Outer membrane protein profiles of Xanthomonas maltophilia isolates displaying temperature-dependent susceptibility to gentamicin

Clinical challenges treating Stenotrophomonas maltophilia infections: an update

Stenotrophomonas maltophilia is a non-fermenting, Gram-negative bacillus that has emerged as an opportunistic nosocomial pathogen. Its intrinsic multidrug resistance makes treating infections caused by S. maltophilia a great clinical challenge. Clinical management is further complicated by its molecular heterogeneity that is reflected in the uneven distribution of antibiotic resistance and virulence determinants among different strains, the shortcomings of available antimicrobial susceptibility tests and the lack of standardized breakpoints for the handful of antibiotics with in vitro activity against this microorganism. Herein, we provide an update on the most recent literature concerning these issues, emphasizing the impact they have on clinical management of S. maltophilia infections.

Evaluation of the Vitek 2, Phoenix, and MicroScan for Antimicrobial Susceptibility Testing of Stenotrophomonas maltophilia

Stenotrophomonas maltophilia causes high-mortality infections in immunocompromised hosts with limited therapeutic options. Many U.S. laboratories rely on commercial automated antimicrobial susceptibility tests (cASTs) and use CLSI breakpoints (BPs) for S. maltophilia. However, contemporary data on these systems are lacking. We assessed performance of Vitek 2, MicroScan WalkAway, and Phoenix relative to that of reference broth microdilution for trimethoprim-sulfamethoxazole (SXT), levofloxacin (LEV), minocycline (MIN), and ceftazidime (CAZ) with 109 S. maltophilia bloodstream isolates. Using CLSI breakpoints, categorical agreement (CA) was below 90% on all systems and drugs, with the exception of SXT by MicroScan (98.1%) and Phoenix (98.1%) and MIN by MicroScan (100%) and Phoenix (99.1%). For SXT, Vitek 2 yielded a 77.1% CA. LEV and CAZ CA ranged from 67% to 85%. Very major errors (VME) were >3% for SXT (MicroScan, Phoenix), LEV (MicroScan), and CAZ (all systems). Major errors (ME) were >3% for SXT (Vitek 2), LEV (Phoenix), and CAZ (MicroScan, Phoenix). Minor errors were >10% for CAZ and LEV on all systems. Data were analyzed with EUCAST pharmacokinetic/pharmacodynamic CAZ, LEV, ciprofloxacin (CIP), and tigecycline (TGC) breakpoints when possible. CA was <90% for all. VME were >3% for CAZ (all systems), LEV (MicroScan), and TGC (Vitek 2), and ME were >3% for LEV (MicroScan), CAZ (all systems), ciprofloxacin (Vitek 2 and MicroScan), and TGC (Vitek 2, Phoenix). Minor errors (MI) were >10% for all agents and systems, by EUCAST breakpoints with an intermediate category (LEV, CAZ, CIP). Laboratories should use caution with cASTs for S. maltophilia, as a high rate of errors may be observed.

Partial characterization of chorionic gonadotropin-like binding sites from the bacteria Xanthomonas maltophilia

The gram-negative bacterium, Xanthomonas maltophilia, has low- and high-affinity luteinizing hormone/chorionic gonadotropin (LH/CG)-binding sites, similar to the LH/CG receptor found in mammals. Although the low-affinity site binds both LH and human CG (hCG), the high-affinity site is specific for hCG. In the current investigation, these two binding sites were independently isolated from X. maltophilia for further characterization. To isolate functional binding sites, we developed a solubilization method using the detergent zwittergent 3,14 and high glycerol concentrations that allowed for the maintenance of ligand-binding integrity. Gel filtration experiments established molecular weights of 170 and 11.5 kDa for the two binding sites, which were supported by data from photoaffinity labeling and ultracentrifugation experiments. Gel filtration data also suggested the presence of a third binding site of 5.4 kDa. The 170-kDa site had a binding affinity of Kd = 12 x 10(-6) and bound both LH and hCG. The small molecular weight site had an affinity of Kd = 9.4 x 10(-8) and was CG specific. Collectively, these data demonstrate the presence of multiple hormone binding sites in X. maltophilia that differ in molecular size, binding affinity, and ligand specificity.

Antibiotic resistance

Widespread resistance problems exist today in a global sense because of the incorporation of antibiotics with a high resistance potential into animal feeds and because of the uncontrolled use of antibiotics with a high resistance potential in the clinical setting. The only proven method of controlling nonoutbreak resistance problems in hospitals is to limit the hospital formulary to antibiotics with little or no resistance potential. The control of multiresistant organisms in outbreaks occurring in hospitals is best contained using appropriate infection control containment measures. Physicians treating infections in the community, with all other factors being equal, should preferentially select antibiotics with a low resistance potential. The titles and headings of much of the resistance literature are misleading. Articles should not contain fluoroquinolone resistant in the title when ciprofloxacin-resistant organisms are described. Many articles concerning penicillin-resistant pneumococci are entitled fluoroquinolone-resistant S. pneumoniae. These articles describe ciprofloxacin-resistant S. pneumoniae and not resistance to other fluoroquinolones. The same error is perpetuated in describing third-generation cephalosporins and carbapenems. Virtually all of the resistance problems associated with third-generation cephalosporins and carbapenems are due to ceftazidime or imipenem. More precise titling in the literature would remind physicians that antibiotic resistance is related to a specific agent and not class phenomena.

Genotypic and phenotypic relationships between clinical and environmental isolates of Stenotrophomonas maltophilia

While the gram-negative bacterium Stenotrophomonas maltophilia is used in biotechnology (e.g., for biological control of plant pathogens and for bioremediation), the number of S. maltophilia diseases in humans has dramatically increased in recent years. A total of 40 S. maltophilia isolates from clinical and environmental sources (plant associated and water) was investigated to determine the intraspecies diversity of the group and to determine whether or not the strains could be grouped based on the source of isolation. The isolates were investigated by phenotypic profiling (enzymatic and metabolic activity and antibiotic resistance patterns) and by molecular methods such as temperature-gradient gel electrophoresis of the 16S rRNA gene fragment, PCR fingerprinting with BOX primers, and pulsed-field gel electrophoresis (PFGE) after digestion with DraI. Results of the various methods revealed high intraspecies diversity. PFGE was the most discriminatory method for typing S. maltophilia when compared to the other molecular methods. The environmental strains of S. maltophilia were highly resistant to antibiotics, and the resistance profile pattern of the strains was not dependent on their source of isolation. Computer-assisted cluster analysis of the phenotypic and genotypic features did not reveal any clustering patterns for either clinical or environmental isolates.

Characterization of the chromosomal aac(6')-Iz gene of Stenotrophomonas maltophilia

The aac(6')-Iz gene of Stenotrophomonas maltophilia BM2690 encoding an aminoglycoside 6'-N-acetyltransferase was characterized. The gene was identified as a coding sequence of 462 bp corresponding to a protein with a calculated mass of 16,506 Da, a value in good agreement with that of ca. 16,000 found by in vitro coupled transcription-translation. Analysis of the deduced amino acid sequence indicated that the protein was a member of the major subfamily of aminoglycoside 6'-N-acetyltransferases. The enzyme conferred resistance to amikacin but not to gentamicin, indicating that it was an AAC(6') of type I. The open reading frame upstream from the aac(6')-Iz gene was homologous to the fprA gene of Myxococcus xanthus (61% identity), which encodes a putative pyridoxine (pyridoxamine) 5'-phosphate oxidase. Pulsed-field gel electrophoresis of total DNA from BM2690 and S. maltophilia ATTC 13637 digested with XbaI, DraI, and SpeI followed by hybridization with rRNA and aac(6')-Iz-specific probes indicated that the gene was located in the chromosome. The aac(6')-Iz gene was detected by DNA-DNA hybridization in all 80 strains of S. maltophilia tested. The MICs of gentamicin against these strains of S. maltophilia were lower than those of amikacin, netilmicin, and tobramycin, indicating that production of AAC(6')-Iz contributes to aminoglycoside resistance in S. maltophilia.

The increase in carbapenem use and emergence of Stenotrophomonas maltophilia as an important nosocomial pathogen

Carbapenems, being the broadest spectrum antibiotics, may allow those organisms intrinsically resistant to these drugs to be involved more frequently in nosocomial infections. Imipenem was introduced to the specialized hospital units in Kuwait in October, 1992 and meropenem in late 1996. The main objective of this study was to observe prospectively whether, under similar laboratory conditions for microbial isolation/identification while these drugs are in use in the hospital, there is any proportional increase over time in the recovery of Stenotrophomonas maltophilia in relation to the number of yearly admissions and drug use. In addition, we also looked for categories of patients infected by S. maltophilia, type of infection and antibiotic susceptibility. There was an increase in the number of S. maltophilia isolates from 1993 to 1997 significantly correlated with the increase in year-wise consumption of carbapenems (p<0.004). No correlation was observed between yearly number of admissions and both the consumption of carbapenems (p>0.51) and isolation of the organism (p>0.59). Most isolates were from cancer, burns and cardiac patients. The commonest types of infection were wound and septicemia. The organisms were susceptible mostly to ciprofloxacin and co-trimoxazole. The study thus indicates that carbapenem use in a hospital environment may result in emergence of nosocomial infections due to multiresistant S. maltophilia in high risk patients with very limited choice of antibiotics for therapy.

Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia

The gram-negative bacterium Stenotrophomonas maltophilia is increasingly recognized as an important cause of nosocomial infection. Infection occurs principally, but not exclusively, in debilitated and immunosuppressed individuals. Management of S. maltophilia-associated infection is problematic because many strains of the bacterium manifest resistance to multiple antibiotics. These difficulties are compounded by methodological problems in in vitro susceptibility testing for which there are, as yet, no formal guidelines. Despite its acknowledged importance as a nosocomial pathogen, little is known of the epidemiology of S. maltophilia, and although it is considered an environmental bacterium, its sources and reservoirs are often not readily apparent. Molecular typing systems may contribute to our knowledge of the epidemiology of S. maltophilia infection, thus allowing the development of strategies to interrupt the transmission of the bacterium in the hospital setting. Even less is known of pathogenic mechanisms and putative virulence factors involved in the natural history of S. maltophilia infection and this, coupled with difficulties in distinguishing colonization from true infection, has fostered the view that the bacterium is essentially nonpathogenic. This article aims to review the current taxonomic status of S. maltophilia, and it discusses the laboratory identification of the bacterium. The epidemiology of the organism is considered with particular reference to nosocomial outbreaks, several of which have been investigated by molecular typing techniques. Risk factors for acquisition of the bacterium are also reviewed, and the ever-expanding spectrum of clinical syndromes associated with S. maltophilia is surveyed. Antimicrobial resistance mechanisms, pitfalls in in vitro susceptibility testing, and therapy of S. maltophilia infections are also discussed.

Multiple antibiotic resistance in Stenotrophomonas maltophilia

A cryptic multidrug resistance (MDR) system in Stenotrophomonas maltophilia, the expression of which is selectable by tetracycline, is described. Tetracycline resistance was the consequence of active efflux of the antibiotic, and it was associated with resistance to quinolones and chloramphenicol, but not to aminoglycosides or beta-lactam antibiotics. MDR is linked to the expression of an outer membrane protein (OMP54) both in a model system and in multidrug-resistant clinical isolates.

Structure of the O20 antigen of Stenotrophomonas (Xanthomonas or Pseudomonas) maltophilia

The O-antigen polymer recovered from the reference strain for Stenotrophomonas (Xanthomonas or Pseudomonas) maltophilia serogroup O20, by mild acid hydrolysis of the lipopolysaccharide, was found to contain D-rhamnose and D-mannose. By means of chemical degradations and NMR studies, the repeating-unit of the polymer was deduced to be a linear tetrasaccharide with the structure shown. -->2)-alpha-D-Manp-(1-->3)-beta-D-Rhap-(1-->2)-alpha-D-Rh ap-(1-->2)-alpha-D- Rhap-(1-->.

Structure of the O6 antigen of Stenotrophomonas (Xanthomonas or Pseudomonas) maltophilia

A polysaccharide containing D-xylose, L-rhamnose, and N-acetyl-D-glucosamine was released on mild acid hydrolysis of the lipopolysaccharide extracted from defatted cell walls of Stenotrophomonas (Xanthomonas or Pseudomonas) maltophilia strain 557, the reference strain for serotype O6. By means of NMR spectroscopy and chemical degradations, the repeating unit of the polymer was identified as a branched trisaccharide with the structure shown. [formula: see text]

The emergence of epidemic, multiple-antibiotic-resistant Stenotrophomonas (Xanthomonas) maltophilia and Burkholderia (Pseudomonas) cepacia

Stenotrophomonas (Xanthomonas) maltophilia has recently emerged as an important nosocomial pathogen in immunocompromised cancer patients and transplant recipients. S. maltophilia has been documented as a cause of bacteraemia, infections of the respiratory and urinary tracts, meningitis, serious wound infections, mastoiditis, epididymitis, conjunctivitis and endocarditis. The reservoir of S. maltophilia and the mechanisms by which it is transmitted, remain largely unknown. Risk analysis has shown that mechanically ventilated intensive care unit patients, receiving antibiotics especially carbapenems, are at increased risk of colonization/infection. Because of the in vitro resistance to many commonly used agents, it is essential that S. maltophilia is isolated and identified correctly. Over the last decade Burkholderia (Pseudomonas) cepacia has become a major threat to the management of patients with cystic fibrosis (CF). The spread of B. cepacia through previously stable CF clinic populations, is an increasing cause for concern. Anxiety has arisen following the observation that some patients with previously mild disease, experience an accelerated and fatal deterioration in pulmonary function with fever, necrotizing pneumonia, and in some cases septicaemia. Early UK surveillance studies suggested a maximum prevalence of 7%, though this has risen in recent reports to approach the 40% described in the US. Mounting evidence of person-to-person transmission has led the Cystic Fibrosis Trust to issue guidelines for the management of colonized patients. In an attempt to monitor and understand the spread of B. cepacia, typing techniques such as ribotyping have been employed. Because of these problems, together with multiple-antibiotic resistance, there is an urgent need to identify the major routes of transmission, colonizing, pathophysiological and immunological factors.