Diarrheagenic Escherichia coli in children under five in the Americas: Prevalence, pathotype distribution, and socioenvironmental drivers

AimTo characterize the prevalence, pathotype distribution, and socioenvironmental drivers of diarrheagenic Escherichia coli (DEC) in children under five in the Americas. MethodsA systematic review and meta-analysis of studies (2015-2024) from PubMed, Scopus, Springer, SciELO, LILACS and Web of Science were conducted. Eligible studies reported DEC prevalence in children [≤] 5 years with acute diarrhea using molecular/microbiological diagnostics. ResultsThirteen studies (7,485 participants) were included. Pooled DEC prevalence was 28.3% (95% CI: 21.6-35.7). PCR detected 1.4-fold higher prevalence than culture. Regional disparities included EPEC dominance in the Andean highlands (50.0%) and EAEC/EHEC co-occurrence in Amazonia (EAEC 8x post-hurricane). Limited water access (aOR 3.2) and poor sanitation were key risk factors; a 10% increase in water access reduced EPEC burden by 17%. ConclusionDEC poses a significant health burden in the Americas, with pathotype distribution linked to socioeconomic inequities. Molecular diagnostics are crucial for surveillance, and policy should prioritize WASH infrastructure and equitable diagnostics access to mitigate morbidity, antimicrobial resistance, and climate-amplified outbreaks. SummaryO_LIRegional variations in the prevalence of diarrhoeagenic Escherichia coli and associated risk factors in children under five in the Americas were poorly understood, necessitating a systematic review. C_LIO_LIThe study found a prevalence of 28.3%, with regional disparities and socioeconomic factors such as limited access to water driving infections. C_LIO_LIImproved water, sanitation and hygiene infrastructure, as well as molecular diagnostics, are critical for reducing paediatric diarrhoeal morbidity and antimicrobial resistance. C_LI