Catheter-related Bloodstream Infection Caused by Stenotrophomonas maltophilia in An Adult
Patient with End-stage Renal Disease:
Successful Treatment with Ceftazidime and Removal of Catheter
Chang-Hua Chen1, Yu-Min Chen2, and Chia-Chu Chang3
1Division of Infectious Diseases, Department of Internal Medicine; 2Department of Pharmacy;
3Division of Nephrology, Department of Internal Medicine;
Changhua Christian Hospital, Changhua, Taiwan
Abstract
Catheter-related bloodstream infection (CrBSI) is an important clinical problem in critically ill patients, such as patients with end-stage renal disease (ESRD). We report a case of CrBSI caused by Stenotroph- omonas maltophilia (S. maltophilia) in an adult patient with ESRD. It is not known whether S. maltophilia is susceptible to ceftazidime (CAZ) becasue there is no standard breakpoint for CAZ. Following removal of the catheter and a 17-day course of CAZ the patient made a good recovery. (J Intern Med Taiwan 2014; 25:
215-219)
Key Words: Stenotrophomonas maltophilia, Catheter, Bloodstream infection, End-stage renal disease
Background
Stenotrophomonas maltophilia (S. maltophilia) was first isolated in 1943 as Bacterium bookeri, and then renamed as Pseudomonas maltophilia1. Later, it was named Xanthomonas maltophilia according to rRNA cistron analysis2. After a large study of Xanthomonas strains, the name was changed to S.
maltophilia according to DNA-rRNA hybridization studies, and sequencing and mapping of PCR-ampli- fied 16S rRNA genes3.
S. maltophilia is not a highly virulent pathogen, but it has emerged as an important noso- comial pathogen associated with higher mortality rates4. A variety of infections are associated with S. maltophilia5, including indwelling catheter infec- tions6. Patients with end-stage renal disease (ESRD) are more susceptible to infections from indwelling catheters7. Thus, catheter-related S. maltophilia bacteremia has been described in these patients with ESRD8-9. Resistance of S. maltophilia to multiple antibiotics, as well as the potential adverse reactions
Reprint requests and correspondence：Dr. Chia-Chu Chang
Address：Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, 135 Nanhsiao Street, Changhua 500, Taiwan
associated with the use of trimethoprim-sulfa- methoxazole (TMP-SMX), has made the choice of drugs very difficult in patients with ESRD10. Although Betriu et al found that ceftazidime(CAZ) was the most active of the cephalosporins for S.
maltophilia11, it is not known whether S. malto- philia is susceptible to CAZ becasue there is no standard breakpoint for CAZ. Here we report an interesting case of catheter-related bloodstream infection (CrBSI) caused by S. maltophilia in an adult receiving hemodialysis. We treated this patient successfully with CAZ and catheter removal.
Case presentation
A 78-years-old female presented with fever and chills. She had a history of ESRD for three years and received dialysis through a tunneled hemodialysis catheter. She suffered from fever and chills while on hemodialysis for one day prior to the present admission. She was sent to the emergency department of our institute. Upon admission, she was afebrile,with a blood pressure of 120/80 mmHg, and had a gangrenous lesion on her right big toe. At admission, the laboratory results were as follows:
white blood cell count, 18,900/mm3; and C-reactive protein (CRP), 7.65 mg/dL. A plain chest radiograph showed cardiomegaly. Based on these findings, sepsis was suspected and she was admitted to the infectious diseases ward for further management.
On the day of admission, the patient was treated for sepsis with a 400 mg stat dose of teico- planin plus 2000 mg/day of CAZ. Blood and urine samples were obtained for culture. On day 3 following admission, S. maltophilia was isolated.
S. maltophilia was identified with a Vitek-2 System (Biomerieux, Hazlewood, Mo.). We performed an antibiotic susceptibility test for S. maltophilia. The results indicated that S. maltophilia was sensitive to TMP-SMX and resistant to the cephalosporin group (including cefmetazole, CAZ, cefotaxime, cefepime, and cefpirome), penicillin group
(ampicillin, amoxicillin-clavulanate, piperacillin, piperacillin-tazobactam,), carbepenem group (imipenem-cilastatin, and meropenem), aminogly- cosides (gentamicin and amikacin), and fluoroqui- nolone (ciprofloxacin). We continued using CAZ because of the potential adverse reactions known to be associated with TMP-SMX especially in patients with ESRD, according to Salter’s recommenda- tion10. During the hospitalization, serial microbio- logical studies, as well as analysis of blood samples taken via the catheter, showed S. maltophilia growth. After obtaining consent from the patient and her family, we removed the catheter on day 10 following admission, after which her condition started improving. S. maltophilia was isolated from the tip of the hemodialysis catheter. Her vital signs stabilized and she received a full 17-days course of CAZ. She was followed-up at an outpatient depart- ment, and she recoved well.
Discussion
We reported a case of CrBSI caused by S. maltophilia in an adult patient with ESRD.
Catheters cause up to 50% of nosocomial bacte- remias, and central vascular catheters account for 80%–90% of such infections5. National estimates from the United States indicated that as many as 250,000 BSIs associated with central vascular cath- eters occur each year in the United States, with an attributable mortality of 12%–25% and an estimated cost of $25,000 per case7. These risk factors for S.
maltophilia infection are summarized in Table12-22. Our patient was in critical condition prior to the commencement of CAZ therapy, and her condi- tion stabilized following the removal of the cath- eter. Araoka et al reported patients with underlying diseases including ESRD is extremely vulnerable to this organism. S. maltophilia bacteremia has a mortality rate of up to 51% if appropriate antibi- otics are not instituted early16. Although knowledge of local susceptibility patterns of S. maltophilia
is helpful in determining empirical antibiotics, appropriate antibiotic therapy may not be possible because of lack of standard breakpoints. Micozzi’s studies have suggested an association between inap- propriate antibacterial treatment and mortality18. Wang's study showed S. maltophilia were suscep- tible in vitro to the combination of ticarcillin and clavulanic acid (72%), and to levofloxacin (55%)19. In our patient, the antibiotic susceptibility result of S. maltophilia showed resistance to all antibiotics except for TMP-SMX, and therefore TMP-SMX has been regarded as an agent of choice in this patient.
However, TMP-SMX is relatively unsafe in patients with ESRD23. Levofloxacin is not appropriate choice for such an ESRD patient with cardiomegaly and QTc prolongation. Ticarcillin and clavulanic acid is not avaiable at our institute and minocycline is only bacteriostatic effect. At the critical moment, we chose CAZ because of less adverse reaction and and possible activity in previous study11. Concerning
treatment of this patient, the infection was controlled only after the catheter was removed. Friedman et al emphasized the importance of the removal of indwelling catheters and commencement of appro- priate antibiotic therapy because all deaths were preceded by an episode of S. maltophilia infection, although underlying disease processes also played a major role17. Hanna et al concluded that patients with documented CrBSI, should have their catheter removed within 48 to 72 hours to prevent relapse24. In our patient, the removal of the catheter was an important part of the treatment.
Conclusions
We reported a case of CrBSI caused by S. maltophilia in an adult patient with ESRD. The treatment approach included the removal of the catheter and a 17-day course of CAZ. Isolation of S. maltophilia from blood culture should prompt a careful review of the patient with particular Table 1. Literature Review of Risk Factors and Mortaliry rate for Stenotrophomonas maltophilia infection
Country Study Design Enrolled cases Risk factors Mortality rate References
Turkey case–control 37 cases 1. Presence CVC
2. Carbapenem use 21.6% 12
USA case–control 13 cases Prior use of antibiotics No record 13
Taiwan Retrospective review 84 episodes Long-term hospitalization or ICU stay 33.0% 14 USA case–control 30 cases 1. Presence CVC
2. Previous aminoglycoside use 30.0% 15
Japan Retrospective review 53 cases 1. Neytropenia 2. Presence CVC
3. Mixed infection with enterococci 51.0% 16 Australia Retrospective review 45 episodes 1. Presence CVC
2. Prior use of antibiotics 18.0% 17
Taiwan Retrospective review 50 episodes 1. Receiving mechanical ventilation in the ICU
2. Presence CVC 62.0% 18
Italy Retrospective review 37 cases 1. Neutropenia
2. Severe cellulitis 24.0% 19
USA Retrospective review 102 cases 1. Presence CVC 212.Neutropenia 48.3% 20
USA Retrospective review 217 episodes 1. Presence CVC
2. Prior intensive care unit admission
3. Neutropenia 11.0% 21
Taiwan Retrospective review 14 episodes 1.Presence CVC
2.Prior use of antibiotics 30.7% 22
emphasis on the commencement of appropriate antibiotic therapy and prompt removal of indwelling catheters whenever possible.
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尿毒症病患罹患導管相關嗜麥芽單胞菌 (Stenotrophomonas maltophilia) 血流感染：
移除導管與使用頭孢他啶 (Ceftazidime) 成功治療病患
陳昶華1 陳昱旻2 張家築3
彰化基督教醫院 內科部感染科1 藥劑部2 腎臟科3
摘 要
導管相關血流感染是種嚴重疾病，在尿毒症病患是一個重要的臨床問題。我們報告一例
嗜麥芽單胞菌(Stenotrophomonas maltophilia) 引起在尿毒症病患的血流感染。目前並沒有頭孢
他啶（Ceftazidime) 對於嗜麥芽單胞菌的判讀標準。本案例移除導管與使用頭孢他啶成功治療
病患。
