Viridans Group Research Articles

S3246 Streptococcus Anginosus Causing Simultaneous Infections in an Elderly Male: Empyema and Infrahepatic Abscess: Case Report and Literature Review

Introduction: Streptococcus Anginosus is a gram-positive bacterium of the Streptococcus Viridians group. Usually presents as normal flora in the oral cavity and the gastrointestinal tract, S. Anginosus can cause pyogenic infections in multiple organs in the body especially in the immunocompromised host. We present a case of S. Anginosus multiple sites infection in an immunocompetent host that was successfully treated. Case Description/Methods: A 75-year-old male with history of diabetes, coronary artery disease, and heart failure with reduced ejection fraction presented to ER with worsening lower abdominal pain associated with poor appetite and decreased oral intake over 3 weeks. He had cholecystectomy about a year prior to presentation. He was clinically stable on examination with mild right upper quadrant tenderness without rebound. CT abdomen with intravenous contrast showed 10*7 cm low-density fluid collection with mild rim enhancement inferior to the right hepatic lobe. He underwent CT-guided drainage of the infrahepatic collection with removal of 50 cc of purulent material and placement of an intraabdominal drain. Also, a loculated right pleural effusion was noted on CT, and 350 cc of purulent pleural fluid was drained, with analysis compatible with empyema. Both fluid cultures grew S. anginosus. Empirical antibiotics were changed to ceftriaxone, but patient had recurrence of right pleural effusion and required repeat thoracentesis. He gradually improved and completed 6 weeks of Ceftriaxone. Discussion: S. anginosus is a normal flora that can cause infection in any organ. Most of the patients reported to have S. anginosus infection were immunosuppressed by cancer, long term steroid use, diabetes or splenectomy. It is less common for this organism to cause concurrent multiple organs infections. Published cases of simultaneous S. anginosus infection of multiple organs were limited and usually ended in poor prognosis like death or turned out to be the same infection with an anatomic connection between the organs. Our patient had the infrahepatic collection diagnosed first before the right sided pleural effusion enlarged. When the infrahepatic collection was drained, the pleural effusion size did not go down, suggesting lack of connection between both collections. S. anginosus is commonly sensitive to antibiotics. Thus, it is commonly treated with Ceftriaxone. Penicillin-intermediate or resistant S. anginosus is rare comprising < 2% of infections and does not usually lead to treatment failure.

Weighing the odds of bloodstream infection. What is the perfect model to predict this risk?

Bloodstream infection (BSI) is a leading cause of morbidity and mortality worldwide [1]. Timely diagnosis of BSI is essential to improve clinical and antimicrobial management [2]. The consequences of missing a BSI diagnosis are grave given the high risk of complications. On the other hand, obtaining unnecessary blood cultures increases the cost of healthcare. Occasional growth of skin contaminants in blood cultures and the physiologic phenomenon of transient bacteraemia caused by viridans group streptococci may often complicate clinical management.

71-Year-Old Man With a New Heart Murmur

71-Year-Old Man With a New Heart Murmur

Genetic variability of the helix 54 of the 23S rDNA and its use as a molecular target for identification of species within the viridans group streptococci (VGS)

The aim of the present study is to establish a method, based on sequence analysis of the helix 54 of 23S rRNA gene, to identify clinical relevant strains belonging to viridans group streptococci (VGS). A set of 25 randomly selected clinical isolates of alpha-hemolytic streptococci from upper respiratory tract were characterized by the routine phenotypic methods (API 20 Strep test). Molecular characterization was assessed by genotypic analysis of the nucleotide sequence of the helix 54 of 23S rRNA and Intergenic spacer region 16S23S. Partial sequencing of the gdh gene was used on 10 strains of mitis group. Sequence variations of the helix 54 allowed the identification of strains to group level and even to species level for certain strains within sanguinis and anginosus groups. Infact, species identification was ambiguous for some strains belonged to the salivarius group (of VGS16 to VGS20) and the mitis group (of VGS1 to VGS14). These results are almost similar to those obtained by sequencing the 16S23S intergenic region. Thus, we use the gdh gene sequencing for the identification of strains, not recognized, within the mitis group. The results generated herein indicate that no single methodology can be used to provide an accurate identification to the species level of all VGS, although nucleotide sequence analysis of the helix 54 of 23S rRNA gene proved to be a reliable method for the identification of VGS to the group level and even to the species level within sanguinis and anginosus groups.

1 Viridans group streptococcal bacteraemia: species specific infection association, a 5 year retrospective cohort analysis

1 Viridans group streptococcal bacteraemia: species specific infection association, a 5 year retrospective cohort analysis

Viridans streptococcal immunopositivity associates with calcified coronary plaque area and coronary stenosis severity. The Tampere Sudden Death Study (TSDS)

Background and Aims : Development of atherosclerosis shares features of chronic inflammation. Most chronic infections are considered to be due to biofilms. We have shown that coronary atheromas and thrombosis aspirates harbor DNA from several oral bacteria among which DNA from viridans group streptococci was the most common. In the oral cavity viridans streptococci act as early colonizers in the formation of dental biofilm which calcifies into dental plaque. Here we studied whether viridans streptococcal immunopositivity correlates with coronary calcification and stenosis percentage.Methods: The surface areas of atherosclerosis lesion types (fatty, fibrous, calcified, complicated) and stenosis percentage were measured in the left anterior descending (LAD) coronary artery of 121 victims of sudden out-of-hospital death in the Tampere Sudden Death Study (TSDS). Coronary sections were stained immunohistochemically with a pool of antibodies raised against 3 most common viridans streptococcal strains. The strength of the immunopositivity was scored into no positivity (-), slight (+), moderate (++) or severe (+++).Conclusions: Viridans streptococcal immunopositivity of coronary atheromas was linked with coronary atheroma calcification and stenosis but not with other atherosclerosis lesion types. This suggests a new mechanism involved in the calcification of coronary atheroma. Background and Aims : Development of atherosclerosis shares features of chronic inflammation. Most chronic infections are considered to be due to biofilms. We have shown that coronary atheromas and thrombosis aspirates harbor DNA from several oral bacteria among which DNA from viridans group streptococci was the most common. In the oral cavity viridans streptococci act as early colonizers in the formation of dental biofilm which calcifies into dental plaque. Here we studied whether viridans streptococcal immunopositivity correlates with coronary calcification and stenosis percentage. Methods: The surface areas of atherosclerosis lesion types (fatty, fibrous, calcified, complicated) and stenosis percentage were measured in the left anterior descending (LAD) coronary artery of 121 victims of sudden out-of-hospital death in the Tampere Sudden Death Study (TSDS). Coronary sections were stained immunohistochemically with a pool of antibodies raised against 3 most common viridans streptococcal strains. The strength of the immunopositivity was scored into no positivity (-), slight (+), moderate (++) or severe (+++). Conclusions: Viridans streptococcal immunopositivity of coronary atheromas was linked with coronary atheroma calcification and stenosis but not with other atherosclerosis lesion types. This suggests a new mechanism involved in the calcification of coronary atheroma.

Gram-Positive Bacterial Infections and Antibiotics Resistance in Jordan: Current Status and Future Perspective

Background: Antibiotic resistance is expanding worldwide at alarming rates. Middle East countries including Jordan have high prevalence of antibiotic resistance.&#x0D; Aims: The main aims of this review are to summarize the situation with Gram-positive bacterial infections and antibiotic resistance in Jordan, identify areas where further investigation is required, and suggest strategies to combat antibiotic resistance.&#x0D; Methods: A systematic literature search was conducted by two independent researchers using general and specific combinations of MeSH search terms using Embase, PubMed, Web of Science, and Google Scholar databases.&#x0D; Results: Staphylococci and Streptococci were commonly isolated from environmental, animal, and human samples, while Staphylococci, Enterococci, and Listeria were commonly isolated from food. Staphylococci, Streptococci, and Enterococci human colonization were documented at variable but high rates. Methicillin-resistant S. aureus (MRSA) and methicillin-resistance coagulase-negative Staphylococci (MR-CoNS) infections were common with high rates of antibiotic resistance. S. pneumoniae showed increased resistance rates to most antimicrobials. Enterococci and C. difficile resistance rates were moderate, while group B Streptococci (GBS), viridans group streptococci (VGS), C. perfringens and L. monocytogenes antibiotic susceptibility patterns were not reported. All MRSA and vancomycin-resistant Enterococci (VRE) isolates were mec-A positive, while resistance genes among CoNS, S. pneumoniae, S. pyogenes, S. agalactia, C. perfringens, and L. monocytogenes were not investigated.&#x0D; Conclusions: Gram-positive bacterial infections and antibiotic resistance rates were high in Jordan. Molecular epidemiology studies, a nationwide surveillance program, and action plans are urgently required to combat antibiotic resistance.

Demographic Characteristics, Predisposing Factors, Clinical Presentations, Echocardiographic Findings, Complications, and Outcomes of Patients with Viridans Streptococcal Endocarditis

Background: Several microorganisms are associated with infective endocarditis (IE), but the most common IE causes are staphylococci and streptococci. Among streptococci, the viridans group streptococci are responsible for a considerable percentage of all IE cases. Methods: Since 2006, the Iranian Registry of Infective Endocarditis has recorded information regarding all adult patients with a definite or possible IE diagnosis according to the modified Duke criteria. Patients with viridans streptococcal endocarditis were detected through three blood culture sets. The patients' demographic characteristics, predisposing factors, clinical presentations, and echocardiographic findings were recorded. Results: Of 731 patients diagnosed with endocarditis, viridans streptococci were found in 46 (6.3%) patients, consisting of 28 (60.9%) men and 18 (39.1%) women at a mean age of 42.56 ± 15.46 years, who were subsequently included in the study. Among the 46 patients with viridans streptococcal endocarditis, 26 had a subacute course, whereas 20 had an acute course. Vegetation was detected in 35 patients. All the patients were treated with the standard antibiotic regimen for viridans streptococcal endocarditis, and cardiac surgery was performed on 16 patients. Conclusions: Clinicians should pay sufficient heed to the following points in all cases of viridans streptococcal endocarditis: firstly, an appropriate antibiotic regimen must be based on a precise minimal inhibitory concentration determination for the usual antibiotics. Secondly, since prolonged antibiotic therapy is crucial to the eradication of microorganisms within vegetation, all patients with viridans streptococcal endocarditis must receive an adequate therapy course.

Effect of Antibacterial Prophylaxis on Febrile Neutropenic Episodes and Bacterial Bloodstream Infections in Dutch Pediatric Patients with Acute Myeloid Leukemia: A Two-Center Retrospective Study.

Simple SummaryThe intensive chemotherapy that children with acute myeloid leukemia (AML) receive puts them at high risk of infections. Bloodstream infections (BSI) caused by bacteria are common and known for their associated complications but may be prevented by the use of antibacterial agents. Literature on this matter is scarce. We evaluated the effect of different antibacterial prophylaxis regimens on the occurrence of fever and bacterial BSIs in 82 Dutch children with AML. A combination of prophylactic teicoplanin and ciprofloxacin had the best outcomes, resulting in significantly fewer episodes of fever and bacterial BSIs. The combination of teicoplanin and ciprofloxacin was previously suggested by others, but not yet studied. Currently, a randomized trial is ongoing to address and validate the efficacy of teicoplanin prophylaxis in pediatric AML.Bloodstream infections (BSIs), especially those caused by Gram-negative rods (GNR) and viridans group streptococci (VGS), are common and potentially life-threatening complications of pediatric acute myeloid leukemia (AML) treatment. Limited literature is available on prophylactic regimens. We retrospectively evaluated the effect of different antibacterial prophylaxis regimens on the incidence of febrile neutropenic (FN) episodes and bacterial BSIs. Medical records of children (0–18 years) diagnosed with de novo AML and treated at two Dutch centers from May 1998 to March 2021 were studied. Data were analyzed per chemotherapy course and consecutive neutropenic period. A total of 82 patients had 316 evaluable courses: 92 were given with single-agent ciprofloxacin, 138 with penicillin plus ciprofloxacin, and 51 with teicoplanin plus ciprofloxacin. The remaining 35 courses with various other prophylaxis regimens were not statistically compared. During courses with teicoplanin plus ciprofloxacin, significantly fewer FN episodes (43 vs. 90% and 75%; p < 0.0001) and bacterial BSIs (4 vs. 63% and 33%; p < 0.0001) occurred than with single-agent ciprofloxacin and penicillin plus ciprofloxacin, respectively. GNR and VGS BSIs did not occur with teicoplanin plus ciprofloxacin and no bacterial BSI-related pediatric intensive care unit (PICU) admissions were required, whereas, with single-agent ciprofloxacin and penicillin plus ciprofloxacin, GNR BSIs occurred in 8 and 1% (p = 0.004), VGS BSIs in 24 and 14% (p = 0.0005), and BSI-related PICU admissions were required in 8 and 2% of the courses (p = 0.029), respectively. Teicoplanin plus ciprofloxacin as antibacterial prophylaxis is associated with a lower incidence of FN episodes and bacterial BSIs. This may be a good prophylactic regimen for pediatric AML patients during treatment.

Systematic Immune-Inflammation Index Predicts Embolic Events in Infective Endocarditis.

Infective endocarditis (IE) is a life-threatening disease with embolisms occurring in 20%-50% of cases. We aimed to evaluate the value of the systemic immune-inflammation index (SII) in predicting embolic events (EEs) in patients with infective endocarditis.A total of 186 patients diagnosed with definite IE, who admitted to the Union Hospital affiliated to Tongji Medical College, Huazhong University of Science and Technology, were retrospectively identified from November 2011 to March 2019.The median (interquartile) age of the patients was 46 (32-57) years. Viridans group streptococci were the most common microorganism identified from blood culture (24.7%). The most frequent complication was heart failure (64.2%), followed by EEs (30.2%). Patients complicated with EEs presented a significantly higher SII than those without EEs (1605.38 versus 1039.61, P = 0.001). SII had an area under the curve (AUC) value for EEs of 0.661 (95% CI: 0.575-0.747, P = 0.001), which predicted the presence of EEs with a sensitivity of 42.6% and specificity of 86.3%. Multivariate logistic regression analysis revealed that SII (OR = 6.925; 95% CI: 1.035-46.318, P = 0.046) was an independent predictor of EEs in IE patients.We demonstrated that a high level of SII is associated with a higher likelihood of EEs. The SII may be a promising predictor for EEs in patients with IE.

Clinical characteristics and outcome of infective endocarditis due to Abiotrophia and Granulicatella compared to Viridans group streptococci

To describe the clinical characteristics and outcome of Abiotrophia and Granulicatella infective endocarditis and compare them with Viridans group streptococci infective endocarditis. All patients in the International Collaboration on Endocarditis (ICE) - prospective cohort study (PCS) and the ICE-PLUS cohort were included (n = 8112). Data from patients with definitive or possible IE due to Abiotrophia species, Granulicatella species and Viridans group streptococci was analyzed. A propensity score (PS) analysis comparing the ABI/GRA-IE and VGS-IE groups according to a 1:2 ratio was performed. Forty-eight (0.64%) cases of ABI/GRA-IE and 1,292 (17.2%) VGS-IE were included in the analysis. The median age of patients with ABI/GRA-IE was lower than VGS-IE (48.1 years vs. 57.9 years; p = 0.001). Clinical features and the rate of in-hospital surgery was similar between ABI/GRA-IE and VGS-IE (52.1% vs. 45.4%; p = 0.366). Unadjusted in-hospital death was lower in ABI/GRA-IE than VGS-IE (2.1% vs. 8.8%; p = 0.003), and cumulative six-month mortality was lower in ABI/GRA-IE than VGS-IE (2.1% vs. 11.9%; p<0.001). After PS analysis, in-hospital mortality was similar in both groups, but six-month mortality was lower in the ABI/GRA IE group (2.1% vs. 10.4%; p = 0.029). Patients with ABI/GRA-IE were younger, had similar clinical features and rates of surgery and better prognosis than VGS-IE.

Epidemiology of ascites fluid infections in patients with cirrhosis in Queensland, Australia from 2008 to 2017: A population-based study.

Spontaneous bacterial peritonitis (SBP), a common infection in patients with cirrhosis and ascites, is associated with high morbidity and mortality. The aim of this study was to investigate changes in the epidemiology of ascites fluid infections over time in an Australian population, including patient demographics, trends in mortality, length of hospital stay and the nature and antibiotic resistance profile of causative organisms.An observational descriptive population-based epidemiological study of patients with cirrhosis admitted to public hospitals in Queensland during 2008–2017 was performed, linking demographic/clinical and microbiology data.Among 103,165 hospital admissions of patients with cirrhosis, ascites was present in 16,550 and in 60% (9977) a sample of ascitic fluid was tested. SBP was diagnosed in 770 admissions (neutrophil count >250/ml) and bacterascites in 552 (neutrophil count <250/ml with positive culture). The number of admissions with an ascites fluid infection increased by 76% from 2008 to 2017, paralleling an 84% increase in cirrhosis admissions over the same timeframe. Patients with SBP had a longer hospital stay (median 15.7 vs 8.3 days for patients without SBP, P < .001) and higher in-hospital mortality, although this decreased from 39.5% in 2008 to 2010 to 24.8% in 2015 to 2017 (P < .001). Common Gram-positive isolates included coagulase negative staphylococci (37.9%), viridans group streptococci (12.1%), and Staphylococcus aureus (7.2%). Common Gram-negative isolates included Escherichia coli (13.0%), Klebsiella pneumoniae (3.1%) and Enterobacter cloacae (2.6%). The prevalence of resistance to any tested antibiotic was <10%.SBP remains associated with high in-hospital mortality and long hospital stay. Typical skin and bowel pathogens were common, therefore, empirical antibiotic therapy should target these pathogens. This study provides valuable evidence informing infection management strategies in this vulnerable patient population.

Antibiotic susceptibility patterns of viridans group streptococci isolates in the United States from 2010 to 2020.

BackgroundViridans group streptococci (VGS) are typically part of the commensal flora but can also cause severe invasive diseases such as infective endocarditis. There are limited data available showing antibiotic susceptibility over time for VGS.ObjectivesTo evaluate antibiotic susceptibility trends in VGS over time.Methods In vitro susceptibility patterns for 33 antibiotics were examined for Streptococcus mitis, Streptococcus oralis, and non-speciated VGS isolates from patients in Veterans Affairs (VA) Medical Centers in the United States between 2010 and 2020. Susceptibility determinations were made by the individual clinical microbiology laboratories and data were retrospectively collected from the VA Corporate Data Warehouse. Susceptibility trends were analysed using Poisson regression.ResultsA total of 14 981 VGS isolates were included of which 19.5%, 0.7% and 79.8% were S. mitis, S. oralis and non-speciated VGS isolates, respectively. Cumulative susceptibility rates across all years were similar between species for ceftriaxone (range: 96.0% to 100%), clindamycin (81.3% to 84.5%), and vancomycin (99.7% to 100%). For penicillin, susceptibility rates were 71.0%, 80.9% and 86.3% for S. mitis, S. oralis and non-speciated isolates, respectively. From 2010 to 2020, susceptibility of non-speciated VGS isolates decreased for erythromycin (P = 0.0674), penicillin (P = 0.0835), and tetracycline (P = 0.0994); though the decrease was only significant for clindamycin (P = 0.0033). For S. mitis, a significant susceptibility rate decrease was observed for erythromycin (P = 0.0112).ConclusionsSusceptibility rates for some clinically relevant antibiotics declined between 2010 and 2020. This worrisome trend highlights the need to improve antimicrobial stewardship efforts to limit unnecessary antibiotic use and preserve empirical treatment options.

Echocardiographic features of infective endocarditis in South Africa: A prospective cohort study

Background. Historically, infective endocarditis (IE) in South Africa (SA) was associated with the viridans group of streptococci affecting patients with underlying rheumatic heart disease (RHD). A changing IE bacteriological profile raises the question of whether the profile of underlying valvular abnormality has changed. Objectives. To investigate the prevalence of underlying structural valve abnormalities and their aetiologies associated with IE in SA, and describe the typical imaging findings. Methods. The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and April 2021. Patients underwent detailed transthoracic and transoesophageal echocardiography to assess their underlying cardiac and valvular structure. Results. Among 71 patients included, a predisposing endocardial abnormality was detected in 49.3%, with RHD the most common single identifiable aetiology (16.9%). The in-hospital mortality rate was similar in patients with and without a predisposing endocardial abnormality (20% v. 16.7%; p=0.72), as was the rate of embolic events (20% v. 27.2%; p=0.58). Significantly more patients with a predisposing endocardial abnormality had an indication for surgery (94.3% v. 69.4%; p&lt;0.01). The viridans group of streptococci was more prevalent in patients with a predisposing endocardial abnormality (25.7% v. 2.7%; p&lt;0.01). Left-sided linear vegetation size &gt;10 mm was associated with an increased risk of in-hospital mortality (24% v. 5%; p=0.05). Conclusion. We observed a marked decrease in the prevalence of RHD in this cohort of patients with IE. The viridans group of streptococci was an uncommon cause of IE in patients with no predisposing endocardial abnormality detected. The presence of a predisposing endocardial abnormality was not associated with an increased risk of in-hospital mortality or embolic events. Linear vegetation length &gt;10 mm was associated with an increased risk of in-hospital mortality in patients with left-sided IE.

Correction to: Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association.

Correction to: Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association.

A Retrospective Study on the Predictors of Outcome in Patients with Infective Endocarditis

Background Infective endocarditis (IE) is associated with significant mortality and morbidity. This study aims to update the epidemiology of IE and to identify predictors of adverse outcome in the Chinese population in Hong Kong. Methods This was a single-centre retrospective study of patients diagnosed with IE in Princess Margaret Hospital in Hong Kong during 2002-2016. Primary outcome was defined as in-hospital mortality. Secondary outcomes included 1-year mortality, valvular surgical intervention, heart failure, stroke and systemic embolization. Results In total, 196 patients with definite or possible IE were included in the study. The incidence of IE was 2.26 per 100,000 person-years and had remained stable. Health care-associated IE (HCAIE) accounted for 32% of cases, with an increasing trend. Staphylococcus aureus was the most frequently isolated organism in the overall study population (37.8%) and among intravenous drug users (85.2%). In-hospital mortality remained high (29.1%) and was independently associated with higher Charlson Comorbidity Index (OR 1.24, p=0.001), heart failure (OR 5.65, p Discussion This study showed that the incidence of IE remained stable during 2002-2016. There was an increasing proportion of HCAIE and Staphylococcus aureus has become the most common causative organism. IE was associated with high mortality and morbidity. Independent predictors for in-hospital mortality were patient’s medical comorbidity, large vegetation size and heart failure, while infection by viridans group streptococci was associated with reduced risk.

Prosthetic joint infection diagnosis applying the three-level European Bone and Joint Infection Society (EBJIS) approach

Sensitive and specific tests for the diagnosis of prosthetic joint infection (PJI) are lacking. The aim of this study was to report clinical and microbiological findings of consecutive patients diagnosed with PJI at the University Hospital of Perugia, Perugia, Italy, and to validate these diagnoses utilizing the European Bone and Joint Infection Society (EBJIS) three-level diagnostic approach from 2021. Patients with a PJI diagnosis were included in this study and examined retrospectively. Overall, 133 patients were diagnosed with PJI: mean age 72 years, 54.9% female, and 55.6% with more than one comorbidity. The most frequent involved joints were hip 47% and knee 42%. Aetiology was identified in 88/133 (66.2%): staphylococci resulted the most frequent microorganisms and over 80% (45/54) resulted rifampin susceptible. Applying the EBJIS approach, PJI diagnosis resulted: confirmed in 101 (75.9%), likely in 25 (18.8%), and unlikely in 7 (5.3%). Likely PJIs aetiology was Staphylococcus aureus 11/25, coagulase-negative staphylococci 8/25, Streptococcus agalactiae 3/25, viridans group streptococci 2/25, and Pseudomonas aeruginosa 1/25. No statistically significant differences were detected among the three diagnosis groups with regard to clinical characteristics with the exception of a higher number of confirmed PJIs occurring < 3 months after implantation. The logistic regression analysis did not disclose any independent predictor of confirmed PJIs. We recommend using all the diagnostic tests available to approach PJI diagnosis, and suggest caution before rejecting PJI diagnosis in the presence of highly virulent microorganisms from a single sample, in patients without sinus tract, and in those receiving antimicrobial at the time microbiologic samples are collected. Study approved by Umbrian Regional Ethical Committee, Perugia, Italy, Prot. N. 23,124/21/ON of 10.27.2021.

Sign of the Times: Updating Infective Endocarditis Diagnostic Criteria to Recognize Enterococcus faecalis as a Typical Endocarditis Bacterium.

The modified Duke criteria requires that Enterococcus faecalis bacteremia must be both community-acquired and without known focus in order to be considered a microbiological "Major" diagnostic criterion in the diagnosis of infective endocarditis. We believe that the microbiological diagnostic criteria should be updated to regard E. faecalis as a "typical" endocarditis bacterium as is currently the case, for example, viridans group streptococci and Staphylococcus aureus. Using data from a prospective study of 344 patients with E. faecalis bacteremia evaluated with echocardiography, we demonstrate that designating E. faecalis as a "typical" endocarditis pathogen, regardless the place of acquisition or the portal of entry, improved the sensitivity to correctly identify definite endocarditis from 70% (modified Duke criteria) to 96% (enterococcal adjusted Duke criteria).

Surgery for infective endocarditis following low-intermediate risk transcatheter aortic valve replacement-a multicentre experience.

With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. Median age was 78 years (72-81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5-24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the 'endocarditis team' in referral centres.

Identification and molecular epidemiology of routinely determined Streptococcus pneumoniae with negative Quellung reaction results.

BackgroundSome streptococci strains identified as Streptococcus pneumoniae (S. pneumoniae) by routine clinical methods exhibiting negative Quellung reaction results may belong to other species of viridans group streptococci or non‐typeable S. pneumoniae. The purpose of this study was to investigate the identification and molecular characteristics of S. pneumoniae with negative Quellung reaction results.MethodsOne hundred and five isolates identified as S. pneumoniae using routine microbiological methods with negative Quellung reaction results were included. Multilocus sequence analysis (MLSA) was used as a gold standard in species identification, and the capacity of matrix‐assisted laser desorption ionization‐time of flight mass spectrometry (MALDI‐TOF MS) in identification was evaluated. Capsular genes and sequence types of S. pneumoniae isolates were determined by sequential multiplex PCR and multilocus sequence typing. Antimicrobial susceptibility patterns were determined via broth microdilution with a commercialized 96‐well plate.ResultsAmong the isolates, 81 were identified as S. pneumoniae and 24 were S. pseudopneumoniae by MLSA. MALDI‐TOF MS misidentified six S. pneumoniae isolates as S. pseudopneumoniae and nine S. pseudopneumoniae isolates as S. pneumoniae or S. mitis/S. oralis. Thirty‐one sequence types (STs) were detected for these 81 S. pneumoniae isolates, and the dominant ST was ST‐bj12 (16, 19.8%). The non‐susceptibility rates of S. pseudopneumoniae were comparable to those of NESp strains.ConclusionsSome S. pneumoniae isolates identified by routine methods were S. pseudopneumoniae. Most NESp strains have a different genetic background compared with capsulated S. pneumoniae strains. The resistance patterns of S. pseudopneumoniae against common antibiotics were comparable to those of NESp.