eMedicine Specialties > Infectious Diseases > Bacterial Infections

Streptococcus Group D Infections: Treatment & Medication

Author: John W Downs, MD, Resident Physician, Department of Medicine, Tripler Army Medical Center
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Jan 23, 2009

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.

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

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

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

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.

Adult

2 g IV q24h

Pediatric

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

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

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); administration can lead to pseudocholelithiasis


Vancomycin (Lyphocin, Vancocin, Vancoled)

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

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

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

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).

Adult

3 mg/kg IV q24h

Pediatric

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

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)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

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

More on Streptococcus Group D Infections

Overview: Streptococcus Group D Infections
Differential Diagnoses & Workup: Streptococcus Group D Infections
Treatment & Medication: Streptococcus Group D Infections
Follow-up: Streptococcus Group D Infections
References
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References

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Further Reading

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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

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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.

 
 
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