Predictive implications of albumin and C-reactive protein for progression to pneumonia and poor prognosis in Stenotrophomonas maltophilia bacteremia following allogeneic hematopoietic stem cell transplantation

Machine learning applications and challenges in graft-versus-host disease: a scoping review

PURPOSE OF REVIEW

This review delves into the potential of artificial intelligence (AI), particularly machine learning (ML), in enhancing graft-versus-host disease (GVHD) risk assessment, diagnosis, and personalized treatment.

RECENT FINDINGS

Recent studies have demonstrated the superiority of ML algorithms over traditional multivariate statistical models in donor selection for allogeneic hematopoietic stem cell transplantation. ML has recently enabled dynamic risk assessment by modeling time-series data, an upgrade from the static, "snapshot" assessment of patients that conventional statistical models and older ML algorithms offer. Regarding diagnosis, a deep learning model, a subset of ML, can accurately identify skin segments affected with chronic GVHD with satisfactory results. ML methods such as Q-learning and deep reinforcement learning have been utilized to develop adaptive treatment strategies (ATS) for the personalized prevention and treatment of acute and chronic GVHD.

SUMMARY

To capitalize on these promising advancements, there is a need for large-scale, multicenter collaborations to develop generalizable ML models. Furthermore, addressing pertinent issues such as the implementation of stringent ethical guidelines is crucial before the widespread introduction of AI into GVHD care.

Risk factors and outcome of Stenotrophomonas maltophilia infection after allogeneic hematopoietic stem cell transplantation: JSTCT, Transplant Complications Working Group

Stenotrophomonas maltophilia (S. maltophilia) is an aerobic nonfermenting Gram-negative bacillus widely distributed in the environment that has inherent multidrug resistance to beta-lactam and carbapenem antibiotics. S. maltophilia infection (SMI) is known as an important fatal complication following allogeneic hematopoietic stem cell transplantation (HSCT), but its clinical characteristics have not been well clarified. A retrospective study to identify the incidence, risk factors, and outcomes of SMI after allogeneic HSCT was performed using the database of the Japanese nationwide registry, including 29,052 patients who received allogeneic HSCT in Japan between January 2007 and December 2016. A total of 665 patients developed SMI (sepsis/septic shock, 432; pneumonia, 171; other, 62). The cumulative incidence of SMI at 100 days after HSCT was 2.2%. Among risk factors identified for SMI (age ≥ 50 years, male, performance status 2-4, cord blood transplantation [CBT], myeloablative conditioning, Hematopoietic Cell Transplant-Comorbidity Index [HCT-CI] score 1-2, HCT-CI score ≥ 3, and active infectious disease at HSCT), CBT was the strongest risk factor (hazard ratio, 2.89; 95%CI, 1.94-4.32; p < 0.001). The survival rate at day 30 after SMI was 45.7%, and SMI before neutrophil engraftment was significantly associated with poor survival (survival rate 30 days after SMI, 40.1% and 53.8% in patients with SMI before and after engraftment, respectively; p = 0.002). SMI is rare after allogeneic HSCT, but its prognosis is extremely poor. CBT was a strong risk factor for SMI, and its development prior to neutrophil engraftment was associated with poor survival.

The influence of the China GLIM standards on the diagnosis of malnutrition in patients with hematopoietic stem cell transplant

Background

The muscle-related indicator is removed from Global Leadership Initiative on Malnutrition (GLIM) criteria implemented in China for many reasons. Patients with hematopoietic stem cell transplants are at nutrition risk and can enter into the second step of GLIM; thus, they are suitable for learning the diagnosing malnutrition significance between primary GLIM and GLIM-China criteria. This article aims to explore the role of muscle mass in the diagnostic criteria of malnutrition and the effects of GLIM-China for diagnosing malnutrition.

Methods

A total of 98 inpatients with hematopoietic stem cell transplants (HSCT) were recruited. Nutrition risk was assessed by using the Nutritional Risk Screening 2002 (NRS-2002). Appendicular skeletal muscle mass (ASMI) and fat-free mass index (FFMI) were determined using the bioelectrical impedance analysis (BIA) method. Malnutrition is defined by GLIM-China, GLIM, and PG-SGA. We use erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess inflammation in GLIM and GLIM-China. The correlation or consistency among ASMI, FFMI, ESR, CRP, GLIM-China, GLIM, and PG-SGA was evaluated, respectively.

Results

One hundred percent instead of the patients had nutritional risk. The magnitude of malnutrition using PG-SGA, GLIM, and GLIM-China was 75.5, 80.6, and 64.3%, respectively. GLIM-China and PG-SGA showed the same performance (p = 0.052 vs. 1.00) and agreement (kappa = 0.404 vs. 0.433, p < 0.0001) with the FFMI. Consistency was noted between ASMI and PG-SGA in the assessment of malnutrition (p = 0.664) with a good agreement (kappa = 0.562, p = 0.084). ASMI and FFMI could determine muscle mass reduction, which could not be determined by BMI, albumin (ALB), and pre-albumin (pre-ALB); 34% of GLIM-China (-) patients were with low ASMI, and 40% with low FFMI; 30.0% of patients with PG-SGA (<4) still have low ASMI, and 38.2% have low FFMI.

Conclusion

If only the PG-SGA scale is used as a diagnostic criterion for evaluating malnutrition, a large proportion of patients with reduced muscle mass will be missed, but more patients with muscle loss will be missed via GLIM-China. Muscle-related indicators will help diagnose malnutrition.

Pre-transplant CRP-albumin ratio as a biomarker in patients receiving haploidentical allogeneic hematopoietic transplantation: Developing a novel DRCI-based nomogram

Background

In allogeneic hematopoietic stem cell transplantation (allo-HSCT), prognostic indicators effectively predict survival. The Disease conditions prior to transplantation dramatically affects the outcome of HSCT. Optimization of the pre-transplant risk assessment is critical for enhancing allo-HSCT decision-making. Inflammation and nutritional status play significant roles in cancer genesis and progression. As a combined inflammatory and nutritional status biomarker, the C-reactive protein/albumin ratio (CAR) can accurately forecast the prognosis in various malignancies. This research sought to examine the predictive value of CAR and develop a novel nomogram by combining biomarkers and evaluating their importance following HSCT.

Methods

Analyses were conducted retroactively on a cohort of 185 consecutive patients who underwent haploidentical hematopoietic stem cell transplantation (haplo-HSCT) at Wuhan Union Medical College Hospital during the period from February 2017 to January 2019. Of these patients, 129 were randomly assigned to the training cohort, and the remaining 56 patients constituted the internal validation cohort. Univariate and multivariate analyses were carried out to examine the predictive significance of clinicopathological factors in the training cohort. Subsequently, the survival nomogram model was developed and compared with the disease risk comorbidity index (DRCI) using the concordance index (C-index), calibration curve, receiver operating characteristics (ROC) curve, and decision curve analysis (DCA).

Results

Patients were separated into low and high CAR groups using a cutoff of 0.087, which independently predicted overall survival (OS). Based on risk factors, CAR, the Disease Risk Index(DRI), and the Hematopoietic Cell Transplantation-specific Comorbidity Index(HCT-CI), the nomogram was developed to predict OS. The C-index and area under the ROC curve confirmed the improved predictive accuracy of the nomogram. The calibration curves revealed that the observed probabilities agreed well with those predicted by the nomogram in training, validation and entire cohort. It was confirmed by DCA that the nomogram offered greater net benefits than DRCI among all cohorts.

Conclusion

CAR is an independent prognostic indicator for haplo-HSCT outcomes. Higher CAR was related to worse clinicopathologic characteristics and poorer prognoses in patients underwent haplo-HSCT. This research provided an accurate nomogram for predicting the OS of patients following haplo-HSCT, illustrating its potential clinical utility.

A Scoring System for Predicting the Prognosis of Late-Onset Severe Pneumonia after Allogeneic Hematopoietic Stem Cell Transplantation

Late-onset severe pneumonia (LOSP) is defined as severe pneumonia developing during the late phase of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Because of the high mortality in patients with LOSP, it is important to identify prognostic factors. In this study, we aimed to develop a risk score system with broad applicability that can help predict the risk of LOSP-associated mortality. We retrospectively analyzed 100 patients with LOSP after allo-HSCT between June 2009 and July 2017. The assessment variables included immune, nutritional, and metabolic parameters at the onset of LOSP. Of these 100 patients, 45 (45%) eventually died, and 55 (55%) were positive for organisms, most commonly viruses. In the multivariate analysis, higher monocyte count (≥0.20 × 10⁹/L versus <0.20 × 10⁹/L; P = .001), higher albumin level (≥30.5 g/L versus <30.5 g/L; P = .044), lower lactic dehydrogenase level (<250 U/L versus ≥250 U/L; P = .008) and lower blood urea nitrogen concentration (<7.2 mmol/L versus ≥7.2 mmol/L; P = .026) at the onset of LOSP were significantly associated with better 60-day survival. A risk score system based on the foregoing results showed that the probability of 60-day survival decreased with increasing risk factors, from 96.3% in the low-risk group to 49.1% in the intermediate-risk group and 12.5% in the high-risk group. Our results indicate that this scoring system using 4 variables can stratify patients with different probabilities of survival after LOSP, which suggests that patients' immune, nutritional, and metabolic status are crucial factors in determining outcome.

An Intelligent Clinical Decision Support System for Predicting Acute Graft-versus-host Disease (aGvHD) following Allogeneic Hematopoietic Stem Cell Transplantation

Background:

Acute graft-versus-host disease (aGvHD) is a complex and often multisystem disease that causes morbidity and mortality in 35% of patients receiving allogeneic hematopoietic stem cell transplantation (AHSCT).

Objective:

This study aimed to implement a Clinical Decision Support System (CDSS) for predicting aGvHD following AHSCT on the transplantation day.

Material and Methods:

In this developmental study, the data of 182 patients with 31 attributes, which referred to Taleghani Hospital Tehran, Iran during 2009–2017, were analyzed by machine learning (ML) algorithms which included XGBClassifier, HistGradientBoostingClassifier, AdaBoostClassifier, and RandomForestClassifier. The criteria measurement used to evaluate these algorithms included accuracy, sensitivity, and specificity. Using the machine learning developed model, a CDSS was implemented. The performance of the CDSS was evaluated by Cohen’s Kappa coefficient.

Results:

Of the 31 included variables, albumin, uric acid, C-reactive protein, donor age, platelet, lactate Dehydrogenase, and Hemoglobin were identified as the most important predictors. The two algorithms XGBClassifier and HistGradientBoostingClassifier with an average accuracy of 90.70%, sensitivity of 92.5%, and specificity of 89.13% were selected as the most appropriate ML models for predicting aGvHD. The agreement between CDSS prediction and patient outcome was 92%.

Conclusion:

ML methods can reliably predict the likelihood of aGvHD at the time of transplantation. These methods can help us to limit the number of risk factors to those that have significant effects on the outcome. However, their performance is heavily dependent on selecting the appropriate methods and algorithms. The next generations of CDSS may use more and more machine learning approaches.

Oral microorganisms and bloodstream infection in allogeneic hematopoietic stem cell transplantation

OBJECTIVES

We aimed to compare oral and pathogenic microorganisms in bloodstream infections (BSIs) in allogeneic hematopoietic stem cell transplantation (allo-HSCT). We also investigated the relationship between BSIs and oral mucositis to identify the ratio of BSIs caused by oral microorganisms and the pathogenic microorganisms involved.

MATERIALS AND METHODS

We collected data on BSIs in 96 patients who underwent allo-HSCT in our institute between April 2009 and December 2019, including BSI pathogens isolated from blood cultures (BBSIs) and microorganisms isolated from washing the oral cavity with sterile distilled water. Oral microorganisms obtained at the onset of BSI (OBSIs) and during allo-HSCT (OSCTs) were defined as isolates collected during the week of blood culturing. Study entry was limited to samples collected up to 1 month after allo-HSCT without BSI. When the BBSI and OBSI were the same, we considered the oral microorganism to have caused the BSI.

RESULTS

The incidence rate of BSIs was 27%, and the predominant microorganism was coagulase-negative Staphylococci. Normal bacterial flora were decreased to 15.8% in OBSIs and 25.5% in OSCTs. The distribution of microorganisms without normal bacterial flora showed significant difference between BBSIs and OSCTs (p < 0.05). Oral mucositis was found in 72.9%, and BSI caused by oral microorganisms occurred in 46.2% of BSIs in allo-HSCT patients.

CONCLUSION

The distribution of microorganisms obtained from blood in patients with BSI during allo-HSCT was found to be similar to that of microorganisms from oral cultures.

CLINICAL RELEVANCE

Oral microorganism monitoring may be able to predict BSI during allo-HSCT.

Stenotrophomonas maltophilia bloodstream infections in adult recipients of umbilical cord blood transplantation

Limited data are available on Stenotrophomonas maltophilia bloodstream infections (SM-BSIs) and the therapeutic efficacy of trimethoprim-sulfamethoxazole (SXT) against SM-BSI in umbilical cord blood transplant (uCBT) recipients. Medical and microbiological records of adult patients who received uCBTs between December 2008 and December 2015 at Toranomon Hospital (Tokyo, Japan) were reviewed. The efficacy and safety of SXT were evaluated only for recipients who were treated with ≥7 days of intravenous SXT for SM-BSI (evaluation cohort). Of 561 uCBT recipients, 34 developed SM-BSI. Diabetes mellitus (P = .005) and age ≥ 60 years (P = .013) were significant independent risk factors for SM-BSI. Moreover, SM-BSI was identified as an independent risk factor for all-cause mortality up to 100 days following uCBT (P = .025). Of the 34 recipients with SM-BSI, 24 were treated with an intravenous SXT-containing regimen (iSXT-CR). Septic shock (P = .0021), pneumonia (P = .011), neutropenia (P = .0015), and systemic steroid administration (P = .018) were identified as significant independent risk factors for 7-day crude mortality. The evaluation cohort included nine recipients. Doses of SXT were 2.4 to 6.9 mg/kg/day of the trimethoprim component. Of the nine recipients, five developed SM-BSI during the pre-engraftment phase. The 30-day crude-mortality rate and clinical cure rate of the cohort were 22% and 67%, respectively. Only one of the nine recipients experienced significant neutrophil toxicity. In this study, the epidemiology of SM-BSI in uCBT recipients was determined and its negative impact on survival was demonstrated. A low- to moderate-dose iSXT-CR appeared to be a tolerable and important therapeutic option for SM-BSI in the uCBT setting, including during the pre-engraftment phase.

Clinical Characteristics of Rapidly Progressive Fatal Hemorrhagic Pneumonia Caused by Stenotrophomonas maltophilia

Objective Hemorrhagic pneumonia due to Stenotrophomonas maltophilia (SM) in severely immunocompromised patients has a very poor prognosis. However, the risk factors for hemorrhagic pneumonia are not clear. Methods This study assessed the predictive factors of hemorrhagic pneumonia caused by SM. The medical records of patients admitted to Osaka City University Hospital with SM bacteremia between January 2008 and December 2017 were retrospectively reviewed. Patients All patients who had positive blood cultures for SM were included in this study. They were categorized into two groups: the SM bacteremia with hemorrhagic pneumonia group and the SM bacteremia without hemorrhagic pneumonia group. The clinical background characteristics and treatments were compared between these groups. Results The 35 patients with SM bacteremia included 4 with hemorrhagic pneumonia and 31 without hemorrhagic pneumonia. Hematologic malignancy (p=0.03) and thrombocytopenia (p=0.04) as well as the prior use of quinolone within 30 days (p=0.04) were more frequent in the SM bacteremia patients with hemorrhagic pneumonia than in those without hemorrhagic pneumonia. The mortality of the SM bacteremia patients with hemorrhagic pneumonia was higher than that of those without hemorrhagic pneumonia group (p=0.02). Conclusion Patients with SM bacteremia who have hematologic malignancy, thrombocytopenia, and a history of using quinolone within the past 30 days should be treated with deliberation.

Prognostic value of C-reactive protein/albumin ratio in neurocritically ill patients

BACKGROUND

The C-reactive protein (CRP)/albumin ratio has been regarded as an outcome predictor in patients with cancer and sepsis. In this study, we evaluated the prognostic value of the CRP/albumin ratio in neurocritically ill patients.

METHODS

We retrospectively reviewed consecutive patients admitted to the neurocritical care unit (NCU) of a university-affiliated hospital, between January 2013 and January 2017. The CRP/albumin ratio was calculated by dividing the CRP level by the albumin concentration that was obtained at NCU admission. Univariable and multivariable logistic regression were used to identify risk factors for 30-day unfavorable outcome (modified Rankin Scale of 4 to 6). The performance of the CRP/albumin ratio was further assessed by receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 701 patients included, 398 (56.8%) had unfavorable outcome at 30 days. The median (interquartile range) value of the CRP/albumin ratio was noticeably higher in the unfavorable outcome group (0.9 [0.2-2.5]) than that in the favorable group (0.3 [0.1-1.2]). After adjustment for established prognostic markers of outcome, the CRP/albumin ratio (OR 1.205; 95% CI: 1.082-1.344) remained significant in predicting 30-day unfavorable outcome, with an area under the ROC curve of 0.644 and a cutoff value of 0.58. Further exploration showed that the prognostic value of the CRP/albumin ratio existed mainly in patients suffering septic shock (OR 1.616; 95% CI: 1.167-2.236), with an area under the ROC curve of 0.672 and a cutoff value of 1.75.

CONCLUSIONS

A high CRP/albumin ratio at NCU admission was an independent predictor of 30-day unfavorable outcome in neurocritically ill patients, especially in those suffering septic shock.

Pulmonary infectious complications after hematopoietic stem cell transplantation: a practical guide to clinicians

PURPOSE OF REVIEW

The current review highlights the most relevant articles on lung infections following hematopoietic stem cell transplantation (HCT) published over the last year. Between 30 and 50% of HCT recipients will develop pulmonary infiltrates. These pulmonary complications may be infectious (caused by virus, bacteria, fungi, or protozoa) or noninfectious (e.g., fluid overload, heart failure, transfusion reactions like transfusion associated lung injury and transfusion-associated circulatory overload, drug reactions, engraftment syndrome, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, cryptogenic organizing pneumonia, and bronchiolitis obliterans syndrome).

RECENT FINDINGS

New data on the yield of bronchoscopy and bronchoalveolar lavage (BAL), the prevalence and clinical manifestations of respiratory viruses and the usefulness of molecular techniques for diagnosis have been published. In addition, guidelines or meta-analyses on the management of neutropenic fever, serological diagnosis of fungal infections and diagnosis and management of Pneumocystis and aspergillosis have been published.

SUMMARY

Respiratory viruses are important pathogens after HCT. PCR in the BAL is becoming the diagnostic modality of choice for a variety of infections. The best approach for the empirical management of pulmonary infiltrates following HCT remains to be defined.

Is hospital-acquired pneumonia different in transplant recipients?

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included. HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high. HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.

Bloodstream infections with vancomycin-resistant enterococci are associated with a decreased survival in patients with hematological diseases

Enterococcus species are commensals of the human gastrointestinal tract with the ability to cause invasive infections. For patients with hematological diseases, enterococcal bloodstream infections (BSI) constitute a serious clinical complication which may even be aggravated if the pathogen is vancomycin-resistant. Therefore, we analyzed the course of BSI due to vancomycin-susceptible enterococci (VSE) in comparison to vancomycin-resistant enterococci (VRE) on patient survival. In this retrospective single-center study, BSI were caused by VRE in 47 patients and by VSE in 43 patients. Baseline patient characteristics were similar in both groups. Concerning infection-related characteristics, an increased CRP value and an increased rate of prior colonization with multidrug-resistant organisms were detected in the VRE BSI group. More enterococcal invasive infections were found in the VSE group. The primary endpoint, overall survival (OS) at 30 days after BSI, was significantly lower in patients with VRE BSI compared to patients with VSE BSI (74.5% vs. 90.7%, p = 0.039). In a multivariate regression analysis, VRE BSI and a Charlson comorbidity index higher than 4 were independent factors associated with 30-day mortality. Moreover, we found that VRE with an additional teicoplanin resistance showed a trend towards an even lower OS.

Fatal Neutropenic Enterocolitis Caused by Stenotrophomonas maltophilia: A Rare and Underrecognized Entity

Although Stenotrophomonas maltophilia causes substantial morbidity and mortality in immunocompromised patients, it has not been described as a causal pathogen of neutropenic enterocolitis (NEC). We describe the first case of histologically-confirmed NEC caused by S. maltophilia accompanied by bacteremia and pneumonia after salvage chemotherapy for acute myeloid leukemia relapse following a second hematopoietic stem cell transplantation. S. maltophilia should be included as a pathogenic organism of NEC in severely immunocompromised patients to prevent a delayed diagnosis, which carries a high risk of inappropriate antimicrobial selection and fatal outcome.

Fluoroquinolones versus trimethoprim-sulfamethoxazole for the treatment of Stenotrophomonas maltophilia infections: a systematic review and meta-analysis

BACKGROUND

Fluoroquinolones are a popular alternative to trimethoprim-sulfamethoxazole for Stenotrophomonas maltophilia infections.

OBJECTIVES

To compare the effects of fluoroquinolones and trimethoprim-sulfamethoxazole on mortality of S. maltophilia infections.

DATA SOURCES

PubMed and EMBASE.

STUDY ELIGIBILITY CRITERIA

Clinical studies reporting mortality outcomes of S. maltophilia infections.

PARTICIPANTS

Patients with clinical infections caused by S. maltophilia.

INTERVENTIONS

Fluoroquinolone monotherapy in comparison with trimethoprim-sulfamethoxazole monotherapy.

METHODS

Systematic review with meta-analysis technique.

RESULTS

Seven retrospective cohort and seven case-control studies were included. Three cohort studies were designed to compare the two drugs, whereas others had other purposes. A total of 663 patients were identified, 332 of which were treated with trimethoprim-sulfamethoxazole (50.1%) and 331 with fluoroquinolones (49.9%). Three cohort studies were designed to compare the effect of the two drugs, whereas the others had other purposes. Levofloxacin was most frequently used among fluoroquinolones (187/331, 56.5%), followed by ciprofloxacin (114/331, 34.4%). The overall mortality rate was 29.6%. Using pooled ORs for the mortality of each study, fluoroquinolone treatment (OR 0.62, 95% CI 0.39-0.99) was associated with survival benefit over trimethoprim-sulfamethoxazole treatment, with low heterogeneity (I² = 18%). Specific fluoroquinolones such as ciprofloxacin (OR 0.44, 95% CI 0.17-1.12) and levofloxacin (OR 0.78, 95% CI 0.48-1.26) did not show a significant difference in comparison with trimethoprim-sulfamethoxazole. In the sub-group analyses of adult and bacteraemic patients, significant differences in mortality were not observed between fluoroquinolones and trimethoprim-sulfamethoxazole.

CONCLUSIONS

Based on a meta-analysis of non-randomized studies, fluoroquinolones demonstrated comparable effects on mortality of S. maltophilia infection to trimethoprim-sulfamethoxazole, supporting the use of fluoroquinolones in clinical S. maltophilia infections. Although the pooled analysis of overall studies favoured fluoroquinolones over trimethoprim-sulfamethoxazole, the studies included were observational, and sub-group analyses of certain fluoroquinolone agents did not show statistical differences with trimethoprim-sulfamethoxazole. Randomized clinical studies are needed to address these issues.

Resurgence of Global Opportunistic Multidrug-resistant Stenotrophomonas maltophilia

CONTEXT

Stenotrophomonas maltophilia is a known nosocomial pathogen which is intrinsically resistant to multiple antibiotics. In India, S. maltophilia infection has only few case reports.

AIM

To determine the incidence of S. maltophilia infection from clinical isolates based on the specimen type, antibiotic susceptibility pattern, and impact on outcome.

SETTINGS AND DESIGN

One-year retrospective study was done at a tertiary liver care center.

METHODS

Patients with S. maltophilia isolation in clinical samples were selected. Serial levels of serum procalcitonin and total leukocyte count were recorded. Environmental surveillance was done from the wards of S. maltophilia isolation as part of routine practice.

STATISTICAL ANALYSIS

Continuous data were compared using Kruskal-Wallis test/Mann-Whitney test. The categorical data were compared by Chi-square/Fisher's exact test, wherever necessary. Besides this, an appropriate analysis like survival was carried out at the time of data analysis.

RESULTS

One hundred isolates were obtained from eighty patients of six wards. The greatest number (44/100, 44%) were from the Liver Coma Intensive Care Unit and the lowest (3/100) from the day care. Isolation from the respiratory samples was 1.32% and bloodstream infection 0.6%. Of 100 isolates, 12 (12%) were resistant to both trimethoprim-sulfamethoxazole and levofloxacin.

CONCLUSION

S. maltophilia was effectively isolated from the hospital environment, with two of hand impression and three of water samples' positive. Patients with respiratory infection had most S. maltophilia isolates. Antibiotic susceptibility revealed more resistance than reported in this region.