Stenotrophomonas maltophilia: A Rare Cause of Recurrent Necrotizing Pancreatitis

Abstract

Stenotrophomonas maltophilia is an aerobic Gram-negative bacterium that is well known for its capacity to produce biofilms. It has recently been implicated as an emerging nosocomial pathogen in cases of pneumonia, endocarditis, and septic arthritis, particularly in patients that are immunosuppressed or admitted to intensive care units. S. maltophilia is also known for its resistance to multiple conventional pharmacological therapies, including some cephalosporins and carbapenems. We present one of the few cases of S. maltophilia causing necrotizing pancreatitis. Our case involves a 73-year-old male who presented from an outside facility after undergoing a protracted five-week course of severe pancreatitis complicated by subsequent sepsis, acute hypoxic respiratory failure, and pancreatic pseudocyst formation. Due to a decline in clinical status, magnetic resonance imaging of the abdomen was obtained, which noted two enlarging pancreatic pseudocysts and new areas of pancreatic necrosis causing gastric outlet obstruction. Blood cultures were obtained and showed no evidence of bacterial growth, however endoscopic drainage of one of the pancreatic pseudocysts yielded Enterobacter cloacae, Enterococcus faecium, and S. maltophilia. The patient underwent recurrent endoscopic ultrasonography with debridement of necrotic tissue in attempts to relieve the obstruction, along with cystogastrostomy stent placement. The patient was initially treated with broad spectrum antibiotics including vancomycin and meropenem, and then transitioned to a regimen of linezolid and trimethoprim/sulfamethoxazole. Despite aggressive antibiotic therapy and necrotic tissue debridement, the patient did not survive. Treatment of S. maltophilia associated pancreatitis is still highly contested, as this organism is resistant to many antibiotics and even has varying susceptibilities to the preferred treatment modalities—fluoroquinolones and trimethoprim-sulfamethoxazole. Recent cases have noted increasing prevalence of S. maltophilia in bloodstream and hepatobiliary infections, thereby increasing the possibility that it may become a common causative organism of necrotizing pancreatitis in the future. This case illustrates the importance of continued research regarding appropriate antibiotic coverage for necrotizing pancreatitis and possible need for early initiation of targeted antibiotics, as S. maltophilia becomes more prevalent.