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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 450-452
Stenotrophomonas maltophilia: A rare cause of bacteraemia in a patient of end stage renal disease on maintenance hemodialysis


Microbiologist Infexn Laboratories Private Limited, Khopat, Thane, Mumbai, Maharashtra, India

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Date of Web Publication22-Jun-2017
 

   Abstract 

We report a case of bacteraemia due to Stenotrophomonas maltophilia in 60-year-old male patient who presented with high fever to hospital. He was on maintenance hemodialysis (HD) suffering from end stage renal disease. Blood culture from central line was sent from which S. maltophilia was isolated which was resistance to most of antibiotics tested. Central line was removed and peripheral line was established for maintenance HD. Patient was started on levofloxacin to which it was sensitive for 2 weeks, the fever subsided thereafter, and repeat blood culture was negative. S. maltophilia is resistance to most of routinely used antibiotic so this case highlights the importance of early detection and antibiotic sensitivity workup.

Keywords: Bacteraemia, hemodialysis, S. maltophilia
Key message The treatment of catheter-related infections caused by S. maltophilia must include early and accurate diagnosis, use of effective preventive strategies, and appropriate therapeutic clinical decisions about catheter removal.

How to cite this article:
Bangde SR, Galate LB. Stenotrophomonas maltophilia: A rare cause of bacteraemia in a patient of end stage renal disease on maintenance hemodialysis. Ann Trop Med Public Health 2017;10:450-2

How to cite this URL:
Bangde SR, Galate LB. Stenotrophomonas maltophilia: A rare cause of bacteraemia in a patient of end stage renal disease on maintenance hemodialysis. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Dec 9];10:450-2. Available from: http://www.atmph.org/text.asp?2017/10/2/450/208712

   Introduction Top


Stenotrophomonas maltophilia is a ubiquitous, nonfermentative gram-negative bacterium [Figure 1],usually of low virulence, predominantly resulting in colonization. However, it has become a focus of interest lately because of the increased frequency of its isolation from hospitalized patients, the ever-expanding spectrum of diseases it causes, especially in patients with immunocompromised states, and its broad-spectrum antimicrobial resistance.[1] S. maltophilia infection has been reported in end-stage renal disease (ESRD) patients receiving peritoneal dialysis,[2] but to our knowledge very few cases of S. maltophilia infection have been reported in patients receiving maintenance hemodialysis (HD). We report a case of S. maltophilia infection occurring in patients receiving maintenance HD.
Figure 1: S. maltopholia on secondary smear.

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   Case Report Top


A 60-year-old man had been receiving maintenance HD via right internal jugular tunneled catheter having ESRD secondary to hypertension and diabetes mellitus. He presented to hospital with high grade fever and chills. On examination tunneled catheter site was without any signs of inflammation, there is no clinical evidence of tunnel infection. Patient was admitted to hospital and all related investigations were done. Total leucocyte count was high (13,600/cumm). Other hematological and nonhematological reports were within normal limit. Patient was started on empirical antibiotic to which he didn't responded. Blood for culture was drawn from tunneled catheter on third day of hospitalization. In laboratory, BACTEC BD 9120 indicated growth after 48 h of incubation. Bacteriological work up of it was done. Smear from bottle showed gram negative bacilli. Subculture was made on 5% sheep blood agar (SBA) [Figure 2] and MaConkey. After 24 h of incubation pure growth of smooth, pigmented, glistering with entire margin colonies were seen. Growth was catalase positive and oxidase negative, nonfermenter suggesting S. maltophilia. Identification was confirmed by phoenix ver.6.01. The isolate was resistant to B-lactam antibiotic and most of other antibiotic tested and only sensitive to levofloxacin and trimethoprim-sulfamethoxazole. Patient was then started on levofloxacin, central line was removed, and peripheral line was established. Patient recovered in 2 weeks of levofloxacin therapy.
Figure 2: S. maltopholia on sheep blood agar.

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   Discussion Top


S. maltophilia was first identified in 1943 in the United Kingdom and was named Bacterium bookeri. It was previously considered a pseudomonad and was grouped under the genus Xanthomonas in 1983, but a decade later it was reclassified as the single species of the new genus Stenotrophomonas.[3] S. maltophilia is a low-virulence organism but can become pathogenic in patients in immunocompromised states such as those with hematologic and nonhematological malignancies, receiving corticosteroid therapy, with previous antibiotic therapy, having neutropenia, or receiving cytotoxic chemotherapy.[4] S. maltophilia is known to cause infection via invasive medical devices such as central venous catheters,[5] chronic indwelling urinary catheters, endotracheal or tracheostomy tubes,[6] and peritoneal catheters,[2] by which the organism bypasses normal host defenses and causes nosocomial outbreaks of infection. Persons often come in contact with S. maltophilia through environmental water sources, including hospital tap water or faucets, dialysis machines, nebulizers, showerheads, deiodinized water dispensers, and ice machines.[7],[8]

Besides peritonitis,[2] S. maltophilia has been reported to cause a variety of infections. Although S. maltophiliainfection is rare in patients receiving peritoneal dialysis, approximately 23 cases have been reported so far. To our knowledge, very few cases has been reported in patients receiving maintenance HD. Gnanasekaran et al. in 2009 reported series of three cases who were on maintenance HD suffered from S. maltophilia bacteremia presented with different clinical features.[9] With the increasing prevalence of ESRD patients receiving dialysis via tunneled catheters, S. maltophilia may be encountered more frequently and should be considered a true pathogen. The source of infection should be identified, and invasive medical devices should be removed/changed, if feasible, along with antibiotic therapy, as in our cases. Although trimethoprim-sulfamethoxazole (TMP-SMX) and ticarcilllin/clavulanate appear to be the most effective antimicrobial agents and TMP-SMX is considered the first drug of choice.[10] However, TMP-SMX has various side effects in renal disease patient.

Catheter-related bacteremia frequently occurs in outpatients undergoing hemodialysis. The incidence of bacteremia in outpatients undergoing hemodialysis with dual-lumen, tunneled, cuffed catheters has been reported to be 3.9 episodes per 1000 catheter-days, although catheter-related bacteremia is thought to occur less frequently in patients with tunneled, cuffed catheters.[11] Organisms causing catheter related bacteremia generally enter the bloodstream from the skin insertion site or through the hub of the catheter device. Hub contamination is more common in long-term catheters that are left in place for more than 10 days, because such catheters often have to be intercepted and manipulated.[12] Elting and Bodey,[13] together with other investigators,[14],[15] have also shown that most patients with S. maltophilia infections had received broad-spectrum antibiotics, and a large percentage of these patients had indwelling catheters. Moreover, antibiotic therapy alone does not generally cure catheter related bacteremia and removal of the catheter is recommended.[16]

In conclusion, the treatment of catheter-related infections caused by S. maltophilia must include early and accurate diagnosis, use of effective preventive strategies, and appropriate therapeutic clinical decisions about catheter removal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Barbier-Frebour N, Boutiba-Boubake I, Nouvello M, Lemelan J. Molecular investigation of Stenotrophomonas maltophilia isolates exhibiting rapid emergence of Ticarcillin-clavulanate resistance. J Hosp Infect 2000;45:35-41.  Back to cited text no. 1
[PUBMED]    
2.
Tzanetou K, Triantaphilis G, Tsoutsos D, Stenotrophomonas maltophilia peritonitis in CAPD patients: susceptibility to antibiotics and treatment outcome: a report of five cases. Perit Dial Int 2004;24:401-4.  Back to cited text no. 2
    
3.
Denton M, Stenotrophomonas maltophilia-Questions and Answers [online]. Leeds University Teaching Hospitals, Leeds, UK May 2001 Available at: http://www.cysticfi brosismedicine.com/htmldocs/CFText/stenotr.htm. [[Last accessed on 2014 Nov 25].  Back to cited text no. 3
    
4.
Khardori N, Elting L, Wong E. Nosocomial infections due to Xanthomonas maltophilia (Pseudomonasmaltophilia) in patients with cancer. Rev Infect Dis1991;12:997-1003.  Back to cited text no. 4
    
5.
Boktour M, Hanna H, Ansari S. Central venous catheter and Stenotrophomonas maltophilia bacteremia in cancer patients. Cancer 2006;106:1967-973.  Back to cited text no. 5
    
6.
Gardner P, Griffin WB, Swartz MN, Kunz LJ. Nonfermentative gram-negative bacilli of nosocomial interest. Am J Med 1970;48:735-74.  Back to cited text no. 6
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7.
Denton M, Kerr KG. Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia infection. Clin Microbiol Rev 1998;11:57-80.  Back to cited text no. 7
[PUBMED]    
8.
Villarino ME, Stevens LE, Schable B. For National Center for infectious diseases, centers for disease control.Risk factors for epidemic Xanthomonas maltophilia infection/colonizationin intensive care unit patients. Infect Control Hosp Epidemiol1992;13:201-6.  Back to cited text no. 8
    
9.
Gnanasekaran Isaiarasi,Bajaj Rishi. Stenotrophomonas maltophilia bacteremia in end-stage renal disease patients receiving maintenance hemodialysis. Dial Transplant 2009;38:30-2.  Back to cited text no. 9
    
10.
Valdezate S, Vindel A, Loza E. Antimicrobial susceptibilities of unique Stenotrophomonas maltophilia clinical strains. Antimicrob Agents Chemother2001;45:1581-584.  Back to cited text no. 10
    
11.
Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ, Kirkland KB. Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis. Ann Intern Med 1997;127:275-80.  Back to cited text no. 11
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12.
Linares J, Sitges-Serra A, Garau J, Perez JL, Martin R. Pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures of catheter hub and segments. J Clin Microbiol 1985;21:357-60.  Back to cited text no. 12
    
13.
Elting LS, Bodey GP. Septicemia due to Xanthomonas species and nonaeruginosa Pseudomonas species: increasing incidence of catheter-related infections. Medicine 1990;69:296-6.  Back to cited text no. 13
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14.
Ganadu M, Mura GL, Campus AM. Relapsing pyrogenic reactionsdue to Xanthomonas maltophilia in a dialysis patient with a long-term central venous catheter. Nephrol Dial Transplant 1996;11:197-98.  Back to cited text no. 14
    
15.
Vartivarian S, Anaissie E, Bodey G, Sprigg H, Rolston K. A changing pattern of susceptibility of Xanthomonas maltophilia to antimicrobial agents: implications for therapy. Antimicrob Agents Chemother 1994;38:624-27.  Back to cited text no. 15
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16.
Raad I. Intravascular-catheter-related infections. Lancet 1998;351:893.  Back to cited text no. 16
[PUBMED]    

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Correspondence Address:
Lata B Galate
Infexn Laboratory Private Limited Khopat, Thane (W), Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.208712

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