98; low certainty); this difference was consistent in sensitivity analyses restricted to low-bias studies. In contrast, meta-analysis of studies reporting hazard ratios (HR) indicated a higher risk in males (pooled HR = 1.39, 95% CI 1.14-1.70; very-low certainty), although no difference was identified for 90-day mortality (HR = 1.00, 95% CI 0.92-1.08; low certainty).

Conclusions: In contemporary Western Europe, sex alone is not a robust independent predictor of short-term sepsis mortality. Distinct sex-related patterns of infectious sites were identified. Age and infection sites modify the association, underscoring the need for sex-aware but not sex-determined prognostic assessment.

Keywords: Gender medicine; Critical care; Pneumonia; Septic shock; Severe infections; Women.