Comparative efficacy and safety of antibacterial regimens for severe Stenotrophomonas maltophilia infections: A systematic review and network meta-analysis.

OBJECTIVES

To evaluate the clinical efficacy and survival benefits of alternative antimicrobial regimens compared to conventional TMP-SMX in treating multidrug-resistant Stenotrophomonas maltophilia infections.

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.