Treatment and outcomes of difficult-to-treat Stenotrophomonas maltophilia pneumonia in the intensive care unit: a multinational retrospective cohort study

Difficult-to-treat resistance (DTR) in Stenotrophomonas maltophilia is an emerging concern in ICU-acquired pneumonia, associated with high mortality and limited evidence to guide therapy. This study aimed to evaluate the association between antibiotic regimens and 30-day mortality in DTR S. maltophilia ICU-acquired pneumonia. We conducted a multicenter, international, retrospective study across 31 centers in eight countries, including all adult patients with DTR S. maltophilia ICU-acquired pneumonia treated with ≥24 hours of an in vitro–active antibiotic. The primary outcome was 30-day mortality. Secondary outcomes included clinical cure and a composite of 30-day survival with clinical cure. Each agent was analyzed as a separate exposure using modified Poisson regression with robust variance in a day-3 landmark cohort. Combination therapy and treatment duration were evaluated using overlap weighting. A total of 119 patients were included. Thirty-day mortality was 37.8%. Tigecycline was associated with higher 30-day mortality (aRR 1.95, 95% CI 1.21–3.13). Aztreonam/ceftazidime-avibactam showed a favorable but non-significant trend toward lower mortality (aRR 0.38, 95% CI 0.12–1.15), as did colistin (aRR 0.51, 95% CI 0.22–1.20). No agent other than tigecycline was significantly associated with any outcome, and the active agents had wide, overlapping confidence intervals. Neither combination therapy nor a treatment duration longer than 8 days was associated with any outcome. Tigecycline was associated with excess mortality and should be used with caution. Aztreonam/ceftazidime-avibactam and colistin trended toward lower mortality, whereas the other agents, including cefiderocol, appeared neutral. The study is underpowered to separate the active agents, and these hypothesis-generating findings require prospective confirmation.

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Journal
Critical Care
Published
2026-08-25
DOI
https://doi.org/10.1186/s13054-026-06278-1
Primary Topic
Infections and bacterial resistance
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article
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article

Treatment and outcomes of difficult-to-treat Stenotrophomonas maltophilia pneumonia in the intensive care unit: a multinational retrospective cohort study

Alix Pantel, Cristina Pitart, Laurence Drieux-Rouzet, Romaric Larcher et al.
Critical Care
Infections and bacterial resistance
article

Treatment and outcomes of difficult-to-treat Stenotrophomonas maltophilia pneumonia in the intensive care unit: a multinational retrospective cohort study

Alix Pantel, Cristina Pitart, Laurence Drieux-Rouzet, Romaric Larcher, Laurence Armand-Lefèvre, E De Montmollin, Antoine Studer, Nicolas Bréchot, Stéphane Lo, Quentin Moyon, Grégoire Fourcade, Inès Gragueb-Chatti, Marie-Noelle Didelot, Olivier Mascle, Marion Giry, Marc Le Pape, Ludovic Lemée, Soumaya Skalli, Catia Cillóniz, Edgar Botelho-Moniz, Jean‐Winoc Decousser, Xavier Brousse, Caroline Loïez, Naouale Maataoui, Pauline Guillot, Alexandre Sitbon, João Ferreira‐Coimbra, Juliette Chommeloux, Nacim Benchabane, Florian Blanchard, Matteo Bassetti, Alexandra Doloy, Anahita Rouzé, Antonio Curtoni, Charles‐Édouard Luyt, Anne-Laure Michon, Alicia Silvant, Isabelle Podglajen, Anaïs Curtiaud, Minh-Pierre Lê, Leila S Hojat, Khaldoun Kuteifan, Antoine Piantoni, A. Monsel, Vincent Degos, Julien Charpentier, Anaïs Dartevel, Antonio Vena, Khalil Chaïbi, Kada Klouche, Florent Montini, Amira Jomli, Laura Mezzogori, Maxime Desgrouas, David Mokrani, Lukas Antonitsch, Françoise Jauréguy, Carine Thivilier, Pierre Bay, Yann Dumont, Eugénie Maurin, Jacques Tankovic, María F. Mojica, Marta Hernández-Meneses, Jérôme Guinard, Alain Gravet, Éric Maury, Renaud Guérin, Marine Amiot, Jaime Labarca, José Artur Paiva, Joy Mootien, Jean-Marc Tadié, Alice Jacquens, Antoine Grillon, Bertrand Souweine, Carole Schwebel, Christophe Guitton, Gaëtan Plantefève, Jean-François Timsit, Nicolas Mongardon, Sami Hraiech, Patricio Ross, Vincent Das, François Barbier, Bruno Levy, for the SMR-ICU Study Group, Jean-Michel Constantin, Keyvan Razazi, Fabienne Tamion, Guillaume Thiery, Alexandre Boyer, Giorgia Montrucchio, Adrien Bouglé, Ferhat Meziani, Philippe Montravers, Sophie Nagle, Robert A. Bonomo, Ignacio Martin-Loeches, Antoni Torres
article en

Abstract

Difficult-to-treat resistance (DTR) in Stenotrophomonas maltophilia is an emerging concern in ICU-acquired pneumonia, associated with high mortality and limited evidence to guide therapy. This study aimed to evaluate the association between antibiotic regimens and 30-day mortality in DTR S. maltophilia ICU-acquired pneumonia. We conducted a multicenter, international, retrospective study across 31 centers in eight countries, including all adult patients with DTR S. maltophilia ICU-acquired pneumonia treated with ≥24 hours of an in vitro–active antibiotic. The primary outcome was 30-day mortality. Secondary outcomes included clinical cure and a composite of 30-day survival with clinical cure. Each agent was analyzed as a separate exposure using modified Poisson regression with robust variance in a day-3 landmark cohort. Combination therapy and treatment duration were evaluated using overlap weighting. A total of 119 patients were included. Thirty-day mortality was 37.8%. Tigecycline was associated with higher 30-day mortality (aRR 1.95, 95% CI 1.21–3.13). Aztreonam/ceftazidime-avibactam showed a favorable but non-significant trend toward lower mortality (aRR 0.38, 95% CI 0.12–1.15), as did colistin (aRR 0.51, 95% CI 0.22–1.20). No agent other than tigecycline was significantly associated with any outcome, and the active agents had wide, overlapping confidence intervals. Neither combination therapy nor a treatment duration longer than 8 days was associated with any outcome. Tigecycline was associated with excess mortality and should be used with caution. Aztreonam/ceftazidime-avibactam and colistin trended toward lower mortality, whereas the other agents, including cefiderocol, appeared neutral. The study is underpowered to separate the active agents, and these hypothesis-generating findings require prospective confirmation.

Critical Care
Danube Private University (AT), Inserm (FR), Pontificia Universidad Católica de Chile (CL), Université Paris-Est Créteil (FR), Hospital de São João (PT), Centre Hospitalier Universitaire de Bordeaux (FR), Centre Hospitalier Universitaire de Lille (FR), Sorbonne Université (FR), Azienda Ospedaliera Citta' della Salute e della Scienza di Torino (IT), Hôpital Cochin (FR), Centre Hospitalier Universitaire de Montpellier (FR), Assistance Publique – Hôpitaux de Paris (FR), Centre Hospitalier Régional et Universitaire de Nancy (FR), Hôpital Saint-Antoine (FR), Centre Hospitalier Universitaire de Nîmes (FR), Normandie Université (FR), Hôpital Européen (FR), Administração Regional de Saúde de Lisboa e Vale do Tejo (PT), Hôpital Nord (FR), Pitié-Salpêtrière Hospital (FR), Centre Hospitalier Universitaire de Clermont-Ferrand (FR), Hôpital Avicenne (FR), Hôpitaux Universitaires Henri-Mondor (FR), Hôpital Lapeyronie (FR), Centre hospitalier universitaire d'Orléans (FR), Hôpitaux Universitaires de Strasbourg (FR), Ospedale Policlinico San Martino (IT), St. James's Hospital (IE), Fondation pour l’innovation en Cadiométabolisme et Nutrition (FR), Institut Mondor de Recherche Biomédicale (FR), Consorci Institut D'Investigacions Biomediques August Pi I Sunyer (ES), Groupe de recherche clinique en anesthésie réanimation médecine périopératoire (FR), University of Turin (IT), Case Western Reserve University (US), Université de Rouen Normandie (FR), Imation (United States) (US)
Good health and well-being
Openalex Percentile: Top 12%
Infections and bacterial resistance
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