Stenotrophomonas Maltophilia

Back

Background

Stenotrophomonas (Xanthomonas) maltophilia is an aerobic gram-negative bacillus that is found in various aquatic environments. Although an uncommon pathogen in humans, S maltophilia infection in humans, especially nosocomial, has been increasingly recognized.

S maltophilia is an organism of low virulence and frequently colonizes fluids used in the hospital setting (eg, irrigation solutions, intravenous fluids) and patient secretions (eg, respiratory secretions, urine, wound exudates). S maltophilia usually must bypass normal host defenses to cause human infection. For example, if an irrigation solution becomes colonized with this organism, irrigating an open wound can cause colonization or infection of the wound. S maltophilia is usually incapable of causing disease in healthy hosts without the assistance of invasive medical devices that bypass normal host defenses.[1]

Risk factors associated with S maltophilia infection have been defined and may include underlying malignancy, immunosuppressant therapy, cystic fibrosis, and exposure to broad-spectrum antibiotics.

Pathophysiology

S maltophilia has few pathogenic mechanisms and, for this reason, predominantly results in colonization rather than infection. If infection does occur, invasive medical devices are usually the vehicles through which the organism bypasses normal host defenses. Otherwise, the pathophysiology of this nonfermentative aerobic gram-negative bacillus does not differ from other nonfermentative aerobic organisms.

Epidemiology

Frequency

United States

S maltophilia is a noninvasive organism that has low virulence. It frequently colonizes body fluids but rarely causes infection (eg, intravenous line infections).

International

S maltophilia frequently colonizes the respiratory tract in patients with cystic fibrosis.[2, 3, 4, 5, 6]

Mortality/Morbidity

Mortality and morbidity relate to the inoculum of S maltophilia that is able to bypass normal host defense mechanisms.

If an intravenous infusion contains large numbers of S maltophilia, then direct injection into the bloodstream may result in the signs and symptoms associated with gram-negative bacteremia.

Similarly, in the urinary tract, if urological irrigation fluids that contain large numbers of S maltophilia are used during an invasive urological procedure, eg, cystoscopy, then gram-negative bacteremia may occur with its attendant mortality and morbidity, which depend on host factors.

History

Because S maltophilia infections are extremely uncommon, no specific patient history suggests its presence other than contact with other colonized individuals.

Obtaining a history of the use of irrigant solutions that could potentially contain S maltophilia is important in an epidemiological setting rather than in a clinical setting.

Patients often have a history of indwelling catheters, use of immunosuppressant therapy or broad-spectrum antibiotics, or cystic fibrosis.

Physical

Signs and symptoms of S maltophilia infections are related to the organ system involved and are indistinguishable from infections with other pathogens.

Causes

S maltophilia is a nonfermentative aerobic gram-negative bacillus formerly classified in the genus Pseudomonas. Unlike Pseudomonas aeruginosa, S maltophilia is an organism of low virulence with limited ability to cause infection in humans.

S maltophilia is a water organism, and it survives and multiplies in aqueous environments, particularly respiratory secretions, urine, intravenous fluids, and irrigant solutions.

S maltophilia may persist in an aquatic environment for extended periods.

Sources of S maltophilia colonization include the following:

Laboratory Studies

Culture of the organism from body fluids and proper identification from the microbiology laboratory confirms the presence of S maltophilia. Usually, the presence of S maltophilia represents colonization. A potential pathogenic role must be evaluated by an infectious disease specialist. The mere recovery of a potential pathogen from any body fluid does not indicate a pathogenic role for the organism.

Histologic Findings

The histology of S maltophilia in the rare situations when it causes infection is indistinguishable from the histology of infections caused by other aerobic gram-negative bacilli.

Medical Care

Colonization of body fluids in hospitalized patients should be minimized if possible. Foley catheters should be used only as long as necessary and should be avoided if at all possible in immunocompromised hosts predisposed to urinary tract infections, eg, patients with diabetes, SLE, or multiple myeloma.

Colonization of respiratory secretions in intubated patients in ICUs is the rule and is difficult to prevent.

Patient-to-patient spread of organisms may be minimized or prevented by effective infection-control measures.

Consultations

A consultation with an infectious disease specialist is essential for differentiating colonization from infection in patients with S maltophilia isolated from various body fluids.

Medication Summary

Because S maltophilia is predominantly a colonizer, antimicrobial treatment may be unnecessary and may be potentially harmful. Thus, determination of whether the organism is truly the cause of an infection is necessary to determine the need for antibiotic therapy.

As a general principle, colonization should not be treated with antimicrobial therapy.

S maltophilia, as a non– aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillins, and antipseudomonal third-generation cephalosporins. Tigecycline may potentially be helpful, but clinical investigation is needed.[8, 9]

S maltophilia is consistently susceptible to trimethoprim-sulfamethoxazole (TMP-SMZ).[9, 10] If TMP-SMZ cannot be used, the organism is usually sensitive to minocycline, respiratory quinolones, or colistin/polymyxin B.

Sulfamethoxazole/trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Clinical Context:  Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity includes common urinary tract pathogens, except P aeruginosa.

Cefepime (Maxipime)

Clinical Context:  Fourth-generation cephalosporin with good gram-negative coverage, similar to ceftazidime, but better gram-positive coverage.

Minocycline (Dynacin, Minocin)

Clinical Context:  Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma.

Tigecycline (Tygacil)

Clinical Context:  A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit, and blocks entry of amino-acyl tRNA molecules in ribosome A site. Indicated for complicated skin and skin structure infections caused by E coli, E faecalis (vancomycin-susceptible isolates only), S aureus (methicillin-susceptible and -resistant isolates), S agalactiae, S anginosus group (includes S anginosus, S intermedius, and S constellatus), S pyogenes, and B fragilis.

Class Summary

Therapy should be selective to avoid covering multiple isolates from a body site in the context of the clinical setting.

Deterrence/Prevention

Because S maltophilia is a common nosocomial colonizer in patients and medical fluids, the recovery of S maltophilia should be considered nonpathogenic unless proven otherwise.

If S maltophilia is recovered from several patients in the same area, sections of an ICU or ward can become the focus of further spread within the hospital setting.

Effective infection control measures can minimize or limit the spread of this and other organisms in the ICU.

Appropriate isolation procedures, rather than antimicrobial therapy, should be used to control the spread of S maltophilia.

Medical personnel, including medical students, housekeeping staff, attending physicians, nursing personnel, and respiratory therapists, are potential carriers of the organism from patient to patient.

Author

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michael Stuart Bronze, MD, David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Charles S Levy, MD, Associate Professor, Department of Medicine, Section of Infectious Disease, George Washington University School of Medicine

Disclosure: Nothing to disclose.

References

  1. Araoka H, Baba M, Yoneyama A. Risk factors for mortality among patients with Stenotrophomonas maltophilia bacteremia in Tokyo, Japan, 1996-2009. Eur J Clin Microbiol Infect Dis. 2010 May. 29(5):605-8. [View Abstract]
  2. Burdge DR, Noble MA, Campbell ME, et al. Xanthomonas maltophilia misidentified as Pseudomonas cepacia in cultures of sputum from patients with cystic fibrosis: a diagnostic pitfall with major clinical implications. Clin Infect Dis. 1995 Feb. 20(2):445-8. [View Abstract]
  3. Denton M. Stenotrophomonas maltophilia: An emerging problem in cystic fibrosis patients. Rev Med Microbiol. 1997. 8:15-9.
  4. Hadjiliadis D, Steele MP, Chaparro C, et al. Survival of lung transplant patients with cystic fibrosis harboring panresistant bacteria other than Burkholderia cepacia, compared with patients harboring sensitive bacteria. J Heart Lung Transplant. 2007 Aug. 26(8):834-8. [View Abstract]
  5. Paschoal IA, de Oliveira Villalba W, Bertuzzo CS, et al. Cystic fibrosis in adults. Lung. 2007 Mar-Apr. 185(2):81-7. [View Abstract]
  6. Colin AA, Rabin HR. Stenotrophomonas maltophilia in cystic fibrosis: guilty or innocent?. Am J Respir Crit Care Med. 2011 Mar 1. 183(5):564-6. [View Abstract]
  7. Gopalakrishnan R, Hawley HB, Czachor JS, et al. Stenotrophomonas maltophilia infection and colonization in the intensive care units of two community hospitals: A study of 143 patients. Heart Lung. 1999 Mar-Apr. 28(2):134-41. [View Abstract]
  8. Farrell DJ, Sader HS, Jones RN. Antimicrobial susceptibilities of a worldwide collection of Stenotrophomonas maltophilia isolates tested against tigecycline and agents commonly used for S. maltophilia infections. Antimicrob Agents Chemother. 2010 Jun. 54(6):2735-7. [View Abstract]
  9. Gülmez D, Cakar A, Sener B, Karakaya J, Hasçelik G. Comparison of different antimicrobial susceptibility testing methods for Stenotrophomonas maltophilia and results of synergy testing. J Infect Chemother. 2010 Oct. 16(5):322-8. [View Abstract]
  10. Abbott IJ, Slavin MA, Turnidge JD, Thursky KA, Worth LJ. Stenotrophomonas maltophilia: emerging disease patterns and challenges for treatment. Expert Rev Anti Infect Ther. 2011 Apr. 9(4):471-88. [View Abstract]
  11. Alonso A, Martínez JL. Multiple antibiotic resistance in Stenotrophomonas maltophilia. Antimicrob Agents Chemother. 1997 May. 41(5):1140-2. [View Abstract]
  12. Ansari SR, Hanna H, Hachem R, et al. Risk factors for infections with multidrug-resistant Stenotrophomonas maltophilia in patients with cancer. Cancer. 2007 Jun 15. 109(12):2615-22. [View Abstract]
  13. Azak A, Kocak G, Huddam B, Iscan G, Duranay M. An unusual cause of continuous ambulatory peritoneal dialysis-associated outpatient peritonitis: Stenotrophomonas maltophilia. Am J Infect Control. 2011 Sep. 39(7):618. [View Abstract]
  14. Barchitta M, Cipresso R, Giaquinta L, Romeo MA, Denaro C, Pennisi C, et al. Acquisition and spread of Acinetobacter baumannii and Stenotrophomonas maltophilia in intensive care patients. Int J Hyg Environ Health. 2009 May. 212(3):330-7. [View Abstract]
  15. Belvisi V, Fabietti P, Del Borgo C, Marocco R, DI Vincenzo E, Soscia F, et al. Successful treatment of Stenotrophomonas maltophilia soft tissue infection with tigecycline: a case report. J Chemother. 2009 Jun. 21(3):367-8. [View Abstract]
  16. Berbari N, Johnson DH, Cunha BA. Xanthomonas maltophilia peritonitis in a patient undergoing peritoneal dialysis. Heart Lung. 1993 May-Jun. 22(3):282-3. [View Abstract]
  17. Betts JW, Phee LM, Woodford N, Wareham DW. Activity of colistin in combination with tigecycline or rifampicin against multidrug-resistant Stenotrophomonas maltophilia. Eur J Clin Microbiol Infect Dis. 2014 Sep. 33(9):1565-72. [View Abstract]
  18. Blanquer D, De Otero J, Padilla E, Gómez F, Mayol A, Irigaray R, et al. Tigecycline for treatment of nosocomial-acquired pneumonia possibly caused by multi-drug resistant strains of Stenotrophomonas maltophilia. J Chemother. 2008 Dec. 20(6):761-3. [View Abstract]
  19. Brooke JS. Stenotrophomonas maltophilia: an emerging global opportunistic pathogen. Clin Microbiol Rev. 2012 Jan. 25(1):2-41. [View Abstract]
  20. Cunha BA. Antibiotic Essentials. 5th ed. Royal Oak, Mich: Physicians Press; 2006.
  21. Cunha BA. Pseudoinfections and pseudo-outbreaks. Mayhall G, ed. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia, Pa: Lippencott Williams and Wilkins; 1999. 121-30.
  22. Cunha BA. Infections caused by non-fermentative aerobic gram-negative bacilli in the Critical Care Unit. Antibiotics for Clinicians. 2000. 4:11-6.
  23. Cunha BA. Pneumoniae Essentials. 2nd Ed. Royal Oak, MI: Physicians Press; 2008.
  24. Cunha BA, Klein NC. Pseudoinfections: A review. Infect Dis Clin Pract. 1995. 4:95-103.
  25. De Mauri A, Torreggiani M, Chiarinotti D, Andreoni S, Molinari G, De Leo M. Stenotrophomonas maltophilia: an emerging pathogen in dialysis units. J Med Microbiol. 2014 Nov. 63:1407-1410. [View Abstract]
  26. Denton M, Kerr KG. Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia. Clin Microbiol Rev. 1998 Jan. 11(1):57-80. [View Abstract]
  27. Ece G, Erac B, Limoncu MH, Baysak A, Oz AT, Ceylan KC. Stenotrophomonas maltophilia Pseudo-outbreak at a University Hospital Bronchoscopy Unit in Turkey. West Indian Med J. 2014 Jan. 63(1):59-61. [View Abstract]
  28. Elting LS, Bodey GP. Septicemia due to Xanthomonas species and non-aeruginosa Pseudomonas species: increasing incidence of catheter-related infections. Medicine (Baltimore). 1990 Sep. 69(5):296-306. [View Abstract]
  29. Elting LS, Khardori N, Bodey GP, et al. Nosocomial infection caused by Xanthomonas maltophilia: a case-control study of predisposing factors. Infect Control Hosp Epidemiol. 1990 Mar. 11(3):134-8. [View Abstract]
  30. Entenza JM, Moreillon P. Tigecycline in combination with other antimicrobials: a review of in vitro, animal and case report studies. Int J Antimicrob Agents. 2009 Jul. 34(1):8.e1-9. [View Abstract]
  31. Falagas ME, Kastoris AC, Vouloumanou EK, Dimopoulos G. Community-acquired Stenotrophomonas maltophilia infections: a systematic review. Eur J Clin Microbiol Infect Dis. 2009 Jul. 28(7):719-30. [View Abstract]
  32. Falagas ME, Valkimadi PE, Huang YT, Matthaiou DK, Hsueh PR. Therapeutic options for Stenotrophomonas maltophilia infections beyond co-trimoxazole: a systematic review. J Antimicrob Chemother. 2008 Nov. 62(5):889-94. [View Abstract]
  33. Fang FC, Madinger NE. Resistant nosocomial gram-negative bacillary pathogens: Acinetobacter baumannii, Xanthomonas maltophilia, and Pseudomonas cepacia. Curr Clin Top Infect Dis. 1996. 16:52-83. [View Abstract]
  34. Farrell DJ, Sader HS, Jones RN. Antimicrobial susceptibilities of a worldwide collection of Stenotrophomonas maltophilia isolates tested against tigecycline and agents commonly used for S. maltophilia infections. Antimicrob Agents Chemother. 2010 Jun. 54(6):2735-7. [View Abstract]
  35. Fujita J, Yamadori I, Xu G, et al. Clinical features of Stenotrophomonas maltophilia pneumonia in immunocompromised patients. Respir Med. 1996 Jan. 90(1):35-8. [View Abstract]
  36. Garazi M, Singer C, Tai J, Ginocchio CC. Bloodstream infections caused by Stenotrophomonas maltophilia: a seven-year review. J Hosp Infect. 2012 Jun. 81(2):114-8. [View Abstract]
  37. Garcia-Rodriguez JA, Garcia Sanchez JE, Munoz Bellido JL, et al. In-vitro activity of meropenem, a new carbapenem, against imipenem-resistant Pseudomonas aeruginosa and Xanthomonas maltophilia. J Chemother. 1991 Jun. 3(3):143-6. [View Abstract]
  38. Garcia-Teresa MA, Casado-Flores J, Delgado Dominguez MA, et al. Infectious complications of percutaneous central venous catheterization in pediatric patients: a Spanish multicenter study. Intensive Care Med. 2007 Mar. 33(3):466-76. [View Abstract]
  39. Garrison MW, Anderson DE, Campbell DM, et al. Stenotrophomonas maltophilia: emergence of multidrug-resistant strains during therapy and in an in vitro pharmacodynamic chamber model. Antimicrob Agents Chemother. 1996 Dec. 40(12):2859-64. [View Abstract]
  40. Gilardi GL. Characterization of nonfermentative nonfastidious gram negative bacteria encountered in medical bacteriology. J Appl Bacteriol. 1971 Sep. 34(3):623-44. [View Abstract]
  41. Gilardi GL. Infrequently encountered Pseudomonas species causing infection in humans. Ann Intern Med. 1972 Aug. 77(2):211-5. [View Abstract]
  42. Gilardi GL. Pseudomonas maltophilia infections in man. Am J Clin Pathol. 1969 Jan. 51(1):58-61. [View Abstract]
  43. Hansen CR. Stenotrophomonas maltophilia: to be or not to be a cystic fibrosis pathogen. Curr Opin Pulm Med. 2012 Nov. 18(6):628-31. [View Abstract]
  44. Cunha Ba. Infectious Disease in Critical Care Medicine. 2nd Ed. New York, NY: Informa Healthcare; 2007.
  45. Kagen J, Zaoutis TE, McGowan KL, et al. Bloodstream infection caused by Stenotrophomonas maltophilia in children. Pediatr Infect Dis J. 2007 Jun. 26(6):508-12. [View Abstract]
  46. Khardori N, Elting L, Wong E. Nosocomial infections due to Xanthomonas maltophilia (Pseudomonas maltophilia) in patients with cancer. Rev Infect Dis. 1990 Nov-Dec. 12(6):997-1003. [View Abstract]
  47. Khardori N, Reuben A, Rosenbaum B, et al. In vitro susceptibility of Xanthomonas (Pseudomonas) maltophilia to newer antimicrobial agents. Antimicrob Agents Chemother. 1990 Aug. 34(8):1609-10. [View Abstract]
  48. Krcmery V, Antal M, Langsadl L, et al. Transferable amikacin resistance in pseudomonas maltophilia and acinetobacter calcoaceticus. Infection. 1985 Mar-Apr. 13(2):89-90. [View Abstract]
  49. Lakatos B, Jakopp B, Widmer A, Frei R, Pargger H, Elzi L, et al. Evaluation of treatment outcomes for Stenotrophomonas maltophilia bacteraemia. Infection. 2014 Jun. 42(3):553-8. [View Abstract]
  50. Looney WJ, Narita M, Mühlemann K. Stenotrophomonas maltophilia: an emerging opportunist human pathogen. Lancet Infect Dis. 2009 May. 9(5):312-23. [View Abstract]
  51. Matsuyama JR, Beail B, Wallis C, et al. Susceptibility of Xanthomonas maltophilia and amikacin-resistant gram-negative bacteria to newer antimicrobials. Clin Pharm. 1991 Jul. 10(7):544-8. [View Abstract]
  52. Milne KE, Gould IM. Combination antimicrobial susceptibility testing of multidrug-resistant Stenotrophomonas maltophilia from cystic fibrosis patients. Antimicrob Agents Chemother. 2012 Aug. 56(8):4071-7. [View Abstract]
  53. Milne KE, Gould IM. Combination antimicrobial susceptibility testing of multidrug-resistant Stenotrophomonas maltophilia from cystic fibrosis patients. Antimicrob Agents Chemother. 2012 Aug. 56(8):4071-7. [View Abstract]
  54. Morrison AJ Jr, Hoffmann KK, Wenzel RP. Associated mortality and clinical characteristics of nosocomial Pseudomonas maltophilia in a university hospital. J Clin Microbiol. 1986 Jul. 24(1):52-5. [View Abstract]
  55. Nicodemo AC, Paez JI. Antimicrobial therapy for Stenotrophomonas maltophilia infections. Eur J Clin Microbiol Infect Dis. 2007 Apr. 26(4):229-37. [View Abstract]
  56. Nseir S, Di Pompeo C, Brisson H, et al. Intensive care unit-acquired Stenotrophomonas maltophilia: incidence, risk factors, and outcome. Crit Care. 2006. 10(5):R143. [View Abstract]
  57. Sattler CA, Mason EO Jr, Kaplan SL. Nonrespiratory Stenotrophomonas maltophilia infection at a children's hospital. Clin Infect Dis. 2000 Dec. 31(6):1321-30. [View Abstract]
  58. Saugel B, Eschermann K, Hoffmann R, et al. Stenotrophomonas maltophilia in the respiratory tract of medical intensive care unit patients. Eur J Clin Microbiol Infect Dis. 2012 Jul. 31(7):1419-28. [View Abstract]
  59. Semel JD, Trenholme GM, Harris AA, et al. Pseudomonas maltophilia pseudosepticemia. Am J Med. 1978 Mar. 64(3):403-6. [View Abstract]
  60. Shigemura K, Arakawa S, Tanaka K, Fujisawa M. Clinical investigation of isolated bacteria from urinary tracts of hospitalized patients and their susceptibilities to antibiotics. J Infect Chemother. 2009 Feb. 15(1):18-22. [View Abstract]
  61. Shiratori S, Wakasa K, Okada K, Sugita J, Akizawa K, Shigematsu A, et al. Stenotrophomonas maltophilia infection during allogeneic hematopoietic stem cell transplantation: a single-center experience. Clin Transplant. 2014 Jun. 28(6):656-61. [View Abstract]
  62. Steere AC, Tenney JH, Mackel DC. Pseudomonas species bacteremia caused by contaminated normal human serum albumin. J Infect Dis. 1977 May. 135(5):729-35. [View Abstract]
  63. Sutter VL. Identification of Pseudomonas species isolated from hospital environment and human sources. Appl Microbiol. 1968 Oct. 16(10):1532-8. [View Abstract]
  64. Tekce YT, Erbay A, Cabadak H, Sen S. Tigecycline as a therapeutic option in Stenotrophomonas maltophilia infections. J Chemother. 2012 Jun. 24(3):150-4. [View Abstract]
  65. Vidigal PG, Dittmer S, Steinmann E, Buer J, Rath PM, Steinmann J. Adaptation of Stenotrophomonas maltophilia in cystic fibrosis: molecular diversity, mutation frequency and antibiotic resistance. Int J Med Microbiol. 2014 Jul. 304(5-6):613-9. [View Abstract]
  66. Villarino ME, Stevens LE, Schable B, et al. Risk factors for epidemic Xanthomonas maltophilia infection/colonization in intensive care unit patients. Infect Control Hosp Epidemiol. 1992 Apr. 13(4):201-6. [View Abstract]
  67. Waters V, Atenafu EG, Lu A, Yau Y, Tullis E, Ratjen F. Chronic Stenotrophomonas maltophilia infection and mortality or lung transplantation in cystic fibrosis patients. J Cyst Fibros. 2013 Jan 4. [View Abstract]
  68. Wilsher ML, Kolbe J, Morris AJ, et al. Nosocomial acquisition of Burkholderia gladioli in patients with cystic fibrosis. Am J Respir Crit Care Med. 1997 Apr. 155(4):1436-40. [View Abstract]
  69. Wishart MM, Riley TV. Infection with Pseudomonas maltophilia hospital outbreak due to contaminated disinfectant. Med J Aust. 1976 Nov 6. 2(19):710-2. [View Abstract]
  70. Wu Y, Shao Z. High-dosage tigecycline for Stenotrophomonas maltophilia bacteremia. Chin Med J (Engl). 2014. 127(17):3199. [View Abstract]
  71. Yeshurun M, Gafter-Gvili A, Thaler M, et al. Clinical characteristics of Stenotrophomonas maltophilia infection in hematopoietic stem cell transplantation recipients: a single center experience. Infection. 2010 Jun. 38(3):211-5. [View Abstract]
  72. Yu VL, Rumans LW, Wing EJ, et al. Pseudomonas maltophilia causing heroin-associated infective endocarditis. Arch Intern Med. 1978 Nov. 138(11):1667-71. [View Abstract]
  73. Chang YT, Lin CY, Chen YH, Hsueh PR. Update on infections caused by Stenotrophomonas maltophilia with particular attention to resistance mechanisms and therapeutic options. Front Microbiol. 2015. 6:893. [View Abstract]
  74. Sánchez MB. Antibiotic resistance in the opportunistic pathogen Stenotrophomonas maltophilia. Front Microbiol. 2015. 6:658. [View Abstract]
  75. Juhász E, Krizsán G, Lengyel G, Grósz G, Pongrácz J, Kristóf K. Infection and colonization by Stenotrophomonas maltophilia: antimicrobial susceptibility and clinical background of strains isolated at a tertiary care centre in Hungary. Ann Clin Microbiol Antimicrob. 2014 Dec 31. 13:333. [View Abstract]
  76. Hand E, Davis H, Kim T, Duhon B. Monotherapy with minocycline or trimethoprim/sulfamethoxazole for treatment of Stenotrophomonas maltophilia infections. J Antimicrob Chemother. 2016 Apr. 71 (4):1071-5. [View Abstract]
  77. De Mauri A, Torreggiani M, Chiarinotti D, Andreoni S, Molinari G, De Leo M. Stenotrophomonas maltophilia: an emerging pathogen in dialysis units. J Med Microbiol. 2014 Nov. 63 (Pt 11):1407-10. [View Abstract]
  78. Cunha CB, Cunha BA. Antibiotic Essentials. 15th ed. New Delhi: JayPee Medical Publishers; 2016.
  79. Cunha BA. Antibiotic Essentials. 3rd ed. Sudbury, MA: Jones & Bartlett; 2010.
  80. Cunha BA. Infectious Disease in Critical Care Medicine. 3rd ed. New York, NY: Informa Healthcare; 2010.
Infection Predisposing Factor
Catheter-associated bacteriuriaIndwelling urinary catheters
Intravenous line infectionsCentral intravenous catheters
UrosepsisUrinary tract instrumentation
Primary bacteremiaArterial monitoring devices
PseudobacteremiaContamination of blood during collection/processing of blood cultures