Infections Due To Gram Positive Cocci

1.

A 19-year-old woman presents to your clinic complaining of fevers and arthritis for 2 weeks. Her symptoms first started with right knee pain and swelling. She then developed bilateral knee pain followed by left elbow pain. On examination, she has a fever, synovitis, and a pericardial friction rub. Her laboratory testing reveals acute renal failure (creatinine 2.4 mg/dL) and an elevated C-reactive protein. An electrocardiogram shows a prolonged PR interval. The patient had a sore throat 3 weeks ago that resolved spontaneously after a few days.

What is the best prophylactic treatment to prevent a recurrence of this patient's symptoms?

Penicillin p.o. or IM

Aspirin p.o.

Azithromycin p.o.

Prednisone p.o

There are five major clinical manifestations of acute renal failure (ARF): carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum. Carditis develops in about 60% of patients; it involves the endocardium, myocardium, and pericardium. The typical manifestations of rheumatic carditis are sinus tachycardia (sometimes with first-degree heart block), mitral regurgitation, a pericardial friction rub, and cardiomegaly; congestive heart failure indicates severe carditis. Although most cases of carditis resolve within 3 months, patients with moderate to severe carditis or recurrent ARF are at risk for the late manifestation of mitral valve or aortic valve scarring. Polyarthritis develops in about 70% of patients with ARF. It is characteristically a migratory arthritis involving the large joints of the extremities; it resolves without sequelae in days to weeks. On rare occasions, adults may develop a persistent arthropathy of the hands and feet. Chorea, subcutaneous nodules, and erythema marginatum are all self-limited; each occurs in fewer than 10% of children with ARF and only very rarely in adults.

The minor manifestations of ARF are fever, arthralgias, and inflammation. The inflammation in such cases is evidenced by elevated erythrocyte sedimentation rates and C-reactive protein levels. The diagnosis of ARF is made on the basis of clinical features. The classic Jones criteria include the presence of either two major manifestations or one major and two minor manifestations, as well as laboratory evidence of a recent streptococcal infection (e.g., a positive throat culture or rising antistreptococcal antibody levels).

Treatment of ARF focuses on eradication of streptococcal pharyngitis and reduction of inflammation. Most clinicians recommend a course of penicillin or, as an alternative, other antistreptococcal antibiotics, even if the throat culture is negative at the time ARF is diagnosed. Antiinflammatory therapy includes aspirin and bed rest until inflammatory symptoms resolve; corticosteroids may have a role for patients with severe carditis.

ARF can be prevented by adequate treatment of streptococcal pharyngitis, even if antibiotics are delayed for up to 9 days after the onset of pharyngitis. Patients with a history of ARF are particularly vulnerable to recurrent attacks. Consequently, they should receive continuous prophylaxis for at least 5 years with daily oral penicillin (250 mg twice a day) or monthly injections of 1.2 million units of benzathine penicillin G. Prophylaxis can be discontinued when young patients who are at low risk for recurrence reach adulthood or when small children are no longer in the household.

Explanation

There are five major clinical manifestations of acute renal failure (ARF): carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum. Carditis develops in about 60% of patients; it involves the endocardium, myocardium, and pericardium. The typical manifestations of rheumatic carditis are sinus tachycardia (sometimes with first-degree heart block), mitral regurgitation, a pericardial friction rub, and cardiomegaly; congestive heart failure indicates severe carditis. Although most cases of carditis resolve within 3 months, patients with moderate to severe carditis or recurrent ARF are at risk for the late manifestation of mitral valve or aortic valve scarring. Polyarthritis develops in about 70% of patients with ARF. It is characteristically a migratory arthritis involving the large joints of the extremities; it resolves without sequelae in days to weeks. On rare occasions, adults may develop a persistent arthropathy of the hands and feet. Chorea, subcutaneous nodules, and erythema marginatum are all self-limited; each occurs in fewer than 10% of children with ARF and only very rarely in adults.

The minor manifestations of ARF are fever, arthralgias, and inflammation. The inflammation in such cases is evidenced by elevated erythrocyte sedimentation rates and C-reactive protein levels. The diagnosis of ARF is made on the basis of clinical features. The classic Jones criteria include the presence of either two major manifestations or one major and two minor manifestations, as well as laboratory evidence of a recent streptococcal infection (e.g., a positive throat culture or rising antistreptococcal antibody levels).

Treatment of ARF focuses on eradication of streptococcal pharyngitis and reduction of inflammation. Most clinicians recommend a course of penicillin or, as an alternative, other antistreptococcal antibiotics, even if the throat culture is negative at the time ARF is diagnosed. Antiinflammatory therapy includes aspirin and bed rest until inflammatory symptoms resolve; corticosteroids may have a role for patients with severe carditis.

ARF can be prevented by adequate treatment of streptococcal pharyngitis, even if antibiotics are delayed for up to 9 days after the onset of pharyngitis. Patients with a history of ARF are particularly vulnerable to recurrent attacks. Consequently, they should receive continuous prophylaxis for at least 5 years with daily oral penicillin (250 mg twice a day) or monthly injections of 1.2 million units of benzathine penicillin G. Prophylaxis can be discontinued when young patients who are at low risk for recurrence reach adulthood or when small children are no longer in the household.

2.

A 40-year-old female presents to the emergency department critically ill. She is 1 day postoperative from a rhinoplasty. In the emergency department, her blood pressure is 90/60 mm Hg, heart rate is 120 beats per minute, respiration is 20 breaths/min, and temperature is 38.3°C (101°F). On examination, the patient is in significant distress and has a nasal packing in place. Her laboratory evaluation reveals a leukocytosis, thrombocytopenia, and acute renal failure.

What is the most appropriate next step in the management of this patient?

Remove nasal packing and IV vancomycin

Remove nasal packing and IV ciprofloxacin

IV vancomycin only

IV ciprofloxacin only

Staphylococcal TSS was first reported in 1978; by 1990, more than 3,300 cases had been reported in the United States, 90% of which occurred during menstruation in women who were using tampons. The incidence of staphylococcal TSS declined precipitously after superabsorbent tampons were withdrawn from the market. Most cases are now nosocomially acquired, often as a result of postoperative staphylococcal wound infections, particularly those associated with nasal packing after rhinoplasty. Staphylococcal TSS caused by toxin-producing strains of methicillin-resistant Staphylococcus aureus has been reported in the United States and Japan.

TSS is a multisystem disease with diverse clinical manifestations. Leukocytosis and thrombocytopenia (

Explanation

Staphylococcal TSS was first reported in 1978; by 1990, more than 3,300 cases had been reported in the United States, 90% of which occurred during menstruation in women who were using tampons. The incidence of staphylococcal TSS declined precipitously after superabsorbent tampons were withdrawn from the market. Most cases are now nosocomially acquired, often as a result of postoperative staphylococcal wound infections, particularly those associated with nasal packing after rhinoplasty. Staphylococcal TSS caused by toxin-producing strains of methicillin-resistant Staphylococcus aureus has been reported in the United States and Japan.

TSS is a multisystem disease with diverse clinical manifestations. Leukocytosis and thrombocytopenia (

3.

A 35-year-old man with a history of HIV presents to the emergency department after developing cough with blood-tinged sputum, shortness of breath, and fever for 1 day. He has not had recent exposures or sick contacts. He is on highly active antiretroviral therapy (HAART) and has never had an opportunistic infection. His last CD4 count was greater than 300/μL. On examination, he is febrile (39.1°C [102.4°F]) and tachypneic (26/min). Ronchi and egophony are noted in the right lower lobe. A chest x-ray shows a right lower lobe consolidation.

What is the most likely cause of this patient's current infection?

Reactivation of a latent disease

Aspiration of oropharyngeal secretions containing bacteria

Inhalation of droplets from another person with the infection

Intravenous (IV) drug use

Pneumococci produce IgA protease, which cleaves the secretory immunoglobulin IgA1. IgA protease may be partly responsible for the high carrier rate and the respiratory tract pathogenicity of these bacteria. The organisms do not provoke an inflammatory response or cause clinical illness in the nasopharynx. Host defense mechanisms prevent penetration into more vulnerable areas, such as the paranasal sinuses, middle ear, and pulmonary alveoli. Examples of these defenses include the cough, gag, and sneeze reflexes; the viscous mucus that lines the respiratory epithelium and traps bacteria; and ciliary action, which expels trapped particles. Pneumococcal infection often follows influenza or other viral infections of the upper respiratory tract, which impair host defenses by increasing the volume and decreasing the viscosity of secretions. Other factors that predispose to pneumococcal infection include dementia, seizure disorders, alcoholism, stupor, and other conditions that increase the likelihood that oropharyngeal contents will be aspirated into the lungs. Air pollution, cigarette smoking, heart failure, chronic obstructive pulmonary disease (COPD), and HIV infection increase the risk of pneumococcal infection, but diabetes does not.
Pneumococcal pneumonia begins with aspiration of small quantities of oropharyngeal secretions containing pneumococci. Normally, alveolar macrophages ingest and kill such bacteria, but in the absence of type-specific immunity, strains of pneumococci are protected from ingestion.

Explanation

Pneumococci produce IgA protease, which cleaves the secretory immunoglobulin IgA1. IgA protease may be partly responsible for the high carrier rate and the respiratory tract pathogenicity of these bacteria. The organisms do not provoke an inflammatory response or cause clinical illness in the nasopharynx. Host defense mechanisms prevent penetration into more vulnerable areas, such as the paranasal sinuses, middle ear, and pulmonary alveoli. Examples of these defenses include the cough, gag, and sneeze reflexes; the viscous mucus that lines the respiratory epithelium and traps bacteria; and ciliary action, which expels trapped particles. Pneumococcal infection often follows influenza or other viral infections of the upper respiratory tract, which impair host defenses by increasing the volume and decreasing the viscosity of secretions. Other factors that predispose to pneumococcal infection include dementia, seizure disorders, alcoholism, stupor, and other conditions that increase the likelihood that oropharyngeal contents will be aspirated into the lungs. Air pollution, cigarette smoking, heart failure, chronic obstructive pulmonary disease (COPD), and HIV infection increase the risk of pneumococcal infection, but diabetes does not.
Pneumococcal pneumonia begins with aspiration of small quantities of oropharyngeal secretions containing pneumococci. Normally, alveolar macrophages ingest and kill such bacteria, but in the absence of type-specific immunity, strains of pneumococci are protected from ingestion.

4.

A 40-year-old male with a history of IV drug abuse presents to your clinic with fevers and chills for 1 week. His examination reveals a new holosystolic murmur at the left lower sternal border that increases with inspiration. He is febrile at 38.9°C (102°F). The remainder of the examination is unremarkable. A chest x-ray shows scattered opacities. You plan to admit him for workup and treatment of infective endocarditis.

What duration of IV antibiotics is necessary for this patient's illness?

4 to 6 weeks

7 to 10 days

3 months

1 year

Patients with staphylococcal bacteremia have generally been treated with parenteral antibiotics for 4 to 6 weeks. This recommendation was made on the basis of the results of a study conducted from 1940 to 1954 in which endocarditis developed in 64% of 55 patients with staphylococcal bacteremia. Subsequent investigations suggested that patients with a removable or treatable primary focus of infection (most often infected IV devices) who have no clinical evidence of endocarditis can be treated safely with only 10 to 21 days of IV antibiotics. Other studies, however, reported development of endocarditis in 22 to 38% of patients with a primary focus of bacteremia. Therefore, the possibility of endocarditis should not be ignored, even if a primary focus is present. Moreover, major complications, including shock, acute respiratory distress syndrome, and metastatic infection, can occur even in the absence of endocarditis.

Controlled trials are necessary to determine the safety and efficacy of short-term therapy for staphylococcal bacteremia. It may therefore be prudent to treat patients with staphylococcal bacteremia as though they have endocarditis, unless all of the following features are present: clear evidence of only a transient bacteremia; a removable primary focus of infection; a benign clinical course; an absence of echocardiographically demonstrable valvular abnormalities and metastatic infection; and intact host defenses. Negative titers of teichoic acid antibodies would bolster the decision to shorten the IV antibiotic therapy, which should, in any case, be continued for at least 10 to 15 days.

Explanation

Patients with staphylococcal bacteremia have generally been treated with parenteral antibiotics for 4 to 6 weeks. This recommendation was made on the basis of the results of a study conducted from 1940 to 1954 in which endocarditis developed in 64% of 55 patients with staphylococcal bacteremia. Subsequent investigations suggested that patients with a removable or treatable primary focus of infection (most often infected IV devices) who have no clinical evidence of endocarditis can be treated safely with only 10 to 21 days of IV antibiotics. Other studies, however, reported development of endocarditis in 22 to 38% of patients with a primary focus of bacteremia. Therefore, the possibility of endocarditis should not be ignored, even if a primary focus is present. Moreover, major complications, including shock, acute respiratory distress syndrome, and metastatic infection, can occur even in the absence of endocarditis.

Controlled trials are necessary to determine the safety and efficacy of short-term therapy for staphylococcal bacteremia. It may therefore be prudent to treat patients with staphylococcal bacteremia as though they have endocarditis, unless all of the following features are present: clear evidence of only a transient bacteremia; a removable primary focus of infection; a benign clinical course; an absence of echocardiographically demonstrable valvular abnormalities and metastatic infection; and intact host defenses. Negative titers of teichoic acid antibodies would bolster the decision to shorten the IV antibiotic therapy, which should, in any case, be continued for at least 10 to 15 days.

5.

An 85-year-old woman with dementia presents to the emergency department from a nursing home with delirium. She was in her usual state of health until 3 days ago, when her symptoms developed. The staff at the nursing home report that the patient's urine is dark and she is having low-grade fevers. A urinalysis obtained 2 days previously shows leukocyturia and gram-positive cocci in chains. The culture is available today and shows widely sensitive Enterococcus faecalis. On examination, you see a confused elderly woman. Her temperature is 37.9°C (100.2°F). She is wearing malodorous diapers.

What is the most appropriate antibiotic for this patient's infection?

Vancomycin

Ciprofloxacin

Ampicillin

Linezolid

Changing resistance patterns will necessitate changes in antibiotic therapy for patients with enterococcal infections. Traditionally, ampicillin has been the drug of choice for enterococcal urinary tract infections, largely because of the high concentrations of drug excreted in the urine. In penicillin-allergic patients, nitrofurantoin, a fluoroquinolone, or trimethoprim-sulfamethoxazole may be effective for the treatment of simple urinary tract infections; however, because in vitro susceptibility testing of enterococci is often misleading and because resistance to these agents may rapidly emerge, patients should be continually evaluated through assessment of their clinical response and by use of follow-up cultures.

Infections caused by strains that are highly resistant to aminoglycosides can be treated with vancomycin. Infections caused by vancomycin-resistant strains are the most difficult to treat; linezolid has been particularly helpful, and quinupristin-dalfopristin is also effective. Doxycycline, chloramphenicol, and, for urinary tract infections, nitrofurantoin have also been used. In all cases, removal of infected indwelling catheters and foreign bodies and drainage of septic foci are essential. It is also essential to limit the spread of vancomycin-resistant Enterococcus by intensive surveillance, infection control measures, and prudent use of vancomycin and other antibiotics.

Explanation

Changing resistance patterns will necessitate changes in antibiotic therapy for patients with enterococcal infections. Traditionally, ampicillin has been the drug of choice for enterococcal urinary tract infections, largely because of the high concentrations of drug excreted in the urine. In penicillin-allergic patients, nitrofurantoin, a fluoroquinolone, or trimethoprim-sulfamethoxazole may be effective for the treatment of simple urinary tract infections; however, because in vitro susceptibility testing of enterococci is often misleading and because resistance to these agents may rapidly emerge, patients should be continually evaluated through assessment of their clinical response and by use of follow-up cultures.

Infections caused by strains that are highly resistant to aminoglycosides can be treated with vancomycin. Infections caused by vancomycin-resistant strains are the most difficult to treat; linezolid has been particularly helpful, and quinupristin-dalfopristin is also effective. Doxycycline, chloramphenicol, and, for urinary tract infections, nitrofurantoin have also been used. In all cases, removal of infected indwelling catheters and foreign bodies and drainage of septic foci are essential. It is also essential to limit the spread of vancomycin-resistant Enterococcus by intensive surveillance, infection control measures, and prudent use of vancomycin and other antibiotics.