Travel-Associated Melioidosis in Non-Endemic Regions: A Systematic Review and Meta-Analysis

Abstract

Background: Travel-associated melioidosis, caused by Burkholderia pseudomallei, is increasingly reported in non-endemic countries due to rising global travel. Understanding demographic, clinical, and outcome patterns of imported cases is important to improve recognition and management in settings where melioidosis is uncommon. Methods: We systematically searched PubMed, Embase, and Scopus (last search: 24 September 2025) for case reports and case series of melioidosis diagnosed outside endemic regions and linked to travel exposure. Data were extracted on demographics, comorbidities, clinical manifestations, and outcomes. We performed descriptive analyses, subgroup analyses, and Firth’s penalized logistic regression to explore predictors of death. The protocol was registered in PROSPERO (CRD420251154559). Results: A total of 104 studies, encompassing 143 individual cases, were included. Most diagnoses occurred in non-endemic, high-income countries, especially the Netherlands (21%), France (10%), the United States (9%), and South Korea (7%). Infections were predominantly acquired in Southeast Asia, particularly Thailand (39%). The mean patient age was 50.6 years, with a male predominance (78%). Diabetes mellitus was the most frequent comorbidity (28%). Clinical presentations included pulmonary (33%), sepsis (27%), cutaneous (13%), abdominal (4%), and osteoarticular disease (1%). Overall mortality was 12.6% and relapse occurred in 7%. In penalized regression analyses, no baseline characteristic was statistically significantly associated with mortality; septic presentation showed an elevated point estimate for odds of death, but with imprecise estimates. Conclusions: Travel-associated melioidosis is a rare but clinically significant imported infection. Most cases followed exposure in Southeast Asia, and pulmonary disease and sepsis were the most frequent presentations. Mortality remained substantial (12.6%), and relapse was reported in 7%, underscoring the need for early recognition, appropriate therapy, and follow-up in non-endemic settings.