Viridans group streptococci septicaemia and endocarditis : Molecular diagnostics, antibiotic susceptibility and cinical aspects

Viridans group streptococci (VGS) are inhabitants in the oral cavity and in the gastrointestinal tract. They cause severe infections, they are responsible for up to 39 % of the cases of septicaemia in neutropenic patients with haematological diseases and cause infective endocarditis (IE), mainly in patients with native valves and previous heart disease. Different species cause different clinical picture, therefore the identification of the species is important. The conventional methods for identification of VGS strains, Strep API and API ZYM have not been optimal. A reduced antibiotic susceptibility to penicillin in VGS has developed during the last years, primarily for patients with haematological diseases. In the present studies we have investigated the rate of infective endocarditis and risk factors, in immunocompetent and immunocompromised patients with septicaemia. We have identified species of VGS septicaemia with old and new diagnostic methods and analysed the antibiotic susceptibility for penicillin and other antimicrobial agents in the oral cavity and blood cultures. In these studies we found that infective endocarditis was rare in patients with haematological diseases, in this group of patients VGS species as Streptococcus mitis and Streptococcus oralis dominated. When we used rnpB sequencing and PCR, it was possible to identify species of VGS that earlier has been difficult to classify. In patients with infective endocarditis, strains for the Streptococcus sanguinis group dominated, when using rnpB sequencing we also found Streptococcus gordonii and Streptococcus oralis strains in these patients. We found a reduced susceptibility to pencillin in 18 % (MIC >= 0.25 µg/ml) of the VGS isolates in 1998-2003, that is lower compared to studies from Canada where 37 % of the strains had a reduced susceptibility to pencillin. The antibiotic resistance to VGS was increased compared to 1992-1997, however different methods had been used. The highest rate of pencillin resistance in this study was found in oral swabs from haematological patients where 25% of the VGS isolates were resistant to penicillin (MIC >= 4.0 µg/ml), which was higher that we had expected. This is an important observation because the oral cavity has been described as a genetic reservoir for transferring resistance genes from VGS to Streptococcus pneumoniae. We also found that 19% of the isolates had a reduced susceptibility to erythromycin (MIC >= 0.5 µg/ml) and 80% of these strains harboured mefA and 40 % ermB. The VGS strains in 19982003 had a reduced susceptibility to ciprofloxacin; which has previously been used as antibiotic prophylaxis in neutropenic patients but is not generally recommended because of emergence of resistance. Vancomycin had a high susceptibility to VGS but it should only be used as empiric therapy for severe cases and for resistant strains because of the emergence of resistance. New antimicrobial agent as linezolid seems susceptible but should be saved for cases of antibiotic resistance

Cardiac Implantable Electronic Device Infections; Long-Term Outcome after Extraction and Antibiotic Treatment

Background: The aim of the study was to examine the treatment outcome for patients with cardiovascular implantable electronic device (CIED) infections after extraction. Methods: Patients who underwent CIED extractions due to an infection at Karolinska University Hospital 2006–2015 were analyzed. Results: In total, 165 patients were reviewed, 104 (63%) with pocket infection and 61 (37%) with systemic infection. Of the patients with systemic infection, 34 and 25 patients fulfilled the criteria for definite and possible endocarditis, respectively. Complications after extraction occurred only in one patient. Reimplantation was made after a mean of 9.5 days and performed in 81% of those with pocket infection and 44.3% in systemic infection. Infection with the new device occurred in 4.6%. The mean length of hospital stay for patients with pocket infection was 5.7 days, compared to 38.6 days in systemic infection. One-year mortality was 7.7% and 22.2% in pocket infection and systemic infection, respectively. Patients with Staphylococcus aureus infection had a higher mortality. Conclusions: In this study, the majority of the patients had a pocket CIED infection, with a short hospital stay. Patients with a systemic infection, and S. aureus etiology, had a prolonged hospital stay and a higher mortality

A nationwide cohort study of mortality risk and long-term prognosis in infective endocarditis in Sweden.

OBJECTIVES: Infective endocarditis (IE) remains a serious disease with substantial mortality. In this study we investigated the incidence of IE, as well as its associated short and long term mortality rates. METHODS: The IE cases were identified in the Swedish national inpatient register using ICD-10 codes, and then linked to the population register in order to identify deaths in the cohort. Crude mortality rates among IE patients were obtained for different time intervals. These rates were directly standardized using sex- and age-matched mortality in the general population. RESULTS: The cohort consisted of 7603 individuals and 7817 episodes of IE during 1997-2007. The 30 days all-cause crude mortality rate was 10.4% and the standardized mortality ratio (SMR) was 33.7 (95% confidence interval [CI]: 31.0-36.6). Excluding the first year of follow-up, the long term mortality (1-5 years) showed an increased SMR of 2.2 (95% CI: 2.0-2.3) compared to the general population. Significantly higher SMR was found for cases of IE younger than 65 years of age with a 1-5 year SMR of 6.3, and intravenous drug-users with a SMR of 19.1. Native valve IE cases, in which surgery was performed had lower crude mortality rates and Mantel-Haenzel odds ratios of less than one compared to those with medical therapy alone during 30-day and 5-years follow-up. CONCLUSIONS: The 30-days crude mortality rate for IE was 10.4% and long-term relative mortality risk remains increased even up to 5 years of follow-up, therefore a close monitoring of these patients would be of value

Comparison of Mortality Risks between Patients with Infective endocarditis treated with Medical Therapy Alone (n = 6613) and Valve Surgery (n = 990) using Mantel-Haenszel Statistics.

<p>Comparison of Mortality Risks between Patients with Infective endocarditis treated with Medical Therapy Alone (n = 6613) and Valve Surgery (n = 990) using Mantel-Haenszel Statistics.</p

Absolute Mortality Risks among Infective endocarditis (IE) Patients grouped by Native Valve IE surgery (n = 881), Native Valve IE non-surgery (n = 5257), Prosthetic Valve IE surgery (n = 109) and Prosthetic valve IE non-surgery (n = 781), 5-year Follow-up.

<p>Absolute Mortality Risks among Infective endocarditis (IE) Patients grouped by Native Valve IE surgery (n = 881), Native Valve IE non-surgery (n = 5257), Prosthetic Valve IE surgery (n = 109) and Prosthetic valve IE non-surgery (n = 781), 5-year Follow-up.</p

Incidence Rate and 30-days Mortality (%) of Infective endocarditis (IE) hospitalizations in Sweden during 1997 through 2007.

<p>Incidence Rate and 30-days Mortality (%) of Infective endocarditis (IE) hospitalizations in Sweden during 1997 through 2007.</p

Long-term Mortality in the Infective endocarditis Cohort compared to the Age- and Sex-matched Swedish General Population (n = 7603).

<p>IQR, Interquartile range; Obs, Observed; Exp, Expected; SMR, Standardized mortality ratio; CI, Confidence interval.</p

Demographic data and All Cause 30-days Crude Mortality Rates (%) among Different Categories of Infective endocarditis (IE) Subjects (n = 7603).

<p>Individual who both have a current drug use and a prosthetic valve are categorized among drug-users.</p><p>IQR, Interquartile range.</p

Prophylaxis and treatment of HIV-1 infection in pregnancy: Swedish recommendations 2007

Prophylaxis and treatment with antiretroviral drugs, a consequent low viral load, and the use of elective Caesarean section, are factors that radically decrease the risk of HIV transmission from mother to child during pregnancy and delivery. The availability of new antiretroviral drugs, updated general treatment guidelines and increasing knowledge of the importance of drug resistance, have necessitated recurrent revisions of the recommendations for 'Prophylaxis and treatment of HIV-1 infection in pregnancy'. For these reasons, The Swedish Reference Group for Antiviral Therapy (RAV) has, at an expert meeting on May 4, 2007, once more updated the treatment recommendations of 1999, 2002 and 2005, which were defined in cooperation with the Swedish Medical Products Agency (Lakemedelsverket). This new text takes the recently updated general HIV treatment recommendations into account. Furthermore, the very low risk of HIV transmission when the mother is treated with combination antiretroviral therapy, has undetectable levels of viraemia and no obstetric risk factors, has been considered in the recommendations concerning the mode of delivery. Finally, the recommendations for monitoring of infants born to HIV-infected mothers have been modified. The recommendations are evidence graded in accordance with the Oxford Centre for Evidence Based Medicine, 2001 (see http://www.cebm.net/levels_of_evidence.asp#levels)