Effect of penicillin resistance on presentation and outcome of nonenterococcal streptococcal infective endocarditis

BACKGROUND AND AIMS: Most cases of infective endocarditis are caused by nonenterococcal streptococci. The emergence of strains resistant to penicillin is increasingly recognized worldwide. This study sought to assess the effect of penicillin resistance on presentation and outcome of streptococcal endocarditis. METHODS: A retrospective study was conducted in a single tertiary care hospital. RESULTS: Between August 1996 and December 2004, patients infected with nonenterococcal streptococcal endocarditis and known minimal inhibitory concentrations (MICs) to penicillin were included in this study. A total of 62 cases were identified: 48 (77%) cases of the streptococcal endocarditis were caused by viridans streptococci. The most common species groups identified were Streptococcus mitis in 12 (19%) cases, Streptococcus oralis in 9 (15%) cases, Streptococcus sanguis in 7 (11%) cases and Streptococcus mutans in 7 (11%) cases. There were 36 male and 26 female patients with a median age of 46 years (range: 1-85). Twenty-two patients (35%) had peripheral embolization and 10 patients (16%) died in hospital. Twenty-eight (45%) of the 62 patients were infected with streptococcal strains of MICs > or =0.125 microg/ml to penicillin. Infection with streptococcal strains of MICs > or =0.125 microg/ml to penicillin was associated with a lower incidence of all-site embolization, but was not associated with higher mortality or increased frequency of surgery. CONCLUSIONS: High-level penicillin resistance of the streptococci responsible for endocarditis was increasingly common and medical therapy with vancomycin had a good response. Penicillin resistance was associated with a decreased risk of embolization, but was not associated with higher mortality.     

Group B streptococcal endocarditis of tricuspid valve

We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.     

Streptococcus agalactiae (group B) endocarditis — A description of twelve cases and review of the literature

The group B streptococcus has been shown to be a major cause of meningitis in the newborn and an occasional cause of endocarditis and sepsis in postpartum women. Little attention has been devoted to this organism as a cause of bacterial endocarditis. Twelve patients with group B streptococcal endocarditis were seen at The Presbyterian Hospital, New York, NY, between 1974 and 1985. There were seven women, five men. Ages ranged from 32 to 81 years. Serious underlying disease was present in all - diabetes mellitus in seven, carcinoma in three (bladder in two, and breast in one), alcoholism in three, malnutrition in two, heroin addiction in one, tuberculosis in one, serious prior valvular heart disease in two. The aortic valve was affected in four patients - mitral in two, mitral and aortic in one, tricuspid in four, unknown in one. The presentation was acute in seven patients. Metastatic infection occurred in seven, heart failure in six, major emboli in four, septic pericarditis in one, myocardial abscess in one. The group B streptococcus should be considered as a pathogen capable of causing acute endocarditis in certain patients with defects of host defense, particularly patients with diabetes mellitus, carcinoma or alcoholism. Cardiac surgery may be necessary in these patients due to the rapid destruction of the valves which occurs, in spite of the fact that the organisms are usually highly susceptible to penicillin.     

Listeria monocytogenes endocarditis: a review of the literature 1950-1986

34 cases of Listeria monocytogenes endocarditis reported in the literature from 1950-1986 were reviewed. The male to female ratio was 2: 1. The average age was 49 years, and 35% of patients were 60 years of age or older. A single case of polymicrobial endocarditis was identified. There were 8 cases of prosthetic valve endocarditis. Left-sided cardiac involvement predominated, with only a single case of right-sided endocarditis reported. Aortic and mitral valvular involvement accounted for 32 and 29% of cases respectively. Underlying cardiac disease was present in over half of the cases, with rheumatic heart disease being the most common underlying cardiac condition. Noncardiac underlying conditions were found in 38% of cases. These included chronic hemodialysis, alcoholism, pregnancy, malignancies, diabetes mellitus, steroid therapy and malnutrition. Onset of the disease was varied as was initial presentation. There was a high incidence of vascular phenomena (59%), with large vessel emboli seen late in the course of many cases. Many cases were diagnosed late. Overall mortality was 50%. Treatment of listeria endocarditis varied from case to case. A review of in vitro and in vivo studies as well as case reports suggests that ampicillin or penicillin plus an aminoglycoside may be the treatment of choice.     

Group B streptococcal infective endocarditis

From 1970 to 1983, five patients with group B streptococcal endocarditis were treated at the Mayo Clinic, Rochester, Minn. The minimal inhibitory concentration and the minimal bactericidal concentration of penicillin were 0.09 microgram/mL or less and 1.56 micrograms/mL or less, respectively. The in vitro activity of cefazolin against group B streptococci was similar to that of penicillin. In three of the five cases, penicillin and streptomycin acted synergistically in vitro against group B streptococci. Four of the five patients were cured, three by use of an aminoglycoside combined with penicillin, ampicillin, or vancomycin. Three of the five patients had multiple large systemic emboli, and one of the three died of brain-stem infarct. Penicillin alone or in combination with an aminoglycoside is effective therapy for group B streptococcal endocarditis. Patients unable to tolerate penicillin may be treated with cefazolin or vancomycin. Clindamycin therapy should be avoided in patients with endocarditis caused by strains that are tolerant in vitro to clindamycin.     

Group G streptococcal endocarditis: two case reports, a review of the literature and recommendations for treatment

Two cases of endocarditis caused by a group G streptococcus are reported and the literature on group G streptococcal endocarditis is reviewed. The onset of illness is usually acute and the portal of entry for the organism through the skin. The left side of the heart is mainly involved and in about 50% cases the endocarditis arises on a normal valve. Most patients develop complications, both embolic and cardiac, and the mortality is high (36%). We suggest that patients with proven group G streptococcal endocarditis should be treated with large doses of benzyl penicillin and with an aminoglycoside for not less than 4 weeks. Patients with complications should be referred to a cardiothoracic centre. We should be glad to know details of complications, treatment and outcome in other cases of group G streptococcal endocarditis.     

Survey of infective endocarditis in the last 10 years: analysis of clinical, microbiological and therapeutic features

Infective endocarditis still presents problems with early diagnosis, selection of antibiotics and timing of surgical procedure despite modern antibiotics and investigative procedures. A retrospective study was performed to clarify the clinical and microbiological spectrum of recent infective endocarditis in the Japanese population in 38 patients with infective endocarditis (mean age 42.7 +/- 12.5 years) treated from March 1986 to March 1996. The portal of entry to bacteremia was unknown in most cases (57.9%), but the commonest identified portal was dental procedure (18.4%). Overall, the aortic valve was infected most frequently (44.7%) and followed by the mitral valve (36.8%). The most common complication of infective endocarditis were emboli (11/38, 28.9%) and congestive heart failure, NYHA class III and IV (14/38, 36.8%). Organisms were isolated from 26 of the 38 (68.4%) patients. Streptococcus viridans was the most frequent organism (34.2%), and then Staphylococcus aureus (13.2%). The blood culture positivity of microorganism was significantly higher in patients not receiving antibiotics than in those the received antibiotics (87.5% vs 50%, p < 0.05). The prevalence of streptococcal endocarditis decreased in the 1990s (1992-1996) in comparison with those in the 1980s (1986-1988). Multiple antibiotics were used frequently in 1990s and the sensitivity titer to piperacillin reduced from 3.0 in the 1980s to 1.8 in the 1990s. In contrast to reduction of streptococcal endocarditis, Staphylococcus aureus endocarditis has increased recently from 12.5% to 30.8%. The most common clinical features are valve destruction, low sensitivity of penicillin, and significantly higher in-hospital mortality. Surgical treatment was indicated most commonly in cases of uncontrollable heart failure, and infected valves were replaced during the active stage in 11/23 cases (47.8%). In-hospital mortality was higher in the medical treatment group than in the surgical group, but a long-term mortality of mean observation term 4.2 +/- 3.2 years was identical in the chronic phase. In patients with infective endocarditis and successful treatment in the acute stage, a long-term survival rate in medically treated patients was found almost comparable to surgically treated patients in our series. However, it should be emphasized that streptococcal endocarditis is being replaced by infection by Staphylococcus aureus, which is resistant to penicillin and requires intensive chemotherapy and proper decision at suitable timing for surgical therapy in the early stage.     

Trend and contributing factors of in-hospital deaths in patients with infective endocarditis over the last twenty years

OBJECTIVES: To evaluate the changes in the clinical background to infective endocarditis and identify the contributing factors to in-hospital deaths over the last 20 years. METHODS: Seventy-five patients (mean age 48.2 +/- 24.0 years) with infective endocarditis treated between January 1984 and December 2003 at our hospital were evaluated retrospectively. The patients were divided into two groups (first decade, n = 26 and second decade, n = 49). RESULTS: The infection route was unknown in 65% of the patients, but the oral route was the most common known route (16.0%). Congenital heart disease (24.0%)was the most common background disease, followed by valvular heart disease (22.7%), and post prosthetic valve replacement (22.7%). The mitral valve was most frequently infected(56.0%), followed by the aortic valve (34.7%). Multi-valve infection was present in 13.3% of the patients. Although the frequency of streptococcal endocarditis reduced, that of staphylococcal endocarditis increased in the second decade. The overall in-hospital mortality was 26.7%, but slightly improved in the second decade (34.6% vs 22.4%, p = 0.26). The overall in-hospital mortality was similar between the surgically treated group and the non-surgically treated group (25.0% vs 27.3%, NS). In the surgically treated group, in-hospital mortality was lower in the second decade than the first decade, but higher in the group treated for active infective endocarditis. Multivariate analysis found age > or = 51 years, renal insufficiency, neurological abnormality, and culture negative as predictors of in-hospital mortality. CONCLUSIONS: Rapid and appropriate primary medical treatment are important in the active phase of infective endocarditis. Age > or = 51 years was the strongest predictor of in-hospital infective endocarditis death.     

Group B streptococcal bacteremia in a community teaching hospital

Group B streptococcal bacteremia outside the perinatal setting is not commonly emphasized. This report reviews all episodes of group B streptococcal bacteremia during a four and a half year period in a large community teaching hospital. Fourteen episodes occurred in neonates, four in parturient women, and 28 in other adults. Bacteremic adults were usually elderly with an average age of 68 years. Group B streptococcal bacteremia occurred in adults with various underlying diseases, including diabetes mellitus, liver disease, peripheral vascular disease, and hematologic disease, and in those receiving long-term steroid therapy. Infections causing group B streptococcal bacteremia in adults included decubitus ulcers, pneumonia, endocarditis, cellulitis, arthritis, osteomyelitis, and meningitis. Thirteen of 28 episodes of group B streptococcal bacteremia in adults were hospital-acquired. Overall mortality in adults was 70 percent. Group B streptococcal bacteremia in adults outside of the perinatal setting is associated with significant underlying diseases and has a high mortality.     

Replacement of the mitral valve in an infant with group B streptococcal endocarditis

Endocarditis due to group B streptococcus is very rare in infants, and may be associated with significant morbidity and mortality. Review of the literature reveals only a single reported case of an infant with this type of streptococcal endocarditis involving the mitral valve. This infant had underlying congenital heart disease, and died shortly after catheterization. We now report group B streptococcal endocarditis occurring in an infant with a structurally normal heart who was treated successfully by replacement of the mitral valve.     

Once weekly azithromycin in secondary prevention of rheumatic fever

Rheumatic fever and rheumatic heart disease (RHD) are still important problems in developing countries. Secondary prophylaxis which is the most cost-effective method in preventing recurrences of rheumatic fever is fraught with problems of drug compliance. The utility of 500 mg once weekly azithromycin (AZT), an orally effective long-acting antibiotic was evaluated against oral penicillin (phenoxy methyl penicillin 250 mg twice daily) in this study. Forty-eight consecutive patients (44% males, mean age 29.4 years) with established RHD were randomised into two groups-26 patients received AZT and 22 received oral penicillin. Patients were evaluated at randomisation, at 1 month, 3 months, and 6 months, clinically, serologically and by throat swab culture. End points were absence of streptococcal colonisation, infection or fever at the end of 6 months. During the study, 4 patients (15.4%) in the AZT group developed sore throat and fever, had positive throat culture and positive serology indicating streptococcal infection. None satisfied the criteria for rheumatic fever reactivation. None in the oral penicillin group developed streptococcal infection. In conclusion, weekly 500 mg of AZT is not effective in the prevention of streptococcal throat infection compared to oral penicillin therapy in adult patients with established RHD.     

Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country

BACKGROUND: In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. Objective: Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. Setting: A tertiary referral center for paediatric and adult cardiology. PATIENTS AND METHODS: All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases. RESULTS: Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients). CONCLUSIONS: The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.     

Isolated native tricuspid valve endocarditis caused by viridans streptococcus

The present report describes a case of native tricuspid valve endocarditis caused by viridans group streptococcus in a 43-year-old man who had recently undergone dental extraction. The patient had no history of intravenous drug use, heart disease or right heart catheterization. Although there have been scattered reports of unusual organisms, to the authors'' knowledge, this is the first case of viridans group streptococcal endocarditis involving only the tricuspid valve after dental manipulation.Key Words: Tricuspid valve endocarditis, Viridans streptococcusIsolated native tricuspid valve endocarditis (TVE) accounts for only 5% to 10% of all cases of infective endocarditis (1,2) and is rarely seen in the absence of intravenous drug use (IDU) or intracardiac catheterization or cardiac anomalies (3,4). The present report describes a case of isolated viridans streptococcal TVE after dental manipulation in a nonintravenous drug user without underlying cardiac disease or central venous catheterization. We are not aware of any cases reported in the English literature of isolated native TVE caused by viridans streptococcal species after dental procedures. The expedient identification of patients with TVE in the absence of predisposing factors can be difficult, and thus delay in diagnosis may delay appropriate therapeutic intervention.     

Clinical evaluation of anti-DNAse B test in rheumatic fever and rheumatic heart disease]

Anti-DNAse B test was performed with microtechnique in 160 subjects including patients with acute streptococcal pharyngitis, rheumatic fever and rheumatic heart disease as well as normal controls. It was shown that the antibody titer varied with age, stage of rheumatic fever and rheumatic heart disease as well as the frequency of benthazine penicillin injections. It was also shown in this study that the school children group had considerably higher geometric mean antibody titer than the adult group. The upper normal limit of anti-DNAse B titer was 240 units in the school children group and 160 units in the adult group. The anti-DNAse B test shows a higher positive detection rate for streptococcal infection than ASO, especially when these two tests are used in combination. In patients with manifestations of acute rheumatic fever without elevation of ASO titer, anti-DNAse B test will be of great diagnostic value.     

Group A streptococcus endocarditis: Report of five cases and review of literature

Group A streptococcus is an uncommon cause of infective endocarditis. We report five probable cases during a 10-year period (1980-1989) from a 750-bed community-teaching hospital. None of the patients were drug abusers. Group A streptococcus is the cause of infective endocarditis in between 0 and 5% cases in reported series. Since the introduction of penicillin 69 cases of group A streptococcus endocarditis have been reported in the literature. Clinical details of 14 patients, none of whom were drug abusers, are available. Included are our five cases. Eight patients had no underlying valve lesions. The overall mortality was 21% but only 15% for patients treated approximately. Among the 25 reported IV drugs abusers with group A streptococcus endocarditis and known valve involvement, right-sided heart valves were involved in 19 and left sided in six. The overall mortality was 9%.     

Infective endocarditis: report of a prospective study in an Indian hospital

Forty-six patients who fulfilled the Duke's clinical diagnostic criteria for infective endocarditis (IE) were evaluated. Thirty-five (76%) patients were below 40 years of age with rheumatic heart disease being the most common underlying heart lesion affecting 26 (56%). An obvious predisposing cardiac lesion could not be ascertained in 22%. Blood culture positivity was 44% with streptococcus heading the list. The incidence of the staphylococcal (25%) and gram negative bacillary endocarditis (15%) were found to be increasing. Streptococci were susceptible to penicillin with minimum bactericidal concentration: minimum inhibitory concentration within acceptable limits. However, the appearance of methicillin resistant staphylococcus aureus and high level gentamicin resistant enterococcus as aetiological agents of infective endocarditis were found to add to the complexity of the problem. With the emergence of drug-resistant organisms as causative agents of IE, whenever medical therapy is the primary method of treatment of this condition, the selection of antibiotics should depend upon extensive in vitro testing and in vivo monitoring of clinical efficacy.     

Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum.

Streptococci other than Streptococcus pneumoniae are a rare cause of bacterial meningitis in adults. We report 29 cases of streptococcal meningitis (1977-1997). The patients comprised 19 men and 10 women, with a mean age +/- standard deviation of 47 +/- 18 years. Nine cases were secondary to neurosurgical procedures, seven to brain abscess, five to cerebrospinal fluid pericranial fistula, and three to endocarditis. Causative microorganisms included the following: viridans group streptococci, 20 cases; anaerobic streptococci, 3; Streptococcus agalactiae, 3; Streptococcus bovis, 2; and Streptococcus pyogenes, 1. Four Streptococcus mitis strains showed decreased susceptibility to penicillin (MIC, 0.5-2 microg/mL). Five patients (17%) died. The infection is increasing in the hospital setting. Streptococci resistant to penicillin should be considered in the empirical treatment of nosocomial meningitis. In cases of community-acquired infection, anaerobic streptococci or streptococci of the Streptococcus milleri group should alert the clinician to the presence of an undiagnosed brain abscess, whereas oral streptococci of the viridans group suggest the diagnosis of bacterial endocarditis.     

Retrospective study on 100 cases of infective endocarditis, Rabta University Hospital, Tunis, from 1980 to 2004

This retrospective study describes 100 cases of infective endocarditis (IE), collected between 1980 and 2004. Patients were subdivided into 2 groups, according to the use of trans-esophageal echocardiography (TOE) in the institution where the study was performed: group A (GA=55 patients, between 1980 and 1991) and group B (GB=45 patients, between 1992 and 2004). The IE cases of 59 men and 41 women were analyzed. Patients had a mean age of 33 years (range 15-75 years). An underlying heart disease was involved in all cases, mainly rheumatic heart disease (93% of cases). Native valve endocarditis (NVE) was seen in a majority of cases (93%), and the localization of IE was aortic in 36 cases, mitral in 36 cases, mitro-aortic in 26 cases and mitro-aortic-tricuspid in 2 cases. Prosthetic valve endocarditis (PVE) occurred in 12 cases. Blood cultures were positive in 31 cases, with 14 staphylococcal infections (3 in GA and 11 in GB) (p < 0.05), of which 6 were coagulase-negative; 13 were streptococci and 4 were Gram negative bacilli. All patients had a transthoracic echocardiography (TTE), and patients in group B also had a TOE. Seventeen patients had a favorable outcome without need of a surgical intervention. Early surgery was necessary in 71 cases (85.5%), and elective surgery in 12 cases (14.5%). Mortality while awaiting surgery was 27%, and has been decreasing for the past decade (41.8% in GA and 8.9% in GB) [p < 0.05]. Postoperative mortality after early surgery intervention was 13.6% (6 among 44 patients), and it was 8.3% (1 among 12 patients) after elective surgery intervention. Overall mortality was 34%: 27 deaths with NVE (30.7% [27/88]), and 7 deaths with PVE (58.3% [7/12]) [NS]. Predictors of mortality in this observational study were positive blood cultures involving staphylococci, the presence of valve mutilations, unstable prostheses, and heart failure.     

Endocardite tricuspide du post-partum à streptocoque B

The B streptococcal endocarditis are very rare. They primarily affect the left heart valves, the achievement of the tricuspid valve is exceptional. We report a young patient aged of 36 years who presented in postpartum a tricuspid endocarditis with streptococcus B. She was treated by third-generation cephalosporin and aminoglycoside. The evolution after 5 days of antibiotic therapy was marked by a rapid valvular destruction with worsening tricuspid insufficiency leading to death of the patient. This is the 23rd case of tricuspid endocarditis streptococcal B reported in the literature. The mortality of this disease reached 36% in the absence of surgical treatment. The medico-surgical approach is the treatment of choice for these patients.     

Serious infections due to group G streptoccocci: Report of 15 cases with in vitro-in vivo correlations

Serious infections due to group G streptococci have been infrequently reported. Fifteen such cases are described. Endovascular infection, particularly endocarditis, and septic arthritis were the most common clinical syndromes observed. Despite exquisite in vitro sensitivity of group G streptococci to penicillin G, the in vivo clinical response was disappointing in six of nine patients with either endocarditis or septic arthritis. The group G streptococcal isolates from the patients in this study were uniformly sensitive to the inhibitory and killing action of penicillin G, ampicillin, cefotaxime, cephalothin, cefoxitin, and vancomycin. In contrast, clindamycin, erythromycin, and chloramphenicol had relatively poor bactericidal activity against these strains, including several “tolerant” strains. Timed-kill studies with penicillin G revealed impaired killing of group G streptococci at in vitro conditions of high inocula and stationary growth phases. This may partially explain the poor clinical responses in cases of group G streptococcal endocarditis.