eMedicine Specialties > Infectious Diseases > Bacterial Infections

Streptococcus Group D Infections

John W Downs, MD, Resident Physician, Department of Medicine, Tripler Army Medical Center
Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada; Tomas Michael Ferguson, MD, Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Tripler Army Medical Center

Updated: Jan 23, 2009

Introduction

Background

Streptococcus group D infections in humans are most often associated with bacteremia, with or without endocarditis. Other less-common infections involving group D streptococci include urinary tract infections, meningitis, neonatal sepsis, spontaneous bacterial peritonitis, septic arthritis, and vertebral osteomyelitis. Traditionally, group D streptococcal infections have predominantly been caused by Streptococcus bovis, but recent taxonomy changes have produced confusion among clinicians.

S bovis is well-established in the literature as a cause of bacteremia and endocarditis and has a well-known association with gastrointestinal malignancy. For simplicity, S bovis is the terminology used throughout this article.

Pathophysiology

The portal of entry for S bovis bacteremia is the gastrointestinal tract, with the urinary tract, the hepatobiliary tree, or the oropharynx acting as the source in some cases. S bovis bacteremia, with or without endocarditis, is strongly associated with an underlying malignancy or premalignant lesions of the colon. S bovis has also been isolated more frequently from the stools of patients with such malignancies.

Associations with nonmalignant diseases of the colon have also been reported. A similar relationship between bacteremia (or endocarditis) and chronic liver disease has been established.¹ In rare cases, gastric cancer has been found upon investigation following S bovis bacteremia.² Every patient with S bovis bacteremia, with or without endocarditis, should undergo evaluation for gastrointestinal malignancy.

Frequency

United States

Isolation of S bovis from microbiology specimens, particularly blood cultures, is uncommon. The SENTRY Antimicrobial Surveillance Program in the United States does not list group D streptococci among the 10 most common organisms that cause bloodstream infections, accounting for no more than 1% of all cases.³ According to the SCOPE Program, streptococci accounted for 6% of all blood culture isolates among 30 US hospitals, with S bovis accounting for 2.4% of those streptococci.⁴

Despite these findings, the microorganisms most commonly implicated as etiologic agents in subacute infective endocarditis occurring on native valves in patients who were not intravenous drug users were Streptococcus viridans and S bovis. Since 1997, a review of the International Collaboration on Endocarditis merged database (ICE-MD) found that S bovis accounted for 16.7% of all streptococcal infective endocarditis cases reported in the United States.⁵ However, this study reported findings from only two US hospitals.

International

SENTRY data indicate that S bovis was isolated in 1.3% and 6.9% of streptococcal bloodstream infections in Canada and Latin America, respectively. Kupferwasser et al compared patients with S bovis endocarditis with patients with endocarditis secondary to other causative microorganisms. In this German study, 177 cases of definite infective endocarditis were reported between 1983 and 1996, with 22 cases (12.5%) caused by S bovis.⁶

More-recent studies have shown an increasing proportion of infective endocarditis caused by S bovis, particularly in France and neighboring areas of southern Europe. An analysis of 559 cases of infective endocarditis in France in 1999 found that 25% were caused by S bovis.⁷ A Spanish study recently reported similar findings.⁸

Mortality/Morbidity

Morbidity: A study by Kupferwasser et al showed that S bovis endocarditis is a severe infection. The duration of fever and the increased acute-phase reactants after the onset of treatment were longer than with infective endocarditis caused by other bacteria. Involvement of multiple valves and valvular damage resulting in moderate-to-severe regurgitation were also more common. Embolic events were less common and correlated with the smaller sizes of S bovis vegetations observed on transesophageal echocardiograms. Gastrointestinal lesions were observed in nearly 50% of patients with S bovis endocarditis.⁶
Mortality: Mortality rates from the same study were 45% for S bovis endocarditis and 25% for non– S bovis endocarditis. This is higher than the 7.5-38% mortality range reported previously. The increased mortality was related to the virulence of S bovis and to a more common occurrence of underlying extracardiac disease of which patients died during follow-up care.⁶

Race

Streptococcus group D infections have no known racial predilection.

Sex

Streptococcus group D infections have no reported sexual predilection.

Age

Nearly all individuals with S bovis endocarditis are older than 50 years, with a mean age of 67 years and age range of 49-76 years. This once meant that patients with S bovis endocarditis were on average older than patients with endocarditis caused by other species. However, the mean age for all cases of endocarditis has recently increased, making patients with S bovis endocarditis generally no older than those with endocarditis from other causes.⁹

Clinical

History

Meningitis, peritonitis, septic arthritis, urinary tract infections, and neonatal sepsis due to group D streptococci do not have specific clinical features.

Group D streptococcal endocarditis
- Subacute endocarditis with persistent fever lasting days or weeks
- Associated with nonspecific symptoms of systemic lupus erythematosus, including anorexia, weight loss, fatigue, night sweats, and weakness
Group D streptococcal bacteremia
- Fever
- Only possible to distinguish from endocarditis with patient history and echocardiography

Physical

Group D streptococcal bacteremia manifests as fever without localizing signs.

The following are the physical findings of group D streptococcal endocarditis:

A minority of patients with group D streptococcal endocarditis have heart murmurs.
Classic peripheral signs occasionally observed include splinter hemorrhages, conjunctival petechiae, Osler nodules, Janeway lesions, and Roth spots. At least one of these manifestations occurs in approximately 50% of cases.
Embolic phenomena may include hematuria, neurologic manifestations, and splenomegaly.
Renal failure may be present and is caused by an immune-complex glomerulonephritis.
If cerebral hemorrhage is observed, it is a consequence of a ruptured mycotic aneurism.

Causes

Group D streptococci, along with other catalase-negative, gram-positive cocci, belong to the family Streptococcaceae. Group D streptococci may also be referenced as the S bovis–Streptococcus equinus complex.¹⁰ S bovis has recently been reclassified as Streptococcus gallolyticus, but references to S bovis remain prevalent in the clinical literature . S equinus is almost never isolated from human specimens.
Group D streptococci share many features with enterococci. In the mid 1980s, Streptococcus faecalis, Streptococcus faecium, and others were reclassified under the newly created genus Enterococcus.
Similar to enterococci, S bovis possesses the group D lipoteichoic acid antigen in its cell wall. It also shares the ability to hydrolyze esculin in the presence of bile. Unlike enterococci, S bovis fails to grow in broth containing a concentration of 6.5% sodium chloride and is negative for the pyrrolidonyl arylamidase reaction.
S bovis was traditionally differentiated into two biotypes, termed S bovis or S bovis I (now termed S gallolyticus subspecies gallolyticus) and S bovis variant or S bovis II. S bovis II was further differentiated into 2 sub-biotypes, S bovis II/1 (now termed Streptococcus infantarius) and S bovis II/2 (now termed S gallolyticus subspecies pasteurianus or Streptococcus pasteurianus).
In a study of patients with S bovis bacteremia, Ruoff et al demonstrated the following:¹¹
- S bovis I is most often associated with endocarditis and/or malignant or premalignant colonic lesions.
- S bovis II (mainly sub-biotype II/1) is most often associated with a bacteremia of hepatobiliary origin.

Differential Diagnoses

Infective Endocarditis
Meningitis
Pneumococcal Infections
Sepsis, Bacterial
Streptococcus Group A Infections
Streptococcus Group B Infections

Workup

Laboratory Studies

Basic laboratory studies to evaluate for Streptococcus group D infections should include CBC count, electrolyte evaluation, creatinine level, and LFTs.
Blood cultures are the most important tests.
- Blood culture results are usually positive during the first 24-48 hours. In cases of endocarditis and sustained bacteremia, blood culture results are positive.
- Gram stain from the blood culture bottles demonstrates gram-positive cocci in pairs or chains. S bovis cannot be differentiated from other streptococci using Gram staining.
- Differentiating S bovis from Streptococcus salivarius is sometimes very difficult because S salivarius yields a positive reaction on the bile-esculin test. This happens with approximately 20% of the isolates.
- Sensitivity testing is recommended, although most S bovis strains are exquisitely sensitive to penicillin. In a study by Mouton et al on 19 strains of S bovis, the minimal inhibitory concentrations (MICs) 50 and 90 were, respectively, 0.06 mg/L (susceptible) and 1 mg/L (intermediate susceptibility). The highest MIC was 2 mg/L (resistant).¹²

Imaging Studies

Echocardiography
- Transthoracic or transesophageal (more sensitive) echocardiography frequently permits visualization of vegetations. Echocardiography should be performed in all patients with S bovis bacteremia.
- An absence of vegetation does not rule out infective endocarditis. For more information on echocardiography findings, see Infective Endocarditis.
Colonoscopy
- This test is used to detect malignant lesions of the colon.
- Colonoscopy should be performed in all patients with S bovis bacteremia or endocarditis.
- Regular-interval follow-up colonoscopy should be performed in patients in whom no lesion is found on initial investigation.
Esophagogastroduodenoscopy
- Esophagogastroduodenoscopy (EGD) is used to detect malignant lesions of the esophagus, stomach, and duodenum.
- EGD should be performed in patients with S bovis bacteremia or endocarditis who have no evidence of colonic malignancy.
Liver ultrasonography and CT scanning
- Both of these studies should be performed in cases of associated hepatobiliary disease.
- Usually, liver ultrasonography is performed first, followed by CT scanning.

Other Tests

Consider referral of the organism for formal MIC testing if the response to antibiotic therapy is unfavorable.

Treatment

Medical Care

Most S bovis isolates are susceptible to penicillin (MIC £ 0.1 mg/L) and should be treated with intravenous penicillin G or ceftriaxone for 4 weeks. An alternative for only uncomplicated cases of native-valve endocarditis is a 2-week course of therapy with a combination of penicillin G or ceftriaxone and gentamicin. For moderately susceptible isolates (MIC >0.1 mg/L, MIC £ 0.5 mg/L), penicillin or ceftriaxone and gentamicin should be administered for 4 weeks and 2 weeks, respectively.¹³

Surgical Care

Surgical valve replacement is indicated in some cases, particularly for heart failure or complications of endocarditis (see Complications).
Mycotic aneurysm clipping after cerebral arteriography may be indicated.
Based on the findings from the evaluation of the gastrointestinal tract, colon or hepatobiliary surgery may be indicated.

Consultations

Consult an infectious diseases specialist to confirm the diagnosis of Streptococcus group D infection and to recommend treatment for endocarditis or bacteremia.
Consult a cardiologist to evaluate heart function, including echocardiography findings.
A cardiovascular surgeon can assist with valvular replacement, if indicated. Having the cardiac surgeon involved from the start is a good practice in case the patient's heart condition abruptly deteriorates.
Obtain a consultation with a neurosurgeon for possible clipping if mycotic aneurysms are present.
Obtain a consultation with a general surgeon or gastroenterologist to investigate and treat colonic or hepatobiliary disease.

Medication

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Dosing

Adult

12-18 million U IV q24h in 6 equally divided doses or continuously

Pediatric

<4 weeks: Not established
>4 weeks: 25,000-400,000 U/kg/d IV q4-6h; not to exceed adult dose

Interactions

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Contraindications

Documented hypersensitivity; interstitial nephritis; rare reactions, including serum sickness, Stevens-Johnson syndrome, allergic vasculitis, and major hepatic injury

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Obtain CBC counts at regular intervals for possible hematologic toxicity that may include neutropenia (when large doses are used) or Coombs-positive hemolytic anemia; monitor creatinine levels for interstitial nephritis and electrolytes for possible hypokalemia; reduce dosage with severe renal impairment (CrCl <10 mL/min) for CNS toxicity (seizures)

Ceftriaxone (Rocephin)

Alternative to penicillin. Third-generation cephalosporin equally effective against infections caused by S bovis. Has advantage of once daily administration. For penicillin IgE–mediated hypersensitivity, cross-reactions with third-generation cephalosporins are very rare.

Dosing

Adult

2 g IV q24h

Pediatric

<4 weeks: Not established
>4 weeks: 50-100 mg/kg/d IV q12-24h

Interactions

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Vancomycin (Lyphocin, Vancocin, Vancoled)

A glycopeptide very active against isolates of S bovis. Useful for patients who are allergic to penicillin.

Dosing

Adult

30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h unless concentrations in serum are inappropriately low

Pediatric

<4 weeks: Not established
>4 weeks: 40 mg/kg/d IV q6-8h

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure or neutropenia; red man syndrome is caused by rapid IV infusion (dose administered over a few min) but rarely happens when dose is administered over 2 h; red man syndrome is not an allergic reaction

Gentamicin (Garamycin, Gentacidin)

Should be used together with penicillin when bacterial isolates are only moderately susceptible to penicillin or to reduce treatment duration from 4 wk to 2 wk when infection is fully susceptible to penicillin. Preferred aminoglycoside for synergy. Should be administered at lower dosage (3 mg/kg/d) than for treatment of infections caused by gram-negative organisms (5 mg/kg/d).

Dosing

Adult

3 mg/kg IV q24h

Pediatric

<4 weeks: Not established
>4 weeks: 1 mg/kg IV q8h

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Follow-up

Further Inpatient Care

Approximately 72 hours after beginning antibiotics, run two series of blood cultures. If the results are positive, repeat every 3-4 days until the results are negative.
Monitor serum creatinine levels closely in patients receiving gentamicin and vancomycin.

Further Outpatient Care

Patients who are stable and infected with a penicillin-sensitive strain of S bovis and whose conditions have improved with antibiotic therapy can be discharged to complete their intravenous treatment on an outpatient basis.

Complications

Complications of S bovis infection are similar to those of S viridans endocarditis.
S bovis subacute bacterial endocarditis can involve the heart, kidneys, CNS, spleen, lungs, and eyes. Mycotic aneurysms are potential complications.
- Heart: Destruction of the valve leaflets and rupture of the chordae tendineae, papillary muscles, or interventricular septum may cause intractable heart failure. Other rare complications of SBE include myocarditis, pericarditis, and myocardial infarction. Ring abscesses (mainly with prosthetic valve endocarditis) could extend to the septum and cause atrioventricular blockade.
- Kidneys: Embolization could cause kidney infarction or abscesses. Immune complexes are responsible for glomerulonephritis.
- CNS: Cerebral emboli can cause cerebral infarction, arteritis, mycotic aneurysms, hemorrhage, cerebritis, and meningitis.
- Spleen: Splenic infarction or abscesses may occur.
- Lungs: With right-sided endocarditis, pulmonary emboli are common and may cause infarction or septic emboli.
- Eyes: Endogenous endophthalmitis may occur.
- Mycotic aneurysms: Found most commonly in the CNS, they also occur in the abdominal aorta; the sinus of Valsalva; and splenic, coronary, pulmonary, and mesenteric arteries.

Prognosis

See Mortality/Morbidity.
S bovis endocarditis is an aggressive disease with significant mortality.
- Heart failure is a frequent complication and an indication for valve replacement.
- In a study by Kupferwasser et al, 73% of patients with S bovis endocarditis underwent surgical treatment, but only 34%, 34%, and 41% of patients with endocarditis caused by other streptococci, staphylococci, or other bacteria underwent surgery, respectively.⁶

Miscellaneous

Medicolegal Pitfalls

Failure to investigate the gastrointestinal tract for possible diseases, either neoplastic or nonneoplastic, in patients with S bovis bacteremia or endocarditis

References

Tripodi MF, Adinolfi LE, Ragone E, et al. Streptococcus bovis endocarditis and its association with chronic liver disease: an underestimated risk factor. Clin Infect Dis. May 15 2004;38(10):1394-400. [Medline].
Montalto M, Izzi D, La Regina M, Nucera G, Manna R, Gasbarrini G. Non-life-threatening sepsis: report of two cases. Am J Med Sci. May 2004;327(5):275-7. [Medline].
Biedenbach DJ, Moet GJ, Jones RN. Occurrence and antimicrobial resistance pattern comparisons among bloodstream infection isolates from the SENTRY Antimicrobial Surveillance Program (1997-2002). Diagn Microbiol Infect Dis. Sep 2004;50(1):59-69. [Medline].
Pfaller MA, Jones RN, Marshall SA, et al. Nosocomial streptococcal blood stream infections in the SCOPE Program: species occurrence and antimicrobial resistance. The SCOPE Hospital Study Group. Diagn Microbiol Infect Dis. Dec 1997;29(4):259-63. [Medline].
Hoen B, Chirouze C, Cabell CH, Selton-Suty C, Duchêne F, Olaison L, et al. Emergence of endocarditis due to group D streptococci: findings derived from the merged database of the International Collaboration on Endocarditis. Eur J Clin Microbiol Infect Dis. Jan 2005;24(1):12-6. [Medline].
Kupferwasser I, Darius H, Muller AM, et al. Clinical and morphological characteristics in Streptococcus bovis endocarditis: a comparison with other causative microorganisms in 177 cases. Heart. Sep 1998;80(3):276-80. [Medline].
Giannitsioti E, Chirouze C, Bouvet A, Béguinot I, Delahaye F, Mainardi JL, et al. Characteristics and regional variations of group D streptococcal endocarditis in France. Clin Microbiol Infect. Aug 2007;13(8):770-6. [Medline].
Corredoira J, Alonso MP, Coira A, Casariego E, Arias C, Alonso D, et al. Characteristics of Streptococcus bovis endocarditis and its differences with Streptococcus viridans endocarditis. Eur J Clin Microbiol Infect Dis. Apr 2008;27(4):285-91. [Medline].
Karchmer AW. Infective endocarditis. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8^th ed. Saunders; 2007:1713.
van't Wout JW, Bijlmer HA. Bacteremia due to Streptococcus gallolyticus, or the perils of revised nomenclature in bacteriology. Clin Infect Dis. Apr 1 2005;40(7):1070-1. [Medline].
Ruoff KL, Miller SI, Garner CV, et al. Bacteremia with Streptococcus bovis and Streptococcus salivarius: clinical correlates of more accurate identification of isolates. J Clin Microbiol. Feb 1989;27(2):305-8. [Medline].
Mouton JW, Endtz HP, den Hollander JG, et al. In-vitro activity of quinupristin/dalfopristin compared with other widely used antibiotics against strains isolated from patients with endocarditis. J Antimicrob Chemother. May 1997;39 Suppl A:75-80. [Medline].
Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. Jun 14 2005;111(23):e394-434. [Medline].
Bayer AS, Scheld WM. Endocarditis and intravascular infections. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. Vol 1. 5^th ed. Philadelphia, Pa: Churchill Livingstone; 2000:857-902.
Burns CA, McCaughey R, Lauter CB. The association of Streptococcus bovis fecal carriage and colon neoplasia: possible relationship with polyps and their premalignant potential. Am J Gastroenterol. Jan 1985;80(1):42-6. [Medline].
Corredoira J, Alonso MP, Coira A, Varela J. Association between Streptococcus infantarius (formerly S. bovis II/1) bacteremia and noncolonic cancer. J Clin Microbiol. Apr 2008;46(4):1570. [Medline].
Cunha BA. Antibiotic Essentials. 7^th ed. Royal Oak, Mich: Physicians Press; 2008.
Cunha BA. Antimicrobial therapy of multidrug-resistant Streptococcus pneumoniae, vancomycin-resistant enterococci, and methicillin-resistant Staphylococcus aureus. Med Clin North Am. Nov 2006;90(6):1165-82. [Medline].
Cunha BA. New uses for older antibiotics: nitrofurantoin, amikacin, colistin, polymyxin B, doxycycline, and minocycline revisited. Med Clin North Am. Nov 2006;90(6):1089-107. [Medline].
Cunha BA. Oral antibiotic therapy of serious systemic infections. Med Clin North Am. Nov 2006;90(6):1197-222. [Medline].
Diekema DJ, Pfaller MA, Jones RN, et al. Trends in antimicrobial susceptibility of bacterial pathogens isolated from patients with bloodstream infections in the USA, Canada and Latin America. SENTRY Participants Group. Int J Antimicrob Agents. Feb 2000;13(4):257-71. [Medline].
Diekema DJ, Pfaller MA, Jones RN; SENTRY Participants Group. Age-related trends in pathogen frequency and antimicrobial susceptibility of bloodstream isolates in North America: SENTRY Antimicrobial Surveillance Program, 1997-2000. Int J Antimicrob Agents. Dec 2002;20(6):412-8. [Medline].
García-Porrúa C, González-Gay MA, Monterroso JR, Sánchez-Andrade A, González-Ramirez A. Septic arthritis due to Streptococcus bovis as presenting sign of 'silent' colon carcinoma. Rheumatology (Oxford). Mar 2000;39(3):338-9. [Medline].
Gavin PJ, Thomson RB Jr, Horng SJ, Yogev R. Neonatal sepsis caused by Streptococcus bovis variant (biotype II/2): report of a case and review. J Clin Microbiol. Jul 2003;41(7):3433-5. [Medline].
Gonzlez-Quintela A, Martinez-Rey C, CastroagudÃn JF, et al. Prevalence of liver disease in patients with Streptococcus bovis bacteraemia. J Infect. Feb 2001;42(2):116-9. [Medline].
Grant RJ, Whitehead TR, Orr JE. Streptococcus bovis meningitis in an infant. J Clin Microbiol. Jan 2000;38(1):462-3. [Medline].
Hechmann Wittrup I, Chenoufi Schaadt ML, Arpi M, Danneskiold-Samsoe B. Bacteremia complicated by vertebral osteomyelitis due to Streptococcus bovis. Eur J Clin Microbiol Infect Dis. May 1999;18(5):365-7. [Medline].
Klein RS, Catalano MT, Edberg SC, et al. Streptococcus bovis septicemia and carcinoma of the colon. Ann Intern Med. Oct 1979;91(4):560-2. [Medline].
Klein RS, Recco RA, Catalano MT, et al. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med. Oct 13 1977;297(15):800-2. [Medline].
Moellering RC Jr. Enterococcus species, Streptococcus bovis, and Leuconostoc species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 6^th ed. Philadelphia, Pa: Churchill Livingstone; 2005.
Moellering RC Jr, Watson BK, Kunz LJ. Endocarditis due to group D streptococci. Comparison of disease caused by streptococcus bovis with that produced by the enterococci. Am J Med. Aug 1974;57(2):239-50. [Medline].
Murray HW, Roberts RB. Streptococcus bovis bacteremia and underlying gastrointestinal disease. Arch Intern Med. Jul 1978;138(7):1097-9. [Medline].
Pfaller MA, Jones RN, Doern GV, et al. Survey of blood stream infections attributable to gram-positive cocci: frequency of occurrence and antimicrobial susceptibility of isolates collected in 1997 in the United States, Canada, and Latin America from the SENTRY Antimicrobial Surveillance Progr. Diagn Microbiol Infect Dis. Apr 1999;33(4):283-97. [Medline].
Rehm SJ. Outpatient intravenous antibiotic therapy for endocarditis. Infect Dis Clin North Am. Dec 1998;12(4):879-901, vi. [Medline].
Reynolds JG, Silva E, McCormack WM. Association of Streptococcus bovis bacteremia with bowel disease. J Clin Microbiol. Apr 1983;17(4):696-7. [Medline].
Selton-Suty C, Hoen B, Grentzinger A, et al. Clinical and bacteriological characteristics of infective endocarditis in the elderly. Heart. Mar 1997;77(3):260-3. [Medline].
Siegman-Igra Y, Schwartz D. Streptococcus bovis revisited: a clinical review of 81 bacteremic episodes paying special attention to emerging antibiotic resistance. Scand J Infect Dis. 2003;35(2):90-3. [Medline].
Terpenning MS, Buggy BP, Kauffman CA. Infective endocarditis: clinical features in young and elderly patients. Am J Med. Oct 1987;83(4):626-34. [Medline].
Vilaichone RK, Mahachai V, Kullavanijaya P, Nunthapisud P. Spontaneous bacterial peritonitis caused by Streptococcus bovis: case series and review of the literature. Am J Gastroenterol. Jun 2002;97(6):1476-9. [Medline].
Wilson WR, Karchmer AW, Dajani AS, et al. Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK microorganisms. American Heart Association. JAMA. Dec 6 1995;274(21):1706-13. [Medline].

Keywords

Streptococcus group D infections, streptococcal group D infections, group D Streptococcus, group D streptococci, Streptococcus bovis–Streptococcus equinus complex, Streptococcus bovis, Streptococcus gallolyticus, Streptococcus infantarius, Streptococcus pasteurianus, S bovis–S equinus complex, S bovis, S gallolyticus, S infantarius, S pasteurianus, infective endocarditis, infectious endocarditis, bacterial endocarditis, endocarditis, neonatal sepsis, streptococcal bloodstream infections, S bovis bacteremia, S bovis endocarditis

Contributor Information and Disclosures

Author

John W Downs, MD, Resident Physician, Department of Medicine, Tripler Army Medical Center
John W Downs, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada
Christian P Sinave, MD is a member of the following medical societies: American Society for Microbiology and Canadian Infectious Disease Society
Disclosure: Nothing to disclose.

Tomas Michael Ferguson, MD, Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Tripler Army Medical Center
Tomas Michael Ferguson, MD is a member of the following medical societies: American College of Physicians, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Pranatharthi Haran Chandrasekar, MD, Director of Infectious Disease Fellowship, Professor, Department of Internal Medicine, Harper Hospital, Wayne State University School of Medicine
Pranatharthi Haran Chandrasekar, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Further Reading