Streptococcus milleri

Streptococcus milleri and Recurrent Intra-Abdominal Abscesses: A Case Report and Literature Review

Streptococcus milleri

We report a case of recurrent intra-abdominal abscesses as a postoperative complication following diverticular perforation in which Streptococcus milleri (SM) was isolated. SM is evaluated here as a potent pyogenic organism commonly associated with intra-abdominal abscess especially in the postoperative setting.

With the commonly adopted conservative management, the challenges of recurrence and prolonged hospital stay experienced in the indexed case as well as many other previous reports are highlighted.

We also present a recommendation of the need for a more intensive approach of SM-related abscess drainage along with areas that would benefit further research.

1. Introduction

Streptococcus milleri (SM) infection (also known as Streptococcus anginosus) has been shown to be commonly associated with surgical intervention.

These organisms are well known for their very potent pyogenic potential and high abscess recurrence rate despite antibiotic treatment.

We report a case of SM isolation from intraabdominal pus following sigmoid diverticular perforation and the challenges involved in the surgical management.

2. Case Report

An otherwise fit and healthy 56-year-old man presented to the emergency department with a week history of generalized abdominal pain associated with nausea and anorexia.

Examination revealed generalized peritonitis.

Erect chest X-ray showed extensive free air under both hemidiaphragms suggesting a perforated viscus while C-reactive protein and white cell count were raised at 368 mg/L and 20.16 × 109/L, respectively.

He was resuscitated with intravenous fluids, analgesia, commenced on empiric antibiotics (1.2 grams of amoxicillin/clavulanic acid and 500 milligrams of metronidazole, three times a day) and scheduled for urgent surgery. Initially, a laparoscopic approach was employed but converted to open due to technical difficulties.

Intraoperative findings included multiple intraperitoneal abscess cavities and an inflamed and thickened sigmoid colon. The perforation was not distinctively identified and was thought to be sealed within the thickened sigmoid colon.

Hartmann’s procedure was performed, abscesses were drained, aspirate was sent for culture, and peritoneum copiously lavaged.

The patient had a slow postoperative recovery on ICU with persistently raised inflammatory markers (C-reactive protein > 200 mg/L and white cell count > 15 × 109/L) which necessitated changing antibiotics to 4.5 grams of piperacillin/tazobactam, three times a day. Peritoneal aspirate was positive for S. milleri and a scanty amount of E.

coli after 48 hours of culture; following this, weight-tailored doses of gentamicin were added. Histopathology analysis of the sigmoid specimen revealed evidence of perforated diverticulum. CT scan on the 5th postoperative day showed extensive multiloculated gas and fluid collection in the left abdomen extending from the diaphragm to the pelvis.

Percutaneous drainage of this collection was performed, following which the patient made remarkable clinical progress initially. However, shortly after, he developed pyrexia and abdominal pain.

Repeat CT scan showed a reduction in the size of the left flank and pelvic collections but presence of a left subphrenic collection.

Due to lack of clinical improvement over the following days with continued antibiotics, another drain was into the left subphrenic collection. He made good clinical improvement, drain output reduced and inflammatory markers normalized.

After a total course of about 2 weeks of IV antibiotics, he had the flank drain removed and was discharged with oral antibiotics. On follow-up in the clinic after 2 weeks, he was clinically well and the subphrenic drain was also removed.

3. Discussion

SM organisms are well known for their very potent pyogenic potential and high abscess recurrence rate despite antibiotic treatment. Abscess formation by these organisms has been reported in a wide range of organs and systems; however they cause more intra-abdominal infections compared to other sites [1, 2].

While the exact mechanism of abscess formation by SM organisms is yet to be fully established, this has been linked to their ability to secrete toxins that inhibit polymorphonuclear leukocytes ingestion and also prolong their survival after ingestion [3]. They also produce hydrolytic enzymes such as hyaluronidase which is thought to be responsible for spreading organisms through tissue and assist in the liquefaction of pus [4, 5].

SM infection has been shown to be commonly associated with surgical intervention, especially abdominal procedures. Stezmuller et al. in a study assessing pattern of infection in 24 patients with SM bacteraemia found that up to 15 patients (62.5%) had a surgical procedure before SM-positive blood culture.

They noted that SM can be considered a “strong surgical pathogen” and recommended that, with a positive blood culture, a surgical sepsis should be considered. In another report, SM was the commonest organism found in pus culture (73%) following drainage of intra-abdominal abscess complicating appendectomy [6].

Similarly, SM organisms were associated with a sevenfold increase in abscess formation following appendectomy despite antibiotics and consequently increased morbidity and prolonged hospital stay [7]. SM isolation from intra-abdominal pus following sigmoid diverticular perforation is presented here along with the challenges involved in the surgical management.

Similar to previous reports, extensive postoperative multiloculated intra-abdominal abscesses were found which necessitated repeated percutaneous drainage and prolonged antibiotic use.

In terms of antimicrobial therapy, SM organisms are largely susceptible to penicillins and also show good sensitivity to other beta-lactam antibiotic cephalosporins and carbapenems [8, 9].

Similar to other reported cases, antibiotics here were tailored to the sensitivity of SM isolated; however the patient did not make significant clinical progress postoperatively until the abscesses were repeatedly drained.

Though it is well established that successful treatment of abscess generally relies on their drainage, evidence points to a need for a closer look into the method of achieving the optimal drainage in intra-abdominal abscess caused by such pyogenic organisms SM. Current approach of radiologically guided drainage and antibiotics is associated with a high recurrence rate. Ripley et al.

in a study of 39 patients with SM pleural space infection retrospectively compared operative drainage (video-assisted thoracoscopic surgery and thoracotomy) with nonoperative drainage (thoracostomy tube and radiologically placed pigtail catheters) [10]. They reported shorter hospital stay and less mortality in the operative compared to the nonoperative group.

Their explanation was that SM infections tend to cause loculated collections which are less ly to be amenable to tube or catheter drainage. The intra-abdominal abscess in the case we reported was noted to be similarly multiloculated.

It is therefore a plausible extrapolation that an operative, for example, laparoscopic washout may have benefited our patient more; however this requires further studies to validate.

With such robust evidence for SM association with recurrent intra-abdominal abscesses, we suggest that a more intensive approach to drainage may be necessary as conservative use of radiologically placed drains have been met with high recurrence and morbidity.

The value of surgical drainage in comparison to radiologic drainage is worth investigation as preliminary evidence has shown that operative drainage offers better outcome in pleural space collections.

Other modifications in the management of SM abscess that needs further research into for added benefit include the timing and duration of antibiotics, use of repeated imaging to aid in timely identification of recollection, and optimal size and type of drains to be used.

Competing Interests

The authors declare that they have no competing interests.

Copyright © 2016 Tabitha M. Gana et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Источник: https://www.hindawi.com/journals/cris/2016/6297953/

Pleural Effusion Due to Streptococcus milleri: Case Descriptions | Archivos de Bronconeumología (English Edition)

Streptococcus milleri

In this study we analyzed the characteristics of patients with pleural effusion secondary to Streptococcus milleri studied retrospectively between January and March 2013 and found seven patients with a mean age of 60 years; 43% of them were smokers and 57% with a drinking habit. The most common associated factors were alcoholism, previous pneumonia and diabetes.

Other bacteria were identified as Enterobacter aerogenes, Bacteroides and Prevotella intermedia capillosus in two patients. The mean duration of antibiotic therapy was 28 days; six patients underwent pleural drainage by chest tube and one patient needed surgery due to poor clinical progress.

The mean duration of hospitalization was 30days with satisfactory outcome in all cases, despite some changes in residual function.

Se realiza un análisis retrospectivo de las características de los pacientes con derrame pleural secundario a Streptococcus milleri diagnosticados en nuestro hospital entre enero de 2011 y marzo 2013.

Se diagnosticaron 7pacientes con una edad media de 60años, el 57% con hábito enólico importante y el 43% fumadores. Los factores asociados más frecuentemente fueron el alcoholismo, la existencia de neumonía previa y diabetes mellitus.

En 2pacientes se identificaron otros gérmenes, como Enterobacter aerogenes, Bacteroides capillosus y Prevotella intermedia. La duración media del tratamiento antibiótico fue de 28días. En 6casos (86%) se realizó drenaje pleural con tubo de tórax, y un paciente precisó cirugía por evolución tórpida.

La duración media de la hospitalización fue de 30días, con evolución satisfactoria en todos los casos, aunque con alteración funcional restrictiva residual.

Introduction

The term Streptococcus milleri, traditionally classified under the viridans group, is a heterogeneous group of microorganisms that includes Streptococcus anginosus, intermedius and constellatus.

They are oral, nasopharyngeal, gastrointestinal and genitourinary mucosa saprophytes and are pathological in patients with predisposing factors.1 In contrast to the patterns observed some decades ago, bacteria in this group are now the most common pathogens in the etiology of community-acquired pleural infections.

1,2 The aim of our study is to analyze the clinical characteristics, associated factors, and clinical course of patients with S. milleri empyema.

Patients and Methods

This was a retrospective study performed in patients with a diagnosis of pleural empyema in whom S. milleri was isolated in pleural fluid in our hospital between January 2011 and March 2013.

The variables studied were age, sex, associated factors, smoking habit, consumption of alcohol, previous endoscopic procedures, symptoms, clinical laboratory and radiological changes, treatment and clinical course.

The SPSS 12.0 statistical software package was used for statistical analysis. A descriptive analysis was performed with qualitative variables expressed as simple frequencies and quantitative variables as mean and standard deviation.

Results

A total of 7 patients were studied, of which 6 (86%) were male. Mean age was 60.2 years (55–67; SD: 3.7). Three were smokers (43%) and 2 were ex-smokers (27%). Most common associated factors were alcoholism in 4 patients (57%), previous pneumonia in 3 (43%) and diabetes mellitus in 3 (43%). None of the patients had neurological disease or swallowing disorders.

The main symptoms were fever in 5 patients (71%), pleuritic pain in 4 (57%) and cough with purulent expectoration in 3 (43%). Elevated C-reactive protein (CRP) was found in all patients, with a mean level of 36mg/l (SD: 15). Only 2 patients (29%) had raised procalcitonin (PCT); the mean value was 0.8ng/ml (SD: 0.8).

Empyema was primary with no evidence of consolidation in 3 patients (43%). Anaerobic bacteria were isolated in 2 patients (29%): Enterobacter aerogenes, Bacteroides capillosus and Prevotella intermedia. In 3 cases, S. milleri was resistant to erythromycin, clindamycin and amoxicillin. The mean duration of antibiotic treatment was 28 days (SD: 11).

Pleural drainage by chest tube was required in 6 patients (86%) and 1 patient underwent ultrasound-guided thoracocentesis for evacuation of fluid. Three patients required fibrinolytics with urokinase for a mean of 6 days (SD: 2). Clinical course was satisfactory in 5 patients (71%).

One patient required surgery due to poor clinical progress, undergoing pleural decortication and pulmonary debridement without complications. One patient was admitted to the intensive care unit due to septic shock associated with empyema and sub-diaphragmatic abscess secondary to perforated gangrenous appendicitis.

Length of hospitalization was 30 days (8–72; SD: 23.7). None of the patients died. They all had minimal pleural thickening and 2 individuals (29%) had restrictive ventilatory changes.

The main patient characteristics are described in Table 1. Fig. 1 shows the radiological characteristics of one of the patients.

Discussion

S. milleri is the most common causative agent in pyogenic infections, and most of which are located in the abdomen, the central nervous system and the chest.

3 These infections usually occur in adults over 50 years of age and more often in patients with predisposing pathological factors.

In our series, 86% of the patients had predisposing factors which could cause a certain degree of immunosuppression and their mean hospital stay was prolonged due to the need for pleural procedures and prolonged antimicrobial regimens.

S. milleri bacteremia is uncommon and generally associated with a septic intraabdominal focus,5 as was the case in one of our patients. The chest is involved in one fifth of S.

milleri infections, the most common manifestations being empyema and less frequently mediastinitis and lung abscess.

1,3–5 In our series, empyema was associated with lung abscess in 2 cases (29%), and 3 cases (43%) were primary empyema.

The pathogenic role of the co-existence of anaerobic bacteria and Streptococcus has been established. This concomitancy leads to synergy that increases virulence, lung tissue damage and the dissemination of the infection4: this was the case in 2 of our patients (29%).

Earlier studies in patients with S. milleri pleuropulmonary infection found that between 67% and 87% of cases required invasive procedures and antimicrobial treatment.5 Pleural fluid drainage may suffice in early stages, but advanced stages require video-assisted thoracic surgery (VATS) that according to most studies should be carried out between 3 and 7 days after failed drainage.5

This group of bacteria are very sensitive to ureidopenicillins, carbapenem and cephalosporins,3–5 although resistance has been reported in up to 33% of cases of S. intermedius.

3 In our series, the mean antibiotic treatment time was 28 days, but this varies in other published series (10–65 days).5 Our conclusion is that S.

milleri must be considered in community-acquired empyemas, and should be appropriately treated with antibiotics and early pleural drainage in order to avoid major surgical procedures and long periods of hospitalization and to improve prognosis.

Please cite this article as: Madrid-Carbajal CJ, Molinos L, García-Clemente M, Pando-Sandoval A, Fleites A, Casan-Clarà P. Descripción de casos de derrame pleural secundario a Streptococcus milleri. Arch Bronconeumol. 2014;50:404–406.

Источник: https://www.archbronconeumol.org/en-pleural-effusion-due-streptococcus-milleri-articulo-S1579212914002031

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Источник: https://link.springer.com/article/10.1007/BF01960802

Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (“Streptococcus milleri Group”) Are of Different Clinical Importance and Are Not Equally Associated with Abscess

Streptococcus milleri

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Difficulties in distinguishing organisms of the “Streptococcus milleri group” (SMG; Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus), have caused ambiguity in determining their pathogenic potential. We reviewed 118 cases in which SMG isolates had been identified using 16S rDNA sequence. S. constellatus and S. anginosus were isolated far more frequently than was S. intermedius. Nearly all isolates of S. intermedius and most isolates of S. constellatus, but only 19% of those of S. anginosus, were associated with abscess. Our findings suggest that speciation of the SMG may guide diagnostic evaluation, give insight into the possible role of coinfecting organisms, and help assess the need to search for occult abscess.

The “Streptococcus milleri group” (SMG) has been known by a variety of names [1] and, in the past, has been considered a single species that is loosely synonymous with S. anginosus [2].

Members of the SMG are now separated into 3 distinct species—Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus—with S. constellatus and S. intermedius being more closely related to each other than to S. anginosus [3–5].

However, because many phenotypic tests for the characterization of these species yield similar results, identification of isolates can be difficult.

Possibly because of this difficulty in the identification of isolates, studies that have speciated isolates of SMG and have attempted to correlate them with clinical syndromes have not reached definitive or consistent conclusions; the species seem to have overlapping clinical associations [6–9].

However, some studies that have detailed the site of isolation have suggested that S. anginosus is more ly to be isolated from blood, urogenital, and gastrointestinal specimens, whereas S. intermedius tends to be associated with infection of the head, neck, and respiratory tract [1, 8–10].

One of the most striking features of species in the SMG is their tendency to cause abscesses.

However, both the potential of each of the SMG species to cause abscess and the clinical features of the cases associated with abscess have not been addressed in depth with regard to well-identified strains.

We definitively identified the isolates to species that led to 118 cases of infection due to SMG by use of 16S rRNA gene sequence and biochemical tests, and we evaluated the data for clinical significance by means of careful and complete review of medical records. Cases of infection that were associated with abscess were examined in greater detail for severity, site of abscess, and coisolated organisms.

Methods. Identification of clinical isolates, which were recovered by and stored (at a temperature of −70°C) at the Microbiology Laboratory, Veterans Affairs Medical Center, Houston, during 1989–1999, was done as described elsewhere [3].

In brief, strains were characterized as belonging to the SMG by means of biochemical profiling done with the use of the API 20 Strep test (BioMérieux Vitek), and they were characterized as to species by use of the Fluo-Card Milleri test kit (KEY Scientific Products).

16S RNA sequencing was used to definitively identify all strains [3]. The PCR products were sequenced and purified with use of the MicroSeq 500 gene kit protocols and were run on an ABI Prism 377 Sequencer (PE Applied Biosystems).

Bacterial identifications 16S rRNA gene sequence data were assigned by use of MicroSeq Microbial Identification and Analysis Software (PE Applied Biosystems).

Patients were included in the study if the infecting streptococcus could be assigned unambiguously to a species and if available clinical information allowed for the type of infection to be clearly characterized.

To avoid bias, record review and clinical characterization were completed without knowledge of the results of the microbiological studies. For all patients, a careful search was made for evidence of abscess formation.

For the purposes of this study, we regarded localized infection in closed spaces as abscess; examples include thoracic empyema, subdural abscess, ventriculitis, subcutaneous abscess, and septic arthritis.

Certain cases of suppurative soft tissue infection, including gangrene, infection of either a decubitus ulcer or a foot affected by diabetic neuropathy, and cellulitis were not regarded as abscess.

Fisher's exact test was used to determine whether there were significant differences among the 3 bacterial species. For all tests, α =.05.

Results. The distribution of individual species of the SMG, stratified according to the type of specimen submitted to the laboratory, is shown in table 1. Of 122 SMG isolates, 58 (48%) were recovered from exudate, aspirate, or fluid samples, and 33 (27%) were recovered from blood samples.

The remaining 31 isolates (25%) were recovered from the genitourinary tract, the upper respiratory tract, or other sources. The SMG was isolated from 2 sites in each of 3 patients, and S. intermedius and S. constellatus both were isolated from the same specimen obtained from 1 patient.

Therefore, we analyzed a total of 122 isolates from 118 patients.

Open in new tabDownload slide

Distribution of individual species within the “Streptococcus milleri group,” according to the specimen submitted to the laboratory for culture.

S. intermedius was the least commonly isolated member of the SMG (14 [11%] of 122 isolates). Twelve (86%) of these 14 isolates were recovered from an abscess (4 isolates) or from a normally sterile site in association with an abscess (3 of 5 blood isolates and 2 of 2 CSF isolates).

The 2 blood isolates that were not definitely associated with abscess were recovered from a paraplegic man who had a deep decubitus ulcer and from a man who had diabetes and gangrene of the foot. S. intermedius was not isolated from genitourinary tract or upper respiratory tract sources.

Therefore, 12 (86%) of 14 isolates obtained from 10 (83%) of 12 patients were attributed to an abscess.

Fifty-six isolates of S. constellatus (46% of the SMG) were recovered from 54 patients. Thirty-nine were recovered from exudate, aspirate, or fluid samples; 38 of these were from an abscess, and 1 was from an area of cellulitis adjacent to a scorpion bite.

Only 1 of 7 blood isolates was associated with abscess; the remaining 6 were associated with perforated bowel due to cancer, cholangitis, pancreatitis, and/or gangrene. The genitourinary tract isolates were recovered from a periurethral abscess and a scrotal abscess.

Therefore, in 41 (73%) of 56 isolates obtained from 41 (76%) of 54 patients, S. constellatus was implicated as the cause of an abscess.

A total of 52 isolates of S. anginosus were recovered from 52 patients, representing 43% of SMG. These were obtained from a broader range of sources and were less ly to be associated with abscesses. Eight (67%) of 12 isolates recovered from exudate, aspirate, or fluid samples were from abscesses; as observed for S.

constellatus, nonabscess sources included gangrenous tissue, decubitus ulcers, and areas of cellulitis. Only 2 (10%) of 21 blood isolates were recovered from patients who had an abscess; the others occurred in patients with decubitus ulcers or conditions that might be associated with translocation from the bowel, such as obstruction, colon cancer, or alcoholic cirrhosis. S.

anginosus was also isolated from urine samples obtained from 13 patients and from sputum or pharyngeal swab samples obtained from 12 patients without an abscess, as well as from miscellaneous sources. In these patients, S. anginosus was isolated as part of mixed flora; an abscess was not present, and, in fact, no infection was attributable to the organism.

For example, the β-hemolytic strains from the pharynx had been identified in a search for group A Streptococcus. Only in samples (all urine isolates) obtained from 3 patients did the streptococcus predominate, and the patients were not treated and did not have apparent sequelae. Therefore, of 52 isolates of S.

anginosus, only 10 (19%) were associated with an abscess, a frequency lower than that associated with S. intermedius or constellatus (P

Источник: https://academic.oup.com/cid/article/32/10/1511/467974

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