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)

https://doi.org/10.1016/j.jhin.2006.07.006Get rights and content

Summary

Risk factors for the selection of Stenotrophomonas maltophilia were analysed by correlating antimicrobial use and structure parameters (e.g. hospital type) with the incidence density of S. maltophilia and the percentage of S. maltophilia isolated from 39 intensive care units (ICUs). 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. The percentage of S. maltophilia among these organisms and the number of S. maltophilia per 1000 patient-days were calculated. The data were subsequently correlated with antibiotic use density calculated in defined daily doses (DDDs) per 1000 patient-days and structure parameters. The data covered a total of 28 266 isolates and 431 351 DDDs. The antibiotic use density ranged from 427 to 2218, with the median being 1346. Over the two-year period, the median of S. maltophilia per 1000 patient-days was 1.4 (range 0–7.6). Calculation of antibiotic use and S. maltophilia per 1000 patient-days showed a significant positive correlation with the use of carbapenems, ceftazidime, glycopeptides and fluoroquinolones, as well as with total antibiotic use. In the multiple logistic regression analysis, carbapenem use and >12 ICU beds were independently and positively associated with a high number of S. maltophilia per 1000 patient-days. Benchmarking data provided for incidence densities of S. maltophilia in ICUs revealed the heterogeneous situation of the burden of S. maltophilia in individual ICUs. The multi-centre data showed that carbapenem use and >12 ICU beds were independent risk factors for the isolation of S. maltophilia.

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.

  • 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).

References (19)

  • G. Steinkamp et al.

    Prospective evaluation of emerging bacteria in cystic fibrosis

    J Cyst Fibros

    (2005)
  • H.S. Sader et al.

    Antimicrobial susceptibility of uncommonly isolated non-enteric Gram-negative bacilli

    Int J Antimicrob Agents

    (2005)
  • M. Denton et al.

    Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia

    (1998)
  • R.R. Muder et al.

    Bacteremia due to Stenotrophomonas (Xanthomonas) maltophilia: a prospective, multicenter study of 91 episodes

    Clin Infect Dis

    (1996)
  • L. Calza et al.

    Stenotrophomonas (Xanthomonas) maltophilia as an emerging opportunistic pathogen in association with HIV infection: a 10-year surveillance study

    Infection

    (2003)
  • A. von Graevenitz et al.

    Accuracy of the KOH and vancomycin tests in determining the Gram reaction of non-enterobacterial rods

    J Clin Microbiol

    (1983)
  • K.G. Kerr et al.

    Infections due to Xanthomonas maltophilia in patients with hematologic malignancy

    Rev Infect Dis

    (1991)
  • A. Apisarnthanarak et al.

    Stenotrophomonas maltophilia intestinal colonization in hospitalized oncology patients with diarrhea

    Clin Infect Dis

    (2003)
  • N.M. Clark et al.

    Antimicrobial resistance among Gram-negative organisms in the intensive care unit

    Curr Opin Crit Care

    (2003)
There are more references available in the full text version of this article.

Cited by (30)

  • Changes of resistance rates in Pseudomonas aeruginosa strains are unrelated to antimicrobial consumption in ICU populations with invasive device-related infection

    2020, Medicina Intensiva
    Citation Excerpt :

    The relationship between antimicrobial use and increasing emergence of resistance to specific agents or antimicrobial families has been well documented.1–11

  • Stenotrophomonas maltophilia: From trivial to grievous

    2017, Indian Journal of Medical Microbiology
  • An overview of various typing methods for clinical epidemiology of the emerging pathogen Stenotrophomonas maltophilia

    2015, Diagnostic Microbiology and Infectious Disease
    Citation Excerpt :

    It is rare for S maltophilia to cause eye infections (Akçakaya et al., 2011; Lin et al., 2011; Mauger et al., 2010), endocarditis (Gutiérrez Rodero et al., 1996), and meningitis (Rojas et al., 2009). Several hospitals in different countries perform surveillance on infections due to S. maltophilia (Emerson et al., 2010; Jones, 2010; Lai et al., 2004; Meyer et al., 2006; Razvi et al., 2009; Wang et al., 2004; Wu et al., 2006). S. maltophilia isolates exhibit high genetic diversity that were identified through the use of a variety of molecular biology methods (da Silva Filho et al., 2004; Nicoletti et al., 2011; Schaumann et al., 2008; Valdezate et al., 2005).

  • Stenotrophomonas maltophilia in Malaysia: Molecular epidemiology and trimethoprim-sulfamethoxazole resistance

    2012, International Journal of Infectious Diseases
    Citation Excerpt :

    In the current study, S. maltophilia strains isolated over a 1-year period at the largest public hospital of Kuala Lumpur were examined. As noted by others,15,16 S. maltophilia was found as a high-risk nosocomial pathogen in the ICU (Table 1). This unfortunate trend is reinforced by the generally weak and immune-compromised state of ICU patients and other factors including increased length of stay, mechanical ventilator support, and inadequate empiric antibiotic therapy.

View all citing articles on Scopus
View full text