Infectious Disease Compendium

Streptococcus

Microbiology

Gram positive cocci in chains; includes S. agalactiae, S. anginosus, S. bovis, S. canis, S. equi, S. equisimilis, S. iniae, S. intermedius, S. milleri, S. mitis, S. tigurinus, S. morbillorum, S. mutans, S. oralis, S. pneumoniae, Streptococcus pseudopneumoniae , S. pyogenes, S. sanguis, S. salivarius, S. tigurinus.

The classification of streptococci is always changing and I do not think even microbiologists truly understand it.

Epidemiologic Risks

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%). "

S. agalactiae aka Group B strep: part of the human GI tract. 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). Serotype IV is passed back and forth from human and cattle in Europe (Pubmed). There is a rare Group B streptococcus, Streptococcus halichoeri, in seals (PubMed).

S. anginosus: mouth flora.

S. bovis: gi flora. Now called Streptococcus gallolyticus.

S. canis: dogs and other animals. Its group G.

S. constellatus: mouth flora.

S. equi/Streptococcus equi subspecies zooepidemicus: horses, pigs, ruminants, monkeys, cats, and dogs, and guinea pigs.

S. subspecies equisimilis (was S. equisimilis): human.

S. gallolyticus: gi tract. Was S. bovis.

S. iniae: farm raised tilapia fish.

S. intermedius: mouth flora.

S. milleri: mouth flora.

S. mitis: mouth flora.

S. morbillorum: mouth flora.

S. mutans: mouth flora.

S. oralis: mouth flora.

S. pneumoniae: 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). Besides the 'classic' risks enumerated in the vaccine reccomendations (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.

Streptococcus pseudopneumoniae; can be mistaken for S. pneumoniae.

S. pyogenes: 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).

S. sanguis: mouth flora.

S. salivarius: mouth flora. It is a cause of post LP meningitis (PubMed).

S. suis: 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).

Syndromes

S. agalactiae: neonatal sepsis and bacteremia in both mother and child. And eating freeze dried placenta (PubMed). Soft tissue infections. Immunoincompetent adults (diabetes, ETOH, cancer) can get bacteremia and septic arthritis. Bacteremia without a focus.

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

S. bovis: now S. gallolyticus.

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).

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

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

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).

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

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 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.

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

S. intermedius: bacteremia and endocarditis.

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

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

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

S. morbillorum: bacteremia and endocarditis.

S. mutans: bacteremia and endocarditis.

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

S. pneumoniae: sepsis, meningitis, pneumonia, empyema, endocarditis, pericarditis, bacteremia in HIV, Hemolytic Uremic Syndrome. 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).

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

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

"Acute nonrheumatic 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).

S. sanguis: bacteremia and endocarditis.

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

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

S. tigurinus.  bacteremia and and a hodgepodge of infections (PubMed).

Treatment

Except where noted below, any beta lactam (except aztreonam) will kill any Streptococcus, penicillin is 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.

S. agalactiae:

Any beta lactam (except aztreonam) will do, penicillin is 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:

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.

S. bovis:

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. constellatus:

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.

S. equi:

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.

Streptococcus dysgalactiae subspecies equisimilis (S. equisimilus):

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.

S. gallolyticus:

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. iniae:

Any beta lactam (except aztreonam) will do, penicillin is 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. intermedius:

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.

S. milleri

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.

S. mitis:

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.

S. morbillorum:

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.

S. mutans:

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.

S. oralis:

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.

S. pneumoniae:

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 gatifloxacin or moxifloxacin may have good enough MIC's to work, If allergies, vancomycin or linezolid are reasonable alternatives.

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.

What is cool is vaccination of children with the 7-valent vaccine leads to a decrease in adult disease (PubMed). Treating the vector is an effective preventative.

Streptococcus pseudopneumoniae

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:

Any beta lactam (except aztreonam) will do, penicillin is 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).

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. No matter that it will not look infected. 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

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.

S. salivarius

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.

S. suis:

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