Laboratory identification and clinical characteristics of Streptococcus bovis/Streptococcus equinus complex bacteremia: a retrospective, multicenter study in Hiroshima, Japan
Yuki KaikiHiroki KitagawaKayoko TaderaHiroyuki TaogoshiMitsuyasu IkedaMikihiro KanoToshie HarinoToshihito NomuraKeitaro OmoriNorifumi ShigemotoShinya TakahashiHiroki Ohge
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Abstract Background Bacteremia due to the Streptococcus bovis / Streptococcus equinus complex (SBSEC) is associated with specific diseases, such as colorectal cancer and infective endocarditis. This study aimed to evaluate the clinical characteristics of SBSEC bacteremia and the accuracy of identification of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and phenotypic identification systems for SBSEC isolates. Methods We analyzed patients with SBSEC bacteremia retrospectively between 2012 and 2019 at three hospitals in Japan. We re-identified each SBSEC isolate using sequencing superoxide dismutase ( sodA ) analysis, MALDI-TOF MS using the MALDI Biotyper, and phenotypic identification using the VITEK2. Results During the study period, 39 patients with SBSEC bacteremia were identified. S. gallolyticus subsp. pasteurianus (SGSP, n = 29), S. gallolyticus subsp. gallolyticus (SGSG, n = 5), S. lutetiensis (SL, n = 4), and S. infantarius subsp. infantarius ( n = 1) were identified using sodA sequencing analysis. Primary bacteremia (36%) was the most common cause of bacteremia, followed by infective endocarditis (26%) and biliary tract infections (23%). Colorectal cancer was associated significantly with SGSG bacteremia, while the sources of bacteremia were similar in each SBSEC subspecies. The MALDI Biotyper was significantly more accurate in identifying the SBSEC isolates at the subspecies level compared to the VITEK2 (92% vs. 67%, P = 0.010). In contrast, there were no significant differences in the rates of correct identification of the SBSEC isolates at the species level between the MALDI Biotyper and the VITEK2 (100% vs. 87%, P = 0.055). Conclusions Bacteremia with SGSG was associated with colorectal cancer, and the sources of bacteremia were similar in each SBSEC subspecies. The MALDI-TOF MS was significantly more accurate in identifying SBSEC isolates at the subspecies level than the phenotypic identification systems. The accurate identification of SBSEC isolates using the MALDI-TOF MS and phenotypic identification systems was sufficient at the species level, but it was insufficient at the subspecies level. Therefore, it may be reasonable for clinicians to perform echocardiographies and colonoscopies in all patients with SBSEC bacteremia.Keywords:
Bacteremia
Streptococcus bovis
Medical microbiology
Purpose. Colon cancer is increasing in incidence and is the leading cause of cancer-related death worldwide. S. bovis bacteremia frequently occurs with colonic neoplasia. The aim of this study is to assess the clinical characteristics of patients with S. bovis bacteremia in VGHKS. Methods. From January 2001 to December 2006, 68 patients hospitalized at Kaohsiung Veterans General Hospital had bacteremia caused by S. bovis. This retrospective clinical evaluation was carried out to evaluate the relationship of these patients with S. bovis bacteremia to the endocarditis, colonic neoplasia and bacteremia of hepatobiliary origin. Data was analyzed using the Student t-test for numberical variables and chi-squared for categorical variables. Differences were considered to be significant at p＜0.05. Results. Of 68 isolates of S. bovis, 25 were biotype Ⅰ and 43 were biotype Ⅱ. We excluded 16 cases because of incomplete survey. The sex and age distributions of patients infected were not significantly different. S. bovis Ⅰ bacteremia had a higher rate of endocarditis than S. bovis Ⅱ (53.3% vs. 13.5%, respectively; p=0.003). S. bovis Ⅰ bacteremia also had a higher rate of colonic neoplasia (60.0% vs. 18.9%, respectively; p=0.004). However, S. bovis Ⅰ had a lower rate of hepatobiliary source (46.7% vs. 59.5%, respectively; p=0.4). Conclusion. Because S. bovis bacteremia is the high incidence of colonic neoplasia, especially biotype Ⅰ, we should complete studies (e.g.: cardiac echo, colonoscopy, upper abdominal sonography or abdominal CT scan) as soon as possible.
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Twenty-six adults with Streptococcus bovis endocarditis and ten with bacteremia alone were studied to determine possible portals of entry. Of 36 patients (17 with endocarditis, eight with bacteremia alone), 25 had gastrointestinal lesions or manipulation. In 22, the gastrointestinal tract appeared to be the source of S bovis bacteremia. Four patients had either carcinoma of the colon (two) or potentially malignant villous adenomas (two) when first seen because of S bovis bacteremia. None of these, nor two other patients with benign colonic polyps, had bowel-related symptoms or signs prior to admission. Since S bovis is a normal intestinal tract inhabitant, bacteremia may frequently be associated with bowel lesions. Streptococcus bovis bacteremia may provide an early clue to the presence of serious and clinically unexpected gastrointestinal disease. Gastrointestinal tract evaluation should be part of S bovis bacteremia patient management, with or without endocarditis.
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Streptococcus bovis recovered from blood cultures may represent bacteremia alone, bacteremia from an extravascular source, or endocarditis. Patients with S. bovis endocarditis frequently have a gastrointestinal focus. S. bovis has been associated with many gastrointestinal diseases and in particular with colon carcinoma. S. bovis endocarditis may be complicated by embolic events or osteomyelitis. Vertebral osteomyelitis is a rare complication of S. bovis endocarditis. We report the third known case of S. bovis endocarditis with vertebral osteomyelitis.
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We prospectively studied five patients with a remote history of Streptococcus bovis bacteremia who had not previously been evaluated for colonic pathology. This study was prompted by several reports of concomitant neoplasia in patients with recent S. bovis bacteremia. The patients were studied at a mean of 32 months after bacteremia. Despite the absence of other signs or symptoms suggestive of bowel disease, a negative test for occult blood in stool and a negative fecal culture for S. bovis, two patients were found to have neoplastic polyps of the colon. These findings suggest that the risk of colonic neoplasia in patients with remote S. bovis septicemia is similar to that found in patients with recent bacteremia, but evaluation of a larger group of these patients will be necessary to establish this risk.
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BACKGROUND: Many studies in the literature have warned of the need for investigation of colonic lesions among patients, especially elderly ones, who have bacteremia and/or endocarditis from Streptococcus bovis. Bacteremia and infectious endocarditis from Streptococcus bovis may be related to the presence of neoplastic lesions in the large intestine and hepatic disease. AIM: This report describes a patient who presented infectious endocarditis from Streptococcus bovis associated with colonic carcinoma and tubular-villous adenomas. CONCLUSIONS: The finding of this bacterium among patients with septicemia and/or endocarditis is also related to the presence of villous or tubular-villous adenomas in the large intestine. For this reason, complete and detailed investigation of the large intestine must be performed in patients with infectious endocarditis, even in the absence of intestinal symptoms. An increased incidence of this condition or hepatic dysfunction has been reported among patients with infectious endocarditis from Streptococcus bovis. Patients with infectious endocarditis from Streptococcus bovis and normal colonoscopy may be included in the group at risk for developing colonic cancer. The knowledge that there is an association between endocarditis from Streptococcus bovis and carcinoma of the colon has important clinical implications. If the lesion can be discovered at an early stage, curative resection may become possible.
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Streptococcus bovis is a relatively frequent causative agent of endocarditis or bacteriaemia, particularly in the elderly. In the past S. bovis has often been incompletely or even falsely classified. For therapeutic and prognostic reasons it is important to classify this agent exactly with biochemical methods even in the routine laboratory. Endocarditis or bacteriaemia due to S. bovis are often seen in conjunction with malignant, potentially malignant or benign colorectal neoplasias. After endocarditis or bacteriaemia due to S. bovis thorough investigation of colon and rectum is indicated. On the other hand, in presence of fever in patients with colorectal tumors, S. bovis bacteriaemia or endocarditis must be considered. The available literature is inconclusive on the question whether, after S. bovis endocarditis or bacteriaemia with initially normal colorectal findings, examination of the upper gastrointestinal tract and periodic inspection of the colon is needed. Up to now there has been no satisfactory explanation for the concomitant occurrence of endocarditis or bacteriaemia due to S. bovis and colorectal neoplasia.
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Abstract Two patients are described in whom Streptococcus bovis bacteremia was the only clue to the presence of a colonic neoplasm. A third patient had the rare association of gastric carcinoma and Streptococcus bovis bacteremia that followed an operation for the carcinoma. The need for both complete gastrointestinal survey in patients with Streptococcus bovis bacteremia and administration of appropriate antibiotic prophylaxis during surgical manipulation is emphasized.
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Two biotypes of Streptococcus bovis can be identified by laboratory testing and can be distinguished from the phenotypically similar organism Streptococcus salivarius. We assessed the clinical relevance of careful identification of these organisms in 68 patients with streptococcal bacteremia caused by these similar species. S. bovis was more likely to be clinically significant when isolated from blood (89%) than was S. salivarius (23%). There was a striking association between S. bovis I bacteremia and underlying endocarditis (94%) compared with that of S. bovis II bacteremia (18%). Bacteremia with S. bovis I was also highly correlated with an underlying colonic neoplasm (71% of patients overall, 100% of those with thorough colonic examinations) compared with bacteremia due to S. bovis II or S. salivarius (17% overall, 25% of patients with thorough colonic examinations). We conclude that careful identification of streptococcal bacteremic isolates as S. bovis biotype I provides clinically important information and should be more widely applied.
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