Strep Salivarius

Case presentation of native valve infective endocarditis with Streptococcus salivarius

1. TEMUJIN T. CHAVEZ, M.D.
LCDR MC USN
INFECTIOUS DISEASEAS FELLOW
National Naval Medical Center
Case Conference

2. 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.

3. 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

4. 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

5. Grams stain

6. Gram stain 100x

7. Blood agar plate

8. CT Chest

9. 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

10. Microbiology
Streptococcus salivarius by biochemical
identification
16S rRNA sequence analysis confirmation
PCN susceptibility indeterminate
</= 0.03 mcg/ml
Ceftriaxone MIC </=0.0625 mcg/ml

11. Clinical significance of Streptococcus
salivarius bacteremia
Eur J Clin Microbiol Inf Dis 2004;24:250-5.

12. 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

13. 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

14. 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

15. Highly PCN Susceptible Viridans Group
Streptococcus and S. bovis
Circulation 2005;111:e396-e434

16. Highly PCN Susceptible Viridans Group
Streptococcus and S. bovis
Circulation 2005;111:e396-e434

17. 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

18. 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

19. PCN Susceptible IE
CID 1998;27:1470-4.

20. 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 procedures
Ensure age appropriate cancer screening

21. 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.

22. IE prophylaxis