Global coinfections with bacteria, fungi, and respiratory viruses in children with SARS-CoV-2: A systematic review and meta-analysis

Background: Coinfection with bacteria, fungi, and respiratory viruses has been described as a factor associated with more severe clinical outcomes in children with COVID-19. Such coinfections in children with COVID-19 have been reported to increase morbidity and mortality. Objectives: To identify the type and proportion of coinfections with SARS-CoV-2 and bacteria, fungi, and/or respiratory viruses, and investigate the severity of COVID-19 in children. Methods: For this systematic review and meta-analysis, we searched ProQuest, Medline, Embase, PubMed, CINAHL,Wiley online library, Scopus, and Nature through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies on the incidence of COVID-19 in children with bacterial, fungal, and/or respiratory coinfections, published from 1 December 2019 to 1 October 2022, with English language restriction. Results: Of the 169 papers that were identified, 130 articles were included in the systematic review (57 cohort, 52 case report, and 21 case series studies) and 34 articles (23 cohort, eight case series, and three case report studies) were included in the meta-analysis. Of the 17,588 COVID-19 children who were tested for co-pathogens, bacterial, fungal, and/or respiratory viral coinfections were reported ('n' = 1633, 9.3%). The median patient age ranged from 1.4 months to 144 months across studies. There was an increased male predominance in pediatric COVID-19 patients diagnosed with bacterial, fungal, and/or viral coinfections in most of the studies (male gender: 'n' = 204, 59.1% compared to female gender: 'n' = 141, 40.9%). The majority of the cases belonged to White (Caucasian) ('n' = 441, 53.3%), Asian (n = 205, 24.8%), Indian (n = 71, 8.6%), and Black (n = 51, 6.2%) ethnicities. The overall pooled proportions of children with laboratory-confirmed COVID-19 who had bacterial, fungal, and respiratory viral coinfections were 4.73% (95% CI 3.86 to 5.60, 'n' = 445, 34 studies, 'I2' 85%, 'p' < 0.01), 0.98% (95% CI 0.13 to 1.83, 'n' = 17, six studies, 'I2' 49%, 'p' < 0.08), and 5.41% (95% CI 4.48 to 6.34, 'n' = 441, 32 studies, I2 87%, 'p' < 0.01), respectively. Children with COVID-19 in the ICU had higher coinfections compared to ICU and non-ICU patients, as follows: respiratory viral (6.61%, 95% CI 5.06-8.17, 'I2' = 0% versus 5.31%, 95% CI 4.31-6.30, 'I2' = 88%) and fungal (1.72%, 95% CI 0.45-2.99, 'I2' = 0% versus 0.62%, 95% CI 0.00-1.55, 'I2' = 54%); however, COVID-19 chi