Comparative Efficacy and Safety of Antibacterial Regimens for Severe Stenotrophomonas maltophilia Infections: A Systematic Review and Network Meta-Analysis
Abstract
BACKGROUND
Stenotrophomonas maltophilia (SMA) is a multidrug-resistant pathogen with high mortality. Trimethoprim-sulfamethoxazole (TMP-SMX), the conventional preferred therapy, is limited by toxicity and resistance.
METHODS
We searched PubMed, Embase, Cochrane, and Web of Science up to April 2026 for cohorts comparing TMP-SMX, levofloxacin, minocycline, and tigecycline. A frequentist random-effects network meta-analysis was performed. Primary outcomes were overall survival and clinical efficacy (odds ratios [ORs] with 95% CIs). Treatments were ranked by SUCRA.
RESULTS
Fifteen cohorts were included. Levofloxacin significantly improved survival versus TMP-SMX (OR=2.01, 95%CI 1.16-3.47, P=0.012). Tigecycline showed the highest clinical response (OR=4.97, 95%CI 1.69-14.61, P=0.004) but no survival benefit. SUCRA ranked levofloxacin first for mortality reduction (91.3%) and tigecycline first for efficacy (91.3%); minocycline performed consistently across endpoints.
CONCLUSIONS
A "survival paradox" exists in SMA treatment: tigecycline yields superior initial response without improving survival, whereas levofloxacin provides the most significant survival benefit. Levofloxacin should be prioritized for critically ill patients, while high-dose TMP-SMX and tigecycline warrant cautious re-evaluation.
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid.
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