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