A 71-year-old male with a history of coronary artery disease and autoimmune hepatitis was admitted with fever. Blood cultures grew Streptococcus salivarius. S. salivarius bacteremia can represent a serious underlying illness. The patient's treatment plan includes 2 weeks of intravenous ceftriaxone and gentamicin, followed by surveillance blood cultures and endocarditis prophylaxis for dental procedures.

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