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Pimpawan Boapimp, MD

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PI: 43 y/o WF with PMH of COPD presented. with fever, cough, SOB ... HTN, fibromyalgia, COPD, anemia, MVP. NKDA. quit smoking one week PTA ... – PowerPoint PPT presentation

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Title: Pimpawan Boapimp, MD


1
INFECTIOUS DISEASES CASE CONFERENCE
Pimpawan Boapimp, MD Wake Forest Baptist Medical
Center May 10, 2004
2
PI 43 y/o WF with PMH of COPD presented
with fever, cough, SOB CXR showed bilat lower
lobes infiltrate was admitted for 8 days,
treated for pneumonia with Levaquin
gentamicin and sent home with Levaquin PCN SOB
got worse assoc. with DOE, orthopnea

3
  • 2 days later was seen in OPD, TTE done
  • TTE- severe MR, vegetation on MV and AV
  • BC grew fastidious streptococcus viridans
  • Readmitted for GPC bacteremia and IE
  • OSH called ID at Baptist for a brief
    consultation. Ceftriaxone and gentamicin
  • were started

4
PMH
  • Denies recent tooth pain, dental abscesses,
  • dental work
  • Had UGIB several months ago
  • Depression
  • HTN, fibromyalgia, COPD, anemia, MVP
  • NKDA
  • quit smoking one week PTA
  • ROS DOE , otherwise negative

5
  • transferred to Baptist Med Ctr
  • TEE done on admission showed
  • - LAE, severe AR, MR
  • - vegetation on MV, AV
  • BC at our hospital no growth
  • underwent AVR and MVR (porcine)

6
  • tissue from MV and AV
  • -Gram stain no organism
  • -C/S no growth
  • no complication after Sx
  • ID was consulted for ATBs management

7
Physical Examination
  • VS T 98.6 F P 64 RR 18 BP 101/57
  • PO 97 2LNC
  • GA AO x 3, afebrile, NAD
  • HEENT PERRLA, EOMI
  • CHEST decrease BS bases,
  • Sx wound-healing well
  • HEART RSR, valve click

8
Physical Examination
  • ABD soft, not tender, BS ,
  • no organomegaly
  • EXT no edema
  • NS no focal deficit
  • SKIN no rash
  • IV PICC at LUE

9
Diagnostic Data
  • CBC WBC 15.6 Hb 9.8 Hct 29.8 Plt 189
  • BMP WNL , LFT WNL
  • BNP 862
  • UA -WNL
  • CXR
  • COPD with bilateral pleural effusions and
    bibasilar aeration disturbance which could
    reflect pneumonia

10
  • C/S from OSH grew fastidious S. viridans
  • MICs not available
  • ATBs was changed to PCN and C/W gentamicin
  • clinically stable, no F/C, no signs of CHF

11
BC from OSH
  • Streptococcus viridans group
  • nutritionally deficient streptococci
  • The isolate is too fastidious for susceptibility
    studies.

12
  • Facklam R.What happened to the streptococci
    overview of taxonomic and nomenclature changes.
    Clin Microbiol Rev. 2002 Oct15(4)613-30.
    Streptococcus Laboratory, Centers for Disease
    Control and Prevention

13
  • Brouqui P, Raoult D.Endocarditis due to rare
    and fastidious bacteria.
  • Clin Microbiol Rev. 2001 Jan14(1)177-207.

14
Nutritionally variant streptococci NVS
  • originally described in 1961 as a new type of
    viridans streptococci
  • In 1989, Bouvet et al. demonstrated 2 species
    within the NVS, S. adjacens and S. defectives
  • In 1995, using the 16S rRNA gene sequencing NVS,
    Kawamura et al. proposed a new genus, __________

Abiotrophia
15
Nutritionally variant streptococci NVS
  • 4 species of Abiotrophia
  • A. defectiva
  • A. adiacens
  • A. balaenopterae
  • A. elegans
  • In 2000, Collins and Lawson proposed a new genus,
    Granulicatella, to reclassify
  • Abiotrophia

16
Abiotrophia spp.
  • Abiotrophia consisted of only A. defectiva
  • fastidious organisms
  • streptococcal L-forms
  • required metabolic products of other bacteria for
    growth

17
Abiotrophia spp.
  • Numerous synonyms
  • -satelliting Streptococcus
  • -thiol-requiring Streptococcus
  • -vitamin B6-dependant Streptococcus
  • -pyridoxal-dependent Streptococcus
  • -symbiotic Streptococcus
  • -nutritionally variant streptococci

18
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19
Abiotrophia spp.
  • More than 100 cases of Abiotrophia endocarditis
    reported
  • cause 5 to 6 of all cases of streptococcal
    endocarditis
  • 4.3 of cases of streptococcal IE caused by
    Abiotrophia spp.
  • may be underestimated because they are fastidious
    organisms, it is likely that most cases are
    misdiagnosed as culture-negative IE

Brouqui P, Raoult D. Endocarditis due to rare and
fastidious bacteria. Clin Microbiol Rev. 2001
Jan14(1)177-207.
20
Abiotrophia spp.
  • Preexisting heart disease is found in 90 of
    patients
  • known cardiac murmur - most common finding
  • prosthetic heart valves -only 10 of patients

21
Abiotrophia spp.
  • normal oral, genitourinary, and intestinal floras
  • Endocarditis usually occurs as a result of
    bacteremia in patients with an underlying valve
    injury.
  • slow and indolent course of IE
  • With progression of the disease, complications
    such as septic arthritis are observed.

22
Abiotrophia spp.
  • The classical peripheral manifestations of
    endocarditis, including digital clubbing,
    petechiae, and Osler nodes, are not frequently
    observed.
  • But embolization occurs in one-third of patients
  • Affects the aortic and mitral valves with similar
    frequency (13 and 11, respectively)

23
Abiotrophia spp.
  • CHF may be the first manifestation in some
    late-recognized cases.

24
Abiotrophia spp.
  • Culture
  • cysteine was added into culture media
  • can be detected in routine BC in 2 or 3 days
  • Fresh human blood enhances the recovery of these
    bacteria

25
Abiotrophia spp.
  • In contrast, subcultures usually require
    supplementation of blood agar with
  • -pyridoxal hydrochloride (10 to 100 mg/L)
  • -or L-cysteine (100 mg/L)
  • under an aerobic or anaerobic atmosphere

26
Abiotrophia spp.
  • Alternatively, use a coagulase-positive
    Staphylococcus as helper to induce satellite
    growth
  • Tiny alpha-hemolytic or nonhemolytic colonies
    appear after 18 h either alone or as satelliting
    colonies around a helper strain
  • also found to form satellite colonies around
    Enterobacteriaceae and other streptococci

27
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28
Abiotrophia spp.
  • or use liquid broth supplemented with pyridoxal
    hydrochloride or cysteine
  • Microscopic examination
  • -morphological pleiomorphism
  • cocci, coccobacilli, rod-shaped,
    globular (bulbous) bacteria
  • -variable Gram staining
  • differentiated from viridans streptococci by
    production of pyrrolidone arylamidase

29
Abiotrophia spp.
  • Morbidity and mortality exceed those of the other
    forms of viridans streptococcal and enterococcal
    endocarditis
  • Therapy results in a bacteriological failure in
    41 of patients in spite of the in vitro
    bactericidal effects of antibiotics

30
Abiotrophia spp.
  • 27 of patients require prosthetic valve
    replacement
  • 17 to 20 of patients die due to uncontrolled CHF
    or major systemic emboli
  • More than 30 of strains of Abiotrophia are
    resistant to 0.12 mg of penicillin per liter

31
Abiotrophia spp.
  • In a rabbit model of IE
  • PCN gentamicin more effective than PCN alone
  • Vancomycin alone is as effective as
  • PCN gentamicin in a rabbit model
  • (vancomycin is not bactericidal)
  • Henry NK, et al. Antimicrobial therapy of
    experimental endocarditis caused by nutritionally
    variant viridans group streptococci.Antimicrob
    Agents Chemother. 1986 Sep30(3)465-7.  

32
Granulicatella spp.
  • some of Abiotrophia species were phylogenetically
    distinct from each other
  • New genus- Granulicatella spp.
  • -G. adiacens
  • -G. elegans
  • -G. balaenopterae
  • All species except G. balaenopterae have been
    isolated from human infections

33
Treatment
  • Sanford Guide
  • S. viridans, S. bovis with PCN G MIC 0.1 to
    strep (MBC 32-fold MIC)
  • PCN G 18 mU/d x 4 wks PLUS gentamicin 1 mg/kg q 8
    hrs x 2 wks
  • Alternative
  • Cefazolin (not IgE-mediated PCN allergy)
  • or Vancomycin x 4 wks

34
  • NVS are frequently resistant to penicillin, and
    resistance to extended-spectrum cephalosporins
    and newer fluoroquinolones
  • Tuohy MJ, Procop GW, Washington JA.
    Antimicrobial susceptibility of Abiotrophia
    adiacens and Abiotrophia defectiva. Diagn
    Microbiol Infect Dis 2000 38189 91.

35
  • Liao CH, et al.
  • Nutritionally variant streptococcal infections
    at a University Hospital in Taiwan disease
    emergence and high prevalence of beta-lactam and
    macrolide resistance. Clin Infect Dis. 2004 Feb
    138(3)452-5. Epub 2004 Jan

36
  • 28 pts with NVS infection
  • 9 pts had IE
  • 9 pts had primary bacteremia
  • IE pts were treated with PCN or other ß-lactams
    (ampicillin, ampicillin-sulbactam,
    amoxicillin-clavulanate, cefazolin, cefmetazole,
    ceftriaxone, or meropenem) PLUS gentamicin or a
    glycopeptide (vancomycin or teicoplanin) for 4 -
    6 wks

37
  • All of the isolates were susceptible to
    vancomycin, quinupristin-dalfopristin, linezolid,
    levofloxacin, moxifloxacin, and gatifoxacin.

38
  • 50 of isolates had intermediate susceptibility
    to penicillin (i.e., MICs of 0.25- 2 µg/mL)
  • 33 were not susceptible to cefotaxime
  • 23 of these isolates were fully resistant (MIC
    4 µg/mL)
  • 17 were not susceptible to cefepime
  • 10 of these isolates were fully resistant (MIC
    4 µg/mL)

39
  • Imipenem, meropenem, and teicoplanin had good in
    vitro activity against these isolates
  • Only 7 were susceptible to azithromycin,
  • and 57 of the isolates had an MIC of
    azithromycin of 128 µg/mL.
  • 54 of the isolates that were not susceptible to
    azithromycin (MIC 1 µg/mL) were also resistant
    to clindamycin (MIC 1 µg/mL)

40
  • According to the MIC90 values, fluoroquinolones
    demonstrated potent activity against nearly all
    of the NVS isolates tested
  • (relative MIC90 values sitafloxacin
    garenoxacin moxifloxacin gatifloxacin
    ciprofloxacin levofloxacin)

41
  • Nutrition limitation within vegetation, slow
    growth rate, and production of exopolysaccharide
    contributed to a longer course of endocarditis
    and required a longer duration of effective
    antibacterial coverage

42
  • The existence of significant resistance to
    ß-lactams and macrolides among these NVS isolates
    emphasizes the need for accurate identification
    and antimicrobial susceptibility testing of these
    organisms
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