Strep Salivarius
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Transcript of Strep Salivarius
TEMUJIN T. CHAVEZ, M.D.LCDR MC USN
INFECTIOUS DISEASEAS FELLOW
National Naval Medical Center Case Conference
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.
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
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
Grams stain
Gram stain 100x
Blood agar plate
CT Chest
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
Microbiology
Streptococcus salivarius by biochemical identification
16S rRNA sequence analysis confirmationPCN susceptibility indeterminate
</= 0.03 mcg/ml
Ceftriaxone MIC </=0.0625 mcg/ml
Clinical significance of Streptococcus salivarius bacteremia
Eur J Clin Microbiol Inf Dis 2004;24:250-5.
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
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
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
Highly PCN Susceptible Viridans Group Streptococcus and S. bovis
Circulation 2005;111:e396-e434
Highly PCN Susceptible Viridans Group Streptococcus and S. bovis
Circulation 2005;111:e396-e434
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
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
PCN Susceptible IE
CID 1998;27:1470-4.
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
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.
IE prophylaxis