strep salivarius
DESCRIPTION
Case presentation of native valve infective endocarditis with Streptococcus salivariusTRANSCRIPT
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TEMUJIN T. CHAVEZ, M.D.LCDR MC USN
INFECTIOUS DISEASEAS FELLOW
National Naval Medical Center Case Conference
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Case
71 yo male h/o 2V CAD, AoS, Autoimmune hepatitis admitted for 48 hours after c/o atypical CP.
Inpt eval s/f NSTEMI with PCI revealing non-stentable multivessel disease
Pt with fever at midnight hd1 and evening hd2. Fever w/u initiated and pt discharged hd3.
Pt re-admitted 24 hours after discharge for growth on blood cultures.
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Case
ROS: pt denies f/c. Malaise over past 8 mos. Wt loss during fall 2007.
PMHx: CAD-NSTEMI 1997 with stent to LAD/OM1 with stent
restenosis OM1 Autoimmune hepatitis-6MP stopped June 2007 Prostate CA-5 yrs s/p radical prostatectomy
SurgHx: Prostatectomy Colonoscopy 2005
All: Ticlid Meds: ASA, Zocor, Lisinopril, Atenolol, Lasix, Mobic, Amaryl,
Advair, Singulair, Allegra, Nexium, Oscal, MVI
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Case
Labs WBC=6.1, Hgb=11.2, Plt=97 MCV 108.6 Na=137, K=4.4, Cl=101, CO2=28, Bun=10, Cr=0.6 Ucx=ngtd Blood cultures: 3/31@0053 3/4 bottles at 24 hours,
3/31@2336 2/4 bottles at 24 hrs (aerobic)
Rads Chest Ct-stable pulmonary nodules compared to 5 wks
prior at RUL and left lung fissure Wedge shaped splenic infarct
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Grams stain
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Gram stain 100x
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Blood agar plate
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CT Chest
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Differential of bacteria
Streptococcus Viridans group: S. oralis (mitis), S. anginosus, S. sanguis, S.
mutans, S. milleri, S. salivarius, Granulicatella sp. S. bovis Abiotrophia
Granulicatella Lecuonostoc Enterococcus
E. faecium E. faecalis
Staphylococcus S. aureus CoNS
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Microbiology
Streptococcus salivarius by biochemical identification
16S rRNA sequence analysis confirmationPCN susceptibility indeterminate
</= 0.03 mcg/ml
Ceftriaxone MIC </=0.0625 mcg/ml
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Clinical significance of Streptococcus salivarius bacteremia
Eur J Clin Microbiol Inf Dis 2004;24:250-5.
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Clinical significance of Streptococcus salivarius bacteremia
617 strains of S. viridans isolated from blood 1987-2003 52 S. salivarius isolates recovered. 32 clinically significant. Rates of endocarditis and colon ca similar S. salivarius to S. bovis II 31% of S. salivarius isolates not susceptible to PCN
S. mitis (21%), S. sanguinis (11%), S. anginosus (3%) Conclusion: episodes of bacteremia represent mucosal
disruption/serious underlying disease
Eur J Clin Mirobiol Infec Dis 2005;24:250-5
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Streptococcus viridans and antimicrobial susceptibility
Singel center, retrospective, observational study of 50 viridans group streptococcal isolates recovered from pts with infective endocarditis
28 isolates 1971-1986 & 24 isolates 1994-2002 Biochemical identification with, if needed, 16S rRNA sequencing Streptococcus viridans group
S. mitis, S. anginosus, S. mutans, S. salivarius, S. sanguinis
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Streptococcus viridans and antimicrobial susceptibility
Weakness: small sample size did not predict clinically significant differences Strength: first study to temporally evaluate susceptibility patterns of
endocardial infections Importance: may influence antimicrobial prevention and management of IE
Antimicrob Agent Chemother 2004;48:4463-5
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Highly PCN Susceptible Viridans Group Streptococcus and S. bovis
Circulation 2005;111:e396-e434
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Highly PCN Susceptible Viridans Group Streptococcus and S. bovis
Circulation 2005;111:e396-e434
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PCN Susceptible IE
Randomized, multicenter, phase III trial comparing monotherapy Ceftriaxone 2 grams once daily for 4 wks to Ceftriaxone 2 grams once daily and Gentamycin 3mg/kg once daily for 2 weeks
Exclusion criteria Agents other than CTX susceptible viridans strep
or S. bovis, allergy to CTX/aminoglycoside, NYHA IV, cardiac/extracardiac abscess, CrCl <20ml/min, PV, mod-severe hearing loss, neutropenia
Inclusion criteria 18 yo, <72 hrs of parenteral abx, Duke criteria
CID 1998;27:1470-4
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PCN Susceptible IE
Endpoints Microbiologic cure: negative blood cultures
during therapy, 1-2 wks after therapy, and f/u at 3 month visit
Reinfection: new episode of endocarditis with new pathogen
Clinical cure: resolution of clinical findings of endocarditis with no evidence of active endocarditis
Clinical cure w/ surgery: clinical cure and completion of therapy but requirement of valve replacement or other cardiac surgery
CID 1998;27:1470-4
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PCN Susceptible IE
CID 1998;27:1470-4.
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Plan of Care
Antimicrobial therapy Ceftriaxone 1 gram iv q12 and Gentamycin 3mg/kg iv
q24 for 2 weeks
Repeat TEE 7-10 days after initial negative Class 1, level of evidence B Vegetations may reach detectable size and abscess
cavity/fistula tracts appear
Surveillance blood cultures 1 wk post completion of antimicrobial therapy
IE prophylaxis prior to dental proceduresEnsure age appropriate cancer screening
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References
Correidora JC, et al. Clinical characteristics and significance of streptococcus salivarius bacteremia and Streptococcus bovis bacteremia: a prospective 16 year study. European Journal of Clinical Mirobiology and Infectious Diseases 2004;24:250-5.
Prabhu RM, et al. Antimicrobial susceptibility patterns among viridans group streptococcal isolates from infective endocarditis patients from 1971-1986 and 1996-2002. Antimicrobial Agents and Chemotherapy 2004;48:4463-5.
Sexton DJ, et al. Ceftriaxone once daily for four weeks compared with ceftriaxone plus gentamycin once daily for two weeks for treatment of endocarditis due to penicillin-susceptible streptococci. Clinical Infectious Diseases 1998;27:1470-4.
Baddour LM, et al. Infective endocarditis diagnosis, antimicrobial therapy, and management of complicatons. Circulation
2005;111:e394-e434.
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IE prophylaxis