Research on clinical and subclinical characteristics in patients with sepsis caused by Stenotrophomonas maltophilia treated at 103 military hospital and 108 military central hospital (from

Jourrnal of military pharmaco-medicine n09-2019

RESEARCH ON CLINICAL AND SUBCLINICAL
CHARACTERISTICS IN PATIENTS WITH SEPSIS CAUSED BY
STENOTROPHOMONAS MALTOPHILIA TREATED AT
103 MILITARY HOSPITAL AND 108 MILITARY CENTRAL HOSPITAL
(FROM JANUARY 2014 TO OCTOBER 2018)
Nguyen Hoang Thanh1; Hoang Vu Hung1
SUMMARY
Objectives: To describe some clinical and subclinical characteristics in patients with sepsis
caused by S. maltophilia and identify antibiotic resistance status in S. maltophilia strain was
isolated. Subjects and methods: Retrospective combined prospective, descriptive cases in
63 patients with sepsis caused by S. maltophilia treated at 103 Military Hospital and 108 Central
Military Hospital. Results: 61.9% of patients > 60 years old; men: 77.8%; 85.7% pathological
background; 76.2% identified the primary infection source; 99.4% fever in which suddenly of
fever 51.6%, fluctuating of fever 64.5%, hot fever 41.9%. Sepsis caused by S. maltophilia
damaged most organs: 42.9% consciousness disorders; heart rate > 90 cycles/minute: 60.4%;
hypotension: 11.1%; pneumonia: 71.2%; abdominal pain: 18.8%; painful urination: 5.9%;
WBC > 10 G/L: 67.7%; hemoglobin < 120 g/L: 68.4%; platelets < 150 GLl: 19.3%; urea > 7.5 mmol/L:
23.5%; ALT > 80 U/L: 11.8%; 22.7% of patients had total bilirubine > 17 µmol/L; 17.5% of
patients had prothrombine ratio < 70%; 22% of patients had PCT > 10 ng/mL. S. maltophilia
strain isolated were resistant to cefotaxime: 95.7%, ceftriaxone: 95%; imipenem: 100%,
meropenem: 100%; ampicillin resistance: 100%; aminoglycosid antibiotics resistance: 70 - 80%.
Mortality rate was 17/63 patients (27%). Conclusion: Sepsis caused by S. maltophilia was
common in elderly people; the mortality rate was relatively high. S. maltophilia strain isolated
was multi antibiotic resistance.
* Keywords: Sepsis; Stenotrophomonas maltophilia; Clinical and subclinical characteristics.

INTRODUCTION
Sepsis caused by S. maltophilia is rare,
mainly diagnosed in patients with cancer,

lung cystic fibrosis, immunodeficiency.
103 Military Hospital and 108 Military
Central Hospital are equipped with
modern equipment such as Batec blood
culture system, identifier and antimicrobial
Vitek automatic… This has contributed

positively to the diagnosis of rare
pathogens, including S. maltophilia. In
order to contribute to the diagnosis and
timely treatment, selecting appropriate
antibiotics, shortening hospital time,
reducing costs for patients and reduce
mortality rate in patients with sepsis
caused by S. maltophilia, we carried out
this thesis with aims:

1. 103 Military Hospital
Corresponding author: Nguyen Hoang Thanh ()
Date received: 25/09/2019
Date accepted: 19/11/2019

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Jourrnal of military pharmaco-medicine n09-2019
- Survey the number of characteristics
in clinical, subclinical in patients with
sepsis caused by S. maltophilia.
- Determination of antibiotic resistance

of isolated S. maltophilia strains.
SUBJECTS AND METHODS
1. Subjects.
63 patients with sepsis caused by
S. maltophilia: 40 patients were hospitalized
and treated at 103 Military Hospital and
23 patients were hospitalized and treated
at 108 Military Central Hospital from January
2014 to November 2018.
* Criteria for selecting patients:
Patients were diagnosed with sepsis
based on consent of the International
Conference on Sepsis (2001) [6]:
- Having systemic inflammatory response
syndrome: At least 2 of the following 4
criteria (including a compulsory standard
for abnormalities in body temperature or
white blood cell counts).
+ Body temperature > 38ºC or < 36ºC.
+ Heart rate > 90 cycles/minute.
+ Frequency of breathing > 20 cycles/minute
or PaCO2 < 32 mmHg.
+ White blood cell counts > 12,000 or
< 4,000/mm3, or young white blood cell
count > 10%.
- Blood cultures were isolated S. maltophilia
bacteria.
- Patients over 18 years of age.
* Exclusion criteria:
- The patient refused to participate in

the study.
- The patient had a positive blood
culture (+) with at least ≥ 2 pathogens.
256

2. Methods.
Cross-sectional
combined
with
retrospective and prospective study for
enough qualifies cases.
- Retrospective cases of sepsis caused
by S. maltophilia infection hospitalized and
treated between 01 - 2014 and 10 - 2017
(55 patients).
- Prospective cases of sepsis caused
by S. maltophilia infection hospitalized and
treated between 11 - 2017 and 11 - 2018
(08 patients).
Data collection through the store of
medical records, all medical records were
registered under unified form.
* Research content:
- Distribution of patients according to
age, gender, source of infection (hospital
infections and community infections),
pathological background, primary infections
source.
- Shock and mortality rate.
- Clinical symptoms: Characteristics

and properties of fever; skin and mucosa
manifestations; consciousness disorder;
damage to the circulatory system (pulse,
blood pressure...); damage to the respiratory
system (pneumonia, pleural effusion,
respiratory failure...); damage to the
digestive system (digestive disorders,
hepatomegaly, splenomegaly, abdominal
pain, jaundice...); damage to the urinary
system (painful urination, oliguria, anuria...).
- Learn about the clinical indicators:
Number of red blood cells (T/L),
hemoglobine (g/L); leukocyte count (G/L),
percentage of neutrophil; platelets (G/L);
prothrombine rate (%); enzymes AST,


Jourrnal of military pharmaco-medicine n09-2019
ALT (U/L); total bilirubine (µmol/L); blood
urea (mmol/L); blood creatinine (µmol/L);
electrolytes; procalcitonine (ng/mL).

automatically on the system identification
Vitek 2 - BIOMÉRIEUX or performed by
Kirby - Bauer technique.

- Determine antibiotic resistance according
to technical antimicrobial were performed

The results collected were processed

using SPSS software version 23.0.

RESULTS
Table 1: Epidemiological characteristics of patients.
Characteristics

Number of patients (n = 63)

The average age (years): min - max

Rate (%)

65.8 ± 17.7 (21 - 94)

Group over 60 years old

39

61.9

Male

49

77.8

Hospital infection

33

52.4

Yes

54

85.7

Diabetes

22

34.9

Heart failure

10

15.9

Chronic renal failure

10

15.9

Respiratory tract

30

47.6

Gastrointestinal tract

9

14.3

Other

9

14.3

Pathological
background

Primary
infections

The group over 60 years old accounted for the largest proportion (61.9%). The proportion
of male was 3.5 times higher than women.
Table 2: The clinical symptoms.
Symptom

No. patients

Rate %

Symptom

No. patients

Rate (%)

Suddenly

32/62

51.6

Abdominal pains

9/48

18.8

Fluctuating

40/62

64.5

Jaundice

4/48

8.3

Hot fever

26/62

41.9

Hepatomegaly

2/48

4.2

Pale of skin

39/63

61.9

Disorder of
consciousness

27/63

42.9

Circuit > 90 cycles/min

32/53

60.4

Oliguria, anuria

3/51

5.9

Hypotension

7/63

11.1

Painful urination

3/51

5.9

Respiratory failure

12/59

20.3

Septic shock

11/63

17.5

Pneumonia

42/59

71.2

Mortality rate

17/63

27

Pleural effusion

17/59

28.8

Death due to
septic shock

11/11

100

Fever

Suddenly of fever and fluctuating of fever were occured in more than 50% of patients.
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Jourrnal of military pharmaco-medicine n09-2019
Table 3: Subclinical characteristics
No.
patients

Rate (%)

No.
patients

Rate (%)

Hb < 120 g/L

39/57

68.4

CRP > 100 mg/L

21/41

51.2

WBC > 10 G/L

42/62

67.7

PCT > 10 ng/mL

11/50

22

Neutrophil > 70%

51/62

82.3

AST > 80U/L

7/51

13.7

Platelet < 150 G/L

11/57

19.3

ALT > 80 U/L

6/51

11.8

Glucose > 7.1 mmol/L

36/61

59

Bilirubine total > 17 µmol/L

10/44

22.7

Ure > 7.5 mmol/L

12/51

23.5

Albumin < 35 g/L

31/47

66

Creatinine > 120 µmol/L

3/51

5.9

Prothrombine < 70%

7/40

17.5

Subclinical index

Subclinical index

Table 4: Antibiotic resistance of S. maltophilia strain were isolated.
Antibiotics

Total

Sensitive

Intermediate

Resistance

n

%

n

%

n

%

Cefotaxime

23

1

4.3

0

0

22

95.7

Ceftriaxone

20

1

5.0

0

0

19

95.0

Ceftazidime

28

5

17.9

4

14.3

19

67.8

Cefepim

21

3

14.3

4

19.0

14

66.7

Gentamycin

21

3

14.3

3

14.3

15

71.4

Tobramycin

20

4

20.0

2

10.0

14

70.0

Amikacin

30

4

13.3

2

6.7

24

80.0

Minocyclin

9

9

100

0

0

0

0

Doxycillin

11

9

81.8

0

0

2

18.2

Levofloxacin

41

36

87.8

1

2.4

4

9.8

Ciprofloxacin

21

12

57.1

3

14.3

6

28.6

Colistin

20

16

80.0

2

10.0

2

10.0

Imipenem

37

0

0

0

0

37

100

Meropenem

40

0

0

0

0

40

100

Ertapenem

17

1

5.9

1

5.9

15

88.2

Aztreonam

19

0

0

0

0

19

100

Trimethoprim/sulfamethoxazol

44

40

90.9

0

0

4

9.1

Amoxicillin/clavunalic

21

1

4.8

0

0

20

95.2

Ampicillin

4

0

0

0

0

4

100

Ampicillin/sulbactam

9

1

11.1

0

0

8

88.9

Ticarcillin

18

0

0

1

5.6

17

94.4

Ticarcillin/clavunalic

18

6

33.3

0

0

12

66.7

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Jourrnal of military pharmaco-medicine n09-2019

- Bacteria were highly sensitive with
trimethoprim/sulfamethoxazole antibiotics
(90.9%); antibiotics of cycline group:
minocyclin (100%), doxycycllin (81.8%);
colistin (80.0%); levofloxacin (87.8%).
- S. maltophilia most resistant to
cephalosporin antibiotics: Cefotaxime
(95.7%), ceftriaxone (95.0%); carbapenem
antibiotics: imipenem (100%), meropenem
(100%), ertapenem (88.2); aminoglycoside
antibiotics: gentamycin (71.4%), tobramycin
(70.0%), amikacin (80.0%).
DISCUSSION
In recent decades, sepsis caused by
S. maltophilia was a medical problem that
needs attention due to the increasing
incidence of morbidity and mortality.
According to the study by Chung-Hsu Lai
(2004), 84 sepsis patients caused by S.
maltophilia had an average age of 62.3 ±
2.0 years old; male 75%; hospital sepsis
76%; primary infection from respiratory
tract 33% and intravascular catheter 31%;
septic shock 48%; mortality rate of 33%;
antimicrobial results of S. maltophilia
strains were isolated 100% resistant to
imipenem; some antibiotics susceptible
including ciprofloxacin 39/47 (83.0%);
trimethoprim/sulfamethoxazole 64/84
(76.0%); these results were similar to

our study [4].
Xi Chen, Wenjun Wu et al (2017)
studied retrospectively 95 sepsis patients
caused by S. maltophilia in 6 years (2009 2015) at Zhejiang University (China).
Results: The mortality rate was higher than
our study (37.9%); common background
diseases were diabetes and blood cancer
with the same rate (19%), COPD (13.7%)

and chronic kidney failure (6.3%); 93.7%
of patients with fever was higher than
38ºC, the average temperature was 39.2ºC;
proportion of patients with leukocytosis
was 29.5%; CRP concentration > 10 mg/L
accounted for 88.4%; S. maltophilia strains
resistance to gentamycin (87.6%), amikacin
(85.6%), and imipenem (97.8%) [9].
Mustafa Gokhan Gozel (2015) studied
at Turkey's Cumhuriyet Hospital on
35 patients with sepsis caused by
S. maltophilia, the average age of patients
was 61.9 ± 18; proportion of male infected
was 22/35 (62.9%); pathological background
was similar to our research included:
chronic obstructive bronchitis (37.1%),
diabetes (31.4%), cancer (28.6%), heart
failure (17.1%), chronic renal failure (11.4%);
the proportion of patients with anemia
(82.9%); 40% of patients increased the
number of white blood cells; 37.1% of

patients with reduced platelet count;
85.7% of patients increased CRP levels [7].
According to research by Ya-Ting
Chang (2012), 94 patients sepsis caused
by S. maltophilia had common pathological
background included: cancer (41.5%),
diabetes (33.0%), chronic kidney failure
25/94 (26.6%), chronic obstructive bronchopulmonary disease (8.5%); 61.4% of patients
with hospital infections; primary infection
detecting from intravascular catheter
(20.2%), respiratory tract (14.9%),
gastrointestinal tract (7.4%); bacteria
sensitive to the antibiotic TMP/SMX (68.9%),
levofloxacin (89.9%), minocycline (99.4%)
[10]. Research by Hirotaka Ebara (2015):
average age of 44 patients with sepsis
caused by S. maltophilia was 48.9; male
63.6%; 4.5% of patients had damaged
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Jourrnal of military pharmaco-medicine n09-2019
skin and soft tissue; primary infection
from intravascular catheter 36.4%,
gastrointestinal tract 11.4%, respiratory
tract 4.5%, unknown infection source
43.2%; mortality proportion 38.9% [5].
Sumida et al (2015) studied 30 sepsis
patients caused by S. maltophilia with an
average age of 51; the proportion of male

patients were 1.5 times higher than
female; septic shock 20% [8].
Recent domestic studies also reported
S. maltophilia bacteria as an emerging
cause of sepsis. Research by Tran Van Si
et al (2013) at Kiengiang General Hospital
found that sepsis caused by S. maltophilia
accounted for 1.7% [2]. Tran Thi Thanh Nga
studied 8,665 strains of bacteria isolated
from sepsis patients at Cho Ray Hospital
for 5 years showed that S. maltophilia
tend to increase in 2011 and 2012, 5.7%
and 13.7%, respectively compared with
2009 was only 1% [1]. The study by
Le Xuan Truong (2009): 6/79 sepsis
patients (7.6%) caused by S. maltophilia
had average PCT value of 36.2 ng/mL [3].
CONCLUSION
Sepsis caused by S. maltophilia was
common in elderly people (61.9%); 85.7%
of patients had pathological background;
76.2% identified the primary infection
(in which primary infection was common
in respiratory tract 47.6%); fever 99.4%
(in which suddenly fever 51.6%, fluctuating
fever 64.5%, hot fever 41.9%). Sepsis
caused by S. maltophilia damaged most
organs: 42.9% consciousness disorders;
heart rate > 90 cycles/minute 60.4%;
hypotension 11.1%; pneumonia 71.2%;

abdominal pain 18.8%; painful urination
260

5.9%; white blood cells > 10 G/L (67.7%);
Hb < 120 g/L (68.4%); platelets < 150 G/L
(19.3%); ure > 7.5 mmol/L (23.5%);
ALT > 80 U/L (11.8%); 22.7% of patients
had total bilirubine > 17 µmol/L; 17.5% of
patients had prothrombine rate < 70%;
22% patients with PCT > 10 ng/mL. There
were 17.5% of patients manifested septic
shock; 27% mortality.
Strains of S. maltophilia isolated multiple
antibiotic resistance included: Cephalosporin
antibiotic group: cefotaxime 95.7%,
ceftriaxone 95%; carbapenem antibiotic
group: imipenem 100%, meropenem 100%;
100% ampicillin resistance; aminoglycoside
resistance 70 - 80%.

REFERENCES
1. Tran Thi Thanh Nga. Sepsis pathogens
and tendency of resistance to antibiotics for
5 years from 2008 - 2012 at Cho Ray Hospital.
Hochiminh City Medicine. 2014, Vol. 18,
Supplement of number 2, pp.485-490.
2. Tran Van Si, Tran Do Hung, Nguyen
Ngoc Mai. Survey on the situation causing
sepsis at Kien Giang General Hospital.
Journal of Practical in Medicine. 2013, N0. 1,

pp.12-19.
3. Le Xuan Truong. Diagnostic and prognostic
value of serum Procalcitonin in the sepsis.
Hochiminh City Journal of Medicine. 2009, 1 (13),
pp.213-241.
4. Chung-Hsu Lai et al. Clinical characteristics
and prognostic factors of patients with
Stenotrophomonasmaltophilia bacteremia.
J Microbiol Immunol Infect. 2004, 37,
pp.350-358.
5. Hirotaka Ebara et al. Clinical characteristics
of Stenotrophomonas maltophilia bacteremia:


Jourrnal of military pharmaco-medicine n09-2019
A regional report and a review of Japanese
case series. Intern Med. 2015, 56, pp.137-142,

A matched case-control study. PLoS One.
2015, 10 (7), p.0133731.

6. Levy M, Fink M.P, Marshall J.C et al.
"SCCM/ESICM/ACCP/ATS/SIS international
sepsis definitions conferenc. Crit Care Med.
2003.

9. Xi Chen, Wenjun Wu et al. Retrospective
analysis of Stenotrophomonas maltophilia
bacteremia: Clinical features, risk factors and
therapeutic choices. J Clin Exp Med. 2017,

10 (8), pp.12268-12276.

7. Mustafa Gokhan Gozel et al.
Stenotrophomonas maltophilia infections in
adults: Primary bacteremia and pneumonia.
Jundishapur J Microbiol. 2015, August, 8 (8),
e23569.
8. Sumida K et al. Risk factors associated
with Stenotrophomonas maltophilia bacteremia:

10. Ya-Ting Chang, Chun-Yu Lin et al.
Stenotrophomonas maltophilia bloodstream
infection: Comparison between community
onset and hospital-acquired infections. Journal
of Microbiology, Immunology and Infection.
2014 47, pp.28-35.

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