Stenotrophomonas maltophilia outbreak with a commercial blood gas injector as the culprit and interventions for source and prevention: A possible passage between patient and ECMO water heater device


      • Stenotrophomonas maltophilia is a Gram-negative, nonfermentative aerobic bacterium widely found in humid and aqueous environments.
      • S. maltophilia is a Gram-negative bacterium widely found in humid environments.
      • A commercial needless blood gas injector was responsible for the outbreak. Detection of S. maltophilia in ECMO heater devices raises concerns about safety.
      • Routine surveillance should include ECMO water reservoirs.


      Despite low virulence of Stenotrophomonas maltophilia, it represents one of the leading drug-resistant bacteria. We report a large outbreak of S. maltophilia infection associated with an unexpected source, which turned out to be a commercial needleless blood gas injector.


      Over a period from January 1 to December10, 2021, 113 patients were identified to have S. maltophilia infection as documented by positive cultures from the clinical samples, extracorporeal membrane oxygenation (ECMO) water heater devices and commercial needleless blood gas injectors.


      Sixty-seven isolates (59 clinical, 4 ECMO, 4 blood gas injectors) were sent for molecular analysis. Both arbitrarily primed polymerase chain reaction and pulsed-field gel electrophoresis analyses showed 12 distinct genotypes. Of 67 isolates, 58 were clonally related (86.6%), with 52 indistinguishable strains from 4 blood gas needleless injectors, 46 patients’ samples (78%), and 2 ECMO samples (50%). Two ECMO samples and 1 clinical sample were clonally identical.


      In the event that eradication of infections would not be possible despite taking all environmental disinfection measures including the ECMO devices, unexpected sources, such as a commercial needleless blood gas injector, should not be omitted from the list for surveillance. In addition, obtaining surveillance cultures of ECMO water reservoirs should be placed in the routine clinical practice.

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        • Brooke JS.
        Stenotrophomonas maltophilia: an emerging global opportunistic pathogen.
        Clin Microbiol Rev. 2012; 25: 2-41
        • Duan Z
        • Qin J
        • Liu Y
        • Li C
        • Ying C.
        Molecular epidemiology and risk factors of Stenotrophomonas maltophilia infections in a Chinese teaching hospital.
        BMC Microbiol. 2020; 20: 294
        • Neela V
        • Rankouhi SZ
        • van Belkum A
        • Goering RV
        • Awang R.
        Stenotrophomonas maltophilia in Malaysia: molecular epidemiology and trimethoprim-sulfamethoxazole resistance.
        Int J Infect Dis. 2012; 16: e603-e607
        • Chang YT
        • Lin CY
        • Chen YH
        • Hsueh PR.
        Update on infections caused by Stenotrophomonas maltophilia with particular attention to resistance mechanisms and therapeutic options.
        Front Microbiol. 2015; 6: 893
        • Kuzucu C
        • Durmaz R
        • Otlu B
        • Aktas E
        • Gulcan H
        • Cizmeci Z.
        Species distribution, antifungal susceptibility and clonal relatedness of Candida isolates from patients in neonatal and pediatric intensive care units at a medical center in Turkey.
        New Microbiol. 2008; 31: 401-418
        • Durmaz R
        • Otlu B
        • Koksal F
        • Hosoglu S.
        • Ozturk R
        • Ersoy Y.
        The optimization of a rapid pulsed-field gel electrophoresis protocol for the typing of Acinetobacter baumannii, Escherichia coli and Klebsiella spp.
        Jpn J Infect Dis. 2009; 62: 372-377
        • Forgie S
        • Kirkland T
        • Rennie R
        • Chui L
        • Taylor G
        Ralstonia pickettii bacteremia associated with pediatric extracorporeal membrane oxygenation therapy in a Canadian hospital.
        Infect Control Hosp Epidemiol. 2007; 28: 1016-1018
        • Rhee C
        • Baker MA
        • Tucker R
        • et al.
        Cluster of Burkholderia cepacia complex infections associated with extracorporeal membrane oxygenation water heater devices.
        Clin Infect Dis. 2022; ([Ahead of print])
        • Uzodi AS
        • Schears GJ
        • Neal JR
        • Henry NK.
        Cupriavidus pauculus bacteremia in a child on extracorporeal membrane oxygenation.
        ASAIO J. 2014; 60: 740-741
        • Stovall SH
        • Wisdom C
        • McKamie W
        • Ware W
        • Dedman H
        • Fiser RT
        Nosocomial transmission of Cupriavidus pauculus during extracorporeal membrane oxygenation.
        ASAIO J. 2010; 56: 486-487
        • Forsberg BC
        • Novick WM
        • Cervantes C
        • Lopez J
        • Cardarelli M.
        Potential deleterious interactions between certain chemical compounds and a thermoplastic polyurethane heat exchanger membrane oxygenator.
        J Extra Corpor Technol. 2018; 50: 244-247