Stenotrophomonas maltophilia: emerging disease patterns and challenges for treatment

A metagenomic study of antibiotic resistance genes in a hypereutrophic subtropical lake contaminated by anthropogenic sources

Antibiotic resistance genes (ARGs) are a major threat to human and environmental health. This study investigated the occurrence and distribution of ARGs in Lake Cajititlán, a hypereutrophic subtropical lake in Mexico contaminated by anthropogenic sources (urban wastewater and runoff from crop and livestock production). ARGs (a total of 475 genes) were detected in 22 bacterial genera, with Pseudomonas (144 genes), Stenotrophomonas (88 genes), Mycobacterium (54 genes), and Rhodococcus (27 genes) displaying the highest frequencies of ARGs. Among these, Pseudomonas aeruginosa and Stenotrophomonas maltophilia showed the highest number of ARGs. The results revealed a diverse array of ARGs, including resistance to macrolides (11.55 %), aminoglycosides (8.22 %), glycopeptides (6.22 %), tetracyclines (4 %), sulfonamides (4 %), carbapenems (1.11 %), phenicols (0.88 %), fluoroquinolones (0.44 %), and lincosamides (0.22 %). The most frequently observed ARGs were associated with multidrug resistance (63.33 %), with MexF (42 genes), MexW (36 genes), smeD (31 genes), mtrA (25 genes), and KHM-1 (22 genes) being the most common. Lake Cajititlán is a recreational area for swimming, fishing, and boating, while also supporting irrigation for agriculture and potentially acting as a drinking water source for some communities. This raises concerns about the potential for exposure to antibiotic-resistant bacteria through these activities. The presence of ARGs in Lake Cajititlán poses a significant threat to both human and environmental health. Developing strategies to mitigate the risks of antibiotic resistance, including improving wastewater treatment, and promoting strategic antibiotic use and disposal, is crucial. This study represents a significant advancement in the understanding of antibiotic resistance dynamics in a hypereutrophic subtropical lake in a developing country, providing valuable insights for the scientific community and policymakers.

Stenotrophomonas maltophilia outbreak originating from a pull-out faucet in a pediatric intensive care unit in Turkey: Insights from clinical records and molecular typing

BACKGROUND

Nosocomial Stenotrophomonas maltophilia-related cases are rising and pose a threat to immunocompromised patients. Twelve patients from our pediatric intensive care unit (PICU) presented with S maltophilia-associated bloodstream infection.

METHODS

This outbreak investigation includes 12 patients from PICU between the ages of 2 months and 4 years (mean 16 months, 7 male). To identify the origin, samples from all possible sources throughout the hospital were collected and ran through DNA isolation and Pulse Field Gel Electrophoresis.

RESULTS

120 samples were collected during the outbreak. 31 samples (26%) were positive for S maltophilia. 30 S maltophilia isolates were analyzed, 10 different genotypes were identified. Clustering isolates were grouped into 3 different clusters (tolerance and optimization 1.0, cutoff 90%). The largest cluster was genotype 1, which included 19 isolates, those belong to patients' samples and a sample from a pull-out faucet inside the PICU. The Pull-out faucet was the origin of the bloodstream infection.

DISCUSSION

Pull-out faucets allow biofilm production, due its structure. Pulse Field Gel Electrophoresis identifies the transmission dynamics of the outbreak, with its high discriminatory power.

CONCLUSIONS

Water sources should be monitored on a regular basis. Pull-out faucets enable bacterial overgrowth; therefore, we recommend water surveillance during outbreak investigations.

The gain effect of microbial consortia induced by adaptive domestication for efficient conversion of Chinese cabbage waste by anaerobic fermentation

The resource-based treatment of Chinese cabbage waste by anaerobic fermentation can effectively mitigate air, soil, and groundwater pollution. However, the compatibility between fermentative microorganisms and the environment might be a crucial limiting factor for the resource recycling of Chinese cabbage waste. Therefore, the gain effect of microbial consortia (JMRS, JMRST, JMRSZ, JCCW, JCCWT and JCCWZ) induced by adaptive domestication for efficient conversion of Chinese cabbage waste by anaerobic fermentation were explored in this study. A total of 42 single subsamples with same weights were randomly divided into seven treatments: sterile deionized water (Control); anaerobic fermentation inoculated with JMRS (MRS); anaerobic fermentation inoculated with JMRST (MRST); anaerobic fermentation inoculated with JMRSZ (MRSZ); anaerobic fermentation inoculated with JCCW (CCW); anaerobic fermentation inoculated with JCCWT (CCWT); anaerobic fermentation inoculated with JCCWZ (CCWZ) and samples were taken on days 30 and 60 after anaerobic fermentation. The results exhibited that all the treatments contributed to high levels of lactic acid (178.77-201.79 g/kg dry matter) and low levels of ammonia-N (12.99-21.03 g/kg total nitrogen). Meanwhile, MRSZ enhanced (p < 0.05) acetic acid levels (1.53 g/kg dry matter) and resulted in the lowest yeast counts. Microbiologically, the addition of microbial consortia decreased the linear discriminant analysis (LDA) scores of Massilia and Stenotrophomonas maltophilia. Moreover, MRSZ enriched (p < 0.05) Lactobacillus hilgardii, and decreased (p < 0.05) the abundance of bacteria containing mobile elements and potentially pathogenic bacteria. In conclusion, JMRSZ improved the efficient conversion of Chinese cabbage waste for resource utilization.

An Assessment of Human Opportunistic Pathogenic Bacteria on Daily Necessities in Nanjing City during Plum Rain Season

The plum rain season is a special climatic phenomenon in east Asia, which is characterized by persistent rainfall, a high temperature, and humidity, providing suitable environmental conditions for certain pathogenic bacteria, thus increasing the incidence of respiratory, gastrointestinal, and urinary diseases. However, studies on human opportunistic pathogenic bacteria communities during the plum rain season are still limited. In this study, the characteristics of human opportunistic pathogenic bacterial communities on daily necessities during the non-plum and plum rain seasons were investigated using high-throughput sequencing technology. The results revealed that the relative abundance of human opportunistic pathogenic bacteria was higher in the plum rain season (cotton cloth: 2.469%, electric bicycles: 0.724%, rice: 3.737%, and washbasins: 5.005%) than in the non-plum rain season (cotton cloth: 1.425%, electric bicycles: 0.601%, rice: 2.426%, and washbasins: 4.801%). Both temperature and relative humidity affected human opportunistic pathogenic bacterial communities. Stochastic processes dominated the assembly process of human opportunistic pathogenic bacterial communities, and undominated processes prevailed. The stability of the co-occurrence network was higher in the non-plum rain season than that in the plum rain season. In addition, the proportion of deterministic processes showed the same trend as the complexity of the co-occurrence network.

Risk factors and outcome of Stenotrophomonas maltophilia infection after allogeneic hematopoietic stem cell transplantation: JSTCT, Transplant Complications Working Group

Stenotrophomonas maltophilia (S. maltophilia) is an aerobic nonfermenting Gram-negative bacillus widely distributed in the environment that has inherent multidrug resistance to beta-lactam and carbapenem antibiotics. S. maltophilia infection (SMI) is known as an important fatal complication following allogeneic hematopoietic stem cell transplantation (HSCT), but its clinical characteristics have not been well clarified. A retrospective study to identify the incidence, risk factors, and outcomes of SMI after allogeneic HSCT was performed using the database of the Japanese nationwide registry, including 29,052 patients who received allogeneic HSCT in Japan between January 2007 and December 2016. A total of 665 patients developed SMI (sepsis/septic shock, 432; pneumonia, 171; other, 62). The cumulative incidence of SMI at 100 days after HSCT was 2.2%. Among risk factors identified for SMI (age ≥ 50 years, male, performance status 2-4, cord blood transplantation [CBT], myeloablative conditioning, Hematopoietic Cell Transplant-Comorbidity Index [HCT-CI] score 1-2, HCT-CI score ≥ 3, and active infectious disease at HSCT), CBT was the strongest risk factor (hazard ratio, 2.89; 95%CI, 1.94-4.32; p < 0.001). The survival rate at day 30 after SMI was 45.7%, and SMI before neutrophil engraftment was significantly associated with poor survival (survival rate 30 days after SMI, 40.1% and 53.8% in patients with SMI before and after engraftment, respectively; p = 0.002). SMI is rare after allogeneic HSCT, but its prognosis is extremely poor. CBT was a strong risk factor for SMI, and its development prior to neutrophil engraftment was associated with poor survival.

The Prognosis of Patients Tested Positive for Stenotrophomonas maltophilia from Different Sources

Purpose

The purpose of this study was to analyze the prognosis of patients tested positive for Stenotrophomonas maltophilia (SMA) from different sources.

Methods

A retrospective study was conducted among 651 patients tested positive for SMA from January 2020 to October 2022 in the First Affiliated Hospital of Anhui Medical University. The patients were divided into seven groups by the source of SMA. Univariate and multivariate analyses were used to identify risk factors for mortality in patients tested positive for SMA from different sources.

Results

A total of 651 SMA isolates were collected from various sources, including sputum (348 isolates, 53%), bronchoalveolar lavage fluid (52, 8%), abdominal drainage fluid (76, 12%), wound secretion (66, 10%), blood (62, 10%), urine (41, 6%) and cerebrospinal fluid (6, 1%). Compared with other groups, the mortality of the patients in the bronchoalveolar lavage fluid culture group, blood culture group, and abdominal drainage fluid culture group was higher, at 40.38%, 32.26%, and 26.32%, respectively. Multivariate analysis showed that continuous renal replacement therapy was an independent risk factor for mortality in patients with SMA bloodstream infection (P=0.020, OR=6.86), and effective antimicrobial therapy after being positive for S. maltophilia isolates (P=0.002, OR=0.10) was negatively correlated with the death of patients with SMA bloodstream infection. Age ≥65 years (P= 0.043, OR=4.96), kidney disease (P=0.045, OR=4.62) and antifungal agent exposure (P=0.036, OR=5.13) were independent risk factors for mortality in patients with SMA intra-abdominal infection. Antifungal agent exposure (P=0.024, OR=0.51) and glycopeptide exposure (P=0.045, OR=0.53) were independent risk factors for mortality in patients in the sputum culture group.

Conclusion

SMA has a high rate of antimicrobial resistance and can cause multisite infection. Pulmonary infections, bloodstream infections and abdominal infections caused by SMA have high mortality, and timely standardized treatment can reduce mortality.

Characterization of Potential Virulence, Resistance to Antibiotics and Heavy Metals, and Biofilm-Forming Capabilities of Soil Lignocellulolytic Bacteria

Soil bacteria participate in self-immobilization processes for survival, persistence, and production of virulence factors in some niches or hosts through their capacities for autoaggregation, cell surface hydrophobicity, biofilm formation, and antibiotic and heavy metal resistance. This study investigated potential virulence, antibiotic and heavy metal resistance, solvent adhesion, and biofilm-forming capabilities of six cellulolytic bacteria isolated from soil samples: Paenarthrobacter sp. MKAL1, Hymenobacter sp. MKAL2, Mycobacterium sp. MKAL3, Stenotrophomonas sp. MKAL4, Chryseobacterium sp. MKAL5, and Bacillus sp. MKAL6. Strains were subjected to phenotypic methods, including heavy metal and antibiotic susceptibility and virulence factors (protease, lipase, capsule production, autoaggregation, hydrophobicity, and biofilm formation). The effect of ciprofloxacin was also investigated on bacterial susceptibility over time, cell membrane, and biofilm formation. Strains MKAL2, MKAL5, and MKAL6 exhibited protease and lipase activities, while only MKAL6 produced capsules. All strains were capable of aggregating, forming biofilm, and adhering to solvents. Strains tolerated high amounts of chromium, lead, zinc, nickel, and manganese and were resistant to lincomycin. Ciprofloxacin exhibited bactericidal activity against these strains. Although the phenotypic evaluation of virulence factors of bacteria can indicate their pathogenic nature, an in-depth genetic study of virulence, antibiotic and heavy metal resistance genes is required.

Whole-Genome Sequencing-Based Resistome Analysis of Nosocomial Multidrug-Resistant Non-Fermenting Gram-Negative Pathogens from the Balkans

Non-fermenting Gram-negative bacilli (NFGNB), such as Pseudomonas aeruginosa and Acinetobacter baumannii, are among the major opportunistic pathogens involved in the global antibiotic resistance epidemic. They are designated as urgent/serious threats by the Centers for Disease Control and Prevention and are part of the World Health Organization’s list of critical priority pathogens. Also, Stenotrophomonas maltophilia is increasingly recognized as an emerging cause for healthcare-associated infections in intensive care units, life-threatening diseases in immunocompromised patients, and severe pulmonary infections in cystic fibrosis and COVID-19 individuals. The last annual report of the ECDC showed drastic differences in the proportions of NFGNB with resistance towards key antibiotics in different European Union/European Economic Area countries. The data for the Balkans are of particular concern, indicating more than 80% and 30% of invasive Acinetobacter spp. and P. aeruginosa isolates, respectively, to be carbapenem-resistant. Moreover, multidrug-resistant and extensively drug-resistant S. maltophilia from the region have been recently reported. The current situation in the Balkans includes a migrant crisis and reshaping of the Schengen Area border. This results in collision of diverse human populations subjected to different protocols for antimicrobial stewardship and infection control. The present review article summarizes the findings of whole-genome sequencing-based resistome analyses of nosocomial multidrug-resistant NFGNBs in the Balkan countries.

Effect of Dietary Supplemented with Mulberry Leaf Powder on Growth Performance, Serum Metabolites, Antioxidant Property and Intestinal Health of Weaned Piglets

Background: The study aimed to explore the effect of mulberry leaf powder (MP) on the performance, serum metabolites and antioxidant property, as well as intestinal health, of weaned piglets. A total of 120 healthy piglets weighing 8.43 ± 1.91 kg (Duroc × (Landrace × Yorkshire); weaned at 28 d) were chosen and classified into four treatments with three replicates of 10 piglets each based on a randomized complete block design (barrow:gilt = 1:1). The diet treatments were a corn-soybean meal basal diet added with 0% (Ctrl), 2% (MP_2), 4% (MP_4) and 6% MP (MP_6), respectively. The feeding experiment was 28 days in total. The feeding period lasted for 28 days in total. Results: The diet supplemented with 2% MP had no detrimental effects on the growth performance, immunity, enzyme capacity and inflammatory factors, as well as intestinal barrier function. MP_2 is capable of decreasing the levels of serum D-lactic acid and lactate dehydrogenase, enhancing the superoxide dismutase capacity in the liver and diminishing the potential pathogenic bacteria Allisonella in the colon. However, compared with MP_2, MP_6 had unfavorable effects on the average daily gain and average daily feed intake; the concentration of serum non-esterified fatty acids; the activities of superoxide dismutase and glutathione peroxidase and the capacity of lipase and amylase, as well as the intestinal barrier function-related mRNA expression of occludin, claudin-1 and mucin-2 in piglets. Conclusion: Taken together, piglets fed with 2% MP had no adverse effect and was capable of improving the serum metabolites, enhancing the antioxidant capacity (SOD) and lowering the potential pathogenic bacteria of the hindgut (Allisonella). However, the highest concentration of MP (6%) may cause detrimental effects for piglets, which are probably associated with the higher antinutritional factors and fiber. Therefore, the dietary supplementation of 2% MP for piglets may be advisable.

Characterization of the Bacteriophage BUCT603 and Therapeutic Potential Evaluation Against Drug-Resistant Stenotrophomonas maltophilia in a Mouse Model

Stenotrophomonas maltophilia (S. maltophilia) is a common opportunistic pathogen that is resistant to many antibiotics. Bacteriophages are considered to be an effective alternative to antibiotics for the treatment of drug-resistant bacterial infections. In this study, we isolated and characterized a phage, BUCT603, infecting drug-resistant S. maltophilia. Genome sequencing showed BUCT603 genome was composed of 44,912 bp (32.5% G + C content) with 64 predicted open reading frames (ORFs), whereas no virulence-related genes, antibiotic-resistant genes or tRNA were identified. Whole-genome alignments showed BUCT603 shared 1% homology with other phages in the National Center for Biotechnology Information (NCBI) database, and a phylogenetic analysis indicated BUCT603 can be classified as a new member of the Siphoviridae family. Bacteriophage BUCT603 infected 10 of 15 S. maltophilia and used the TonB protein as an adsorption receptor. BUCT603 also inhibited the growth of the host bacterium within 1 h in vitro and effectively increased the survival rate of infected mice in a mouse model. These findings suggest that bacteriophage BUCT603 has potential for development as a candidate treatment of S. maltophilia infection.

In vitro Antibacterial Activity and Resistance Prevention of Antimicrobial Combinations for Dihydropteroate Synthase-Carrying Stenotrophomonas maltophilia

Background

Stenotrophomonas maltophilia (S. maltophilia) is a multidrug-resistant gram-negative bacillus that is known to be an opportunistic pathogen, particularly in a hospital environment. The infection has a high morbidity and mortality. Sulfamethoxazole-trimethoprim (SXT) is the first-line agent recommended for its treatment. The global spread of dihydropteroate synthase (sul) genes has resulted in an increased resistance rate. However, the appropriate therapy for infections caused by sul-carrying S. maltophilia has not yet been established.

Objective

Our study aimed to identify the optimal antibiotic combinations that could both show high antibacterial activity against sul-carrying S. maltophilia and the ability to prevent the emergence of resistance at clinical dosage regimens.

Methods

Time-killing experiments and mutant prevention concentration (MPC) experiments were conducted to evaluate the antibacterial effect and ability to prevent resistance to minocycline, tigecycline, moxifloxacin, and ticarcillin/clavulanic acid (T/K), both alone and in combination, at clinically relevant antimicrobial concentrations.

Results

Minocycline, tigecycline, and T/K all exhibited bacteriostatic activity to sul-carrying S. maltophilia. The combination of minocycline plus T/K and tigecycline plus T/K neither enhanced the bactericidal ability nor prevented drug-resistant mutations. Moxifloxacin, at 2 mg/L, showed good bactericidal activity to most S. maltophilia, but bacterial regrowth at 24 h was observed in two strains. When combined with T/K, moxifloxacin showed good bactericidal activity in all moxifloxacin-sensitive strains. The concentrations of moxifloxacin alone were lower than most MPCs of the tested sul-carrying strains. When combined with T/K, the mean steady-state concentrations (MSC) of moxifloxacin could prevent 70% of resistance, and the peak concentration (C_max) prevented 95% of resistance.

Conclusion

The combination of moxifloxacin and T/K can achieve a good in vitro bactericidal effect and prevent the emergence of resistance at clinical dosage regimens, and may be an optimal therapeutic strategy for S. maltophilia infections, especially for vulnerable immunocompromised and critically ill patients.

Survey on Carbapenem-Resistant Bacteria in Pigs at Slaughter and Comparison with Human Clinical Isolates in Italy

This study is focused on resistance to carbapenems and third-generation cephalosporins in Gram-negative microorganisms isolated from swine, whose transmission to humans via pork consumption cannot be excluded. In addition, the common carriage of carbapenem-resistant (CR) bacteria between humans and pigs was evaluated. Sampling involved 300 faecal samples collected from slaughtered pigs and 300 urine samples collected from 187 hospitalised patients in Parma Province (Italy). In swine, MIC testing confirmed resistance to meropenem for isolates of Pseudomonas aeruginosa and Pseudomonas oryzihabitans and resistance to cefotaxime and ceftazidime for Escherichia coli, Ewingella americana, Enterobacter agglomerans, and Citrobacter freundii. For Acinetobacter lwoffii, Aeromonas hydrofila, Burkolderia cepacia, Corynebacterium indologenes, Flavobacterium odoratum, and Stenotrophomonas maltophilia, no EUCAST MIC breakpoints were available. However, ESBL genes (blaCTXM-1, blaCTX-M-2, blaTEM-1, and blaSHV) and AmpC genes (blaCIT, blaACC, and blaEBC) were found in 38 and 16 isolates, respectively. P. aeruginosa was the only CR species shared by pigs (4/300 pigs; 1.3%) and patients (2/187; 1.1%). P. aeruginosa ST938 carrying blaPAO and blaOXA396 was detected in one pig as well as an 83-year-old patient. Although no direct epidemiological link was demonstrable, SNP calling and cgMLST showed a genetic relationship of the isolates (86 SNPs and 661 allele difference), thus suggesting possible circulation of CR bacteria between swine and humans.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

Prevalence of trimethoprim/sulfamethoxazole resistance genes among Stenotrophomonas maltophilia clinical isolates in Egypt

Stenotrophomonas maltophilia is an important multidrug resistant nosocomial pathogen. Trimethoprim/sulfamethoxazole (TMP/SMX) is considered the drug of choice for treatment of S. maltophilia infections, thus emerging resistance to TMP/SMX poses a serious threat. In the present study we aimed to investigate the frequency of TMP/SMX resistance genes (sul1, sul2, dfrA), and to evaluate their relatedness with integron 1 (int1), and insertion sequence common regions (ISCR) among 100 S. maltophilia from different clinical isolates in Egypt. Isolates were identified biochemically and confirmed by VITEK2. Detection of sul1, sul2, and dfrA genes, int1 and ISCR elements was performed by PCR. Among the 16 TMP/SMX resistant isolates, sul1 gene was detected in all of them, and it was associated with int1 gene presence in all resistant isolates. The sul2 gene was detected in 6 out of 16 resistant isolates (37.5%), and only 2 of the 16 resistant isolates (12.5%) harboured dfrA gene. ISCR was detected in 10 of the resistant isolates (62.5%) and in 4 of them it was associated with the presence of sul2 gene. Among the 84 TMP/SMX sensitive isolates, sul1 gene was detected in 15 (17.8%), int1 in 16 (19%) and ISCR in 6 (7.1%). None of the susceptible isolates had sul2 or dfrA genes. These findings point out an increasing frequency of TMP/SMX resistance genes among S. maltophilia clinical isolates in our region, so the adoption of prudent use of S. maltophilia antimicrobial agents and the establishment of a surveillance system are desperately needed.

Immunoinformatic Approach for the Identification of Potential Epitopes Against Stenotrophomonas maltophilia: A Global Opportunistic Pathogen

Background:

Stenotrophomonas maltophilia is an aerobic, non-fermentative, gram negative, multidrug resistant and opportunistic nosocomial pathogen. It is associated with high morbidity and mortality in severely immunocompromised paediatric patients, including neonates. Immunoinformatic analysis paved a new way to design epitope-based vaccines which resulted in a potential immunogen with advantages such as lower cost, specific immunity, ease of production, devoid of side effects, and less time consumption than conventional vaccines. Till date, there is no development in the vaccines or antibody-based treatments for S. maltophilia-associated infections.

Introduction:

Currently, epitope-based peptide vaccines against pathogenic bacteria have grasped more attention. In our present study, we have utilized various immunoinformatic tools to find a prominent epitope that interacts with the maximum number of HLA alleles and also with the maximum population coverage for developing a vaccine against Stenotrophomonas maltophilia.

Methods:

This study has incorporated an immunoinformatic based screening approach to explore potential epitope-based vaccine candidates in Stenotrophomonas maltophilia proteome. In this study, 4365 proteins of the Stenotrophomonas maltophilia K279a proteome were screened to identify potential antigens that could be used as a good candidate for the vaccine. Various immunoinformatic tools were used to predict the binding of the promiscuous epitopes with Major Histocompatibility Complex (MHC) class I molecules. Other properties such as allergenicity, physiochemical properties, adhesion properties, antigenicity, population coverage, epitope conservancy and toxicity were analysed for the predicted epitope.

Results:

This study helps in finding the prominent epitope in Stenotrophomonas infections. Hence, the main objective in this research was to screen complete Stenotrophomonas maltophilia proteome to recognize putative epitope candidates for vaccine design. Using computational vaccinology and immunoinformatic tools approach, several aspects are obligatory to be fulfilled by an epitope to be considered as a vaccine candidate. Our findings were promising and showed that the predicted epitopes were non-allergenic and fulfilled other parameters required for being a suitable candidate based on certain physio-chemical, antigenic and adhesion properties.

Conclusion:

The epitopes LLFVLCWPL and KSGEGKCGA have shown the highest binding score of −103 and −78.1 kcal/mol with HLA-A*0201 and HLA-B*0702 MHC class I allele, respectively. They were also predicted to be immunogenic and non-allergenic. Further various immunological tests, both in vivo and in vitro methods, should be performed for finding the efficiency of the predicted epitope in the development of a targeted vaccine against Stenotrophomonas maltophilia infection.

Twitching motility of Stenotrophomonas maltophilia under iron limitation: In-silico, phenotypic and proteomic approaches

This study investigates the twitching ability of 28 clinical and five environmental strains of S. maltophilia grown under iron-depleted condition through in-silico, phenotypic and proteomics approaches. Rapid Annotations using Subsystem Technology (RAST) analysis revealed the presence of 21 targets of type IV pilus shared across S. maltophilia strains K279a, R551-3, D457 and JV3. The macroscopic twitching assay showed that only clinical isolates produced a zone of twitching with a mean of 22.00 mm under normal and 25.00 mm under iron-depleted conditions. (p = 0.002). Environmental isolates did not show any significant twitching activity in both conditions tested. Isobaric Tags for Relative and Absolute Quantification (ITRAQ) analysis showed altered expression of twitching motility protein PilT (99.08-fold change), flagellar biosynthesis protein FliC (20.14-fold change), and fimbrial protein (0.70-fold change) in response to iron-depleted condition. Most of the strains that have the ability to twitch under the normal condition, exhibit enhanced twitching during iron limitation.

In Vitro Activity of Ceftazidime-Avibactam Alone and in Combination with Amikacin Against Colistin-Resistant Gram-Negative Pathogens

Aims: Colistin became the critical treatment option for multidrug-resistant Gram-negative bacteria (GNB); however, resistance to colistin is increasingly being reported among clinical isolates. New therapy strategies should be considered nowadays. The aim of this study was to investigate the in vitro activity of a novel β-lactam/β-lactamases inhibitor ceftazidime-avibactam (CZA) alone and in combination with amikacin against colistin-resistant Gram-negative pathogens. Results: Among all the colistin-resistant GNB strains, 30.4% (21/69) were resistant to CZA, which was similar to the resistance rate of 25.4% (35/138) in colistin-susceptible strains (p > 0.05), displaying a relatively lower resistance rate compared with other antimicrobial agents (except amikacin). A majority of CZA-resistant GNB isolates (33/56) produced NDM carbapenemase. The fractional inhibitory concentration index method revealed synergistic (47.6%, 10/21) or additive (52.4%, 11/21) effects of CZA in combination with amikacin against colistin- and CZA-resistant GNB isolates, wherein the synergistic activity was found against all tested Klebsiella pneumoniae isolates (four) and Pseudomonas aeruginosa isolates (two). The time-killing curve assay verified the synergistic activity of CZA and amikacin in K. pneumoniae (FK2778) and P. aeruginosa (TL2294). The susceptible breakpoint index values showed that CZA in combination with amikacin reduced the MIC to less than the susceptibility breakpoint among 71.4% (15/21) of all tested strains. Conclusion: CZA may be a new alternative for colistin-resistant Gram-negative infections and pending clinical studies combining CZA with amikacin should be considered against these pathogens, particularly for K. pneumoniae and P. aeruginosa.

Characteristics of Stenotrophomonas maltophilia infection in children in Sichuan, China, from 2010 to 2017

Stenotrophomonas maltophilia (S. maltophilia) is an important nosocomial bacterial pathogen. However, the clinical features of children with S. maltophilia infection, the predisposing factors, and the antibiotic susceptibility of the bacteria have not been fully evaluated.In this study, the data of children with S. maltophilia infection from the West China Second University Hospital of Sichuan University (Chengdu, China) between July 2010 and October 2017 were collected and analyzed. The clinical features of enrolled children, the predisposing factors, and the antibiotic susceptibility were reported.In total, infection of S. maltophilia was identified in 128 patients. Most of these patients were under 1 year old (67.2%) and were mainly diagnosed as pneumonia (69%). A large proportion had underlying diseases (45.3%), received immunosuppressive therapy (53.1%), had undergone invasive operations (41.4%), had a history of carbapenem antibiotics use within 7 days before culture acquisition (54.7%), history of intensive care unit (ICU) hospitalization within previous 30 days (34.4%), and other risk factors. In particular, invasive operation (95% confidence interval [CI]: 1.125-14.324, P = .032), especially mechanical ventilation (95% CI: 1.277-20.469, P = .021), and ICU admission (95% CI: 1.743-22.956, P = .005) were independent risk factors for the children to develop severe S. maltophilia infection. As for antibiotic susceptibility, trimethoprim sulfamethoxazole (TMP-SMX), piperacillin tazobactam, ticarcillin clavulanate, and ceftazidime exhibited strong antibacterial activities against S. maltophilia, the susceptibility rates were 97.5%, 86.7%, 92.9%, and 81.5%, respectively.We report the clinical features of children with S. maltophilia infection, the predisposing factors and the antibiotic susceptibility. TMP-SMX can continue to be the first choice for the treatment of S. maltophilia infection. Piperacillin tazobactam, ticarcillin clavulanate, and the third generation cephalosporins can be used as alternative drugs.

Oral Infection Caused by Stenotrophomonas maltophilia: A Rare Presentation of an Emerging Opportunistic Pathogen

Stenotrophomonas maltophilia is an emerging multidrug-resistant opportunistic pathogen with an increasing incidence of nosocomial and community-acquired infection cases, mainly in immunocompromised individuals. Oral cavity infections are rare. To learn more about this infection, a case of oral cavity infection caused by S. maltophilia in an immunosuppressed patient under ventilatory therapy has been presented. The patient presented with multiple nonpainful erosive lesions of the tongue, palate, and oral mucosa. A smear of the oral lesions was performed that revealed the presence of S. maltophilia and Candida albicans, and the patient was treated with fluconazole and sulfamethoxazole associated with trimethoprim in accordance with the antimicrobial susceptibility testing. After 14 days of antibiotic therapy, there were almost no signs of the previous lesions.

Resistance Levels and Epidemiology of Non-Fermenting Gram-Negative Bacteria in Urinary Tract Infections of Inpatients and Outpatients (RENFUTI): A 10-Year Epidemiological Snapshot

Background: Urinary tract infections (UTIs) are one of the most common infections in the human medicine, both among outpatients and inpatients. There is an increasing appreciation for the pathogenic role of non-fermenting Gram-negative bacteria (NFGNBs) in UTIs, particularly in the presence of underlying illnesses. Methods: The study was carried out using data regarding a 10-year period (2008-2017). The antimicrobial susceptibility testing was performed using the disk diffusion method, E-tests, and broth microdilution. Results: NFGNB represented 3.46% ± 0.93% for the outpatients, while 6.43% ± 0.81% of all positive urine samples for the inpatients (p < 0.001). In both groups, Pseudomonas spp. (78.7% compared to 85.1%) and Acinetobacter spp. (19.6% compared to 10.9%), were the most prevalent. The Acinetobacter resistance levels were significantly higher in inpatients isolates (p values ranging between 0.046 and <0.001), while the differences in the resistance levels of Pseudomonas was not as pronounced. The β-lactam-resistance levels were between 15-25% and 12-28% for the Acinetobacter and Pseudomonas spp., respectively. 4.71% of Acinetobacter and 1.67% of Pseudomonas were extensively drug resistant (XDR); no colistin-resistant isolates were recovered. Conclusions: Increasing resistance levels of the Acinetobacter spp. from 2013 onward, but not in the case of the Pseudomonas spp. Although rare, the drug resistant NFGNB in UTIs present a concerning therapeutic challenge to clinicians with few therapeutic options left.

Levofloxacin-resistant Stenotrophomonas maltophilia: risk factors and antibiotic susceptibility patterns in hospitalized patients

BACKGROUND

Levofloxacin has been considered as an alternative treatment for Stenotrophomonas maltophilia infection. However, levofloxacin-resistant S. maltophilia (LRSM) are emerging worldwide.

AIM

To investigate LRSM risk factors in hospitalized patients and to determine antibiotic susceptibility patterns of LRSM isolates.

METHODS

In a retrospective matched case-control-control study, LRSM patients (the case group) were compared with two control groups: levofloxacin-susceptible S. maltophilia (LSSM) patients (control group A) and non-S. maltophilia-infected patients (control group B). Conditional logistic regression was used to analyse risk factors for LRSM occurrence. Tigecycline, ceftazidime, colistin, and trimethoprim/sulfamethoxazole (TMP/SMX) susceptibilities in collected LRSM clinical isolates were determined.

FINDINGS

A total of 105 LRSM, 105 LSSM, and 105 non-S. maltophilia-infected patients were analysed. The first multivariate analysis (cases vs group A) revealed that previous fluoroquinolones use was significantly associated with LRSM occurrence, and the second multivariate analysis (cases vs group B) revealed that previous fluoroquinolone use, previous intensive care unit stay, and the number of previous exposures to different classes of antibiotics were significantly associated with LRSM occurrence. Of all the LRSM isolates tested for antibiotic susceptibility, ceftazidime, TMP/SMX, tigecycline, and colistin resistance rates were 42.0, 99.0, 78.0, and 40.0%, respectively.

CONCLUSION

LRSM antibiotic susceptibility patterns revealed multiple-drug resistance, which further limits treatment options for clinicians. To reduce LRSM occurrence, proper use of antibiotics, especially fluoroquinolones, is mandatory.

Temperature, pH and Trimethoprim-Sulfamethoxazole Are Potent Inhibitors of Biofilm Formation by Stenotrophomonas maltophilia Clinical Isolates

Stenotrophomonas maltophilia, an opportunistic pathogen usually connected with healthcare-associated infections, is an environmental bacterium. Intrinsic resistance to multiple antibiotics, with different virulence determinants in the last decade classified this bacterium in the group of global multiple drug resistant (MDR) organism. S. maltophilia clinical isolates, were collected from tertiary care pediatric hospital in Belgrade, Serbia to investigate influence of different factors on biofilm formation, kinetics of biofilm formation for strong biofilm producers and effect of trimethoprim-sulfamethoxazole (TMP/SMX) on formed biofilm. Most of the isolates (89.8%) were able to form a biofilm. Analysis of biofilm formation in different growth conditions showed that changing of temeperature and pH had the stronggest effect on biofilm formation almost equally in group of cystic fibrosis (CF) and non-CF strains. TMP/SMX in concentration of 50 μg/ml reduced completely 24 h old biofilms while concentration of 25 μg/ml effects formed biofilms in a strain dependent manner. Among strains able to form strong biofilm CF isolates formed biofilm slower than non-CF isolates, while shaking conditions did not affect biofilm formation. Swimming motility was detected in both CF and non-CF isolates, however more motile strain formed stronger biofilms. This study suggests that temperature, pH and TMP/SMX had the strongest influence on biofilm formation in analyzed collection of S. maltophilia. A positive correlation between motility and strength of formed biofilm was demonstrated.

Epidemiological Trends and Resistance Associated with Stenotrophomonas maltophilia Bacteremia: A 10-Year Retrospective Cohort Study in a Tertiary-Care Hospital in Hungary

Stenotrophomonas maltophilia has been recognized as an emerging nosocomial pathogen in invasive infections of immunocompromised, severely debilitated patients with significant underlying illnesses. The first-choice drug in these infections is sulfamethoxazole-trimethoprim (SMX/TMP), and resistance to this antimicrobial is a daunting challenge for clinicians. The aim of this study was to assess the prevalence of S. maltophilia bacteremia and SMX/TMP-resistance levels at a tertiary-care university hospital. A total of 175 episodes of S. maltophilia bacteremia were identified (2008-2012: n = 82, 2013-2017: n = 93; p = 0.061), 52% of affected patients were 60 years of age, and had recent surgery, severe injuries or underlying conditions (malignant hematologic diseases and solid tumors) in their history. Sixteen percent of isolates were resistant to SMX/TMP (2008-2012: n = 13.8%, 2013-2017: n = 17.2%; p = 0.076), and out of the resistant strains, 32.7% were also resistant to levofloxacin and colistin. Our findings on the SMX/TMP-resistance were similar to global literature data.

Characterization of Phenotypic and Genotypic Diversity of Stenotrophomonas maltophilia Strains Isolated From Selected Hospitals in Iran

Stenotrophomonas maltophilia is an environmental Gram-negative bacterium that has rapidly emerged as an important nosocomial pathogen in hospitalized patients. Treatment of S. maltophilia infections is difficult due to increasing resistance to multiple antibacterial agents. The purpose of this study was to determine the phenotypic and genotypic characterization of S. maltophilia isolates recovered from patients referred to several hospitals. A total of 164 clinical isolates of S. maltophilia were collected from hospitals in various regions in Iran between 2016 and 2017. Antibiotic susceptibility testing was performed by disc diffusion method and E-test assay according to the Clinical and Laboratory Standards Institute (CLSI) guideline. The ability of biofilm formation was assessed with crystal violet staining and then, biofilm-associated genes were investigated by PCR-sequencing method. The presence of L1 (a metallo-β-lactamase), L2 (a clavulanic acid-sensitive cephalosporinase), sul1 and sul2 (resistance to Trimethoprim/Sulfamethoxazole), Smqnr (intrinsic resistance to quinolones), and dfrA genes (dihydrofolate reductase enzyme that contributes to trimethoprim resistance) was also examined by PCR-sequencing. Relative gene expression of smeDEF efflux pump was assessed by real-time PCR. Genotyping was performed using the multi-locus sequencing typing (MLST) and repetitive extragenic palindromic-PCR (Rep-PCR). Isolates were resistant to imipenem (100%), meropenem (96%), doripenem (96%), and ceftazidime (36.58%). Notably, 5 (3.04%) isolates showed resistant to trimethoprim-sulfamethoxazole (TMP-SMX), an alarming trend of decreased susceptibility to TMP-SMX in Iran. Minocycline and levofloxacin exhibited the highest susceptibility of 91.46 and 99.39%, respectively. Using the crystal violet staining, 157 (95.73%) isolates had biofilm phenotype: 49 (29.87%), 63 (38.41%), and 45 (27.43%) isolates were categorized as strong-, moderate- and weak-biofilm producer while 7 isolates (4.26%) were identified a non-biofilm producer. Biofilm genes had an overall prevalence of 145 (88.41%), 137 (83.53%), and 164 (100%) of rmlA, rpfF, and spgM, respectively. L1, L2, Smqnr, sul1, and sul2 resistance genes were detected in 145 (88.41%), 156 (96.12%), 103 (62.80%), 89 (54.26%), and 92 (56.09%) isolates, respectively. None of the S. maltophilia isolates were positive for dfrA12, dfrA17, and dfrA27 genes. Gene expression analysis showed that smeD efflux system was overexpressed in two out of the five clinical isolates (40%) that showed resistance to TMP-SMX. Most of the isolates were genetically unrelated. Two new sequence types (ST139 and ST259) were determined. Our results showed that TMP-SMX was still an effective antibiotic against S. maltophilia. The findings of the current study revealed an increasing prevalence of antibiotic resistance and biofilm genes in clinical S. maltophilia isolates in Iran.

Treatment Outcomes of Stenotrophomonas maltophilia Bacteremia in Critically Ill Children: A Multicenter Experience

OBJECTIVES

Stenotrophomonas maltophilia is a gram-negative opportunistic bacterium that may cause a myriad of clinical diseases in immunocompromised individuals. We aimed to describe the clinical characteristics, risk factors, mortality, and treatment of S. maltophilia bacteremia in critically ill children, a topic on which data are sparse.

DESIGN

A multicenter observational retrospective study in which medical charts of critically ill children with S. maltophilia bacteremia were reviewed between 2012 and 2017.

SETTING

Data were collected from each of the four largest PICUs nationwide, allocated in tertiary medical centers to which children with complex conditions are referred regularly.

PATIENTS

A total of 68 suitable cases of S. maltophilia bacteremia were retrieved and reviewed.

MEASUREMENTS AND MAIN RESULTS

The total occurrence rate of S. maltophilia isolation had increased significantly during the study period (r = 0.65; p = 0.02). The crude mortality was 42%, and the attributed mortality was 18%. Significant risk factors for mortality were a longer length of hospital stay prior to infection (33 d in nonsurvivors vs 28 in survivors; p = 0.03), a nosocomial source of infection (p = 0.02), presentation with septic shock (p < 0.001), and treatment with chemotherapy (p = 0.007) or carbapenem antibiotics (p = 0.05) prior to culture retrieval. On multivariate analysis, septic shock (odds ratio, 14.6; 95% CI, 1.45-147.05; p = 0.023) and being treated with chemotherapy prior to infection (odds ratio, 5.2; 95% CI, 1.59-17.19; p = 0.006)] were associated with mortality. The combination of ciprofloxacin, trimethoprim-sulfamethoxazole, and minocycline resulted in the longest survival time (p < 0.01).

CONCLUSIONS

The significant attributed mortality associated with S. maltophilia bacteremia in critically ill children calls for an aggressive therapeutic approach. The findings of this investigation favor a combination of trimethoprim-sulfamethoxazole, ciprofloxacin, and minocycline.

Occurrence of Antibiotic-Resistant Bacteria in Therapy Pools and Surrounding Surfaces

The number of patients colonized with antibiotic-resistant bacteria is increasing in health care facilities. Because transmission of antibiotic-resistant bacteria is feared, there exist reports that the affected patients are frequently excluded from hydrotherapy, which is a non-invasive and beneficial treatment used for patients with different diseases. Data from the literature suggest that deficient water disinfection measures exist, which are not always sufficient to kill all released bacteria. If the pool water is not disinfected properly, it may also infect the bathers. Immunocompromised patients are particularly susceptible to be infected with (antibiotic-resistant) bacteria. In order to determine the distribution of antibiotic-resistant bacteria in the pool water treatment system and the pool environment and to estimate the associated transmission risk we analyzed samples from eleven health care facilities. Antibiotic-resistant bacteria were found in the water and surface samples collected. One hundred and two antibiotic-resistant isolates from water samples and 307 isolates from surrounding surfaces were obtained, respectively. The majority of the isolates belonged to non-fermenting Gram-negative rods, like Pseudomonas spp. Some isolates were resistant to a wide range of the tested antibiotics. The results indicate a relation between the number of isolates in water samples and the number of patients using the pools in combination with deficiencies in water treatment. In the pool environment the highest number of isolates was obtained from barefoot areas and floor cleaning equipment.

Iron and Virulence in Stenotrophomonas Maltophilia: All We Know So Far

Stenotrophomonas maltophilia is a multi-drug-resistant global opportunistic nosocomial pathogen, which possesses a huge number of virulence factors and antibiotics resistance characteristics. Iron has a crucial contribution toward growth and development, cell growth and proliferation, and pathogenicity. The bacterium found to acquire iron for its cellular process through the expression of two iron acquisition systems. Two distinct pathways for iron acquisition are encoded by the S. maltophilia genome-a siderophore-and heme-mediated iron uptake system. The entAFDBEC operon directs the production of the enterobactin siderophore of catecholate in nature, while heme uptake relies on hgbBC and potentially hmuRSTUV operon. Fur and sigma factors are regulators of S. maltophilia under iron-limited condition. Iron potentially act as a signal which plays an important role in biofilm formation, extracellular polymeric substances (EPS), extracellular enzymes production, oxidative stress response, diffusible signal factor (DSF) and siderophore production in S. maltophilia. This review summarizes the current knowledge of iron acquisition in S. maltophilia and the critical role of iron in relation to its pathogenicity.

Management of Stenotrophomonas maltophilia Infections in Critically Ill Children

BACKGROUND

Stenotrophomonas maltophilia is a life-threatening nosocomial pathogen with profound multidrug-resistant attributes. It is associated with high mortality, particularly in immunocompromised patients. Data on therapy for S. maltophilia infections are scarce, especially in children hospitalized in intensive care settings (pediatric intensive care unit).

METHODS

A retrospective chart review of pediatric patients with isolates of S. maltophilia hospitalized over a 5-year period in 2 pediatric intensive care units.

RESULTS

Thirty-one patients and 91 isolates from blood, respiratory secretions and soft tissues were identified and reviewed. The overall incidence of S. maltophilia infections increased during the study period (P = 0.003). The all-cause crude mortality was 61%, and the attributed mortality was approximately 16%. Risk factors associated with mortality included longer hospitalization before infection (P = 0.002), septic shock (P = 0.003), mechanical ventilation (P = 0.004), an indwelling central vein catheter (P = 0.03) and prior use of steroids (P = 0.04) and carbapenems (P = 0.004). On multivariate analysis, mortality was associated with mechanical ventilation (P = 0.02) and preinfection hospitalization days (P = 0.01). Combination treatment of trimethoprim and sulfamethoxazole, ciprofloxacin and/or minocycline significantly extended survival time (P < 0.001). The method of treatment did not significantly affect the interval between S. maltophilia isolation to resolution of infection (P = 0.200).

CONCLUSIONS

Combinations of trimethoprim and sulfamethoxazole, ciprofloxacin and minocycline are proposed for pediatric intensive care unit patients harboring S. maltophilia. Meticulous evaluation of central vascular access and prior treatment with carbapenems are indicated, especially for mechanically ventilated and septic children.

Clinical Features, Antibiotic Susceptibility Profile, and Outcomes of Infectious Keratitis Caused by Stenotrophomonas maltophilia

PURPOSE

Stenotrophomonas maltophilia, an uncommon cause of infectious keratitis, is difficult to treat because of its resistance to multiple antibiotics. The purpose of this study is to describe the clinical features, antibiotic susceptibility profile, and outcomes of S. maltophilia keratitis.

METHODS

A retrospective review of records from 1987 to 2016 identified 26 eyes of 26 patients who were treated at the Bascom Palmer Eye Institute for an S. maltophilia corneal ulcer. Clinical data were analyzed as to predisposing factors, clinical presentation, antibiotic susceptibility, treatment selection, and clinical outcomes.

RESULTS

Median age at presentation was 65 years (range, 16-98). Twelve patients were using topical corticosteroids, 8 patients had a history of penetrating keratoplasty, and 9 were contact lens wearers. All patients received topical antibiotics, 2 required therapeutic penetrating keratoplasty, and 1 was enucleated. At presentation, 57.7% (15/26) of the patients had visual acuity of 20/400 or worse. At the final visit, only 30.4% (7/23) of the patients had visual acuity worse than 20/400, whereas 65.2% (15/23) of the patients had 20/100 or better. Almost all isolates (25/26, 96.2%) were susceptible to fluoroquinolones and 77.3% (17/22) of them to polymyxin B/trimethoprim. Only 33.3% (5/15) of the tested isolates were susceptible to aminoglycosides and 58.3% (7/12) to cephalosporins.

CONCLUSIONS

Infectious keratitis due to S. maltophilia presents a treatment challenge because of its resistance to aminoglycosides and cephalosporins, which are typically used for empiric broad-spectrum gram-negative coverage as fortified solutions. Fluoroquinolones and polymyxin B/trimethoprim should be considered instead in cases of S. maltophilia infection.

Emergence of Stenotrophomonas maltophilia nosocomial isolates in a Saudi children's hospital. Risk factors and clinical characteristics

Objectives:

To describe the clinical characteristics of pediatric patients colonized or infected by Stenotrophomonas maltophilia (S. maltophilia) at a Saudi children’s hospital, to identify risk factors associated with infection, and to investigate the antimicrobial resistance patterns of this emerging pathogen.

Methods:

In this cross-sectional observational study, 64 non-duplicating S. maltophilia strains were isolated in Najran Maternity and Children’s Hospital, Najran, Saudi Arabia between January 2015 to February 2016. Antimicrobial susceptibility testing was performed using the reference broth microdilution method.

Results:

In this study, 48 (75%) isolates were identified in true infections and 16 (25%) isolates were considered colonization. The main types of S. maltophilia infection were pneumonia in 22 (45.8%) patients and bloodstream infection in 14 (29.2%) patients. The significant risk factors included exposure to invasive procedure (p=0.02), and presence of acute leukemia as an underlying disease (p=0.02). The most active antimicrobials were trimethoprim/sulfamethoxazole (100% sensitivity) and tigecycline (93.7% sensitivity).

Conclusions:

Stenotrophomonas maltophilia is an emerging nosocomial pathogen among pediatric patients. Accurate identification and susceptibility testing of this emerging pathogen are crucial for the management of infected patients and prevention of spread of this nosocomial pathogen.

An antibiotic stewardship exercise in the ICU: building a treatment algorithm for the management of ventilator-associated pneumonia based on local epidemiology and the 2016 Infectious Diseases Society of America/American Thoracic Society guidelines

Introduction

Management of ventilator-associated pneumonia (VAP), the most common infection in patients on mechanical ventilation, should be tailored to local microbiological data. The aim of this study was to determine susceptibility patterns of organisms causing VAP to develop a treatment algorithm based on these findings and evidence from the literature.

Materials and methods

This is a retrospective analysis of the microbiological etiology of VAP in the intensive care unit (ICU) of a Lebanese tertiary care hospital from July 2015 to July 2016. We reviewed the latest clinical practice guidelines on VAP and tried to adapt these recommendations to our setting.

Results

In all, 43 patients with 61 VAP episodes were identified, and 75 bacterial isolates caused VAP. Extensively drug-resistant (XDR) Acinetobacter baumannii was the most common organism (37%), and it had occurred endemically throughout the year. Pseudomonas aeruginosa was the next most common organism (31%), and 13% were XDR. Enterobacteriaceae (15%) and Stenotrophomonas maltophilia (12%) shared similar incidences. Our algorithm was based on guidelines, in addition to trials, systematic reviews, and meta-analyses that studied the effectiveness of available antibiotics in treating VAP.

Conclusion

Knowing that resistance can rapidly develop within a practice environment, more research is needed to identify the best strategy for the management of VAP.

Stenotrophomonas maltophilia as an Emerging Ubiquitous Pathogen: Looking Beyond Contemporary Antibiotic Therapy

Stenotrophomonas maltophilia is a commensal and an emerging pathogen earlier noted in broad-spectrum life threatening infections among the vulnerable, but more recently as a pathogen in immunocompetent individuals. The bacteria are consistently being implicated in necrotizing otitis, cutaneous infections including soft tissue infection and keratitis, endocarditis, meningitis, acute respiratory tract infection (RTI), bacteraemia (with/without hematological malignancies), tropical pyomyositis, cystic fibrosis, septic arthritis, among others. S. maltophilia is also an environmental bacteria occurring in water, rhizospheres, as part of the animals' microflora, in foods, and several other microbiota. This review highlights clinical reports on S. maltophilia both as an opportunistic and as true pathogen. Also, biofilm formation as well as quorum sensing, extracellular enzymes, flagella, pili/fimbriae, small colony variant, other virulence or virulence-associated factors, the antibiotic resistance factors, and their implications are considered. Low outer membrane permeability, natural MDR efflux systems, and/or resistance genes, resistance mechanisms like the production of two inducible chromosomally encoded β-lactamases, and lack of carefully compiled patient history are factors that pose great challenges to the S. maltophilia control arsenals. The fluoroquinolone, some tetracycline derivatives and trimethoprim-sulphamethaxole (TMP-SMX) were reported as effective antibiotics with good therapeutic outcome. However, TMP-SMX resistance and allergies to sulfa together with high toxicity of fluoroquinolone are notable setbacks. S. maltophilia's production and sustenance of biofilm by quorum sensing enhance their virulence, resistance to antibiotics and gene transfer, making quorum quenching an imperative step in Stenotrophomonas control. Incorporating several other proven approaches like bioengineered bacteriophage therapy, Epigallocatechin-3-gallate (EGCG), essential oil, nanoemulsions, and use of cationic compounds are promising alternatives which can be incorporated in Stenotrophomonas control arsenal.

Surveillance of antimicrobial susceptibility patterns among Stenotrophomonas maltophilia isolated in China during the 10-year period of 2005-2014

The antimicrobial resistance pattern was studied among 300 Stenotrophomonas maltophilia isolates collected from 300 nonduplicated inpatients. The average age of the patients was 73.5 ± 14.6 years old. Isolates nonsusceptible to levofloxacin, chloramphenicol, minocycline or trimethoprim/sulfamethoxazole (SXT) were more prevalent in the 99 patients aged over 81 years than in the other patients (p < 0.05). Multidrug resistance was found to be significantly associated with isolates recovered from the blood (72.7%, p = 0.000) and elderly patients (31.3%, p = 0.003). A trend of increased resistance to antimicrobials and higher and higher frequencies of multidrug-resistant isolates were observed through the 10-year period, wherein the percentage of isolates resistant to SXT was significantly changed from 29.7% in 2005-2009 to 47.1% in 2010-2014 (p = 0.02). Clinicians are recommended to pay special attention to the possibility of multidrug-resistant S. maltophilia infection in elderly inpatients.

Risk factors for hospital acquisition of trimethoprim-sulfamethoxazole resistant Stenotrophomonas maltophilia in adults: A matched case-control study

BACKGROUND/PURPOSE

The emergence of trimethoprim-sulfamethoxazole resistant Stenotrophomonas maltophilia (TSRSM) represents a serious threat to patients. The aim of current study was to identify risk factors associated with hospital-acquired TSRSM occurrence in adult inpatients.

METHODS

We conducted a matched case-control study in Tri-Service General Hospital, Taipei, Taiwan. From January 2014 through June 2015, case patients with TSRSM and control patients with trimethoprim-sulfamethoxazole susceptible S. maltophilia (TSSSM) during hospitalization were identified. Control patients were matched with TSRSM cases for age (within five years), sex, and site of isolation at a ratio of 1:1.

RESULTS

A total of 266 patients were included in our study (133 cases and 133 matched controls). Bivariable analysis showed that previous exposure to fluoroquinolone [odds ratio (OR), 2.693; 95% confidence interval (CI, 1.492-5.884; p = 0.002)], length of intensive care unit stay (OR, 1.015 per day; 95% CI, 1.001-1.030; p = 0.041), and length of hospital stay (OR, 1.012 per day; 95% CI, 1.002-1.023; p = 0.018) prior to S. maltophilia isolation were associated with TSRSM occurrence. A multivariable analysis showed that previous exposure to fluoroquinolone (OR, 3.158; 95% CI, 1.551-6.430; p = 0.002) was an independent risk factor for TSRSM occurrence after adjustment.

CONCLUSION

Previous fluoroquinolone use was an independent risk factor for hospital-acquired TSRSM occurrence in adult inpatients, suggesting that judicious administration of fluoroquinolone may be important for limiting TSRSM occurrence.

Genotypic and Phenotypic Characterization of Stenotrophomonas maltophilia Strains from a Pediatric Tertiary Care Hospital in Serbia

Background

Stenotrophomonas maltophilia is an environmental bacterium and an opportunistic pathogen usually associated with healthcare-associated infections, which has recently been recognized as a globally multi-drug resistant organism. The aim of this study was genotyping and physiological characterization of Stenotrophomonas maltophilia isolated in a large, tertiary care pediatric hospital in Belgrade, Serbia, hosting the national reference cystic fibrosis (CF) center for pediatric and adult patients.

Methods

We characterized 42 strains of cystic fibrosis (CF) and 46 strains of non-cystic fibrosis (non-CF) origin isolated from 2013 to 2015 in order to investigate their genetic relatedness and phenotypic traits. Genotyping was performed using sequencing of 16S rRNA gene, Pulse Field Gel Electrophoresis (PFGE) and Multi locus sequencing typing (MLST) analysis. Sensitivity to five relevant antimicrobial agents was determined, namely trimethoprim/sulfamethoxazole (TMP/SMX), chloramphenicol, ciprofloxacin, levofloxacin and tetracycline. Surface characteristics, motility, biofilm formation and adhesion to mucin were tested in all strains. Statistical approach was used to determine correlations between obtained results.

Results

Most of the isolates were not genetically related. Six new sequence types were determined. Strains were uniformly sensitive to all tested antimicrobial agents. The majority of isolates (89.8%) were able to form biofilm with almost equal representation in both CF and non-CF strains. Swimming motility was observed in all strains, while none of them exhibited swarming motility. Among strains able to adhere to mucin, no differences between CF and non-CF isolates were observed.

Conclusions

High genetic diversity among isolates implies the absence of clonal spread within the hospital. Positive correlation between motility, biofilm formation and adhesion to mucin was demonstrated. Biofilm formation and motility were more pronounced among non-CF than CF isolates.

Surveillance of Dihydropteroate Synthase Genes in Stenotrophomonas maltophilia by LAMP: Implications for Infection Control and Initial Therapy

Stenotrophomonas maltophilia is a common nosocomial pathogen that causes high morbidity and mortality. Because of its inherent extended antibiotic resistance, therapeutic options for S. maltophilia are limited, and sulfamethoxazole/trimethoprim (SXT) is the only first-line antimicrobial recommended. However, with the spread of dihydropteroate synthase (sul1 and sul2) genes, global emergence of SXT resistance has been reported. There is an urgent need to develop a rapid and sensitive but cost-efficient method to monitor the dissemination of sul genes. In this study, we developed loop-mediated isothermal amplification (LAMP) assays for sul1 and sul2 using real-time turbidity and hydroxy naphthol blue coloration methods. The assays could quickly detect sul genes with high sensitivity and specificity. The LAMP detection limit was 0.74 pg/reaction of extracted genomic DNA for sul1 and 2.6 pg/reaction for sul2, which were both 10-fold more sensitive than the corresponding traditional PCR assays. Additionally, the LAMP assays could positively amplify DNA from sul1-producing strains, but not from the negative controls. We then used the LAMP assays to investigate the dissemination of sul genes among S. maltophilia isolates from patients in three hospitals in Beijing, China. Among 450 non-duplicated samples collected during 2012–2014, 56 (12.4%) strains were SXT-resistant. All these SXT-resistant strains were positive for sul genes, with 35 (62.5%) carrying sul1, 17 (30.4%) carrying sul2, and 4 (7.1%) carrying both sul1 and sul2, which indicated that sul genes were the predominant resistance mechanism. Of 394 SXT-susceptible strains, 16 were also sul-positive. To provide epidemiological data for the appropriate choice of antimicrobials for treatment of sul-positive S. maltophilia, we further tested the susceptibility to 18 antimicrobials. Among these, sul-positive strains showed the highest susceptibility to tetracycline derivatives, especially minocycline (MIC₅₀/MIC₉₀, 0.5/4; susceptibility rate, 95.4%). Ticarcillin-clavulanate and new fluoroquinolones (moxifloxacin and levofloxacin) also showed some in vitro activity. Apart from these three kinds of antimicrobials, other agents showed poor activity against sul-positive strains.

Levofloxacin Efflux and smeD in Clinical Isolates of Stenotrophomonas maltophilia

Trimethoprim-sulfamethoxazole is the first-line antimicrobial combination for Stenotrophomonas maltophilia infections. However, allergy or intolerance and increasing resistance limit the use of trimethoprim-sulfamethoxazole. Quinolones can be used as an alternative therapeutic option, but resistance can emerge rapidly during therapy. We analyzed the contribution of SmeABC and SmeDEF efflux pumps to levofloxacin resistance in clinical isolates of S. maltophilia. Nonduplicate clinical isolates of S. maltophilia were collected in 2010 from 11 university hospitals (n = 102). Fifty-five levofloxacin nonsusceptible (minimum inhibitory concentration [MIC] ≥4 μg/ml) and 47 susceptible (MIC ≤2 μg/ml) isolates were tested for efflux pump overexpression. Real-time reverse transcription-PCR was performed for amplification and quantification of smeB, smeC, smeD, and smeF mRNA. To determine which antimicrobials were affected by smeD overexpression, the growth rates of a levofloxacin-susceptible S. maltophilia isolate were compared by measuring absorbance of antimicrobial-supplemented Luria-Bertani broth (LB) cultures with or without triclosan. Significant relationships between sme gene overexpression and resistance were observed for smeD against levofloxacin, smeC and smeF against ceftazidime, and smeC against ticarcillin-clavulanate. The mean MICs of moxifloxacin and tigecycline did not significantly differ for isolates with or without overexpression of smeB, smeC, and smeF, but were significantly higher for isolates with smeD overexpression. The mean MICs of amikacin were significantly higher for smeC or smeF overexpressing isolates. Increased growth of a levofloxacin-susceptible isolate was observed in LB with 1/2 MIC levofloxacin in the presence of triclosan. These data suggest that the expression of smeD plays a role in levofloxacin resistance in S. maltophilia.

Antimicrobial evaluation of quaternary ammonium polyethyleneimine nanoparticles against clinical isolates of pathogenic bacteria

Peritonitis is a disease caused by bacterial strains that have become increasingly resistant to many antibiotics. The development of alternative therapeutic compounds is the focus of extensive research, so novel nanoparticles (NPs) with activity against antibiotic-resistant bacteria should be developed. In this study, the antibacterial activity of quaternary ammonium polyethyleneimine (QA-PEI) NPs was evaluated against Streptococcus viridans, Stenotrophomonas maltophilia and Escherichia coli. To appraise the antibacterial activity, minimal inhibitory concentration (MIC), minimal bactericidal concentration and bactericidal assays were utilised with different concentrations (1.56-100 µg/ml) of QA-PEI NPs. Moreover, 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) and annexin V/propidium iodide toxicity assays were performed in cell cultures. MICs for S. maltophilia and E. coli isolates were 12.5 and 25 µg/ml, respectively, whereas the MIC for S. viridans was 100 µg/ml. Furthermore, the growth curve assays revealed that these QA-PEI NPs at a concentration of 12.5 µg/ml significantly inhibited bacterial growth for the bacterial isolates studied. On the other hand, QA-PEI NPs lacked significant toxicity for cells when used at concentrations up to 50 μg/ml for 48 h. The present findings reveal the potential therapeutic value of this QA-PEI NPs as alternative antibacterial agents for peritonitis, especially against Gram-negative bacteria.

Intra- and Interspecies Effects of Outer Membrane Vesicles from Stenotrophomonas maltophilia on β-Lactam Resistance

The treatment ofStenotrophomonas maltophiliainfection with β-lactam antibiotics leads to increased release of outer membrane vesicles (OMVs), which are packed with two chromosomally encoded β-lactamases. Here, we show that these β-lactamase-packed OMVs are capable of establishing extracellular β-lactam degradation. We also show that they dramatically increase the apparent MICs of imipenem and ticarcillin for the cohabituating speciesPseudomonas aeruginosaandBurkholderia cenocepacia.

Prophylactic removal and microbiological evaluation of calcified plaques after pterygium surgery

PURPOSE

The aim of this study was to investigate microbiological characteristics of prophylactically removed calcified plaques developed after pterygium excision, and to evaluate risk factors for the growth of microorganisms.

METHODS

Only exposed calcified plaques developed at the same site of previous pterygium excision were prospectively removed in 15 eyes of 14 patients. Plaques were completely removed, divided into small pieces and evaluated for microbiological identification. Underlying scleral defects were reconstructed using a conjunctival autograft, amniotic membranes and scleral patch grafts according to the size and depth of the defects. Based on the results of microbiologic cultures, eyes were divided into two groups and risk factors for microbial growth were analyzed.

RESULTS

At surgery, the mean age of the patients was 71.2 ± 5.8 years and 71.4 % were females. The mean time interval between pterygium excision and calcified plaque removal was 19.3 ± 13.8 years. Six of 15 (40 %) removed plaques showed bacterial growth, and Stenotrophomonas maltophilia was the most frequently isolated microorganism. The size of calcified plaques was the only risk factor for culture-positive results (p = 0.045). Underlying scleral defects were successfully repaired without any serious complication.

CONCLUSIONS

Microorganisms can be isolated from calcified plaques developed at the site of previous pterygium excision, and the size of plaques is the only risk factor for culture-positive results. To remove potential source of infection, prophylactic removal of calcified plaques and scleral surface reconstruction should be considered, especially when the plaques are exposed and large.

Laboratory diagnosis, clinical management and infection control of the infections caused by extensively drug-resistant Gram-negative bacilli: a Chinese consensus statement

Extensively drug-resistant (XDR) Gram-negative bacilli (GNB) are defined as bacterial isolates susceptible to two or fewer antimicrobial categories. XDR-GNB mainly occur in Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. The prevalence of XDR-GNB is on the rise in China and in other countries, and it poses a major public health threat as a result of the lack of adequate therapeutic options. A group of Chinese clinical experts, microbiologists and pharmacologists came together to discuss and draft a consensus on the laboratory diagnosis, clinical management and infection control of XDR-GNB infections. Lists of antimicrobial categories proposed for antimicrobial susceptibility testing were created according to documents from the Clinical Laboratory Standards Institute (CLSI), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and the United States Food and Drug Administration (FDA). Multiple risk factors of XDR-GNB infections are analyzed, with long-term exposure to extended-spectrum antimicrobials being the most important one. Combination therapeutic regimens are summarized for treatment of XDR-GNB infections caused by different bacteria based on limited clinical studies and/or laboratory data. Most frequently used antimicrobials used for the combination therapies include aminoglycosides, carbapenems, colistin, fosfomycin and tigecycline. Strict infection control measures including hand hygiene, contact isolation, active screening, environmental surface disinfections, decolonization and restrictive antibiotic stewardship are recommended to curb the XDR-GNB spread.

Resistance of Stenotrophomonas maltophilia to Fluoroquinolones: Prevalence in a University Hospital and Possible Mechanisms

Objective: The purpose of this study was to investigate the clinical distribution and genotyping of Stenotrophomonas maltophilia, its resistance to antimicrobial agents, and the possible mechanisms of this drug resistance. Methods: S. maltophilia isolates were collected from clinical specimens in a university hospital in Northwestern China during the period between 2010 and 2012, and were identified to the species level with a fully automated microbiological system. Antimicrobial susceptibility testing was performed for S. maltophilia with the Kirby-Bauer disc diffusion method. The minimal inhibitory concentrations (MIC_s) of norfloxacin, ofloxacin, chloramphenicol, minocycline, ceftazidime, levofloxacin and ciprofloxacin against S. maltophilia were assessed using the agar dilution method, and changes in the MIC of norfloxacin, ciprofloxacin and ofloxacin were observed after the addition of reserpine, an efflux pump inhibitor. Fluoroquinolone resistance genes were detected in S. maltophilia using a polymerase chain reaction (PCR) assay, and the expression of efflux pump smeD and smeF genes was determined using a quantitative fluorescent (QF)-PCR assay. Pulsed-field gel electrophoresis (PFGE) was employed to genotype identified S. maltophilia isolates. Results: A total of 426 S. maltophilia strains were isolated from the university hospital from 2010 to 2012, consisting of 10.1% of total non-fermentative bacteria. The prevalence of norfloxacin, ciprofloxacin and ofloxacin resistance was 32.4%, 21.9% and 13.2% in the 114 S. maltophilia isolates collected from 2012, respectively. Following reserpine treatment, 19 S. maltophilia isolates positive for efflux pump were identified, and high expression of smeD and smeF genes was detected in two resistant isolates. gyrA, parC, smeD, smeE and smeF genes were detected in all 114 S. maltophilia isolates, while smqnr gene was found in 25.4% of total isolates. Glu-Lys mutation (GAA-AAA) was detected at the 151th amino acid of the gyrA gene, while Gly-Arg mutation (GGC-CGC) was found at the 37th amino acid of the parC gene. However, no significant difference was observed in the prevalence of gyrA or parC mutation between fluoroquinolone-resistant and -susceptible isolates (p> 0.05). The smqnr gene showed 92% to 99% heterogenicity among the 14 S. maltophilia clinical isolates. PFGE of 29 smqnr gene-positive S. maltophilia clinical isolates revealed 25 PFGE genotypes and 28 subgenotypes. Conclusions: Monitoring the clinical distribution and antimicrobial resistance of S. maltophilia is of great significance for the clinical therapy of bacterial infections. Reserpine is effective to inhibit the active efflux of norfloxacin, ciprofloxacin and ofloxacin on S. maltophilia and reduce MIC of fluoroquinolones against the bacteria. The expression of efflux pump smeD and smeF genes correlates with the resistance of S. maltophilia to fluoroquinolones.