Clinical Report: Efficacy and Safety Comparison of Antibacterial Treatments for Severe Infections Caused by Stenotrophomonas maltophilia

Overview

This systematic review and network meta-analysis compared the clinical efficacy, overall survival, and reported safety of trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, minocycline, and tigecycline for severe Stenotrophomonas maltophilia infections.

Background

S maltophilia is an opportunistic pathogen associated with severe hospital-acquired pneumonia, bloodstream infections, and catheter-related infections, particularly among critically ill patients. Its intrinsic resistance to numerous antimicrobial agents complicates treatment. TMP-SMX is the conventional therapy, although resistance and dose-dependent adverse events may limit its use. Levofloxacin and minocycline are guideline-supported primary alternatives, while tigecycline is increasingly used as salvage therapy for multidrug-resistant infections.

Data Highlights

• Retrospective cohorts included: 15

• Clinical-efficacy studies: 15

• Overall-survival studies: 9

• Tigecycline clinical response vs TMP-SMX: OR, 4.97; 95% CI, 1.69–14.61

• Levofloxacin survival vs TMP-SMX: OR, 2.01; 95% CI, 1.16–3.47

• Minocycline survival vs TMP-SMX: OR, 1.51; 95% CI, 0.90–2.54

• Highest clinical-efficacy ranking: Tigecycline; SUCRA, 91.3%

• Highest overall-survival ranking: Levofloxacin; SUCRA, 91.3%

Key Findings

• Tigecycline demonstrated a significantly higher clinical response than TMP-SMX and ranked first for clinical efficacy.

• Levofloxacin was associated with significantly higher overall survival than TMP-SMX and ranked first for survival.

• Tigecycline did not demonstrate a statistically significant survival advantage over TMP-SMX despite its superior clinical-response ranking.

• Minocycline showed a nonsignificant trend toward higher survival than TMP-SMX and performed comparatively consistently across outcomes.

• TMP-SMX ranked last for overall survival and was associated with safety concerns including acute kidney injury, hyperkalemia, and treatment discontinuation.

• Safety outcomes were summarized descriptively because adverse-event definitions and reporting varied among studies.

Clinical Implications

The findings indicate a divergence between clinical response and survival: tigecycline ranked highest for clinical efficacy, whereas levofloxacin produced the strongest survival result. Levofloxacin may be an important option for severe infections, but its use should be guided by local susceptibility patterns and antimicrobial-stewardship principles. Because the evidence came entirely from retrospective cohorts with limited direct comparisons among alternative agents, the treatment rankings warrant cautious interpretation.

Conclusion

Levofloxacin was associated with significantly higher overall survival than TMP-SMX, while tigecycline produced the highest clinical-response ranking without a corresponding survival advantage. Minocycline performed consistently across the evaluated outcomes. Prospective head-to-head studies are needed to clarify comparative treatment effects, including outcomes by infection site and the role of combination therapy.

Related Resources & Content

1. Comparative Efficacy and Safety of Antibacterial Regimens for Severe Stenotrophomonas maltophilia Infections: A Systematic Review and Network Meta-Analysis — Gao S, Lu Y, Qiao Q. International Journal of Infectious Diseases. 2026;171:109023. doi:10.1016/j.ijid.2026.109023.

2. Trimethoprim-Sulfamethoxazole Versus Levofloxacin for Stenotrophomonas maltophilia Infections: A Retrospective Comparative Effectiveness Study of Electronic Health Records From 154 US Hospitals — Sarzynski SH, Warner S, Sun JF, et al. Open Forum Infectious Diseases. 2022;9(2):ofab644.

3. Stenotrophomonas maltophilia Infections: A Systematic Review and Meta-Analysis of Comparative Efficacy of Available Treatments, With Critical Assessment of Novel Therapeutic Options — Maraolo AE, Licciardi F, Gentile I, et al. Antibiotics. 2023;12(5):910.

4. Clinical Outcomes of Stenotrophomonas maltophilia Infection Treated With Trimethoprim/Sulfamethoxazole, Minocycline, or Fluoroquinolone Monotherapy — Junco SJ, Bowman MC, Turner RB. International Journal of Antimicrobial Agents. 2021;58(2):106367.