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Successfully treated nosocomial Stenotrophomonas maltophilia bacteremia following desensitization to trimethoprim-sulfamethoxazole
J Infect Chemother (2007) 13:122–123 DOI 10.1007/s10156-007-0505-z
© Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2007
NOTE
Mesut Yilmaz · Aykut Ferhat Celik · Ali Mert
Successfully treated nosocomial Stenotrophomonas maltophilia bacteremia following desensitization to trimethoprim-sulfamethoxazole
Received: November 30, 2006 / Accepted: January 24, 2007
Abstract Stenotrophomonas maltophilia has emerged as an important cause of morbidity and mortality in hospitalized patients. Because trimethoprim-sulfamethoxazole (TMPSMX) remains the most effective drug for the treatment of S. maltophilia infections, desensitization should be considered in patients with hypersensitivity to TMP-SMX. Key words Stenotrophomonas maltophilia · Desensitization · Trimethoprim-sulfamethoxazole · Bacteremia Stenotrophomonas maltophilia has emerged as an important cause of morbidity and mortality in hospitalized patients. Despite its low virulence, therapy for infections with this pathogen is challenging because of its intrinsic resistance to most antimicrobial agents. Trimethoprim-sulfamethoxazole (TMP-SMX) is a combination of drugs used extensively in the management of AIDS patients for the treatment of life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia and diarrhea caused by some enteric pathogens and bacterial infections, including S. maltophilia.1–3 However, the use of sulfonamides is often associated with the development of allergic, or more accurately, hypersensitivity reactions, which provoke the substitution of the drug by another that may be less effective. Such reactions occur in 30%–50% of HIV-infected patients who take TMP-SMX.4 Alternatively, attempts are made to desensitize the patients.5–7 A 45-year-old man was investigated for high-grade fever and right upper quadrant pain in November 2005, in the M. Yilmaz (*)1 · A. Mert Infectious Diseases and Clinical Microbiology Department, Cerrahpasa Medical Faculty, University of Istanbul, Turkey A.F. Celik Gastroenterology Unit, Internal Medicine Department, Cerrahpasa Medical Faculty, University of Istanbul, Turkey 1 Present address: Osmanaga Mah. Hasircibasi cad. N0:29/2, 81310 Kadikoy, Istanbul, Turkey Tel. +90-505-553-0350; Fax +90-212-414-3095 e-mail: [email protected]
sixth month of his hospitalization for recurrent cholangitis. Medical history revealed that he had been diagnosed with ulcerative colitis in 1993 and cholangiocarcinoma in 1996. Although he had done well until 2000, he started to have frequent episodes of cholangitis from then on, many of which were treated with various antibiotics, including carbapenems. Initial laboratory investigation included erythrocyte sedimentation rate (88 mm/h), C-reactive protein (CRP; 129 mg/l, normal <5 mg/l), albumin (2.4 g/dl), and total bilirubin (6.3 mg/dl). Complete blood count showed a normal leucocyte count (7700/mm3; 80% neutrophils, 20% lymphocytes) with anemia (hemoglobin, 10.3 g/dl; hematocrit, 30%, mean corpuscular volume [MCV], 76 fL) and a normal platelet count, of 201 000 platelets/mm3. The results of the remaining biochemical tests, urinalysis, and chest X-ray were normal. Four blood cultures obtained revealed nonfermentative Gram-negative bacilli, identified as S. maltophilia based on ID 32 GN (bioMérieux, Marcy l’Etoile, France) and biochemical reactions discussed previously.8 The minimum inhibitory concentrations (MICs) of tested antibiotics for the S. maltophilia isolate were: TMPSMX, 0.032 mg/l; levofloxacin, >32 mg/l; ticarcillin/clavulanic acid, >128 mg/l; ceftazidime, >32 mg/l;, cefoperazone/sulbactam, 24 mg/l;, and amikacin, 1 mg/l, by the E test (AB Biodisk, Solna, Sweden). TMP-SMX (5 mg/kg, TMP component) i.v. was started for the patient; this resulted in pruritus, laryngospasm, and generalized urticaria within 1 h. Treatment was then switched to a combination of cefoperazone/sulbactam and amikacin. As the patient’s fever continued, CRP increased to 300 mg/l, and S. maltophilia continued to grow in blood cultures despite treatment for 10 days, desensitization was considered. Rapid oral desensitization was performed, as shown in Table 1.9 Following desensitization, TMP-SMX i.v. was started at the same dose as that used initially and a treatment course of 2 weeks resulted in defervescence and normalization of CRP levels. A culture of stool from the patient revealed S. maltophilia; therefore, it was hypothesized that the patient’s gastrointestinal tract was colonized with S. maltophilia following
123 Table 1. Oral desensitization schedule Hour
Dose TMP/SMX (mg)
0 1 2 3 4 5
0.004/0.02 0.04/0.2 0.4/2 4/20 40/200 160/180
repeated exposure to carbapenems during hospitalization, causing cholangitis in his predisposed biliary system, and bacteremia. Desensitization was previously shown to be effective in patients with AIDS,1–3 and this is the first report (Medline, 1996–November 2006) that shows it is also successful in a patient with nosocomial S. maltophilia bacteremia with proven hypersensitivity to TMP-SMX. Because TMP-SMX remains the most effective drug for the treatment of S. maltophilia infections, desensitization should be considered in patients with hypersensitivity to TMP-SMX.
References 1. Fischl MA, Dickinson GM, La Voie L. Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS. JAMA 1988;259:1185–9.
2. Masur H. Prevention and treatment of pneumocystis pneumonia. N Engl J Med 1992;327:1853–60. 3. Lai CH, Chi CY, Chen HP, Chen TL, Lai CJ, Fung CP, et al. Clinical characteristics and prognostic factors of patients with Stenotrophomonas maltophilia bacteremia. J Microbiol Immunol Infect 2004; 37:350–8. 4. Carr A, Cooper DA, Penny R. Allergic manifestations of human immunodeficiency virus (HIV) infection. J Clin Immunol 1991;11: 55–64. 5. Soffritti S, Ricci G, Prete A, Rondelli R, Menna G, Pession A. Successful desensitization to trimethoprim-sulfamethoxazole after allogeneic haematopoietic stem cell transplantation: preliminary observations. Med Pediatr Oncol 2003;40:271–2. 6. Yoshizawa S, Yasuoka A, Kikuchi Y, Honda M, Gatanaga H, Tachikawa N, et al. A 5-day course of oral desensitization to trimethoprim/sulfamethoxazole (T/S) in patients with human immunodeficiency virus type-1 infection who were previously intolerant to T/S. Ann Allergy Asthma Immunol 2000;85:241–4. 7. Gompels MM, Simpson N, Snow M, Spickett G, Ong E. Desensitization to co-trimoxazole (trimethoprim-sulphamethoxazole) in HIV-infected patients: is patch testing a useful predictor of reaction? J Infect 1999;38:111–5. 8. Denton M, Kerr KG. Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia. Clin Microbiol Rev 1998;11:57–80. 9. Gluckstein D, Ruskin J. Rapid oral desensitization to trimethoprimsulfamethoxazole (TMP-SMZ): use in prophylaxis for Pneumocystis carinii pneumonia in patients with AIDS who were previously intolerant to TMP-SMZ. Clin Infect Dis 1995;20:849–53.
© Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2007
NOTE
Mesut Yilmaz · Aykut Ferhat Celik · Ali Mert
Successfully treated nosocomial Stenotrophomonas maltophilia bacteremia following desensitization to trimethoprim-sulfamethoxazole
Received: November 30, 2006 / Accepted: January 24, 2007
Abstract Stenotrophomonas maltophilia has emerged as an important cause of morbidity and mortality in hospitalized patients. Because trimethoprim-sulfamethoxazole (TMPSMX) remains the most effective drug for the treatment of S. maltophilia infections, desensitization should be considered in patients with hypersensitivity to TMP-SMX. Key words Stenotrophomonas maltophilia · Desensitization · Trimethoprim-sulfamethoxazole · Bacteremia Stenotrophomonas maltophilia has emerged as an important cause of morbidity and mortality in hospitalized patients. Despite its low virulence, therapy for infections with this pathogen is challenging because of its intrinsic resistance to most antimicrobial agents. Trimethoprim-sulfamethoxazole (TMP-SMX) is a combination of drugs used extensively in the management of AIDS patients for the treatment of life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia and diarrhea caused by some enteric pathogens and bacterial infections, including S. maltophilia.1–3 However, the use of sulfonamides is often associated with the development of allergic, or more accurately, hypersensitivity reactions, which provoke the substitution of the drug by another that may be less effective. Such reactions occur in 30%–50% of HIV-infected patients who take TMP-SMX.4 Alternatively, attempts are made to desensitize the patients.5–7 A 45-year-old man was investigated for high-grade fever and right upper quadrant pain in November 2005, in the M. Yilmaz (*)1 · A. Mert Infectious Diseases and Clinical Microbiology Department, Cerrahpasa Medical Faculty, University of Istanbul, Turkey A.F. Celik Gastroenterology Unit, Internal Medicine Department, Cerrahpasa Medical Faculty, University of Istanbul, Turkey 1 Present address: Osmanaga Mah. Hasircibasi cad. N0:29/2, 81310 Kadikoy, Istanbul, Turkey Tel. +90-505-553-0350; Fax +90-212-414-3095 e-mail: [email protected]
sixth month of his hospitalization for recurrent cholangitis. Medical history revealed that he had been diagnosed with ulcerative colitis in 1993 and cholangiocarcinoma in 1996. Although he had done well until 2000, he started to have frequent episodes of cholangitis from then on, many of which were treated with various antibiotics, including carbapenems. Initial laboratory investigation included erythrocyte sedimentation rate (88 mm/h), C-reactive protein (CRP; 129 mg/l, normal <5 mg/l), albumin (2.4 g/dl), and total bilirubin (6.3 mg/dl). Complete blood count showed a normal leucocyte count (7700/mm3; 80% neutrophils, 20% lymphocytes) with anemia (hemoglobin, 10.3 g/dl; hematocrit, 30%, mean corpuscular volume [MCV], 76 fL) and a normal platelet count, of 201 000 platelets/mm3. The results of the remaining biochemical tests, urinalysis, and chest X-ray were normal. Four blood cultures obtained revealed nonfermentative Gram-negative bacilli, identified as S. maltophilia based on ID 32 GN (bioMérieux, Marcy l’Etoile, France) and biochemical reactions discussed previously.8 The minimum inhibitory concentrations (MICs) of tested antibiotics for the S. maltophilia isolate were: TMPSMX, 0.032 mg/l; levofloxacin, >32 mg/l; ticarcillin/clavulanic acid, >128 mg/l; ceftazidime, >32 mg/l;, cefoperazone/sulbactam, 24 mg/l;, and amikacin, 1 mg/l, by the E test (AB Biodisk, Solna, Sweden). TMP-SMX (5 mg/kg, TMP component) i.v. was started for the patient; this resulted in pruritus, laryngospasm, and generalized urticaria within 1 h. Treatment was then switched to a combination of cefoperazone/sulbactam and amikacin. As the patient’s fever continued, CRP increased to 300 mg/l, and S. maltophilia continued to grow in blood cultures despite treatment for 10 days, desensitization was considered. Rapid oral desensitization was performed, as shown in Table 1.9 Following desensitization, TMP-SMX i.v. was started at the same dose as that used initially and a treatment course of 2 weeks resulted in defervescence and normalization of CRP levels. A culture of stool from the patient revealed S. maltophilia; therefore, it was hypothesized that the patient’s gastrointestinal tract was colonized with S. maltophilia following
123 Table 1. Oral desensitization schedule Hour
Dose TMP/SMX (mg)
0 1 2 3 4 5
0.004/0.02 0.04/0.2 0.4/2 4/20 40/200 160/180
repeated exposure to carbapenems during hospitalization, causing cholangitis in his predisposed biliary system, and bacteremia. Desensitization was previously shown to be effective in patients with AIDS,1–3 and this is the first report (Medline, 1996–November 2006) that shows it is also successful in a patient with nosocomial S. maltophilia bacteremia with proven hypersensitivity to TMP-SMX. Because TMP-SMX remains the most effective drug for the treatment of S. maltophilia infections, desensitization should be considered in patients with hypersensitivity to TMP-SMX.
References 1. Fischl MA, Dickinson GM, La Voie L. Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS. JAMA 1988;259:1185–9.
2. Masur H. Prevention and treatment of pneumocystis pneumonia. N Engl J Med 1992;327:1853–60. 3. Lai CH, Chi CY, Chen HP, Chen TL, Lai CJ, Fung CP, et al. Clinical characteristics and prognostic factors of patients with Stenotrophomonas maltophilia bacteremia. J Microbiol Immunol Infect 2004; 37:350–8. 4. Carr A, Cooper DA, Penny R. Allergic manifestations of human immunodeficiency virus (HIV) infection. J Clin Immunol 1991;11: 55–64. 5. Soffritti S, Ricci G, Prete A, Rondelli R, Menna G, Pession A. Successful desensitization to trimethoprim-sulfamethoxazole after allogeneic haematopoietic stem cell transplantation: preliminary observations. Med Pediatr Oncol 2003;40:271–2. 6. Yoshizawa S, Yasuoka A, Kikuchi Y, Honda M, Gatanaga H, Tachikawa N, et al. A 5-day course of oral desensitization to trimethoprim/sulfamethoxazole (T/S) in patients with human immunodeficiency virus type-1 infection who were previously intolerant to T/S. Ann Allergy Asthma Immunol 2000;85:241–4. 7. Gompels MM, Simpson N, Snow M, Spickett G, Ong E. Desensitization to co-trimoxazole (trimethoprim-sulphamethoxazole) in HIV-infected patients: is patch testing a useful predictor of reaction? J Infect 1999;38:111–5. 8. Denton M, Kerr KG. Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia. Clin Microbiol Rev 1998;11:57–80. 9. Gluckstein D, Ruskin J. Rapid oral desensitization to trimethoprimsulfamethoxazole (TMP-SMZ): use in prophylaxis for Pneumocystis carinii pneumonia in patients with AIDS who were previously intolerant to TMP-SMZ. Clin Infect Dis 1995;20:849–53.