Zhipeng Yang, Bin Zhu, Jianfeng Chen
Iatrogenic bile leak complicated by intra-abdominal infection is a rare but serious complication after laparoscopic cholecystectomy. Stenotrophomonas maltophilia is intrinsically resistant to carbapenems and is an uncommon but clinically relevant pathogen of intra-abdominal infection, particularly in patients with immunosuppression, indwelling drains, and broad-spectrum antibiotic exposure. We report the case of a 55-year-old immunosuppressed man who developed bile leak due to Hem-o-lok clip-associated common bile duct injury after cholecystectomy. The clinical course is described by hospital day (HD) to align the manuscript with the treatment timeline. An initial culture from ascitic fluid indicated the presence of Gram-positive bacilli, whereas subsequent repeated cultures from abdominal drainage fluid yielded S. maltophilia, with no other bacterial species reported and negative anaerobic cultures. The isolate was initially resistant to levofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX). An exploratory disk approximation test showed enlargement of the inhibition zone where the CZA and ATM disks met. This suggested a possible in vitro interaction. Because routine treatment options were limited, CZA plus ATM was administered together with renewed drainage and irrigation and was associated with clinical improvement. Repeat susceptibility testing revealed persistent levofloxacin resistance and susceptibility to TMP-SMX and minocycline, allowing step-down to oral minocycline 100 mg every 12 h after achieving source control. Antibiotics were stopped on HD 85, and the patient was discharged on HD 90 without recurrent fever, drainage, or imaging evidence of a recurrent collection during the final inpatient observation period. This case highlights the importance of repeated cultures, dynamic susceptibility reassessment, and source control in managing bile leak-associated intra-abdominal infection with repeated isolation of S. maltophilia.