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Streptococcus Anginosus Group Infections: Management and Outcome

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Streptococcus Anginosus Group Infections: Management and Outcome Journal of Infection and Public Health 13 (2020) 1749–1754 Contents lists available at ScienceDirect Journal of Infection and Public Health journa l homepage: http://www.elsevier.com/locate/jiph Original Article Streptococcus anginosus group infections: Management and outcome at a tertiary care hospital a,∗ a a b c a F. Al Majid , A. Aldrees , M. Barry , K. Binkhamis , A. Allam , A. Almohaya a Infectious Diseases Division, Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia b Microbiology Unit, Department of Pathology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia c Department of Internal Medicine & Critical Care, King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia a r t i c l e i n f o a b s t r a c t Article history: Background: Data on patients with invasive Streptococcus anginosus group (SAG) infections is limited, as Received 27 April 2020 it’s been considered commensal bacteria in the human microbiota. We conducted an analysis of SAG Received in revised form 7 July 2020 infections to assist clinicians in understanding their burden and clinical outcomes. Accepted 28 July 2020 Methods: A retrospective study of medical records, identifying invasive SAG bacteria of sterile-site isolates that were managed from May 2015 to April 2017, at a tertiary care hospital in Riyadh, Saudi Arabia. Keywords: Demographic data, clinical presentation, site of infection, antibiotic use, and outcome were recorded and Streptococcus anginosus group analyzed to identify factors associated with poor outcome and/or polymicrobial growth. Burden Abscess Results: We identified 105 cases of SAG infections in adults, with 52% of the patients being male and the Polymicrobial mean age of 52.4 years with comorbidities occurring in more than half of the cases such as diabetes (38%) Mortality and malignancy (15%). Overall mortality was 6%, and it was statistically associated with age older than 65 years, polymicrobial growth and a history of malignancy. The infection frequencies were skin and soft tissue infections (SSTI; 55%), intra-abdominal infections (24%), bacteremia (14%), genitourinary infec- tions (8.5%), and pleuropulmonary infections (5%). Abscesses accounted for 68% of cases. Polymicrobial infection (46%) with Enterobacteriaceae and Gram-negative anaerobes coincided with SAG infection. Polymicrobial growth was significantly associated with abscess formation, intra-abdominal source of infections, and poor outcome. In addition, death in patients with SAG was statistically associated with patients older than 65 years of age and those with history of cancer or transplant. Conclusion: SSTIs and intra-abdominal infections are the most common clinical presentations in our cohort. Bacteremia was uncommon; however, the prognosis is less favorable. Overall susceptibility to penicillin was 91%, therefore ␤-lactam antibiotics are the drug of choice and additional coverage for anaerobic and gram-negative bacteria should be considered for intra-abdominal collection and solid or organ abscesses. © 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/). Introduction cus intermedius, and Streptococcus constellatus [1,2]. SAG bacteria are considered commensals of mucosal membranes, i.e., of the The Streptococcus anginosus group (SAG), commonly referred oropharyngeal [2], gastrointestinal, and genitourinary tract [3], to as the Streptococcus milleri group, is among five subgroups with vaginal colonization resulting from spread from the digestive within the viridans-group streptococci that includes three distinct system [4]. There have been several studies demonstrating that SAG species streptococcal species: Streptococcus anginosus, Streptococ- members are increasingly recognized as an etiology of invasive pyo- genic infections at almost every sites in the body in both adults and children [3,5–9]. SAG bacteria were initially recovered from dental abscesses causing oral infections and are frequently isolated from ∗ Corresponding author. dental caries and periodontal diseases [9]. E-mail addresses: [email protected] (F. Al Majid), a m al [email protected] However, these bacteria are now increasingly being found to (A. Aldrees), [email protected] (M. Barry), [email protected] cause infection at any anatomical site in the body, including the (K. Binkhamis), [email protected] (A. Allam), [email protected] lungs, liver, brain, intra-abdominal areas, as well as the skin and (A. Almohaya). https://doi.org/10.1016/j.jiph.2020.07.017 1876-0341/© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1750 F. Al Majid et al. / Journal of Infection and Public Health 13 (2020) 1749–1754 Table 1 soft tissues [10–13]. Clinically, this group is associated with variable Characteristics and laboratory findings of 105 patients. clinical presentation, with a proclivity for causing pyogenic and sys- temic infections with abscess formation [6,14–16]. The incidence of Variable n (%) pyogenic invasive infections caused by SAG exceeds the combined Age, median (years) incidence of group A (Streptococcus pyogenes) and B (Streptococ- Above 65 years 15 (14.3%) cus agalactiae) and different tertiary hospitals have reported an Below 65 years 90 (85.7%) Sex estimated incidence of 8.6–8.8/10,000 hospitalized patients [6]. Male 55 (52.4%) The organisms in this group are microaerophilic, catalase- Female 50 (47.6%) ␣ negative, gram-positive cocci that are often -hemolytic, although Comorbidities ␤ they may occasionally be -hemolytic or nonhemolytic. SAG bac- None 38 (36%) Diabetes mellitus 36 (38%) teria grow aerobically and anaerobically, forming minute colonies Malignancies 16 (15%) (less than 0.5 mm) and producing a sweetish caramel-like odor Chronic renal failure 13 (12%) related to the production of diacetyl [17,18]. They are generally Pregnancy and postpartum 9 (8%) ␤ susceptible to -lactam antibiotics. Site of infection Failure to properly identify the species in streptococcal iso- SSTI 58 (55%) Intra-abdomen 25 (24%) lates in routine diagnosis is a probable explanation for why the Bacteremia 15 (14%) pathogenicity of these species may have previously been over- Genitourinary 9 (8.5%) looked. Another reason may be that they are considered part of Pleuropulmonary 6 (5%) human commensals and are therefore commonly considered a Liver abscess 1(0.9%) Brain abscess 1(0.9%) contaminant, especially in diagnostic samples of polymicrobial infections. Penicillin susceptibility Resistant 6 (5%) The three species in this group tend to be associated with a Intermediate 4 (3%) different clinical presentation [7]. S. anginosus, for example, is pre- Susceptible 95 (91%) dominantly isolated from blood cultures and often presents as part Organisms isolated Monomicrobial 57 (54%) of a polymicrobial infection in patients with oral, head and neck, Polymicrobial 48 (46%) and abdominal abscesses [3,19,20]. S. intermedius is often present Mortality in brain abscesses, while S. constellatus is frequently isolated No 99 (95%) from soft tissue infections, respiratory tract and intra-abdominally Yes 6 (5%) located abscesses [20–22]. However, these species’ associations SSTI: Skin and soft tissue infection. have recently been challenged, and discrepancies between per- ceived species’ associations and clinical presentations may be due with characteristics caramel odor) as well as negative catalase test to different identification methods [6,16]. An increasing number of results [1]. Definite identification was obtained using the VITEK 2 recent findings have shown that SAG members have a pathogenic (BioMerieux,´ Marcy-l’Etoile,´ France) and isolates had been reported effect in cystic fibrosis [6,16,23,24]. Fortunately, the treatment of as SAG and species was not identified. Testing for antimicrobial sus- SAG infection is feasible, as most isolates are susceptible to ␤- ceptibility had been performed using the VITEK 2 Streptococci AST lactam antibiotics [25]. card and the E test (BioMerieux,´ Marcy-l’Etoile,´ France) gradient Since the discovery of SAG in 1956, a number of case series diffusion method for penicillin and ceftriaxone. Clinical & Labora- have been published in the international literature. However, there tory Standards Institute interpretive breakpoints were used [27]. has only been one study conducted in Saudi Arabia, in 1987 [26]. Data on surgical intervention, including drainage of abscesses and Therefore, we aimed to describe the largest series of SAG infections debridement of wounds, were recorded. The outcome was deter- reported in Saudi Arabia to assist clinicians in better understanding mined based on the inpatient survival of the SAG infectious episode. the clinical presentations, potential risk factors, and management Statistical analysis was performed by the SPSS software (version- outcomes of SAG infection. 23, IBM Corp., Armonk, N.Y., USA) to explore the p-value using Pearson chi-square test, and to subject study variables to calculate Methodology the odds ratio and 95% confidence interval. In addition, a dedicated analysis was performed to identify the most significant variables associated with survival and/or
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