157

Stenotrophomonas maltophilia
Jane L. Burns
Stenotrophomonas maltophilia originally was classified as a Pseudomonas, transferred to the genus Xanthomonas because of common biochemical reactions,1 and then transferred to its own genus, Stenotrophomonas, primarily because it differs markedly in appearance from the other xanthomonads and is not a phytopathogen.2 The biochemical reactions this organism has in common with Xanthomonas include a negative indophenol oxidase reaction and a shared pattern of carbohydrate metabolism. Many strains require methionine for growth. A unique feature of S. maltophilia that can aid in its identification is a positive reaction on deoxyribonuclease (DNase) test agar.

BOX 157-1. Risk Factors Associated with Stenotrophomonas maltophilia Bloodstream Infections in Children
Malignancy Acquisition of infection in the community Trimethoprim-sulfamethoxazole exposure in previous 30 days Receipt of corticosteroids or other immunosuppressive therapy African American race

VIRULENCE FACTORS
Potential virulence factors identified in S. maltophilia include protease, elastase, lipase, mucinase, hyaluronidase, deoxyribonuclease, ribonuclease, and hemolysin. Clinical correlation of these factors with disease has not been reported. However, in a single immunocompromised patient with ecthyma gangrenosum caused by S. maltophilia, intense production of protease and elastase by the organism was identified.3

EPIDEMIOLOGY
S. maltophilia is similar to the pseudomonads in two important features: ubiquity (frequently being isolated from soil and water), and association with healthcare-related infections in patients with comorbidities.4 In some patients, it can be difficult to distinguish colonization from true infection. Bloodstream infection (BSI) and pneumonia are the most common infections, but S. maltophilia also has been reported to cause ecthyma gangrenosum, endocarditis, ocular infection, urinary infection, wound infection, and other nosocomial infections.48 In a study of pediatric BSI caused by glucose nonfermenting gram-negative bacilli other than Pseudomonas aeruginosa, S. maltophilia was the most common, occurring in 67% of patients.9 Like Burkholderia cepacia, S. maltophilia can persist in commonly used disinfectant solutions, resulting in both true infections and pseudoinfections.10,11 Risk factors associated with pediatric S. maltophilia BSI are listed in Box 157-1.7 Unlike many other gram-negative pathogens, communityassociated infections are not uncommon4 and polymicrobial infections are typical in children.7 In children with human immunodeficiency virus infection or malignancy, S. maltophilia has been reported as an important cause of central venous catheterassociated BSIs.12 Risk factors associated with S. maltophilia BSI in oncology patients include severe mucositis, diarrhea, and use of

metronidazole. There have been several reports of cross-infections in neonatal nurseries.13,14 S. maltophilia is an emerging pathogen in cystic fibrosis (CF). S. maltophilia was isolated from respiratory tract specimens of 12.5% of CF patients in one study,15 with prevalence doubling in the last decade.16 In one study, isolation of S. maltophilia from the respiratory tract was associated with oral fluoroquinolone use.17 Although S. maltophilia is more frequently isolated from patients with more severely impaired pulmonary function, an association with increased rate of decline has not been demonstrated clearly.18,19 However, a recent study found that S. maltophilia was an independent risk factor for pulmonary exacerbations in CF.20

CLINICAL MANIFESTATIONS AND TREATMENT

Infections caused by S. maltophilia are not distinct from nosocomial infections caused by other gram-negative organisms, with the possible exception of ecthyma gangrenosum. This manifestation appears more commonly during S. maltophilia BSI than during other non-Pseudomonas aeruginosa gram-negative infections. S. maltophilia is highly resistant to antibiotics, making treatment difficult. The organism virtually is always resistant to the car bapenem antibiotics and aminoglycosides and is variably sus ceptible to cephalosporins and penicillins.21,22 The most active agents in vitro continue to include the newer fluoroquinolones, minocycline, and doxycycline, but resistance to trimethoprimsulfamethoxazole and ciprofloxacin is increasing.13,2123 Unlike many multidrug-resistant gram-negative non-Enterobacteriaceae, S. maltophilia appears to be susceptible to the -lactamase inhibitor clavulanic acid. Both ticarcillin-clavulanate and aztreonamclavulanate demonstrate some activity in vitro.24 With the exception of trimethoprim-sulfamethoxazole, isolates from individuals with CF are more resistant than isolates from individuals without CF.21

Stenotrophomonas maltophilia

157

REFERENCES
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