Patient diversity and author representation in clinical studies supporting the Surviving Sepsis Campaign guidelines for management of sepsis and septic shock 2021: a systematic review of citations

Research output: Contribution to journalResearch articleContributedpeer-review


  • Lama Nazer - , King Hussein Cancer Center (Author)
  • Aseel Abusara - , King Hussein Cancer Center (Author)
  • Batoul Aloran - , King Hussein Cancer Center (Author)
  • Tamas Szakmany - , Cardiff University (Author)
  • Hamza Nabulsi - , University of Jordan (Author)
  • Anton Petushkov - , University of Michigan, Ann Arbor (Author)
  • Marie-Laure Charpignon - , Massachusetts Institute of Technology (MIT) (Author)
  • Taghreed Ahmed - , Omdurman Military Hospital (Author)
  • Marisa Cobanaj - , OncoRay ZIC - National Center for Radiation Research in Oncology (Partners: UKD, HZDR) (Author)
  • Mohammad Elaibaid - , Police's Hospital (Author)
  • Christian Lee - , Troy High School (Author)
  • Chenyu Li - , University of Pittsburgh (Author)
  • Donald Mlombwa - , Zomba Central Hospital (Author)
  • Sulaiman Moukheiber - , Worcester Polytechnic Institute (Author)
  • Anupol Panitchote - , Khon Kaen University (Author)
  • Rachael Parke - , Auckland District Health Board (Author)
  • Skyler Shapiro - , Cornell University (Author)
  • Naira Link Woite - , Harvard University (Author)
  • Leo Anthony Celi - , Massachusetts Institute of Technology (MIT) (Author)


BACKGROUND: The generalizability of the Surviving Sepsis Campaign (SSC) guidelines to various patient populations and hospital settings has been debated. A quantitative assessment of the diversity and representation in the clinical evidence supporting the guidelines would help evaluate the generalizability of the recommendations and identify strategic research goals and priorities. In this study, we evaluated the diversity of patients in the original studies, in terms of sex, race/ethnicity, and geographical location. We also assessed diversity in sex and geographical representation among study first and last authors.

METHODS: All clinical studies cited in support of the 2021 SSC adult guideline recommendations were identified. Original clinical studies were included, while editorials, reviews, non-clinical studies, and meta-analyses were excluded. For eligible studies, we recorded the proportion of male patients, percentage of each represented racial/ethnic subgroup (when available), and countries in which they were conducted. We also recorded the sex and location of the first and last authors. The World Bank classification was used to categorize countries.

RESULTS: The SSC guidelines included six sections, with 85 recommendations based on 351 clinical studies. The proportion of male patients ranged from 47 to 62%. Most studies did not report the racial/ ethnic distribution of the included patients; when they did so, most were White patients (68-77%). Most studies were conducted in high-income countries (77-99%), which included Europe/Central Asia (33-66%) and North America (36-55%). Moreover, most first/last authors were males (55-93%) and from high-income countries (77-99%).

CONCLUSIONS: To enhance the generalizability of the SCC guidelines, stakeholders should define strategies to enhance the diversity and representation in clinical studies. Though there was reasonable representation in sex among patients included in clinical studies, the evidence did not reflect diversity in the race/ethnicity and geographical locations. There was also lack of diversity among the first and last authors contributing to the evidence.


Original languageEnglish
Article number751
Pages (from-to)751
JournalBMC infectious diseases
Issue number1
Publication statusPublished - 1 Nov 2023

External IDs

PubMedCentral PMC10621092
Scopus 85175691076



  • Adult, Humans, Male, Female, Shock, Septic/therapy, Sepsis/therapy, Europe, North America