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Alharami M, Anbar A, Alsharif M, Zahrawi F, Hemaidan A. Atypical Presentation of Stenotrophomonas maltophilia Stomatitis Post COVID-19 in an Immunocompetent Adolescent. Cureus 2024; 16:e68464. [PMID: 39360101 PMCID: PMC11446409 DOI: 10.7759/cureus.68464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/04/2024] Open
Abstract
Stenotrophomonas maltophilia (S. maltophilia) is a rare, multi-drug-resistant opportunistic bacteria that typically causes serious infections in immunocompromised and hospitalized patients, often leading to fatal pneumonia or bacteremia. We present the case of a healthy 15-year-old immunocompetent female who developed severe oral ulcers due to S. maltophilia following a recent COVID-19 infection. To our knowledge, this is the first reported case of S. maltophilia manifesting in this manner after COVID-19. Scrapes from the oral lesions were collected and cultured, confirming the infection.The CBC and immunoglobulin reports revealed mildly elevated IgA and platelet levels, with no evidence of immunodeficiency.The patient was treated with trimethoprim/sulfamethoxazole (TMP-SMX) based on culture sensitivity, and she responded well to treatment. She was referred to an infectious disease specialist for further monitoring. COVID-19 has recently been implicated in many unusual presentations, associations, and syndromes. One of the most supported theories about COVID-19 is its association with a transient immunodeficient state or a generalized state of immune system dysregulation that can compromise both innate and adaptive immunity. This case supports that theory, as no other apparent etiology for such an otherwise opportunistic infection was identified. The recognition of such atypical infections in previously healthy individuals, particularly post COVID-19, highlights the importance of sharpening clinical vigilance and considering opportunistic pathogens in differential diagnoses. Further research is warranted to explore the potential link between COVID-19 and the susceptibility to rare opportunistic infections, which may guide future clinical practices.
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Affiliation(s)
- Mohamed Alharami
- Internal Medicine, Alexandria University School of Medicine, Alexandria, EGY
- Gastroenterology, Advanced Medical Research Center, Port Orange, USA
| | - Ahmad Anbar
- Internal Medicine, University of Aleppo School of Medicine, Aleppo, SYR
| | - Mohamed Alsharif
- Neurosurgery, Alfaisal University College of Medicine, Riyadh, SAU
| | - Frhaan Zahrawi
- Internal Medicine, Alexandria University School of Medicine, Alexandria, EGY
| | - Ammar Hemaidan
- Gastroenterology, Florida State University College of Medicine, Daytona Beach, USA
- Gastroenterology, Advanced Medical Research Center, Port Orange, USA
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2
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Carbonell N, Oltra MR, Clari MÁ. Stenotrophomonas maltophilia: The Landscape in Critically Ill Patients and Optimising Management Approaches. Antibiotics (Basel) 2024; 13:577. [PMID: 39061259 PMCID: PMC11273807 DOI: 10.3390/antibiotics13070577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of this review is to synthesise the key aspects of the epidemiology, current microbiological diagnostic challenges, antibiotic resistance rates, optimal antimicrobial management, and most effective prevention strategies for Stenotrophomonas maltophilia (SM) in the intensive care unit (ICU) population. In recent years, resistance surveillance data indicate that SM accounts for less than 3% of all healthcare-associated infection strains, a percentage that doubles in the case of ventilator-associated pneumonia (VAP). Interestingly, SM ranks as the third most isolated non-glucose fermenter Gram-negative bacilli (NFGNB). Although this NFGNB genus has usually been considered a bystander and colonising strain, recently published data warn about its potential role as a causative pathogen of severe infections, particularly pneumonia and bloodstream infections (BSI), not only for the classical immunocompromised susceptible host patients but also for critically ill ones even without overt immunosuppression. Indeed, it has been associated with crude 28-day mortality as high as 54.8%, despite initial response following targeted therapy. Additionally, alongside its intrinsic resistance to a wide range of common antimicrobials, various worldwide and local surveillance studies raise concerns about an increase in ICU settings regarding resistance to first-line drugs such as cotrimoxazole or tigecycline. This scenario alerts ICU physicians to the need to reconsider the best stewardship approach when SM is isolated in obtained samples from critically ill patients. Despite the coverage of this multidrug-resistant bacterium (MDRB) provided by some traditional and a non-negligible number of current pipeline antimicrobials, an ecological and cost-effective strategy is needed in the present era.
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Affiliation(s)
- Nieves Carbonell
- Medical Intensive Care Unit, Clinic University Hospital, INCLIVA Biomedical Research Institute, 46010 Valencia, Spain
| | - María Rosa Oltra
- Infectious Disease Unit, Internal Medicine Department, Clinic University Hospital, INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - María Ángeles Clari
- Microbiology Service, Clinic University Hospital, INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
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3
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Gajdács M, Matuz M, Ria B, Pető Z, Hajdú E. Correlation between Stenotrophomonas maltophilia incidence and systemic antibiotic use: A 10-year retrospective, observational study in Hungary. Eur J Microbiol Immunol (Bp) 2024; 14:185-194. [PMID: 38441614 PMCID: PMC11097780 DOI: 10.1556/1886.2024.00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 05/16/2024] Open
Abstract
Extensive use of carbapenems may lead to selection pressure for Stenotrophomonas maltophilia (SM) in hospital environments. The aim of our study was to assess the possible association between systemic antibiotic use and the incidence of SM. A retrospective, observational study was carried out in a tertiary-care hospital in Hungary, between January 1st 2010 and December 31st 2019. Incidence-density for SM and SM resistant to trimethoprim-sulfamethoxazole (SXT) was standardized for 1000 patient-days, while systemic antibiotic use was expressed as defined daily doses (DDDs) per 100 patient-days. Mean incidence density for SM infections was 0.42/1000 patient-days; 11.08% were were resistant to SXT, the mean incidence density for SXT-resistant SM was 0.047/1000 patient-days. Consumption rate for colistin, glycopeptides and carbapenems increased by 258.82, 278.94 and 372.72% from 2010 to 2019, respectively. Strong and significant positive correlations were observed with the consumption of carbapenems (r: 0.8759; P < 0.001 and r: 0.8968; P < 0.001), SXT (r: 0.7552; P = 0.011 and r: 0.7004; P = 0.024), and glycopeptides (r: 0.7542; P = 0.012 and r: 0.8138; P < 0.001) with SM and SXT-resistant SM incidence-density/1000 patient-days, respectively. Implementation of institutional carbapenem-sparing strategies are critical in preserving these life-saving drugs, and may affect the microbial spectrum of infections in clinical settings.
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Affiliation(s)
- Márió Gajdács
- Department of Oral Biology and Experimental Dental Research, Faculty of Dentistry, University of Szeged, 6720 Szeged, Tisza Lajos krt. 64-66., Hungary
| | - Mária Matuz
- Central Pharmacy Department, Albert Szent-Györgyi Medical Center, University of Szeged, 6725 Szeged, Semmelweis utca 6., Hungary
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Szikra utca 8., Hungary
| | - Benkő Ria
- Central Pharmacy Department, Albert Szent-Györgyi Medical Center, University of Szeged, 6725 Szeged, Semmelweis utca 6., Hungary
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Szikra utca 8., Hungary
- Department of Emergency Medicine, Albert Szent-Györgyi Medical Center, University of Szeged, 6725 Szeged, Semmelweis utca 6., Hungary
| | - Zoltán Pető
- Department of Emergency Medicine, Albert Szent-Györgyi Medical Center, University of Szeged, 6725 Szeged, Semmelweis utca 6., Hungary
| | - Edit Hajdú
- Department of Internal Medicine Infectiology Unit, Albert Szent-Györgyi Clinical Centre, University of Szeged, 6725 Szeged, Állomás Street 1–3, Hungary
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4
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Gill EL, Gill CM, McEvoy C. Validation of a Stenotrophomonas maltophilia bloodstream infection prediction score in the hematologic malignancy population. Ann Hematol 2024; 103:1745-1752. [PMID: 38453704 PMCID: PMC11009769 DOI: 10.1007/s00277-024-05686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
Stenotrophomonas maltophilia (SM) bloodstream infections (BSIs) contribute to significant mortality in hematologic malignancy (HM) and hematopoietic stem cell transplantation (HSCT) patients. A risk score to predict SM BSI could reduce time to appropriate antimicrobial therapy (TTAT) and improve patient outcomes. A single center cohort study of hospitalized adults with HM/HSCT was conducted. Patients had ≥ 1 blood culture with a Gram-negative (GN) organism. A StenoSCORE was calculated for each patient. The StenoSCORE2 was developed using risk factors for SM BSI identified via logistic regression. Receiver operating characteristic (ROC) curves were plotted. Sensitivity and specificity for the StenoSCORE and StenoSCORE2 were calculated. Thirty-six SM patients and 534 non-SM patients were assessed. A StenoSCORE ≥ 33 points was 80% sensitive, 68% specific, and accurately classified 69% of GN BSIs. StenoSCORE2 variables included acute leukemia, prolonged neutropenia, mucositis, ICU admission, recent meropenem and/or cefepime exposure. The StenoSCORE2 performed better than the StenoSCORE (ROC AUC 0.84 vs. 0.77). A StenoSCORE2 ≥ 4 points was 86% sensitive, 76% specific, and accurately classified 77% of GN BSIs. TTAT was significantly longer for patients with SM BSI compared with non-SM BSI (45.16 h vs. 0.57 h; p < 0.0001). In-hospital and 28-day mortality were significantly higher for patients with SM BSI compared to non-SM BSI (58.3% vs. 18.5% and 66.7% vs. 26.4%; p-value < 0.0001). The StenoSCORE and StenoSCORE2 performed well in predicting SM BSIs in patients with HM/HSCT and GN BSI. Clinical studies evaluating whether StenoSCORE and/or StenoSCORE2 implementation improves TTAT and clinical outcomes are warranted.
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Affiliation(s)
- Emily L Gill
- Department of Pharmacy, Barnes Jewish Hospital, 216 S. Kingshighway Blvd, Mailstop 90-52-41, Saint Louis, MO, 63110, USA.
| | - Christian M Gill
- Department of Pharmacy, SSM-Health St. Louis University Hospital, Saint Louis, MO, USA
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Colleen McEvoy
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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Lupia T, Carnevale-Schianca F, Vita D, Busca A, Caravelli D, Crisà E, Gregorc V, Curtoni A, Cerutti A, Shbaklo N, Corcione S, De Rosa FG. Stenotrophomonas maltophilia Infections in Haematological Malignancies and Hematopoietic Stem Cell Transplantation: A Case Series including Cefiderocol-Based Regimens. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:88. [PMID: 38256349 PMCID: PMC10818980 DOI: 10.3390/medicina60010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Stenotrophomonas maltophilia is a ubiquitous, aerobic, Gram-negative bacillus causing increasing concern in patients affected by haematological malignancies. Materials and Methods: We report a case series from two centres in Northern Italy to describe the characteristics, outcome and microbiological response of S. maltophilia infections in patients with haematological malignancies and/or allogenic hematopoietic stem cell transplantation (aHSCT). Results: Ten patients were included. The median age was 67 years, and seven patients (70%) were males. The median Charlson Comorbidity Index was 6 (IQR: 4-8). The most frequent haematological comorbidities were acute myeloid leukaemia (AML; n = 3; 30%) and non-Hodgkin's lymphoma (n = 3; 30%). Three (30%) patients underwent aHSCT before infection, all for AML. All the patients had undergone a recent antibiotics course and had an indwelling central venous catheter before infection. The main clinical presentations were nosocomial pneumonia, with (2; 20%) or without (4; 40%) secondary bloodstream infection and CRBSI (3; 30%). Four patients were treated with cefiderocol in monotherapy or combinations therapy with cotrimoxazole. The rest of the patients were treated with cotrimoxazole or levofloxacin in monotherapy. Conclusions: Despite a high rate of clinical improvement (90%) after starting antimicrobial therapy, we faced high 30-day mortality (30%) and in-hospital mortality (50%) rates in a highly comorbid population.
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Affiliation(s)
- Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy;
| | - Fabrizio Carnevale-Schianca
- Unit of Oncology and Haematology, Candiolo Cancer Institute, FPO-IRCCS Strada Provinciale 142, 10060 Candiolo, Italy; (F.C.-S.); (D.C.); (E.C.); (V.G.)
| | - Davide Vita
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (D.V.); (N.S.); (S.C.)
| | - Alessandro Busca
- Department of Oncology, Stem Cell Transplant Center, Città della Salute e della Scienza Hospital, 10100 Turin, Italy;
| | - Daniela Caravelli
- Unit of Oncology and Haematology, Candiolo Cancer Institute, FPO-IRCCS Strada Provinciale 142, 10060 Candiolo, Italy; (F.C.-S.); (D.C.); (E.C.); (V.G.)
| | - Elena Crisà
- Unit of Oncology and Haematology, Candiolo Cancer Institute, FPO-IRCCS Strada Provinciale 142, 10060 Candiolo, Italy; (F.C.-S.); (D.C.); (E.C.); (V.G.)
| | - Vanesa Gregorc
- Unit of Oncology and Haematology, Candiolo Cancer Institute, FPO-IRCCS Strada Provinciale 142, 10060 Candiolo, Italy; (F.C.-S.); (D.C.); (E.C.); (V.G.)
| | - Antonio Curtoni
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, 10100 Turin, Italy;
| | | | - Nour Shbaklo
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (D.V.); (N.S.); (S.C.)
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (D.V.); (N.S.); (S.C.)
- School of Medicine, Tufts University, Boston, MA 02111, USA
| | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy;
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy; (D.V.); (N.S.); (S.C.)
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6
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Kunz Coyne AJ, Herbin S, Caniff K, Rybak MJ. Steno-sphere: Navigating the enigmatic world of emerging multidrug-resistant Stenotrophomonas maltophilia. Pharmacotherapy 2023; 43:833-846. [PMID: 37199104 DOI: 10.1002/phar.2828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/19/2023]
Abstract
Stenotrophomonas maltophilia is an opportunistic pathogen and frequent cause of serious nosocomial infections. Patient populations at greatest risk for these infections include the immunocompromised and those with chronic respiratory illnesses and prior antibiotic exposure, notably to carbapenems. Its complex virulence and resistance profile drastically limit available antibiotics, and incomplete breakpoint and pharmacokinetic/pharmacodynamic (PK/PD) data to inform dose optimization further complicates therapeutic approaches. Clinical comparison data of first-line agents, including trimethoprim-sulfamethoxazole (TMP-SMX), quinolones, and minocycline, are limited to conflicting observational data with no clear benefit of a single agent or combination therapy. Newer antibiotic approaches, including cefiderocol and aztreonam- avibactam, are promising alternatives for extensively drug-resistant isolates; however, clinical outcomes data are needed. The potential clinical utility of bacteriophage for compassionate use in treating S. maltophilia infections remains to be determined since data is limited to in-vitro and sparse in-vivo work. This article provides a review of available literature for S. maltophilia infection management focused on related epidemiology, resistance mechanisms, identification, susceptibility testing, antimicrobial PK/PD, and emerging therapeutic strategies.
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Affiliation(s)
- Ashlan J Kunz Coyne
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | | | - Kaylee Caniff
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, Michigan, USA
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7
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Sakoh T, Kimura M, Takagi S, Ogura S, Morishima M, Yamamuro R, Yamaguchi K, Yuasa M, Kaji D, Kageyama K, Taya Y, Nishida A, Ishiwata K, Yamamoto H, Yamamoto G, Asano-Mori Y, Wake A, Uchida N, Taniguchi S, Araoka H. Predictive scoring system for distinguishing Stenotrophomonas maltophilia bacteremia from Pseudomonas aeruginosa bacteremia in patients with hematological malignancies. Ann Hematol 2023; 102:1239-1246. [PMID: 36971808 DOI: 10.1007/s00277-023-05185-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
Difficulties in immediately distinguishing Stenotrophomonas maltophilia (SM) bacteremia from Pseudomonas aeruginosa (PA) bacteremia in the clinical setting can lead to treatment delay. We aimed to develop a scoring system to immediately distinguish SM bacteremia from PA bacteremia using clinical indicators. We enrolled cases of SM and PA bacteremia in adult patients with hematological malignancies between January 2011 and June 2018. The patients were randomized into derivation and validation cohorts (2:1), and a clinical prediction tool for SM bacteremia was developed and verified. In total, 88 SM and 85 PA bacteremia cases were identified. In the derivation cohort, the following independent predictors of SM bacteremia were identified: no evidence of PA colonization, antipseudomonal β-lactam breakthrough bacteremia, and central venous catheter insertion. We scored each of the three predictors according to their regression coefficient (2, 2, and 1, respectively). Receiver operating characteristic curve analysis confirmed the score's predictive performance, with an area under the curve of 0.805. The combined sensitivity and specificity (0.655 and 0.821) was highest with a cut-off value of 4 points. Positive and negative predictive values were 79.2% (19/24) and 69.7% (23/33), respectively. This novel predictive scoring system is potentially useful for distinguishing SM bacteremia from PA bacteremia, which would facilitate immediate administration of appropriate antimicrobial therapy.
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8
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Upraising Stenotrophomonas maltophilia in Critically Ill Patients: A New Enemy? Diagnostics (Basel) 2023; 13:diagnostics13061106. [PMID: 36980413 PMCID: PMC10047194 DOI: 10.3390/diagnostics13061106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Stenotrophomonas maltophilia (S. maltophilia), an important pathogen in immuno-compromised patients, has recently gained attention in patients admitted in intensive care units (ICU). We sought to investigate clinical features of infections caused by S. maltophilia in ICU patients and identify risk factors for mortality. We conducted a retrospective study in two multivalent non-COVID-19 ICUs of tertiary-teaching hospitals in Greece and Spain, including patients with isolated S. maltophilia from at least one clinical specimen along with clinical signs of infection. A total of 103 patients (66% male) were analyzed. Median age was 65.5 (54–73.3) years and mean APACHE II and SOFA scores upon ICU admission were 18.36 (±7.22) and 18.17 (±6.95), respectively. Pneumonia was the predominant clinical syndrome (72.8%), while 22% of cases were among hemato/oncology patients. Crude 28-day mortality rate was 54.8%, even though, 14-day clinical and microbiological response was 96%. Age, APACHE II on ICU admission, hemato-oncologic disease, and multi-organ failure were initially identified as potential predictors of mortality. In the multivariable analysis, only increasing age and hemato-oncologic disease were shown to be independent risk factors for 28-day mortality. High all-cause mortality was observed in critically ill patients with predominantly respiratory infections by S. maltophilia, despite initial clinical and laboratory response after targeted treatment. The study elucidates a potentially worrisome emerging pathogen in the ICU.
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9
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Colombo AL, De Almeida JN, Lewis RE, Kontoyiannis DP. Quandaries of deciding when to change first-line therapy in invasive pulmonary aspergillosis. J Antimicrob Chemother 2022; 77:2897-2900. [PMID: 36059133 DOI: 10.1093/jac/dkac301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We read the excellent viewpoint by Slavin et al. (J Antimicrob Chemother 2022; 77: 16-23) that draws upon the experience of an advisory board of notable experts to comprehensively address many of the clinical factors that drive the need for changes in antifungal therapy for invasive aspergillosis (IA). As noted by the authors, there remains a paucity of quality data to support many of the decisions faced by clinicians managing patients with IA. However, we would like to highlight several other important issues, not fully addressed in that viewpoint, that play an important role in deciding when to change antifungal therapy for IA.
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Affiliation(s)
- Arnaldo L Colombo
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - João N De Almeida
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases Infection Control and Employee Health, MD Anderson Cancer Center, Houston, TX, USA
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10
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Mojica MF, Humphries R, Lipuma JJ, Mathers AJ, Rao GG, Shelburne SA, Fouts DE, Van Duin D, Bonomo RA. Clinical challenges treating Stenotrophomonas maltophilia infections: an update. JAC Antimicrob Resist 2022; 4:dlac040. [PMID: 35529051 PMCID: PMC9071536 DOI: 10.1093/jacamr/dlac040] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
Stenotrophomonas maltophilia is a non-fermenting, Gram-negative bacillus that has emerged as an opportunistic nosocomial pathogen. Its intrinsic multidrug resistance makes treating infections caused by S. maltophilia a great clinical challenge. Clinical management is further complicated by its molecular heterogeneity that is reflected in the uneven distribution of antibiotic resistance and virulence determinants among different strains, the shortcomings of available antimicrobial susceptibility tests and the lack of standardized breakpoints for the handful of antibiotics with in vitro activity against this microorganism. Herein, we provide an update on the most recent literature concerning these issues, emphasizing the impact they have on clinical management of S. maltophilia infections.
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Affiliation(s)
- Maria F. Mojica
- Department of Molecular Biology and Microbiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Case Western Reserve University-Cleveland VA Medical Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
| | - Romney Humphries
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John J. Lipuma
- University of Michigan Medical School, Pediatric Infectious Disease, Ann Arbor, MI, USA
| | - Amy J. Mathers
- Division of Infectious Disease and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
- Clinical Microbiology Laboratory, Department of Pathology, University of Virginia Health System, Charlottesville, VA, USA
| | - Gauri G. Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel A. Shelburne
- Department of Infectious Diseases Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Center for Antimicrobial Resistance and Microbial Genomics, University of Texas Health Science Center McGovern Medical School, Houston, TX, USA
| | - Derrick E. Fouts
- Genomic Medicine, The J. Craig Venter Institute, Rockville, MD, USA
| | - David Van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Robert A. Bonomo
- Case Western Reserve University-Cleveland VA Medical Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Senior Clinician Scientist Investigator, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
- Medical Service and Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA
- Departments of Medicine, Biochemistry, Pharmacology, Molecular Biology and Microbiology, and Proteomics and Bioinformatics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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11
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Kullar R, Wenzler E, Alexander J, Goldstein EJC. Overcoming Stenotrophomonas maltophilia Resistance for a More Rational Therapeutic Approach. Open Forum Infect Dis 2022; 9:ofac095. [PMID: 35415194 PMCID: PMC8992361 DOI: 10.1093/ofid/ofac095] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/22/2022] [Indexed: 11/14/2022] Open
Abstract
Stenotrophomonas maltophilia is an underappreciated source of morbidity and mortality among gram-negative pathogens. Effective treatment options with acceptable toxicity profiles are limited. Phenotypic susceptibility testing via commercial automated test systems is problematic and no Food and Drug Administration breakpoints are approved for any of the first-line treatment options for S maltophilia. The lack of modern pharmacokinetic/pharmacodynamic data for many agents impedes dose optimization, and the lack of robust efficacy and safety data limits their clinical utility. Levofloxacin has demonstrated similar efficacy to trimethoprim-sulfamethoxazole, although rapid development of resistance is a concern. Minocycline demonstrates the highest rate of in vitro susceptibility, however, evidence to support its clinical use are scant. Novel agents such as cefiderocol have exhibited promising activity in preclinical investigations, though additional outcomes data are needed to determine its place in therapy for S maltophilia. Combination therapy is often employed despite the dearth of adequate supporting data.
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Affiliation(s)
- Ravina Kullar
- Expert Stewardship, Inc, Newport Beach, California, USA
| | - Eric Wenzler
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Jose Alexander
- Department of Microbiology, Virology, and Immunology, AdventHealth Central Florida, Orlando, Florida, USA
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12
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America Guidance on the Treatment of AmpC β-lactamase-Producing Enterobacterales, Carbapenem-Resistant Acinetobacter baumannii, and Stenotrophomonas maltophilia Infections. Clin Infect Dis 2021; 74:2089-2114. [PMID: 34864936 DOI: 10.1093/cid/ciab1013] [Citation(s) in RCA: 268] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. A previous guidance document focused on infections caused by extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa). Here, guidance is provided for treating AmpC β-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia infections. METHODS A panel of six infectious diseases specialists with expertise in managing antimicrobial-resistant infections formulated questions about the treatment of AmpC-E, CRAB, and S. maltophilia infections. Answers are presented as suggestions and corresponding rationales. In contrast to guidance in the previous document, published data on optimal treatment of AmpC-E, CRAB, and S. maltophilia infections are limited. As such, guidance in this document is provided as "suggested approaches" based on clinical experience, expert opinion, and a review of the available literature. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS Preferred and alternative treatment suggestions are provided, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Suggestions apply for both adult and pediatric populations. CONCLUSIONS The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of September 17, 2021 and will be updated annually. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance-2.0/.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel L Aitken
- Department of Pharmacy, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Departments of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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