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Multidrug Resistant Stenotrophomonas Maltophilia Jebmh.com Original Research Article Multidrug Resistant Stenotrophomonas maltophilia - Changing Sensitivity Pattern with Resistance to Trimethoprim-Sulfamethoxazole - A Retrospective Study from Jaipur, India Dinesh Kumar Jain1, Yogesh Kumar Gupta2, Parul Sinha3, Sandeep Gupta4, Varunika Vijayvergia5, Sivra Batra6 1, 3, 4, 5, 6 Department of Microbiology, S.M.S. Medical College, Jaipur, Rajasthan, India. 2Department of Microbiology, Fortis Hospital, Jaipur, Rajasthan, India. ABSTRACT BACKGROUND Stenotrophomonas maltophilia is a gram-negative bacillus, multidrug resistant Corresponding Author: (MDR) opportunistic pathogen, which is normally present in hospital surroundings. Dr. Dinesh Kumar Jain, A-734-B Siddartha Nagar-A Near It has been one of the leading causes of nosocomial infections due to risk factors Jawahar Circle Jaipur, such as extended intensive care unit (ICU) stays and multiple invasive procedures. Rajasthan, India. In this study we wanted to assess the antibiotic sensitivity pattern with various E-mail: [email protected] antimicrobial agents i.e. levofloxacin, minocycline, ceftazidime, chloramphenicol, & ticarcillin-clavulanic acid with special focus on trimethoprim-sulfamethoxazole DOI: 10.18410/jebmh/2021/436 (TMP-SMX). How to Cite This Article: METHODS Jain DK, Gupta YK, Sinha P, et al. Multidrug resistant Stenotrophomonas In vitro analysis was conducted on 164 Stenotrophomonas maltophilia strains maltophilia - changing sensitivity pattern isolated from blood and respiratory tract from January 2016 to November 2020. with resistance to trimethoprim- Antibiotic susceptibility and minimum inhibitory concentration (MIC) testing for sulfamethoxazole - a retrospective study trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin (LVX), ticarcillin - from Jaipur, India. J Evid Based Med clavulanic acid (TIM), and minocycline (MIN) were performed using Vitek 2, as per Healthc 2021;8(26):2339-2343. DOI: clinical and laboratory standards institute (CLSI) guideline. 10.18410/jebmh/2021/436 RESULTS Submission 13-01-2021, Peer Review 20-01-2021, A total of 164 S. maltophilia were isolated. Out of the 164 S. maltophilia isolates, Acceptance 11-05-2021, 26 (16 %) were isolated from blood, 114 (70 %) were isolated from respiratory Published 28-06-2021. samples, 20 (12 %) from pus & tissue, and 4 (2 %) from urine. Out of the 164 patients, 130 (80 %) were males and 32 (20 %) were females. Maximum patients Copyright © 2021 Dinesh Kumar Jain were above 50 years of age 93 (56 %) followed by 20 - 50 years 55 (34 %). Out et al. This is an open access article of the 164 patients, 67 (40 %) were admitted to wards, 92 (56 %) were in ICU distributed under Creative Commons and 5 (3 %) were seen in out-patient department (OPD). A total of 90 % strains Attribution License [Attribution 4.0 were sensitive to trimethoprim-sulfamethoxazole (TMP-SMX). Total 91 % strains International (CC BY 4.0)] were sensitive to levofloxacin. CONCLUSIONS S. maltophilia is emerging as a significant nosocomial pathogen, with a growing rate of isolation. Trimethoprim- sulfamethoxazole (TMP-SMX) is still the drug of choice, but resistance to it has been reported. KEYWORDS Minimum Inhibitory Concentration, Trimethoprim-Sulfamethoxazole (TMP-SMX), Levofloxacin J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 26 / June 28, 2021 Page 2339 Jebmh.com Original Research Article BACKGROUND disease has arisen as a serious concern in patients with no known risk factors, such as intensive critical unit stay; Medical microbiologists have long realized the significance of treatment-induced neutropenia, mechanical ventilation, long identifying infectious microbes as the cause of ailments in carbapenem therapy, third or fourth cephalosporins, or long human beings. The emergence of novel multidrug-resistant hospital stays. In all geographic regions, this bacterium is bugs found in atmosphere, the growing incidents of most commonly associated with respiratory tract infections. community-acquired infections, and the spread of these Any organ may be affected by Stenotrophomonas microorganisms in the hospital setting have all emphasized maltophilia. Infections of the lungs are common. the necessity to control these pathogens. The increasing Colonization of the respiratory tract normally precedes lung incidents of multidrug-resistant organisms (MDRO) infection. Pleural effusions are uncommon, but lobar or lobar associated infections has spurred efforts to examine consolidation is common. Infected indwelling intravascular potential sources of these pathogens, evaluate current devices cause the most of the Stenotrophomonas antimicrobial strategies used to treat these infections, and maltophilia bloodstream infections. Non–catheter-related explain the mechanisms used by these microbial pathogens bacteraemia is often seen in patients with prolonged 4,5,6 during infection. Gram-negative bacilli have received a lot of neutropenia. attention, as they are frequently associated with multidrug- Trimethoprim-sulfamethoxazole / Co-trimoxazole has resistant mechanisms which include multidrug resistance been the primary treatment for susceptible S. maltophilia pumps, plasmids that harbour antibiotic resistance genetic infections, based on in vitro activity and anecdotal reports of materials, and various gene transfer methods involved in the favourable clinical outcomes. Although levofloxacin and acquisition of antimicrobial resistance. Pseudomonas Minocycline have been considered as alternatives to (TMP- aeruginosa is an example of a multidrug-resistant organism SMX) for the treatment of Stenotrophomonas maltophilia that causes respiratory infections in patients with chronic infections, more clinical data are still needed to validate their 4,6,7,8 lung disease or cystic fibrosis. efficacies. Stenotrophomonas maltophilia was first isolated in 1943 Because Stenotrophomonas maltophilia and B. cepacia and was named Bacterium bookeri by J. L. Edward at that are present in the atmosphere, exposure to these bacteria time. It was later renamed in the Pseudomonas family, then occurs frequently. Bacterial factors contributing to family Xanthomonas, and finally, in 1993, after a very long colonization of the respiratory tract or prosthetic devices period of debate, Palleroni and Bradbury proposed a genus such as intravascular catheters and endotracheal tubes Stenotrophomonas. include cationic surface charge, flagella and fimbriae, which 9,10 It is the only Stenotrophomonas species known to infect promote adhesion and biofilm formation. human being, while its close genetic members are only Patients at high risk for infection are those critically ill infective to plants. Stenotrophomonas maltophilia is an with (1) chronic obstructive pulmonary disease (2) aerobic non-fermentative gram-negative bacillus that is prolonged use of broad-spectrum anti-microbial therapy ubiquitous in the environment in all geographic regions.1,2 with third and fourth generation cephalosporin’s or It acquire motility via multi trichous flagella. The optimal carbapenem’s (3) prolonged need for assisted ventilation temperature for its growth is 35°C- 37°C and no growth requiring tracheotomy (4) high injury severity score (5) occurs below 5°C and above 40°C. It produces lavender- pulmonary contusion and (6) prior respiratory tract S. 11 green color colonies on blood agar (BA) plates, non- maltophilia colonization. pigmented small colonies on MacConkey agar (MHA) plates In the immunosuppressed cancer and transplant and tiny creamy colonies on Muller-Hinton agar (MHA) plates population, well-recognized risk factors for invasive S. after 18 – 24 hours of incubation at 35°C - 37°C. maltophilia disease include (1) presence of long treatment- They do not ferment glucose sugar, and many isolates induced neutropenia (absolute neutrophil count < 150 tend to give a positive oxidase test. These free-living micro- cells/μL) (2) recent or on-going carbapenem, higher- organisms are present in most aquatic and/or humid generation cephalosporin, or fluoroquinolone therapy (3) environment, including hospital drinking water. presence of mucositis (4) presence of indwelling medical Stenotrophomonas maltophilia has arisen as an devices such as intravascular or genitourinary catheters (5) 12,13 important opportunistic nosocomial pathogen, particularly prolonged hospital stay and (6) hyper alimentation. S. among immune-compromised hosts, patients suffering from maltophilia in chlorine treated water distribution hospital malignancy, patients on long steroid therapy and prolonged water supply has been identified as a source for occasional 14 hospitalization. S. maltophilia is a significant nosocomial clusters of nosocomial cases. pathogen that is now considered as a "newly emerging Several molecular mechanisms of S. maltophilia superbug" due to its multi-drug resistance and ability to contributes to its multi-antimicrobial resistance, including, colonise the surfaces of medical devices. S. maltophilia can plasmids, integrons, and jumping genes. Integrons common cause a wide variety of infections, including nosocomial regions and integron-like elements have been reported for pneumonia, acute exacerbations of chronic obstructive S. maltophilia isolates across the world. Integrons are not pulmonary disease (COPD), urinary tract infections (UTI), auto-mobilizable parts but hold an integrase encoding gene bacteraemia, endocarditis, meningitis, and wound & soft that allows the insertion of antibiotic resistance gene tissue infections.3
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