Microbiology
Gram-positive cocci in chains.
There are many ways to classify streptococci: hemolysis, Lancefield (Group A, B, etc. Lansfield typing only of help for A and B. The rest of the time, not so much.) (PubMed), biochemicals and more. Suffice it to say microbiologists like to meet every couple of years, 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. gordonii, S. salivarius. S. tigurinus. Usually cause endocarditis or in mixed infections above the diaphragm like lung or neck abscesses.
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, Streptococcus equi sub-species zooepidemicus.
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 an 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). Also found in Brazilian tilapia fish farms (PubMed).
Serotype IV is passed back and forth from humans 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.
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 susceptibility 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 the 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 the 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).
Dogs licking diabetic leg ulcers a common risk.
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 of 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.
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).
One case of endocarditis who got the organism from his horse (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.
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.
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 tumors (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 the 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.
S. milleri
Epidemiologic Risks
Mouth flora.
Syndromes
S. milleri: endocarditis and is associated with an 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.
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.
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.
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.
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.
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 hypogammaglobulinemia (PubMed). All patients with bacteremia need an HIV and, depending on age, and 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 workup for antibody deficiencies and other immunodeficiencies (PubMed), including specific polysaccharide antibody deficiency, which you test for by looking for a 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 of heart attack or stroke after pneumococcus is maximal in the first week after infection (PubMed).
7% of patients under age 40 with bacteremia from Streptococcus pneumoniae, Streptococcus pyogenes group A, Neisseria meningitidis, Neisseria gonorrhoeae, or Haemophilus influenzae will die and 25% will be readmitted in the subsequent two years. They have immunologic issues: low immunoglobulins or a complement deficiency (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 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, scarlet fever, glomerulonephritis.
"Acute non-rheumatic streptococcal myocarditis is an under-recognized and treatable cause of ST segment elevation and chest pain in young adults with a history of recent pharyngitis (PubMed).
7% of patients under age 40 with bacteremia from Streptococcus pneumoniae, Streptococcus pyogenes group A, Neisseria meningitidis, Neisseria gonorrhoeae, or Haemophilus influenzae will die and 25% will be readmitted in the subsequent two years. They have immunologic issues: low immunoglobulins or a complement deficiency (Pubmed).
Treatment
This should scare the hell out of you: "Decreased beta-lactam susceptibility is geographically widespread in strains of numerically common emm gene subtypes(Pubmed)". Now keep reading with that in mind.
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 always 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 penicillin 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 you 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 days 2 and 3 (PubMed)) to bind toxin (an area of controversy (PubMed), I am a believer). IVIG may not help in children (PubMed) but a meta-analysis found it halved the mortality (PubMed) "with remarkable consistency across the single randomized and four nonrandomized studies."
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.
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.
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 pig 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.
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
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.
Three Thousand Words Plus a Few More
Overcoming the I/O bottleneck to the faulty RAM.
Low levels? I was looking for increased.
Common plus Common equals Uncommon
Unlike NW Forests, ID is Never Clear Cut
Right. Wrong. Then right, kind of.
NSAIDS: Anti inflammatory is a bad thing
Last Update: 02/16/20.