Stenotrophomonas maltophilia and antibiotic use in German intensive care units: data from Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units)
Introduction
The overall isolation rate of Stenotrophomonas maltophilia has increased since the early 1970s, since which time it has been considered as an unusual opportunistic pathogen with limited invasiveness.1 The growing role of this organism is due to the fact that the population at risk is increasing, i.e. the number of severely compromised patients including human immunodeficiency virus positive and haemodialysis patients.2, 3, 4 Although there are some reports of community-acquired infections, S. maltophilia is primarily considered to be a nosocomial pathogen. Faecal carriage has been reported in 10.9% of outpatients with diarrhoea.5 Other studies found faecal carriage in 2.9% of healthy controls and in 33% of patients with haematological malignancies.6, 7 The risk factors predisposing to colonization and infection with S. maltophilia are prolonged hospitalization, admission to an intensive care unit (ICU), the presence of a central venous catheter, malignancies, neutropenia and severe mucositis.1 Another important risk factor consistently associated with S. maltophilia infection is exposure to antibiotic agents.
Infections with S. maltophilia are difficult to manage because clinical isolates are intrinsically resistant to many broad-spectrum antibiotics, particularly the beta-lactams.8, 9 This provides an ecological advantage over other pathogens susceptible to broad-spectrum antibiotic therapy. Although variations in the activity of the carbapenems have been noted, the resistance to this class is well recognized. Prior therapy with carbapenems has been cited by many studies as a risk factor for S. maltophilia isolation or infection.10, 11 However, there is considerable evidence that broad-spectrum antibiotics other than carbapenems, i.e. ceftazidime, aminoglycosides, metronidazole and fluoroquinolones, predispose for the selection of S. maltophilia.12, 13, 14
The purpose of this study was to analyse and correlate multi-centre surveillance data on antimicrobial use and the number of S. maltophilia infections per 1000 patient-days, and the percentages of S. maltophilia isolated in these ICUs. The study also aimed to identify risk factors for the isolation of S. maltophilia.
Section snippets
Methods
SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units) is a prospective unit- and laboratory-based surveillance system that collects data on the 13 most important organisms responsible for nosocomial infections, i.e. Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, Enterococcus faecium, Pseudomonas aeruginosa, Enterobacter cloacae, Citrobacter spp., Serratia marcescens, Acinetobacter baumannii, S. maltophilia,
Results
Thirty-nine ICUs provided data from January 2003 to December 2004 and were thus included in the analysis. In total, 327 108 patient-days were reported, with a total of 28 266 isolates and 431 351 DDDs. Antibiotic use density ranged from 426.7 to 2218.3, with a median of 1346.0. The data covered a total of 28 266 isolates (16 032 Gram-positive organisms and 12 234 Gram-negative organisms). The number of SARI isolates ranged from 37 to 2097, with the median being 599. This corresponds to 17–176
Discussion
This study was based on an ecologic study design and is probably the first to correlate multi-centre surveillance data on antibiotic use with S. maltophilia per 1000 patient-days and percentage of S. maltophilia. Risk factors for the isolation of S. maltophilia were analysed (N = 39 ICUs). The principal findings of this study were as follows.
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There is a large variation in the incidence density of S. maltophilia in individual ICUs (range 0.0–7.6 per 1000 patient-days). The median was 1.4 per 1000
Acknowledgement
SARI is part of the SIR (Spread of Nosocomial Infections and Resistant Pathogens) research network and was supported by a grant from the German Ministry of Education and Research (01 KI 9907).
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