Rates, Predictors and Mortality of Community-Onset Bloodstream Infections due to Pseudomonas aeruginosa: Systematic Review and Meta-Analysis.

BACKGROUND: Pseudomonas aeruginosa is mostly a nosocomial pathogen affecting predisposed patients. However, community-onset bloodstream infections (CO-BSI) caused by this organism are not exceptional. OBJECTIVES: To assess the predisposing factors for CO-BSI due to P. aeruginosa (CO-BSI-PA) and the impact in mortality of inappropriate empirical antimicrobial therapy. DATA SOURCE: A systematic literature search was performed in Medline, EMBASE, Cochrane Library, SCOPUS and Web of Science, databases. STUDY ELIGIBILITY CRITERIA AND PARTICIPANTS: Articles published between, 1st January 2002 and 31st January 2018 reporting at least of 20 adult patients with CO-BSI due to P. aeruginosa were considered. INTERVENTION: Empiric antimicrobial therapy for CO-BSI-PA. METHODS: A systematic review and a meta-analysis were conducted both for risk factors and to evaluate if inappropriate empiric antimicrobial therapy increased mortality in CO-BSI-PA, using a Mantel-Haenzel effects model. RESULTS: Twelve studies with 1,120 patients were included in the systematic review. Solid tumor (33.1%), hematologic malignancy (26.4%), neutropenia (31.7%) and previous antibiotic use (44.8%) were the most prevalent predisposing factors. Septic shock was present in 42.3% cases and 30-day crude mortality was 33.8%. Mortality in meta-analysis (4 studies) was associated with septic shock at presentation (OR 22.31, 95% CI 3.52 - 141.35, p=0.001) and with inappropriate empiric antibiotic therapy (OR 1.83, 95% CI 1.12 - 2.98, p=0.02). CONCLUSIONS: CO-BSI-PA mostly occurred in patients with predisposing factors and had a 30-day mortality comparable to hospital-acquired cases. Inappropriate empirical antibiotic therapy was associated with increased mortality. Appropriate identification of patients at risk for CO-BSI-PA is needed for empirical treatment decisions.