Infections due to Streptococcus bovis/Streptococcus equinus complex (SBSEC; formerly group D streptococci)

Author:: Bruno Hoen, MD, PhD
Section Editor:: Daniel J Sexton, MD
Deputy Editor:: Elinor L Baron, MD, DTMH

Literature review current through: Jan 2024.

This topic last updated: Jan 29, 2023.

INTRODUCTION — The Streptococcus bovis/Streptococcus equinus complex (SBSEC; formerly group D streptococci) includes four major species (table 1) [1].

SBSEC members are gram-positive cocci that are an important cause of bacteremia and infective endocarditis (IE) in adults. In addition, there is a strong association between infection due to SBSEC members and colonic neoplasm (as well as other lesions of the gastrointestinal tract).

Issues related to the microbiology, epidemiology, clinical manifestations, diagnostic evaluation, and management of bacteremia and other forms of infection due to SBSEC will be discussed here. Issues related to management of IE are discussed separately. (See "Overview of management of infective endocarditis in adults" and "Antimicrobial therapy of left-sided native valve endocarditis" and "Antimicrobial therapy of prosthetic valve endocarditis".)

MICROBIOLOGY

Taxonomy — The taxonomy of SBSEC was established in 2003 and is summarized in the table (table 1). Some laboratories report these organisms under the common name S. bovis or S. bovis group [2,3].

In one study including more than 50 blood isolates of SBSEC identified to the subspecies level by 16S rRNA sequencing, detected species included Streptococcus gallolyticus subsp gallolyticus, Streptococcus infantarius subsp coli, and Streptococcus gallolyticus subsp pasteurianus (50, 29, and 21 percent, respectively) [4]. Similarly, in another study including more than 50 blood isolates of SBSEC, the two most frequent strains were S. gallolyticus subsp gallolyticus and S. gallolyticus subsp pasteurianus (36 and 23 percent, respectively) [5].

Identification — SBSEC are catalase-negative, gram-positive cocci in pairs or chains that usually express the Lancefield group D antigen. Colonies are typically small and nonhemolytic on blood agar. Most SBSEC members grow in 40 percent bile and hydrolyze esculin [4,6-8].

SBSEC can be distinguished from enterococci because they are pyrrolidonyl arylamidase negative, fail to hydrolyze arginine, and are typically unable to grow in 6.5 percent salt broth [4,6,9]. However, the traditional tests for enterococci (salt tolerance, growth on bile esculin agar, and expression of Lancefield group D antigen) may not allow a definitive distinction between enterococci and SBSEC, so additional biochemical testing or molecular techniques are needed to avoid misidentification [4,10].

Most clinical microbiology laboratories in the United States use automated testing equipment or other methods for identification to the species and subspecies level. Compared with gene sequencing, matrix-assisted laser desorption/ionization-time of flight appears to be as effective, quicker, and less expensive for SBSEC subspecies identification [2,11,12].

Occasionally, viridans group streptococci (especially Streptococcus salivarius) are misidentified as SBSEC. SBSEC may be differentiated from viridans group streptococci and identified to the species/subspecies level using commercially available kits and automating testing equipment found in most United States clinical microbiology laboratories [4,9,13,14].

EPIDEMIOLOGY

Bloodstream infection — Among hospitalized patients, SBSEC accounts for approximately 5 percent of streptococcal bloodstream isolates [15]. Among patients with infective endocarditis (IE), SBSEC accounts for 2 to 57 percent of organisms in various series [16-20]. S. bovis biotype I is a more frequent cause of IE than S. bovis biotype II. Among patients with bacteremia due to S. bovis biotype I (S. gallolyticus subsp gallolyticus), IE has been observed in 43 to 100 percent of cases; among patients with bacteremia due to S. bovis biotype II (S. gallolyticus subs pasteurianus and S. infantarius), IE has been observed in 8 to 29 percent of cases [16,21]. In a cohort study including 210 episodes of SBSEC bacteremia, the proportions of IE among SBSEC subspecies for S. gallolyticus, S. infantarius, S. pasteurianus, and S. lutetiensis were 33, 16, 5, and 5 percent, respectively [22].

SBSEC have emerged as important etiologic agents of IE in some geographic areas [16-18,23,24]. In one study based on data from the International Collaboration on Endocarditis, SBSEC accounted for 57 percent of IE in France, 9 percent in the rest of Europe, and 6 percent in the United States [18]. Similarly, in an analysis of a large database of IE isolates between 2000 and 2005, the proportion of IE caused by SBSEC in Europe was 10 percent, fivefold higher than in the United States [16]. The reason for these geographic disparities is uncertain; higher rates of IE in certain regions do not appear to be associated with differences in fecal carriage rates [25]. It has been speculated that diet may play a role [26-28].

Many series report a higher incidence of IE due to SBSEC in men [16,29-31]. In addition, patients with IE due to SBSEC are typically older than patients with IE due to other organisms (mean age 59 to 67 years versus 46 to 59 years) [16,18,19,24]. Patients with IE due to SBSEC are less likely to have risk factors that predispose to development of IE (such as intravenous drug use or structural heart disease) [16,18,23,24]. Conversely, such patients are more likely to have chronic conditions such as diabetes and chronic liver disease, especially cirrhosis [24,26].

SBSEC bloodstream infection has been associated with hepatic disease; in such cases, dysfunction of the reticuloendothelial system may compromise bacterial clearance, allowing entry of organisms into the portal or systemic circulation [4,24,30]. Bacteremia of hepatobiliary origin is more frequently associated with S bovis biotype II than S. bovis biotype I; in addition, polymicrobial infection may be observed [16,32,33].

In one study including more than 190 patients with IE (including 30 patients with IE due to S. bovis), advanced liver disease was observed more frequently among patients with IE due to S. bovis biotype I than among patients with non-SBSEC endocarditis (56 versus 15 percent) [24]. In another study including 64 patients with S. bovis bacteremia, infection due to S. bovis biotype II was more frequently associated with a hepatobiliary origin than infection due to S. bovis biotype I (50 versus 5 percent, respectively) [32].

Association with colonic neoplasia — The association between SBSEC bacteremia, IE, and colonic neoplasia is well described [21,30,34,35]. In a multivariate analysis including more than 220 patients with S. bovis bacteremia (159 due to S. bovis biotype I and 64 due to S. bovis biotype II), S. bovis biotype I bacteremia was independently associated with colonic neoplasia (odds ratio [OR] 5.7, 95 % CI 3.0-10.9) [36]. In a meta-analysis including 11 studies of patients with S. bovis infection who underwent colonic evaluation, the median percentage who had concomitant colonic neoplasia was 60 percent (interquartile range, 22 percent), which exceeded the rate of colonic neoplasia in the general asymptomatic population [21]. In addition, colonic neoplasia occurred more frequently among patients with S. bovis IE than among patients with other forms of S. bovis infection (pooled OR 3.72, 95% CI 2.03-6.81).

Bloodstream infection due S. bovis biotype I (S. gallolyticus subsp gallolyticus) has been more strongly associated with colonic neoplasia than bloodstream infection due to S. bovis biotype II [1,21,32,35]. In the above meta-analysis, patients with S. bovis biotype I infection had increased risk of colonic neoplasia (pooled OR 7.26, 95% CI 3.94-13.36) and IE (pooled OR 16.61, 95% CI 8.85-31.16) relative to patients with S. bovis biotype II infection [21]. In the above multivariate analysis, there was no association between S. bovis biotype II bacteremia and colonic neoplasia (OR 0.17, 95% CI 0.09-0.33) [36].

The reason for the association between S. bovis biotype I bloodstream infection and colonic neoplasia is not fully understood; it may be related to presence of proteins in S. bovis biotype I that bind to overexpressed ligands in colonic neoplasms [37]. Selective colonization of colorectal cancer tissue has been suggested for S. gallolyticus subsp gallolyticus, possibly related to increased adhesion to cancerous cell types with enhanced collagen type IV accessibility. S. gallolyticus subsp gallolyticus can colonize, proliferate, and may shape the tumor microenvironment to their benefit [1]. In addition, S. gallolyticus subsp gallolyticus appears uniquely capable of forming biofilms on collagen-rich surfaces such as valve endothelium [37].

The strength of the relationship between SBSEC stool carriage and colonic neoplasia is uncertain, and it is unclear whether SBSEC plays a role in the oncogenic progression of normal colonic mucosa to neoplasia [34,38-42]. SBSEC stool carriage appears to be more commonly associated with S. bovis biotype II than S. bovis biotype I [25,43]. As an example, in one French study including more than 250 patients undergoing colonoscopy, the SBSEC stool carriage rate was 4.6 percent; among the stool isolates, S. bovis biotype II was observed more frequently than S. bovis biotype I (92 versus 8 percent) [25]. The SBSEC fecal carriage rate was 11 percent among patients with colonic neoplasia.

Correlation between SBSEC infection and other lesions of the gastrointestinal tract has also been described, including gastric carcinoma, premalignant or benign polyps, lymphoma, colitis, and mechanical abnormalities [29,30,44-48].

CLINICAL MANIFESTATIONS — Clinical manifestations of SBSEC infection include bacteremia (with or without infective endocarditis [IE]) and SBSEC infection in the absence of bacteremia or IE. The gastrointestinal tract is the most important portal of entry; other potential sources of infection include the urinary tract and hepatobiliary tree.

Bacteremia and endocarditis — Clinical history and physical manifestations of IE due to SBSEC are comparable with manifestations of IE caused by other organisms [18,31]. The presentation is usually subacute (with fever lasting days or weeks), but occasionally acute onset occurs [6]. Nonspecific symptoms may include fever, anorexia, weight loss, fatigue, night sweats, and weakness. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Symptoms and signs'.)

In general, IE may be associated with an array of complications due to septic embolization. Clinical manifestations reflecting these complications may be present at the time of initial presentation and/or may develop subsequently. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Complications as initial presentation'.)

Patients with SBSEC IE tend to have relatively large vegetations. In one study including more than 200 patients with definite IE by Duke criteria, vegetation size >10 mm was observed more frequently in the setting of SBSEC IE than in the setting of IE caused by other streptococci and nonstreptococcal pathogens (50 percent versus 20 and 34 percent, respectively) [49].

IE due to SBSEC may be highly destructive, resulting in valve perforation or invasive disease with cardiac septal or valvular ring abscess [18,29]. In one case series including more than 170 patients with IE, infiltration of the left ventricle was observed more frequently in the setting of IE due to SBSEC than other causes of IE (36 versus 10 percent) [50]. Compared with patients with IE due to other organisms, patients with SBSEC were older, had a longer interval prior to diagnosis, and required surgery more often. Bivalvular involvement has been observed more frequently among patients with IE due to S. bovis than to viridans group streptococci [16].

Data are conflicting as to whether embolic events are more common in IE caused by SBSEC compared with other pathogens [23,24,26,50].

Patients with SBSEC infection may present with complications of bacteremia or IE (such as neurologic complications, septic emboli, or metastatic infection). (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Complications as initial presentation'.)

Other forms of infection — SBSEC infection may present in the absence of bacteremia or IE. Forms of infection include:

●Bone and joint infection – Forms of bone and joint infection attributed to SBSEC include septic arthritis, prosthetic joint infection, spondylitis, discitis, and osteomyelitis [16,24,51-53].

●Meningitis – SBSEC meningitis has been described in infants [54-56] and adults; in adults, meningitis has been observed in association with SBSEC bacteremia and endocarditis [57-60]. In one study including more than 4800 cases of bacterial meningitis in patients <18 years, SBSEC was the cause in 0.5 percent of cases [56]. For cases in which SBSEC was identified, S. gallolyticus subsp pasteurianus comprised 80 percent of cases. In addition, there are case reports describing GDS bacteremia and meningitis complicating Strongyloides stercoralis infection [61,62].

●Neonatal sepsis – The organism S. gallolyticus subsp pasteurianus has been associated with neonatal sepsis, with or without meningitis; clinically, such infections may be indistinguishable from infection caused by Streptococcus agalactiae [54,63,64]. Clusters of S. pasteurianus infections may develop in neonatal intensive care units as a result of nosocomial transmission [63-65].

●Intrapartum bacteremia – Intrapartum infections caused by S. gallolyticus subsp gallolyticus complicated with chorioamnionitis and bacteremia have been described; in most cases, sepsis developed among neonates born to infected mothers [66].

●Peritonitis – Spontaneous peritonitis due to SBSEC has been described [67-69].

●Urinary tract infection – Urinary tract infection due to SBSEC has been described [70,71].

DIAGNOSTIC EVALUATION — In general, infection due to SBSEC usually comes to clinical attention via culture of the organism from blood, other body fluid, or tissue. (See 'Microbiology' above.)

Patients with bacteremia — Patients with SBSEC bacteremia warrant routine laboratory testing (chemistries, assessment of renal function, complete blood count) as well as liver function testing. In addition, such patients warrant careful evaluation for IE and colonic neoplasia:

●Evaluation for infective endocarditis (IE) – In general, patients with SBSEC bacteremia should undergo echocardiography, beginning with a transthoracic echocardiogram (TTE). Transesophageal echocardiography (TEE) is warranted in the following circumstances:

•Negative or technically inadequate TTE with high clinical suspicion for IE (persistent bacteremia despite appropriate antimicrobial therapy and/or multiple minor criteria for endocarditis).

•Positive TTE with concern for presence of intracardiac complications such as paravalvular abscess (risk factors include new conduction delay on electrocardiogram, aortic valve endocarditis, and persistent bacteremia or fever despite appropriate antimicrobial therapy), or significant valvular regurgitation (to determine need for surgery).

In general, for patients with prompt clearance of bacteremia on antibiotic therapy, in the absence of IE stigmata, significant valvular regurgitation, aortic stenosis, prosthetic valve or other intracardiac device, TTE is sufficient if normal.

Issues related to diagnosis of IE are discussed further separately. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Clinical manifestations'.)

●Evaluate for complications of IE – Radiographic imaging to evaluate for complications of IE should be tailored to findings on history and physical examination. As examples, abdominal imaging with computed tomography is appropriate for patients with localized pain, signs of peritonitis, or persistent fever and/or leukocytosis.

●Evaluation for neoplasia – We are in agreement with the American Heart Association/Infectious Diseases Society of America guidelines, which recommend that adults with SBSEC bacteremia undergo colonoscopy to evaluate for carcinoma or other colonic lesions [72]. Colonoscopy is most important for patients with bacteremia due to S. bovis biotype I (S. gallolyticus subsp gallolyticus) and S. bovis isolates not identified to the subspecies level. If negative, colonoscopy should be repeated in four to six months. This approach is based upon on the strong epidemiologic association between SBSEC and colon cancer, rather than on outcome data.

●Evaluation for underlying liver disease – Patients with SBSEC bacteremia should have liver function tests (LFTs) sent, and individuals with risk factors for hepatitis B or C infection should be tested for these conditions. Patients with abnormal LFTs, spontaneous peritonitis, and/or signs of cirrhosis on physical examination (table 2) should undergo abdominal ultrasound. (See "Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis".)

Patients with other forms of infection — Evaluation of patients presenting with other forms SBSEC infection (apart from or in addition to bacteremia) should consist of investigation guided by the clinical presentation, tailored to individual circumstances (see related topics). As an example, patients with focal joint pain and effusion should undergo diagnostic joint aspiration to evaluate for septic arthritis.

In addition, such patients should have surveillance blood cultures (if not already collected) and TTE, as described above for patients with bacteremia, since metastatic infection may reflect bloodstream infection and/or IE. (See 'Patients with bacteremia' above.)

MANAGEMENT

General principles — Patients with SBSEC infection should undergo clinical evaluation as described above. (See 'Diagnostic evaluation' above.)

Management of SBSEC should be guided by the clinical presentation, tailored to individual circumstances (see related topics). As an example, patients with septic arthritis should undergo joint drainage.

Issues related to antibiotic selection are discussed below.

Antibiotic selection — In general, similar antibiotic susceptibility profiles have been observed among the various species and subspecies of the SBSEC group; typically SBSEC are susceptible to penicillins, ceftriaxone, carbapenems, vancomycin, daptomycin, and linezolid [4,73,74].

Antibiotic agents that may not be reliably active against SBSEC include fluoroquinolones, trimethoprim-sulfamethoxazole, tetracyclines, macrolides, and clindamycin [24,75-77]. In a 2019 review, which included all papers published since 2000 with reported resistance rates among SBSEC isolates, tetracycline, erythromycin, and clindamycin were the antimicrobial agents showing the highest resistance rates (36 to 77 percent for tetracycline, 9 to 78 percent for erythromycin, and 11 to 62 percent for clindamycin). Most isolates were susceptible to penicillin; no isolates were resistant to ceftriaxone, glycopeptides, daptomycin, or linezolid [77].

Bacteremia — For treatment of SBSEC bacteremia, we favor ceftriaxone (2 g intravenously every 24 hours); penicillin (12 to 24 million units intravenously daily, divided every four hours) may be used, but logistics of administration are less convenient. Vancomycin (table 3) is an acceptable alternative agent for patients with hypersensitivity to beta-lactam agents. Subsequent management should be guided by antibiotic susceptibility data.

Surveillance blood cultures should be obtained to document clearance of bacteremia. Persist bacteremia despite appropriate antibiotic therapy should prompt further investigation for the source of persistent infection (eg, cardiac, intravascular, device-related, or abscess).

The duration of therapy for treatment of bacteremia (in the absence of other clinical manifestations) is two weeks. It is uncertain whether intravenous therapy is required for the entire duration of antibiotic therapy. Following clearance of bacteremia and resolution of systemic signs of infection, it may be reasonable to complete the course of antibiotic therapy with an oral regimen (such as amoxicillin 500 mg three times daily or 875 mg [extended release] twice daily). Alternative agents for patients with hypersensitivity to beta-lactam agents include cephalexin (500 mg orally four times daily) or clindamycin (300 to 450 mg orally three times daily).

For patients with endocarditis or other manifestations of SBSEC infection (apart from or in addition to bacteremia), the duration of therapy depends on the nature of the underlying infection. (See 'Endocarditis' below and 'Other manifestations' below.)

Endocarditis — Issues related to treatment of endocarditis are discussed in detail separately. (See "Antimicrobial therapy of left-sided native valve endocarditis", section on 'Viridans streptococci and S. bovis/S. equinus complex' and "Antimicrobial therapy of prosthetic valve endocarditis", section on 'Streptococci'.)

Other manifestations — For patients with other manifestations of SBSEC infection, the choice and duration of therapy depends on the nature of the underlying infection, as discussed in the following sections:

●Osteomyelitis (see "Nonvertebral osteomyelitis in adults: Treatment" and "Vertebral osteomyelitis and discitis in adults")

●Prosthetic joint infection (see "Prosthetic joint infection: Treatment")

●Septic arthritis (see "Septic arthritis in adults")

●Meningitis (see "Treatment of bacterial meningitis caused by specific pathogens in adults")

●Neonatal sepsis (see "Management and outcome of sepsis in term and late preterm neonates")

●Peritonitis (see "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis")

SUMMARY AND RECOMMENDATIONS

●The Streptococcus bovis/Streptococcus equinus complex (SBSEC) includes four major species; the taxonomy is summarized in the table (table 1). SBSEC are gram-positive cocci that are an important cause of bacteremia and infective endocarditis (IE) in adults. In addition, there is a strong association between SBSEC infection and colonic neoplasm (as well as other lesions of the gastrointestinal tract), especially for S. gallolyticus. (See 'Introduction' above and 'Microbiology' above.)

●Among hospitalized patients, SBSEC accounts for approximately 5 percent of streptococcal bloodstream isolates. Patients with IE due to SBSEC are typically older than patients with IE due to other organisms, are less likely to have risk factors that predispose to development of IE (such as intravenous drug use or structural heart disease), and are more likely to have chronic conditions such as diabetes and chronic liver disease. (See 'Epidemiology' above.)

●Clinical presentations of SBSEC infection include bacteremia (with or without IE, with or without complications such as septic emboli or metastatic infection) and other forms of SBSEC infection (in the absence of bacteremia or IE). Clinical history and physical manifestations of IE due to SBSEC are comparable with manifestations of IE caused by other organisms. The gastrointestinal tract is the most important portal of entry; other potential sources of infection include the urinary tract and hepatobiliary tree. (See 'Clinical manifestations' above.)

●In general, infection due to SBSEC usually comes to clinical attention via culture of the organism from blood, other body fluid, or tissue. Patients with SBSEC bacteremia warrant liver function tests and careful evaluation for IE. In addition, colonoscopy is warranted to evaluate for carcinoma or other colonic lesions; this approach is based upon on the strong epidemiologic association between SBSEC and colon cancer, rather than on outcome data. Patients presenting with other forms of SBSEC infection (apart from or in addition to bacteremia) warrant evaluation guided by the clinical presentation, tailored to individual circumstances. (See 'Diagnostic evaluation' above and 'Association with colonic neoplasia' above.)

●For treatment of SBSEC bacteremia, we favor ceftriaxone; penicillin may be used, but logistics of administration are less convenient. Vancomycin is an acceptable alternative agent for patients with hypersensitivity to beta-lactam agents. Subsequent management should be guided by antibiotic susceptibility data. (See 'Bacteremia' above.)

●Issues related to treatment of endocarditis are discussed in detail separately. (See "Antimicrobial therapy of left-sided native valve endocarditis", section on 'Viridans streptococci and S. bovis/S. equinus complex' and "Antimicrobial therapy of prosthetic valve endocarditis", section on 'Streptococci'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Howard Gold, who contributed to earlier versions of this topic review.

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Topic 3156 Version 27.0

خرید پکیج

Infections due to Streptococcus bovis/Streptococcus equinus complex (SBSEC; formerly group D streptococci)

References