A systematic review and meta-analyses show that carbapenem use and medical devices are the leading risk factors for carbapenem-resistant Pseudomonas aeruginosa

Abstract

A systematic review and meta-analyses were performed to identify the risk factors associated with carbapenem-resistant Pseudomonas aeruginosa and to identify sources and reservoirs for the pathogen. A systematic search of PubMed and Embase databases from 1 January 1987 until 27 January 2012 identified 1,662 articles, 53 of which were included in a systematic review and 38 in a random-effects meta-analysis study. The use of carbapenem, use of fluoroquinolones, use of vancomycin, use of other antibiotics, having medical devices, intensive care unit (ICU) admission, having underlying diseases, patient characteristics, and length of hospital stay were significant risk factors in multivariate analyses. The meta-analyses showed that carbapenem use (odds ratio [OR] = 7.09; 95% confidence interval [CI] = 5.43 to 9.25) and medical devices (OR = 5.11; 95% CI = 3.55 to 7.37) generated the highest pooled estimates. Cumulative meta-analyses showed that the pooled estimate of carbapenem use was stable and that the pooled estimate of the risk factor "having medical devices" increased with time. We conclude that our results highlight the importance of antibiotic stewardship and the thoughtful use of medical devices in helping prevent outbreaks of carbapenem-resistant P. aeruginosa.

FIG 1

Flow diagram of study selection for the systematic review on carbapenem-resistant P. aeruginosa.

FIG 2

(a) Forest plots of conventional and cumulative meta-analyses of the risk factor carbapenem use in a random-effects model, shown on a logarithmic scale. Plots: 1, conventional meta-analysis including the source given as first author and year of publication, number of case patients (in parentheses), odds ratio, and 95% confidence interval; 2, cumulative meta-analysis including number of case patients, odds ratio, and 95% confidence interval. (b) Forest plots of conventional and cumulative meta-analyses of the risk factor medical devices using a random-effects model, shown on a logarithmic scale. Plots: 1, conventional meta-analysis including source and number of case patients as indicated for panel a, odds ratio, and 95% confidence interval; 2, cumulative meta-analysis including number of case patients, odds ratio, and 95% confidence interval. (c) Forest plots of individual and pooled odds ratios for seven different risk factors of transmission and acquisition of carbapenem-resistant P. aeruginosa, using a random-effects model, shown on a logarithmic scale.

FIG 2

(a) Forest plots of conventional and cumulative meta-analyses of the risk factor carbapenem use in a random-effects model, shown on a logarithmic scale. Plots: 1, conventional meta-analysis including the source given as first author and year of publication, number of case patients (in parentheses), odds ratio, and 95% confidence interval; 2, cumulative meta-analysis including number of case patients, odds ratio, and 95% confidence interval. (b) Forest plots of conventional and cumulative meta-analyses of the risk factor medical devices using a random-effects model, shown on a logarithmic scale. Plots: 1, conventional meta-analysis including source and number of case patients as indicated for panel a, odds ratio, and 95% confidence interval; 2, cumulative meta-analysis including number of case patients, odds ratio, and 95% confidence interval. (c) Forest plots of individual and pooled odds ratios for seven different risk factors of transmission and acquisition of carbapenem-resistant P. aeruginosa, using a random-effects model, shown on a logarithmic scale.