Infectious Disease Compendium

Streptococcus

Microbiology

Gram positive cocci in chains.

There are many ways to classify streptococci: hemolysis, Lancefield (Group A, B etc) (PubMed), biochemicals and more. Suffice it to say microbiologists like to meet every couple, get really drunk, and reclassify streptococci to piss off clinicians. At least that is my suspicion.

Here is my simplistic way of thinking about streptococci:

S. pyogenes aka Group A.

S. agalactiae aka Group B.

The S. milleri group: S. anginosus, S. intermedius, S. constellatus, S. milleri. These cause abscesses.

The oral/viridans strep: S. mitis, S. morbillorum, S. mutans, S. oralis, S. sanguis, S. salivarius. S. tigurinus. Usually cause endocarditis.

The bowel strep: S. bovis, S. pasteurianus, S. gallactolyticus. Bacteremia and endocarditis associated with upper and lower GI malignancy.

Cellulitis strep: S. equi, S. equisimilis, S. pyogenes.

Animal Strep: S. canis, S. iniae.

Respiratory Strep: S. pneumoniae, Streptococcus pseudopneumoniae .

Except where noted below, any beta lactam (except aztreonam) will kill any Streptococcus, penicillins and cephalosporins are still the best. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Macrolides and doxycycline remain active as well.

No Streptococcus makes a beta lactamase, so save the patient a buck and DO NOT give penicillin/beta-lactamase inhibitors for streptococci unless a) you are dumb as a box of rocks and b) you want to give the patient extra expense and diarrhea.

S. agalactiae

Epidemiologic Risks

S. agalactiae aka Group B strep: part of the human GI/GU tract.

Obesity and diabetes are associated with increased risk of infection from invasive infection (PubMed).

Also, fish pedicures. Not pedicure of the fish, they do not have feet (finacure?), but allowing fish to nibble away the dead skin on your feet (PubMed).

And if you eat raw fish? Infection with type 283 (Pubmed). There was an outbreak from eating "yusheng (which is) typically made from sliced Asian bighead carp (Hypophthalmichthys nobilis) and snakehead (Channa spp.) and served as a side dish with porridge by food stalls within larger eating establishments" (PubMed). It then can go to prosthetic joints in mostly normal patients where it is somewhat nasty (PubMed).

Serotype IV is passed back and forth from human and cattle in Europe (Pubmed).

And eating freeze dried placenta (PubMed) has led to disease. Can vegans eat placenta?

There is a rare Group B streptococcus, Streptococcus halichoeri, in seals (PubMed).

Syndromes

S. agalactiae: neonatal sepsis and bacteremia in both mother and child.

Soft tissue infections

Immunoincompetent adults (diabetes, ETOH, cancer) can get bacteremia septic arthritis and get bacteremia without a focus.

Treatment

Any beta lactam (except aztreonam) will do, penicillin, cephalosporins, are still the best. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work.

S. anginosus

Epidemiologic Risks

S. anginosus: mouth flora.

Part of the anginosus/constellatus/intermedius streptococci, the abscess formers.

Syndromes

S. anginosus: endocarditis and is associated with abscesses of the brain, liver, gi. This Streptococcus can form abscesses all by its lonesome.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work.

May have decreased susceptability to vancomycin when part of mixed infections (PubMed).

S. bovis

Epidemiologic Risks

GI flora. Now called Streptococcus gallolyticus.

Syndromes

Endocarditis is more frequent among patients with S. bovis biotype I, whereas bacteremia due to biotype II species is more likely from biliary system (PubMed).

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism? S. canis Any antibiotic will work, but use a Beta lactam.

S. canis

Epidemiologic Risks

Dogs and other animals. It's a group G.

Syndromes

In 54 patients, soft tissue infection (n = 35), bacteremia (n = 5), urinary infection (n = 3), bone infection (n = 2) and pneumonia (n = 1) (PubMed).

Treatment

Any antibiotic will work, but use a beta lactam.

S. constellatus

Epidemiologic Risks

Mouth flora.

Syndromes

S. constellatus: endocarditis and is associated with abscesses of all kinds brain, liver, gi.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. equi/Streptococcus equi subspecies zooepidemicus

Epidemiologic Risks

Horses, pigs, ruminants, monkeys, cats, and dogs, and guinea pigs.

Syndromes

S. equis/Streptococcus equi subspecies zooepidemicus: soft tissue infection, bacteremia, endocarditis and meningitis although related to horses, the cases of meningitis were associated with drinking unpasteurized milk (PubMed).

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. dysgalactiae subspecies equisimilis (was S. equisimilis)

Epidemiologic Risks

Human.

Syndromes

Streptococcus dysgalactiae subspecies equisimilis (S. equisimilis): soft tissue infection (In Finland it is the leading cause of bacteremic cellulitis (PubMed). I would bet in Oregon as well. Bacteremia and endocarditis.

Pharyngitis; there was an outbreak in Japan due to contaminated broccoli salad. 140 kids got sick (PubMed).

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. gallolyticus

Epidemiologic Risks

Gi tract. Was S. bovis. Cancer risk, both colonic and upper gi, depends on type: "Bacteraemia due to S. gallolyticus subspecies gallolyticus was significantly associated with endocarditis while S. gallolyticus subspecies pasteurianus was more likely to be associated with malignancies of the digestive tract, including gastric, pancreatic, hepatobiliary and colorectal cancers " (PubMed).

Syndromes

Streptococcus gallolyticus: bacteremia and endocarditis has a high association with colonic malignancy (PubMed) (PubMed). If it is in the blood, the patient needs a colonoscopy. The reason? It turns out the beast likes to preferentially adhere to proteins made by bowel tumor (PubMed).

Streptococcus gallolyticus subsp. pasteurianus caused meningitis; the source was hemorrhoids (PubMed). Seriously, who would name a rectal bug pasteurianus? Just say it out loud without giggling.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. iniae

Epidemiologic Risks

Farm raised tilapia fish.

Syndromes

S. iniae: soft tissue infection, bacteremia and endocarditis.

Treatment

Any beta-lactam.

S. intermedius

Epidemiologic Risks

Mouth flora.

Syndromes

S. intermedius: bacteremia and endocarditis.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. milleri

Epidemiologic Risks

Mouth flora.

Syndromes

S. milleri: endocarditis and is associated with abscess in the brain, liver, gi.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. mitis

Epidemiologic Risks

Mouth flora.

Syndromes

S. mitis: bacteremia and endocarditis. Especially a problem in cancer patients (PubMed)

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. morbillorum

Epidemiologic Risks

Mouth flora.

Syndromes

S. morbillorum: bacteremia and endocarditis.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. mutans

Epidemiologic Risks

Mouth flora.

Syndromes

S. mutans: bacteremia and endocarditis.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. oralis

Epidemiologic Risks

Mouth flora.

Syndromes

S. oralis: bacteremia and endocarditis. Especially a problem in cancer patients (PubMed)

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. pneumoniae

Epidemiologic Risks

Part of life, human to human spread. There is a vaccine, its efficacy is variable, but it is best at preventing death, decreasing mortality by 40% (PubMed). There are 80 plus serotypes, the most common capsule strains are in the vaccine. But.

The vaccine is directed against the capsule and, evolution being what it is, there are now nonencapsulated strains, in one paper accounting for almost 9% of isolates (PubMed). In the end, the bugs will win.

Besides the 'classic' risks enumerated in the vaccine recommendations (MMWR), rheumatoid arthritis, systemic lupus erythematosus, Crohn’s disease, and neuromuscular or seizure disorders are also at increased risk for pneumococcus (PubMed) and should be considered for vaccination.

At least 13.5% of patients with invasive disease will have some sort of hypogamaglobulinemia (PubMed). All patients with bacteremia need an HIV and, depending on age, an evaluation for CVID or multiple myeloma.

And opioid use us a risk for invasive disease (PubMed).

Syndromes

S. pneumoniae: sepsis, meningitis, pneumonia, empyema, endocarditis, pericarditis, bacteremia in HIV. Invasive disease should result in a work-up for antibody deficiencies and other immunodeficiencies (PubMed), including specific polysaccharide antibody deficiency, which you test for by looking for response to the 23 valent pneumococcal vaccine (PubMed).

Hemolytic Uremic Syndrome can also be caused from bacteremic Streptococcus pneumoniae (PubMed)(PubMed). The mechanism is here: "These clinical isolates of HUS pneumococci efficiently bound human plasminogen via the bacterial surface proteins Tuf and PspC. When activated to plasmin at the bacterial surface, the active protease degraded fibrinogen and cleaved C3b. Here, we show that PspC is a pneumococcal plasminogen receptor and that plasmin generated on the surface of HUS pneumococci damages endothelial cells, causing endothelial retraction and exposure of the underlying matrix (PubMed)."

The risk for heart attack or stroke after pneumococcus is maximal in the first week after infection (PubMed).

Treatment

S. pneumoniae has three forms of resistance to penicillin:

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporin or vancomycin.

If you are treating pneumonia, there are numerous studies to show that combining the beta-lactam with azithromycin decreases mortality.

Can be resistant to tetracyclines, macrolides, tmp/sulfa and quinolones. Never trust levofloxacin or ciprofloxacin, but moxifloxacin may have good enough MIC's to work, If allergies, vancomycin or linezolid are reasonable alternatives.

There is a meropenem resistant strain in Japan (PubMed). Yippy & Skippy.

An ounce of perversion is worth a pound of pure, or something like that. Not only is the old vaccine of some value, the conjugate vaccine is effective and superior in adults (PubMed), at least as far as antibody response goes and it pneumonia related hospitalizations decline.

What is cool is vaccination of children with the Prevnar leads to a decrease in adult disease (PubMed). Treating the vector is an effective preventative.

Streptococcus pseudopneumoniae

Epidemiologic Risks

Can be mistaken for S. pneumoniae.

Syndromes

S. pseudopneumoniae: maybe COPD pneumonia (PubMed for the recent skinny)?

Treatment

High rates of decreased susceptibilities and resistance to erythromycin 57% and tetracycline 43% and reduced susceptibility to penicillin in 21% of the isolates (PubMed).

S. pyogenes

Epidemiologic Risks

Part of life, human to human spread. It can be spread by food leading to outbreaks (PubMed). Obesity and diabetes are risks for invasive disease (Pubmed).

Syndromes

S. pyogenes: cellulitis, toxic shock syndrome, rheumatic fever, pharyngitis, vaginitis, glomerulonephritis.

"Acute non rheumatic streptococcal myocarditis is an under recognized and treatable cause of ST­segment elevation and chest pain in young adults with a history of recent pharyngitis (PubMed).

Treatment

Any beta lactam (except aztreonam) will do, penicillins are still the best. If allergies, vancomycin or linezolid. are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work, macrolides and doxycycline are still active. I was aways taught that S. pyogenes was resistant to sulfa, but that may be an artifact of testing (PubMed).

For severe/extensive disease, ICU bound, cefazolin PLUS clindamycin. Why? The Eagle effect, where high inoculum of Group A Strep are resistant to pencillin and patients do better on clindamycin (PubMed). Plus I do have an affinity for screwing with bacterial virulence factors aka proteins.

IDSA Guidelines for pharyngitis.

BUT. If your are trying to prevent rheumatic Fever, do not trust anything by a beta-lactam (PubMed).

Necrotizing fasciitis or Toxic Shock Syndrome, debride the wound. If you don't debride the wound, the patient will die. Also penicillin to kill the bug PLUS clindamycin (900 q 8 to interfere with toxin production plus the Eagle effect) (PubMed). PLUS IVIG (1 gram/kg on day one and 0.5 gm/kg on day 2 and 3 (PubMed)) to bind toxin (an area of controversy (PubMed), I am a believer). IVIG may not help in children (PubMed).

S. sanguis

Epidemiologic Risks

Mouth flora.

Syndromes

S. sanguis: bacteremia and endocarditis.

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

S. salivarius

Epidemiologic Risks

Mouth flora.

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

Syndromes

S. salivarius: bacteremia and endocarditis. It is a cause of post lumbar puncture meningitis (PubMed) (PubMed).

Treatment

S. suis

Epidemiologic Risks

Pigs (PubMed) (Review), including drinking raw pigs blood, which you think would be a bad idea on the face of it, but not in Vietnam evidently (PubMed).

Of course there was the time my father-in-law to be offered me baked pigs blood, a Minnesota/German thing, that looks just like a brownie. Doesn't taste like it. Hilarity ensued.

Also found in wild boars in Spain (PubMed).

Syndromes

S. suis: In SE Asia the most common cause of meningitis (PubMed).

Treatment

Use penicillin. In Vietnam, resistance to tetracycline, erythromycin and chloramphenicol is increasing.

S. tigurinus

Epidemiologic Risks

Oral flora.

Syndromes

S. tigurinus: "infective endocarditis, spondylodiscitis, bacteremia, meningitis, prosthetic joint infection, thoracic empyema (PubMed)" and a hodgepodge of infections (PubMed).

Treatment

Sensitive: MIC <0.1 ug/ml. Use penicillin.

Intermediate: MIC 0.1 - 1.0 ug/ml use lots of penicillin except for meningitis, where you should use a third generation cephalosporin. For endocarditis use 4 weeks of penicillin PLUS 2 weeks of gentamicin.

Resistant: MIC > 2 ug/ml use a third generation cephalosporins OR vancomycin. For endocarditis use 6 weeks of penicillin PLUS 6 weeks of gentamicin.

Macrolide resistance is increasing. If allergies, vancomycin or linezolid are reasonable alternatives. Never trust levofloxacin or ciprofloxacin, but gatifloxacin or moxifloxacin may have good enough MIC's to work. Did you see that need for evaluation of colonic cancer in a patient who is bacteremic with this organism?

Notes

Here is, I think, a key finding for S. aureus and Streptococcus bacteremia (PubMed):

"An intensive search for metastatic infectious foci was performed including 18F-fluorodeoxyglucose-positron emission tomography in combination with low-dose computed tomography scanning for optimizing anatomical correlation (FDG-PET/CT) and echocardiography in the first 2 weeks of admission. Metastatic infectious foci were detected in 84 of 115 (73%) patients. Endocarditis (22 cases), endovascular infections (19 cases), pulmonary abscesses (16 cases), and spondylodiscitis (11 cases) were diagnosed most frequently. The incidence of metastatic infection was similar in patients with Streptococcus species and patients with S. aureus bacteremia. Signs and symptoms guiding the attending physician in the diagnostic workup were present in only a minority of cases (41%). "

Curious Cases

Relevant links to my Medscape blog

Hey. Look at my cool case.

Unexpecting

Why Why Why

Bovis, part one.

Bovis, yet again.

Holding a Grudge

Frankly

The Names Keep Changing

Fly Like and Eagle

Evolution in action: Strep Pneumoniae resistance over time

A Strep I had not heard of. Which one? I am not telling in the title. Call it a strep tease.

Same bug, different sites

Three's

Worth a Syndrome?

First Ever.

Three Thousand Words Plus a Few More

Creep. Hip Hop or Alt?

Dead Men Tell No Wives

Otitis Gone Bad

Just So

Flight of Fancy

What makes me guilty

Overcoming the I/O bottleneck to the faulty RAM.

Sinking Feeling

Low levels? I was looking for increased.

One Thing

Curbsides

Digital Information

Common plus Common equals Uncommon

Unlike NW Forests, ID is Never Clear Cut

Gee

Big Picture: Why?

Man. I Hate Failure.

Euripides is Setting Me Up

Hand to Mouth Disease

Can't exclude

Rogue Plastic

Right. Wrong. Then right, kind of.

Why? How Long?

True Name

Horsing Around

Take That.

Blue Ink

Rash Treatments

Gas

How did it get there?

Interface Change

Snuggle

More is not better

NSAIDS: Anti inflammatory is a bad thing

Last Update: 07/15/18.