Does Xerava (eravacycline) cover Stenotrophomonas maltophilia?

Xerava Coverage of Stenotrophomonas maltophilia

No, Xerava (eravacycline) should not be relied upon as standard therapy for Stenotrophomonas maltophilia infections, though emerging evidence suggests it may have a role when first-line options are unavailable.

Current Guideline Recommendations

The 2024 IDSA Guidance on Treating Antimicrobial Resistant Gram-negative Infections explicitly advises against using eravacycline for S. maltophilia infections due to insufficient clinical studies 1. This represents the most authoritative current position on this question.

First-Line Treatment Remains TMP-SMX

High-dose trimethoprim-sulfamethoxazole (TMP-SMX) at 15-20 mg/kg/day of the trimethoprim component remains the gold standard first-line treatment for documented S. maltophilia infections 2, 3. Alternative options include:

• Tigecycline-based treatment as an appropriate alternative to TMP-SMX 2
• Minocycline as a non-inferior alternative with treatment failure rates of 30% versus 41% for TMP-SMX 2
• Levofloxacin as part of combination therapy 4

Emerging Evidence for Eravacycline

Despite guideline recommendations against its use, recent data suggests potential utility:

In Vitro Activity

• Eravacycline demonstrates an MIC90 of 2 μg/ml against S. maltophilia, with potency up to 4-fold greater than tigecycline 5
• Shows potent activity against multidrug-resistant Gram-negative pathogens including S. maltophilia 5, 6

Clinical Experience

• A 2025 multicenter retrospective study of 41 patients treated with eravacycline for S. maltophilia infections showed a 73.2% clinical cure rate and 68.3% 30-day survival rate 1
• Median treatment duration was 7 days, with only 9.8% experiencing possible adverse effects 1
• Two case reports of S. maltophilia bloodstream infections in immunocompromised patients showed blood culture clearance within 48 hours when eravacycline was used in combination therapy 7

Mechanism and Pharmacology

• Eravacycline is a fully synthetic fluorocycline with broad-spectrum activity against Gram-positive, Gram-negative, and anaerobic organisms 6
• Has a 20-hour half-life with 80% protein binding, and requires no renal dose adjustments 6
• Structurally similar to tigecycline with unique modifications conferring enhanced activity 8

Clinical Decision Algorithm

When S. maltophilia is documented:

1. First choice: High-dose TMP-SMX (15-20 mg/kg/day of trimethoprim component) 2, 3

2. If TMP-SMX contraindicated or resistant:

   • Tigecycline-based therapy 2
   • Minocycline 2
   • Levofloxacin (as part of combination) 4

3. Consider eravacycline only when:

   • Standard options are unavailable, contraindicated, or have failed 1
   • Patient is immunocompromised with limited alternatives 7
   • Used as part of combination therapy rather than monotherapy 7
   • Recognize this is off-guideline use requiring careful monitoring 1

Critical Pitfalls to Avoid

• Do not use eravacycline as first-line therapy given explicit IDSA guidance against it and lack of robust clinical trial data 1
• Distinguish colonization from true infection before initiating any antimicrobial therapy, as S. maltophilia is frequently an opportunistic colonizer during broad-spectrum antibiotic treatment 2, 3
• Remove catheters in catheter-related bloodstream infections caused by S. maltophilia 8, 2
• Interpret in vitro susceptibility cautiously, as results may not correlate with clinical outcomes 2, 3
• Ensure adequate treatment duration of at least 2 weeks for immunocompromised patients 2

Bottom Line

While eravacycline demonstrates promising in vitro activity and limited clinical success against S. maltophilia, current guidelines do not support its routine use 1. It may serve as a salvage option when standard therapies fail or are contraindicated, but more clinical studies are needed to establish its role 1, 7. TMP-SMX remains the definitive first-line agent 2, 3.