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Joseph M Blondeau,1 Howard M Proskin,2 Christine M Sanfilippo,3 Heleen H DeCory3 1Clinical Microbiology, Royal University Hospital, Saskatoon, SK, Canada; 2Howard M. Proskin & Associates, Rochester, NY, USA; 3Pharmaceutical Medical Affairs, Bausch + Lomb, Rochester, NY, USACorrespondence: Heleen H DeCoryPharmaceutical Medical Affairs, 1400 North Goodman Street, Rochester, NY, 14609, USATel +1 585 338-8161Email Heleen.DeCory@bausch.comIntroduction: The choice of empiric therapy for bacterial conjunctivitis should be guided by an awareness of typical causative pathogen distributions. Bacterial conjunctivitis can be polybacterial, although pediatric-specific data are lacking.Methods: This was a post-hoc analysis of data in pediatric subjects (1– 17 years) from five bacterial conjunctivitis trials evaluating besifloxacin ophthalmic solution 0.6%.Results: Of the 730 pediatric subjects with culture-confirmed conjunctivitis, nearly one-fourth (23.6%) had polybacterial infections and three-fourths (76.4%) had monobacterial infections at baseline. In both polybacterial and monobacterial infections, the most prevalent organisms were Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, and Streptococcus mitis/S. mitis group. In polybacterial versus monobacterial infections, S. mitis/S. mitis group (8.7% vs 4.3%; P=0.032) and Moraxella catarrhalis (4.7% vs 0.5%; P< 0.001) were identified more frequently, whereas S. pneumoniae (14.0% vs 28.1%; P< 0.001) was identified less frequently, as the dominant infecting species. MICs for individual species were similar for tested antibiotics regardless of polybacterial or monobacterial infection, except Staphylococcus epidermidis for which fluoroquinolone MICs were ≥ 3 dilutions higher for isolates of this species sourced from polybacterial compared to monobacterial infections. Treatment with besifloxacin resulted in microbial eradication in 79.1% of polybacterial and 92.3% of monobacterial infections (P≤ 0.005 vs vehicle).Discussion: One in four pediatric bacterial conjunctivitis infections is polybacterial, highlighting the need for a broad-spectrum antibiotic when choosing empiric therapy.Keywords: pediatric, conjunctivitis, polybacterial, besifloxacin, minimum inhibitory concentration

Objective Infants with extrauterine growth restriction (EUGR) experience significant postnatal growth restriction in the first week after birth, which indicates a failure of energy absorption. This study aimed to determine the different intestinal microbial species and metabolites between infants with EUGR and those without EUGR. Methods A total of 73 infants hospitalized in a neonatal intensive care unit were enrolled and divided into the EUGR group (n = 50) and the non-EUGR group (n = 23). Fecal samples were collected during hospitalization. Bacterial species and their relative abundance were identified with metagenome sequencing. The metabolites in the feces and blood were identified with an LC-MS–based non-targeted metabolome. Results The intestinal microbiota of the EUGR group contained less Bacteroides vulgatus, Dorea unclassified, Lachnospiraceae bacterium 1_1_57FAA, and Roseburia unclassified compared to that of the non-EUGR group. More importantly, the intestinal microbiota of the EUGR group contained Streptococcus mitis_oralis_pneumoniae, while that of the non-EUGR group did not. Furthermore, KEGG prediction and a correlation analysis identified that the majority of different microbial species higher in the non-EUGR group were related to metabolism. The results of the non-targeted metabolome revealed that several metabolites in the feces and blood were much higher in either group, some of which were related to the different microbial species. Conclusions This study identified several different intestinal microbial species and metabolites in the patients feces and blood, which may provide evidence to identify the biomarkers of infants with EUGR.

Dental fluorosis is a very prevalent endemic disease. Although oral microbiome has been reported to correlate with different oral diseases, there appears to be an absence of research recognizing any relationship between the severity of dental fluorosis and the oral microbiome. To this end, we investigated the changes in oral microbial community structure and identified bacterial species associated with moderate and severe dental fluorosis. Salivary samples of 42 individuals, assigned into Healthy (N = 9), Mild (N = 14) and Moderate/Severe (M&S, N = 19), were investigated using the V4 region of 16S rRNA gene. The oral microbial community structure based on Bray Curtis and Weighted Unifrac were significantly changed in the M&S group compared with both of Healthy and Mild. As the predominant phyla, Firmicutes and Bacteroidetes showed variation in the relative abundance among groups. The Firmicutes/Bacteroidetes (F/B) ratio was significantly higher in the M&S group. LEfSe analysis was used to identify differentially represented taxa at the species level. Several genera such as Streptococcus mitis, Gemella parahaemolysans, Lactococcus lactis, and Fusobacterium nucleatum, were significantly more abundant in patients with moderate/severe dental fluorosis, while Prevotella melaninogenica and Schaalia odontolytica were enriched in the Healthy group. In conclusion, our study indicates oral microbiome shift in patients with moderate/severe dental fluorosis. We identified several differentially represented bacterial species enriched in moderate and severe fluorosis. Findings from this study suggests that the roles of these bacteria in oral health and related diseases warrant more consideration in patients with moderate and severe fluorosis.

To identify the characteristics and the spectrum of microbial agents of infantile dacryocystitis and to assess the trends in both antibiotic sensitivities and pathogens over the past 10 years. The microbial and medical records of 546 culture-proven patients (546 eyes) of infantile dacryocystitis diagnosed at Henan Eye Hospital between January 2009 and December 2018 were retrospectively reviewed. Patient demographics, microbial analysis, and susceptibility rates to various antibiotics were done. A chi-squared test for trends was applied to evaluate changes in antibiotic susceptibility and microbial spectrum over time. A total of 546 patients with infantile dacryocystitis were documented. The average age was 2.97 ± 4.15 months, and 42.7% were female. The proportion of gram-positive microbes, gram-negative microbes, and fungi was 80.2, 19.4, and 0.4%, respectively. Minocycline was sensitive to gram-positive bacteria (98.0%). Imipenem was sensitive to gram-negative bacteria (89.2%). Increasing susceptibility was observed in two bacterial isolates: Staphylococcus aureus (P = 0.005) and Streptococcus mitis (P = 0.001). Decreasing susceptibility was observed in one bacterial isolate: Staphylococcus epidermidis (P

Background: The recognition of human blood microbiota, consisting of cell wall-deficient microbes (L-forms), is a major challenge today in the field of microbiology. There are accumulating data confirming the concept of “internal” blood L-form microbiota and its significance for health and diseases. Finding out whether the blood microbiota can be of diagnostic and prognostic importance for detection and evaluation of chronic infections anywhere in the body is a major objective. In the context of chronically infected upper respiratory tract (URT), the aim of the current study was to understand whether a local infection can be a source for entry of bacteria and fungi in the blood. Methods: Blood samples from six persons with chronic inflammations in URT diagnosed with hypertrophied adenoids, chronic sinusitis, nasal polyps, chronic naso-pharyngitis and one control healthy person were studied. Blood microbiota assessment methodology that be used, included three phases: 1) isolation of L-form cultures from blood-development and propagation; 2) cultivation directed to conversion of L-forms into bacterial and fungal cultures; 3) isolation of pure classical bacterial and fungal cultures and their identification by MALDI-TOF method. Results: From the patients were isolated L-forms of opportunistic bacteria (Streptococcus mitis, Roseomonas mucosa, Dermacoccus nishinomiyaensis, Enterococcus faecalis, Acinetobacter johnsonii, Pseudomonas putida, Staphylococcus aureus, Pseudomonas luteola, Enterobacter cloacae) and fungi such as Rhodotorula mucilaginosa, Aspergillus niger, Aspergillus fumigatus and Mucorales. Conclusion: The novel innovative methodology for assessment of blood L-form microbiota was successfully applied for detection of microbes responsible for chronic infections at URT.

Background The Modified Duke criteria is an important structured schematic for the diagnosis of infective endocarditis (IE). Corynebacterium jeikeium is a rare cause of IE that is often resistant to standard IE anti-microbials. We present a case of C. jeikeium IE, fulfilling the Modified Duke pathological criteria. Case summary A 50-year-old male presented with left leg peripheral vascular disease with septic changes requiring amputation. Routine echocardiography post-amputation demonstrated severe aortic valve regurgitation with vegetations that required valve replacement. Two initial blood cultures from a single venepuncture showed Streptococcus mitis which was treated with penicillin G prior to surgery. Subsequent aortic valve tissue cultured C. jeikeium with suggestive IE histological valvular changes and was successfully treated on a prolonged course of vancomycin. Discussion This is the first C. jeikeium IE case diagnosed on heart valvular tissue culture and highlights the importance for the fulfilment of the Modified Duke criteria in diagnosing left-sided IE. Mixed infection IE is rare, and this case possibly represents an unmasking of resistant C. jeikeium IE following initial treatment of penicillin G.

A late-preterm boy is delivered at 36 weeks by a 21-year old gravida 1, para 0 woman whose pregnancy was complicated by a complex liver mass noted on third-trimester ultrasonography. The infant undergoes intubation at birth for respiratory failure. His early hospital course is notable for high-output cardiac failure and liver failure with profound cholestasis, thrombocytopenia, and coagulopathy. He requires hemodialysis from weeks 1 to 4 after birth, secondary to abdominal compartment syndrome and acute renal failure with gradual improvement in renal function. Abdominal computed tomography (CT) performed on day 11 after birth demonstrates a large peripherally enhancing complex liver mass. He remains ventilator dependent, but his respiratory function improves, and he tolerates full enteral feeds. Evidence of liver failure and a need for blood product transfusion persists. Serum α-fetoprotein levels decline from 163,000 ng/mL (163,000 μg/L) at birth to 10,500 ng/mL (10,500 μg/L) at 3 weeks of age. The liver mass remains stable in size on serial ultrasonography. The medical team considers liver transplantation. Unfortunately, the patient experiences acute decompensation on day 49 after birth in the setting of Streptococcus mitis sepsis with worsening coagulopathy, pulmonary hemorrhage, and progressive respiratory failure. After discussions with the family regarding goals of care, life support is discontinued. ### Autopsy Findings The heart shows evidence of high-output heart failure. The liver is enlarged, with displacement of the diaphragm …

Context Early microbiological diagnosis and treatment of periodontal pathogens is important for successful retention of dental implants. Aims This study aimed to identify and monitor oral bacterial colonization after successful two-piece dental implants. Settings and Design In this study, 50 two-piece dental implant subjects were included and assessed clinically, radiographically, and microbiologically. Methods and Material All the parameters were recorded at various stages after prosthesis placement. In each stage, nonadherent (peri-implant sulcular fluid) and adherent (curetted inner threads) samples were collected. Semiquantitative anaerobic culture of the samples were done in Anoxomat system. Bacterial colonies were first identified by routine microbiological methods and then by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) method. Statistical Analysis All the results were analyzed by appropriate statistical methods (Chi-square, one factor analysis of variance, etc.). Results All the bacterial isolates were identified in the MALDI-TOF MS system with no failure. After implant placement for the nonadherent samples, the frequency (%) of Fusobacterium nucleatum, Prevotella melaninogenica, and Propionibacterium acnes decreased whereas frequency (%) of Escherichia coli, Staphylococcus epidermidis, and Streptococcus mitis increased. For adherent samples, the frequency (%) of E. coli, Enterococcus faecalis, Porphyromonas gingivalis, P. melaninogenica, and Veillonella parvula decreased, whereas frequency (%) of S. mitis and Streptococcus mutans increased. The postimplant mean nonadherent and adherent bacterial load increased with time but not significantly over the periods (p = 0.302 and 0.123, respectively). Conclusion Combination of basic (semiquantitative culture method) and advanced microbiological method (MALDI-TOF MS) can be useful for accurate detection and monitoring of potential pathogens around two-piece dental implants.

Right-side endocarditis (RSE) is a well-defined clinical entity, rarer than left-side endocarditis. Known risk factors include intravenous drug use or the presence of medical devices. The most frequently affected valve is the tricuspid valve. In most cases, medical treatment is enough. Surgical treatment is reserved for failed medical therapy or in the presence of large vegetations. Although there is a high recurrence rate in intravenous drug users (IDU), RSE has a generally good prognosis. We present the case of a 70-year-old male with no known previous diseases other than alcohol abuse. He was admitted with fever, cough, hemoptysis and a weight loss of 8 kg in two months. Chest X-ray revealed two images of condensation, one in the right pulmonary base and another in the superior right lobe. A computerized tomography of the thorax revealed a subsegmental pulmonary embolism. The patient refused hospitalization and was discharged medicated with levofloxacin and apixaban. In ambulatory, there was a decrease in size of the lesions but with a new lesion in the right hemithorax. Two months after the first episode, the patient is admitted with the same symptoms. The transthoracic echocardiogram showed a 20cm vegetation in the tricuspid valve. He was admitted to the hospital and received treatment with penicillin and gentamicin after isolation of Streptococcus mitis in the blood cultures. Surgical treatment was needed after a weak response to antibiotics, with a good evolution.

Rationale Chronic airway infection and inflammation resulting in progressive, obstructive lung disease is the leading cause of morbidity and mortality in cystic fibrosis. Understanding the lower airway microbiota across the ages can provide valuable insight and potential therapeutic targets. Objectives To characterize and compare the lower airway microbiota in cystic fibrosis and disease control subjects across the pediatric age spectrum. Methods Bronchoalveolar lavage fluid samples from 191 subjects (63 with cystic fibrosis) aged 0 to 21 years were collected along with relevant clinical data. We measured total bacterial load using quantitative polymerase chain reaction and performed 16S rRNA gene sequencing to characterize bacterial communities with species-level sensitivity for select genera. Clinical comparisons were investigated. Measurements and main results Cystic fibrosis samples had higher total bacterial load and lower microbial diversity, with a divergence from disease controls around 2–5 years of age, as well as higher neutrophilic inflammation relative to bacterial burden. Cystic fibrosis samples had increased abundance of traditional cystic fibrosis pathogens and decreased abundance of the Streptococcus mitis species group in older subjects. Interestingly, increased diversity in the heterogeneous disease controls was independent of diagnosis and indication. Sequencing was more sensitive than culture, and antibiotic exposure was more common in disease controls, which showed a negative relationship with load and neutrophilic inflammation. Conclusions Analysis of lower airway samples from people with cystic fibrosis and disease controls across the ages revealed key differences in airway microbiota and inflammation. The divergence in subjects during early childhood may represent a window of opportunity for intervention and additional study.

After staphylococci, streptococci and enterococci are the most frequent causes of periprosthetic joint infection (PJI). MICs and minimum biofilm bactericidal concentrations of rifampin, rifabutin, and rifapentine were determined for 67 enterococcal and 59 streptococcal PJI isolates. Eighty-eight isolates had rifampin MICs of ≤1 μg/ml, among which rifabutin and rifapentine MICs were ≤ 8 and ≤4 μg/ml, respectively. There was low rifamycin in vitro antibiofilm activity except for a subset of Streptococcus mitis group isolates. IMPORTANCE Rifampin is an antibiotic with antistaphylococcal biofilm activity used in the management of staphylococcal periprosthetic joint infection with irrigation and debridement with component retention; some patients are unable to receive rifampin due to drug interactions or intolerance. We recently showed rifabutin and rifapentine to have in vitro activity against planktonic and biofilm states of rifampin-susceptible periprosthetic joint infection-associated staphylococci. After staphylococci, streptococci and enterococci combined are the most common causes of periprosthetic joint infection. Here, we investigated the in vitro antibiofilm activity of rifampin, rifabutin, and rifapentine against 126 Streptococcus and Enterococcus periprosthetic joint infection isolates. In contrast to our prior findings with staphylococcal biofilms, there was low antibiofilm activity of rifampin, rifabutin, and rifapentine against PJI-associated streptococci and enterococci, apart from some Streptococcus mitis group isolates.

Oral microbiota is constantly changing with the host state, whereas the oral microbiome of chronic erythematous candidiasis remains poorly understood. The aim of this study was to compare oral microbial signatures and functional profiling between chronic erythematous candidiasis and healthy subjects. Using shotgun metagenomic sequencing, we analyzed the microbiome in 12 chronic erythematous candidiasis, 12 healthy subjects, and 2 chronic erythematous candidiasis cured by antifungal therapy. We found that the salivary microbiota of chronic erythematous candidiasis was significantly different from that of healthy subjects. Among them, Rothia mucilaginosa and Streptococcus mitis were the most abundant disease-enriched species (Mann-Whitney U-test, P < 0.05). In addition, co-occurrence network analysis showed that C. albicans formed densely connected modules with oral bacterial species and was mainly positive connected to Streptococcus species. Furthermore, we investigated the functional potentials of the microbiome and identified a set of microbial marker genes associated with chronic erythematous candidiasis. Some of these genes enriching in chronic erythematous candidiasis are involved in eukaryotic ribosome, putative glutamine transport system, and cytochrome bc1 complex respiratory unit. Altogether, this study revealed the changes of oral microbial composition, the co-occurrence between C. albicans and oral bacteria, as well as the changes of microbial marker genes during chronic erythematous candidiasis, which provides evidence of oral microbiome as a target for the treatment and prevention of chronic erythematous candidiasis.

Background. Oral sex is postulated to be a risk factor for the introduction of bacteria into the amniotic cavity. Common oropharyngeal bacteria have been implicated in reports of second trimester chorioamnionitis via ascending vaginal transmission following oral sex. Dental scaling can also introduce these pathogens into the blood stream, allowing hematogenous spread of oral pathogens to the fetoplacental unit in pregnant patients. Case. We report a case of Streptococcus mitis chorioamnionitis at 21 weeks and 5 days’ gestation in a patient whose only risk factors were recent dental scaling and recent oral sex with a partner known to have periodontal disease. Conclusion. Bacterial chorioamnionitis should be considered in the differential diagnosis of preterm labour. Oral sex and dental procedures may be risk factors for chorioamnionitis.

Trans-catheter aortic valve implantation (TAVI) has recently emerged as a less invasive alternative to surgical aortic valve replacement (SAVR) in high risk patients. Although several procedures have been performed worldwide, infective endocarditis (IE) has been reported to be a rare TAVI complication, nevertheless if IE occurs it represents a life-threatening condition and treatment is challenging. TAVI-IE are thus normally treated conservatively by targeted antibiotic therapy with a high reported mortality (40%). Surgical explant represent the definitive strategy but, the intervention is at a high risk (risk of complication 87%, with an in hospital mortality of about 47%). In the present paper, we report the case of a 71-year-old patient affected by an early endocarditis after TAVI (TAVI-IE) treated at our Institution by surgical explant. The case highlights a paradox: if TAVI procedures are indicated over traditional surgical valve replacement in treatment of high surgical risk patients, what should be the best management when TAVI-IE occurs in these same population of patients?

Background Streptococcus oralis belongs to the Streptococcus mitis group and is part of the normal flora of the nasal and oropharynx (Koneman et al., The Gram-positive cocci part II: streptococci, enterococci and the ‘Streptococcus-like’ bacteria. Color atlas and textbook of diagnostic microbiology, 1997). Streptococcus oralis is implicated in meningitis in patients with decreased immune function or from surgical manipulation of the central nervous system. We report a unique case of meningitis by Streptococcus oralis in a 58-year-old patient with cerebral spinal fluid leak due to right sphenoid meningoencephalocele. Case presentation A 58-year-old female presented in the emergency department due to altered mental status, fevers, and nuchal rigidity. Blood cultures were positive for Streptococcus oralis. Magnetic resonance stereotactic imaging of head with intravenous gadolinium showed debris in lateral ventricle occipital horn and dural thickening/enhancement consistent with meningitis. There was also a right sphenoidal roof defect, and meningoencephalocele with cerebrospinal fluid leak as a result. The patient was treated with ceftriaxone and had endoscopic endonasal repair of defect. She had complete neurologic recovery 3 months later. Conclusions Cerebrospinal fluid leak puts patients at increased risk for meningitis. Our case is unique in highlighting Streptococcus oralis as the organism implicated in meningitis due to cerebrospinal fluid leak.

The profile of antimicrobial resistance (ie, antibiogram) may be disparate between children and adults. An infant developed severe deep neck infection with a multidrug‐resistant microbe. The microbe was more drug‐resistant in children than in adults, in our hospital. Treatment of a child should be guided by the antibiogram obtained from children.

Background Solobacterium moorei, the only species in the genus Solobacterium, is a Gram-positive, non-spore-forming, strict anaerobic, short to long bacillus. It has rarely been documented to cause blood stream infections. Here we report the first case of bacteremia caused by S.moorei in China. Case presentation A 61-year-old male presented to Peking Union Medical College Hospital (Beijing) with thrombotic thrombocytopenic purpura (TTP) and several other underlying diseases. He also had persistent coma accompanied by intermittent convulsions, halitosis, and intermittent fever. Blood cultures taken when the patient had a high fever were positive, with the anaerobic bottle yielding an organism identified as S.moorei by 16S rRNA gene sequencing, whilst the aerobic bottle grew Streptococcus mitis. After replacement of venous pipeline, and empirical use of vancomycin and meropenem, the patient’s body temperature and white blood cell count returned to normal. Unfortunately, the patient died of severe TTP. Conclusion This is the first case report of S. moorei isolation from blood stream in China. 16S rRNA gene sequencing is the only method that can identify S. moorei. Blood cultures must be taken before administration of antibiotics, and anaerobic culture should be considered for such rare pathogens in patients with oral diseases and immune deficiency.

Background Pulmonary valve infective endocarditis is a rare diagnosis that is usually associated with immunocompromised states or structurally abnormal hearts. It is unusual for it to occur in structurally normal hearts or to cause recurrent symptoms after targeted antibiotics. Although guidelines suggest follow-up with repeat echocardiography and inflammatory marker surveillance, this case demonstrates that these are not always useful investigations, and instead imaging of the chest may be more appropriate. Case presentation We describe a case of a 74-year-old man who presented with respiratory symptoms and was originally misdiagnosed with pneumonia but later found to have a large pulmonary valve vegetation caused by Streptococcus mitis. Despite initially responding to antibiotic therapy, the vegetation continued to cause pulmonary emboli and cavitating lung abscesses months later, necessitating pulmonary valve replacement. Conclusions This case demonstrates that pulmonary valve endocarditis can present atypically with recurrent respiratory symptoms, and in such cases, echocardiography should be considered to investigate for right-sided infective endocarditis. In addition, despite correct treatment, with normalization of inflammatory markers and improvement in vegetation size, infective endocarditis can continue to cause systemic symptoms. Finally, clinicians should consider chest computed tomography routinely as part of right-sided infective endocarditis follow-up.

Viridans streptococci are still under investigation concerning epidemiology, pathogenesis and clinical presentations. We aimed to investigate the clinical presentations and outcomes of pediatric patients infected with Streptococcus mitis/oralis. Based on the accumulation of bloodstream infections (BSI) caused by S. mitis/oralis in 4 patients in our Hematology and Bone Marrow Transplantation Department at a particular time, a review of the medical and microbiological records of pediatric patients with positive blood cultures for S. mitis/oralis in the entire hospital was performed. In addition, a retrospective case-control study was conducted. Pulsed-field gel electrophoresis of S. mitis/oralis in 4 patients displayed unrelatedness of the strains. A total of 53 BSI (42 BSI and 11 catheter-related BSI) were analyzed. Thirty-four percent of patients with BSI caused by S. mitis/oralis had febrile neutropenia. Clinical and microbiological outcomes were favorable and infection-related mortality was not observed. Although not significant, previous antibiotic use and trimethoprim-sulfamethoxazole prophylaxis were more common in the case group. S. mitis/oralis seems likely an important agent in bacteremic children who are particularly neutropenic because of the underlying hematologic and oncologic diseases. Prompt management of infections with appropriate antimicrobials, regarding antibiotic susceptibilities of organisms, may facilitate favorable outcomes.

Members of the viridans group streptococci (VGS) are the cause of local and invasive infections. Due to the severity of these infections and taking into account that reports regarding epidemiological aspects are scarce, the aims of this work were the identification and the study of the antibiotic susceptibility profiles of the isolates recovered from patients that were hospitalized in order to find out about the resistance level and the epidemiology of infections in which VGS are involved. A hundred and thirty two isolates identified as VGS were isolated at Hospital de Clínicas «José de San Martín» during the period 2011-2015. The identification was performed by biochemical test and mass spectrometry by Matrix Assisted Laser Desorption Ionization -Time of Flight Mass Spectrometry. Streptococcus anginosus group was prevalent (42%) followed by Streptococcus mitis group (33%). In the latter, isolates of Streptococcus pneumoniae were excluded. All the VGS isolates were susceptible to ertapenem, meropenem, linezolid and vancomycin; 25.8% were resistant (I+R) to penicillin, being prevalent in the S. mitis group. Regarding ceftriaxone and cefepime 96.9% of the isolates were susceptible. Only two isolates were resistant to levofloxacin, 27.2% to tetracycline and it was not found high level resistance to gentamycin (MIC range 0.5-32 μg/ml). Resistance to erythromycin was 17.4% with no significant difference between M and MLS phenotypes. The most active antibiotics were in addition to ceftriaxone and cefepime, vancomycin, ertapenem, meropenem and linezolid. These results highlight the importance of the continuous surveillance of the infections caused by VGS in order to predict a correct antibiotic therapy. Fil: Heine, Adriana C.. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina Fil: García, Susana. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina Fil: Barberis, Claudia. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina Fil: Vay, Carlos Alberto. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay; Argentina. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina Fil: Mollerach, Marta Eugenia. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay; Argentina. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Departamento de Microbiología, Inmunología y Biotecnología; Argentina Fil: Bonofiglio, Laura. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay; Argentina. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Departamento de Microbiología, Inmunología y Biotecnología; Argentina Fil: Famiglietti, Ángela. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín; Argentina

Infective endocarditis (IE) is associated with relatively high morbidity and mortality and several risk factors have been identified in the past. Several predisposing factors for IE have been recognized in the literature, depending on the type of bacteria. Coronavirus disease 2019 (COVID-19) infection causes coagulopathy-associated complications and damage to many organ systems due to the inflammatory response induced by this viral infection. COVID-19 emerged only about a year ago and there are many unknown post-COVID-19 complications at this time. Here, we present the case of Streptococcus mitis IE in a patient with no prior predisposing factors other than diagnosis with COVID-19 a month ago.

Objetive: Manufacturers of toothpastes claim that their products are active against oral microbiome capable of causing tooth decay. The objective of this study was to investigate the manufacturers’ claim using some of the toothpaste products sold in Ado-Ekiti, Nigeria. Material and methods: The antibacterial potentials of five commercialized toothpaste products (designated sodium fluoride-zinc sulphate, benzyl alcohol-sodium fluorophosphate, sodium fluoride-eugenol, sodium fluoridesodium laurylsulfate and sodium fluoridepotassium nitrate) were tested against six oral isolates of dental caries and periodontal origin – Staphylococcus aureus, Streptococcus mitis, Streptococcus salivarius, Streptococcus pyogenes and Pseudomonas aeruginosa. The antimicrobial potentials were evaluated using modified agar well diffusion method. Various dilutions of the toothpaste products from 1:1 to 1:16 were tested against each test microorganism. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of the toothpastes were determined. Results: sodium fluoride-zinc sulphate, benzyl alcoholsodium fluorophosphate and sodium fluorideeugenol toothpastes showed inhibitory effects on S. aureus, S. mitis and S. salivarius. Sodium fluoride-sodium laurylsulfate and sodium fluoride-potassium nitrate toothpastes showed no inhibitory effect on the organisms except S. pyogenes. Only sodium fluoride-potassium nitrate toothpaste inhibited E. coli while none of the toothpastes inhibited P. aeruginosa. The MIC and MBC of sodium fluoride-zinc sulphate, benzyl alcohol-sodium fluorophosphate, and sodium fluoride-eugenol toothpastes showed bacteriostatic and bactericidal effects on the organisms. Sodium fluoride-zinc sulphate, benzyl alcohol-sodium fluorophosphate, and sodium fluoride-eugenol toothpastes showed comparable effects on S. aureus, S. mitis and S. salivarius. Sodium fluoride-eugenol toothpaste was strongest against S. mitis, benzyl alcoholsodium fluorophosphates toothpaste was strongest against S. pyogenes, sodium fluoridezinc sulphate toothpaste was strongest against S. salivarius and only sodium fluoride-potassium nitrate toothpaste inhibited E. coli. Conclusion: The manufacturer’s claim is upheld by this study for sodium fluoride-zinc sulphate, benzyl alcohol-sodium fluorophosphate and sodium fluoride-eugenol toothpastes. However, sodium fluoride-sodium laurylsulfate and sodium fluoride-potassium nitrate toothpastes showed limited inhibitory potentials. Keywords Antibacterial; Caries; Oral isolates; Periodontitis; Toothpastes.

A 72-year-old woman, with a longstanding history of atrial fibrillation, presented to the dermatology department with a 2-week history of bilateral purpura and leg edema ([Figure 1A][1]). She had received a diagnosis of a giant right atrial myxoma 22 years ago, but had refused surgery. Four months

Background: Denture prostheses are significant interventions in oral environment for restoring lost formand function due to tooth loss. Little is known about change in microflora in removable partial denturewearers with age and time since denture delivery. Therefore, the present study was conducted to evaluateand compare the oral microbial flora pre and post insertion of removable partial denture at different timeintervals and age groups.Materials and Method: A sample of 60 patients wearing removable partial denture was included inthe study, 30 of age group 40-50 years (Group 1) and 30 of age group 50-60 years (Group 2).Sample ofunstimulated saliva was collected from the patient’s mouth from the distal most edentulous area using threesterile cotton swabs by one investigator. Colony count and identification of microorganisms was done.Results: The difference among mean colony counts between group 1 and 2 were not statistically significantat any of the three timeintervals. A statistically significant difference in colony counts was seen betweenbaseline, 1 month and 3 months in whole sample as well as both the age groups. Among various aerobicmicroorganisms, Streptococcus mitis, Diphtheroids and Candida Albicanswere the most prevailing aerobicmicro organism after 3 months of denture use, while among anaerobic organisms, Prophyromonasgingivaliswas the most prevalent microorganism after three months.Conclusion: A significant difference in colony count as well as colonizing microorganisms has been foundin the present study. This difference according to time is an important component in the affect of removablepartial denture on oral health of denture wearers. Age group was not a significant factor affecting microbialhealth in RPD wearers.

To improve our current understanding of normal flora in children, we investigated bacterial isolates from the pharynx and nasopharynx of 173 and 233 healthy children, respectively. The bacterial isolation rates were compared among three age groups: infants (

The COVID-19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID-19 infection from other diseases. COVID-19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life-threatening acute endocarditis was initially misdiagnosed as COVID-19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.

Background Streptococcal toxic shock syndrome (STSS) is an acute, multisystem and toxin-mediated disease that usually causes shock and multiple organ failure in the early stages of its clinical course. It is associated with a substantial increase in mortality rate. The disease has been associated with invasive group A Streptococcus and is rarely caused by Streptococcus mitis (S. mitis). In healthy adults, S. mitis is closely related to endocarditis but rarely related to STSS. Case presentation We report a case of STSS caused by S. mitis in a healthy 45-year-old woman. She presented with fever 14 h after surgery and with hypotension 24 h later, and she subsequently suffered from septic shock, low albumin, dysfunction of coagulation, acute kidney dysfunction, respiratory alkalosis and metabolic acidosis, acute respiratory distress syndrome and cellulitis of the incision. The diagnosis was obtained through clinical manifestation and blood culture examination. The patient was treated with aggressive fluid resuscitation, adequate antibiotics for a total of 4 weeks, respiratory support, and surgical debridement and drainage of the incision. She was discharged after her vital signs returned to normal and the incision healed on day 40 after surgery. Conclusions The diagnosis of STSS is often delayed or missed, which leads to a high mortality rate. It is possible to cure patients if the disease can be identified early and treated with aggressive fluid resuscitation, adequate antibiotics and control of the source of infection. Clinicians should consider the disease in the differential diagnosis of septic shock to prevent death.

This study aimed to evaluate the feasibility of diagnosing periodontitis via the identification of 18 bacterial species in mouth-rinse samples. Patients (n = 110) who underwent dental examinations in the Department of Periodontology at the Veterans Health Service Medical Center between 2018 and 2019 were included. They were divided into healthy and periodontitis groups. The overall number of bacteria, and those of 18 specific bacteria, were determined via real-time polymerase chain reaction in 92 mouth-rinse samples. Differences between groups were evaluated through logistic regression after adjusting for sex, age, and smoking history. There was a significant difference in the prevalence (healthy vs. periodontitis group) of Aggregatibacter actinomycetemcomitans (2.9% vs. 13.5%), Treponema denticola (42.9% vs. 69.2%), and Prevotella nigrescens (80% vs. 2.7%). Levels of Treponema denticola, Prevotella nigrescens, and Streptococcus mitis were significantly associated with severe periodontitis. We demonstrated the feasibility of detecting periopathogenic bacteria in mouth-rinse samples obtained from patients with periodontitis. As we did not comprehensively assess all periopathogenic bacteria, further studies are required to assess the potential of oral-rinsing solutions to indicate oral infection risk and the need to improve oral hygiene, and to serve as a complementary method for periodontal disease diagnosis.

The use of Next Generation Sequencing (NGS) techniques has generated a wide variety of blood microbiome data. Due to the large variation in bacterial DNA profiles between studies and the likely high concentrations of cell-free bacterial DNA in the blood, it is still not clear how such microbiome data relates to viable microbiota. For these reasons much remains to be understood about the true nature of any possible healthy blood microbiota and of bacteraemic events associated with disease. The gut, reproductive tracts, skin, and oral cavity are all likely sources of blood-borne bacteria. Oral bacteria, especially those associated with periodontal diseases, are also commonly associated with cardiovascular diseases such as infective endocarditis, and also have been linked to rheumatoid arthritis and Alzheimer’s disease. Periodontal treatment, dental probing, and toothbrushing have been shown to cause transient bacteraemia and oral bacteria from the phyla Firmicutes (e.g. Streptococci) and Bacteroidetes (e.g. Porphyromonas) are found in cardiovascular lesions (CVD). Many studies of blood bacterial DNA content however, find Proteobacteria DNA to be the dominant microbiome component, suggesting a gut origin. Most studies of this type use total DNA extracted from either whole blood or blood fractions, such as buffy coat. Here, using a method that purifies DNA from intact bacterial cells only, we examined blood donated by those with active, severe periodontitis and periodontally healthy controls and show that 43–52% of bacterial species in blood are classified as oral. Firmicutes, consisting largely of members of the Streptococcus mitis group and Staphylococcus epidermidis, were predominant at 63.5% of all bacterial sequences detected in periodontal health and, little changed at 66.7% in periodontitis. Compared to studies using total DNA Proteobacteria were found here at relatively low levels in blood at 13.3% in periodontitis and 17.6% in health. This study reveals significant phylogenetic differences in blood bacterial population profiles when comparing periodontal health to periodontal disease cohorts.

Background: Pneumonia is a leading cause of death worldwide and is a major healthcare challenge for HIV-infected persons. Despite this, the etiology of pneumonia in this population remains poorly understood. Methods: We employed a combination of bulk RNA sequencing of bronchoalveolar lavage fluid and standard culture- and PCR-based diagnostics to survey the landscape of transcriptionally active respiratory pathogens in 217 Ugandan patients with HIV who were hospitalized for pneumonia. Findings: A microbiologic diagnosis was obtained in 211 (97.2%) of individuals, with at least one microorganism of established respiratory pathogenicity identified in 113 (52.1%) of patients, and a microbe of possible pathogenicity identified in 94 (47.9%) of patients. Mycobacterium tuberculosis (MTB) was the most commonly identified established pathogen in 35 (16.1%) of the patients and bacterial or viral co-infections were found in 13 (37.2%) of MTB-positive individuals. Streptococcus mitis, not previously reported as a cause of pneumonia in patients with HIV, was the most commonly identified bacterial organism (n=37, 17.1% of patients), and Hemophilus influenzae was the most commonly identified established bacterial pathogen (n=20, 9.2% of patients). Pneumocystis jirovecii, Hemophilus influenza, human rhinovirus, Streptococcus species and Veillonella species were more prevalent in patients with a CD4 T-cell count of

Objektives: This study aims to investigate the effects of different antiseptic mouthwash on microbiota around the mini-screw applied to patients undergoing fixed orthodontic treatment. Materials and methods: From patients who have been undergoing fixed orthodontic treatment and who have mini-screws in their mouth, a total of 38 patients were selected for the study consisting of 4 groups, each of which has 15 mini-screws. The patients were selected from the following groups: no use of mouthwash (Group 1), use of 0.12% Chlorhexidine gluconate-containing mouthwash (Group 2), use of Essential oils-containing mouthwash (Group 3) and use of 7.5% Povidone-iodine-containing mouthwash (Group 4). Plaque indices and gingival indices of the patients were measured at the beginning (T 0 ) and at their appointments three weeks later (T 1 ). In addition, biological samples were collected from the sulcus around the mini-screw with the help of sterile paper point. Results: The total number of microorganisms around the mini-screw in Group 2, Group 3 and Group 4 decreased significantly compared to Group 1. A significant decrease in Streptococcus oralis , Streptococcus mitis , Candida parapsilosis, total bacteria, plaque index and gingival index count was observed in T 1 compared to T 0. Conclusion: Antiseptic mouthwash in Group 2, Group 3 and Group 4 can be used to reduce the number of microbial microbiota around the mini-screw and to improve oral hygiene.

This case presents a patient with bacteremia of an unusual organism with a history of monoclonal gammopathy of undetermined significance (MGUS). MGUS is typically thought to be asymptomatic until potential progression of the disease. This case reports a patient with a history of MGUS who does not show disease progression, however, may be showing symptoms, such as immunodeficiency. This case displays bacteremia with Streptococcus mitis within a two-week period of an invasive procedure. Recent studies parallel this case by showing MGUS patients may have two times the risk of infections compared to the unaffected population. This report brings up the question of taking prophylactic measures for this patient population to prevent future complications.

Objectives: This study aims to investigate the effects of various mouthwashes on bacteremia development following a debonding process, which is performed after orthodontic treatment. Subjects and Methods: The study included patients who received fixed orthodontic treatment and were indicated for debonding. A total of 40 patients in four groups were selected for the study; no mouthwash (Group 1), mouthwash containing 0.12% chlorhexidine‑gluconate (Group 2), mouthwash containing essential‑oils (Group 3), and mouthwash containing 7.5% povidone‑iodine (Group 4). Before (T0) and following (T1) the debonding procedure, blood samples were obtained from the patients. Then, the blood samples were placed in blood culture bottles to investigate bacterial growth. Results: Based on the results of the study, it was determined that the blood samples obtained at T0 did not indicate any bacterial growth. Furthermore, it was observed that the blood samples obtained at T1 included Streptococcus viridans, Streptococcus oralis, Streptococcus mutans, and Staphylococcus aereus growth, respectively, in 4 patients from Group 1 while Streptococcus salivarius growth was observed in 1 patient from Group 3 in addition to Streptococcus mitis growth in 1 patient from Group 4. No bacterial growth was observed in Group 2. While the results obtained between Group 1 and Group 2 were statistically significant, no statistically significant difference was observed between other groups. Conclusions: Finally, it was determined that the mouthwash 0.12% chlorhexidine‑gluconate was statistically significant in comparison to the control group. It can be concluded that this mouthwash can be used to decrease bacterial density in oral flora before debonding procedures. Keywords: Bacteremia, bacterial endocarditis, chlorhexidine gluconate, debonding, mouthwashes

Streptococcus mitis (S. mitis) is a commensal bacterial species that commonly colonizes the oropharynx and gastrointestinal tract. It is seldom reported as a human pathogen. However, immunocompromised individuals may be at risk of infection. We describe a 62-year-old male with prostate cancer who presented with multiple S. mitis abscesses masquerading as metastases. In addition, we discuss the differential diagnosis and treatment options for this rare opportunistic infection.

Streptococcus mitis is an alpha-hemolytic species of Streptococcus and is the most prevalent organism of the oral flora. In patients with dental procedures or trauma and underlying damaged heart valves, it can cause infection of the valves (endocarditis). It has a propensity to affect the left-sided heart valves (mitral and aortic valves) in non-intravenous drug users (IVDU), whereas right-sided heart valves (tricuspid and pulmonic valves) in IVDU. We describe a case of a patient who presented with mitral valve endocarditis that was treated with antibiotics. He was lost to follow-up and then presented four years after his index presentation in cardiogenic shock from severe streptococcal mitis endocarditis causing severe mitral regurgitation. His course deteriorated to the point where the patient required a valve replacement surgery under hemodynamic support.

Background: Invasive infections with non-beta-haemolytic streptococci (NBHS) is quite common and presents the clinicians with difficulties regarding which patients are at risk for infective endocarditis (IE). The HANDOC score was developed to identify patients with NBHS bacteraemia who are at low risk of IE. This study was conducted to validate HANDOC in an external cohort. Methods: Patients with NBHS in blood cultures between March and September 2016 in a Danish centre were included as part of an on-going study. Patient characteristics were collected to classify bacteria according to Dukés criteria and the components of the HANDOC score were collected retrospectively from the patients’ medical records. Results: 68 patients were included in the cohort, of which 16 fulfilled Dukés criteria for IE. All patients with IE (16 of 16) had a HANDOC score above the predefined cut-off. Cases of IE were found in patients with. Streptococcus mitis, Streptococcus bovis, Streptococcus mutans, Streptococcus anginosus, and Streptococcus sanguinis group streptococci. The HANDOC score thus had a sensitivity of 100% and a specificity of 62% in this cohort. Conclusions: HANDOC has a sensitivity of 100% and a relatively high specificity (62%) also in a prospectively enrolled cohort of patients from another country than its origin. This indicates that HANDOC can be implemented in clinical practice to identify patients with a low risk of IE in whom echocardiography can be omitted.

Background/purposeTo date, studies examining polymicrobial infections in ocular disease have mostly been limited to keratitis or endophthalmitis. We characterized polybacterial infections compared to monobacterial infections in prior clinical studies evaluating besifloxacin ophthalmic suspension 0.6% for the treatment of bacterial conjunctivitis and report on associated microbiological outcomes.MethodsIn this post-hoc analysis, microbiological data for subjects with conjunctivitis due to one or more than one bacterial species in three previous studies (two vehicle-, one active-controlled) of besifloxacin were extracted. Bacterial species identified at baseline were deemed causative if their colony count equaled or exceeded species-specific prespecified threshold criteria. In subjects with polybacterial infections, the fold-increase over threshold was used to rank order the contribution of individual species. Baseline pathogens and their minimum inhibitory concentrations (MICs) for common ophthalmic antibiotics were compared by infection type, as were microbial eradication rates following treatment with besifloxacin.ResultsOf 1041 subjects with culture-confirmed conjunctivitis, 17% had polybacterial and 83% had monobacterial conjunctivitis at baseline. In polybacterial compared to monobacterial infections, Haemophilus influenzae and Streptococcus pneumoniae were identified less frequently as the dominant infecting species (P = 0.042 and PConclusionsApproximately one in five subjects with bacterial conjunctivitis are infected with more than one bacterial species underscoring the need for a broad-spectrum antibiotic for such infections. Besifloxacin treatment resulted in robust eradication rates of these infections comparable to monobacterial infections.Trial registrationNCT000622908, NCT00347932, NCT00348348.

Fixed orthodontic appliances hinder the maintenance of proper oral hygiene and result in dental plaque accumulation. Many studies report that qualitative changes in the dental flora occur after initiating the orthodontic treatment, but there is a paucity of literature on the same topic among Moroccan orthodontic patients. The aim of this study was to evaluate the changes of the oral microbial flora during the orthodontic treatment period of a young Moroccan population. Materials and Methods. Dental plaque samples of 18 patients, who were randomly selected before the placement of orthodontic appliances, were collected to isolate and identify the bacterial species involved using classical bacteriological methods for species’ culture and identification. The reading was recorded at T0 before placement of the device. New samples were taken again one month later and then three months afterwards, where the readings were recorded as T1 and T2, respectively. The culture was made via Columbia Agar with 5% sheep blood, Todd Hewitt Broth, and Schaedler medium containing vitamin K3. Bacterial species were identified using API-20 Strep for Streptococci and API-20 A for anaerobic bacteria. The phoenix system was used for identification. Results. After three months of orthodontic treatment, the increase in the frequency of Streptococcus sobrinus and Streptococcus mitis were significant (0.01 and 0.02, respectively) as well as for Lactobacillus (0.03). No significant difference was recorded for other bacterial species. Conclusion. There is a significant qualitative change in oral microorganisms after three months of orthodontic treatment, especially for bacteria that are incriminated in caries formation.

We report a rare case of meningitis due to a combination of Streptococcus mitis and Neisseria subflava. An 80-year-old female had a 4-year history of type II diabetes mellitus (DM) and an 11-year history of rheumatoid arthritis, which was treated with prednisolone, tacrolimus, and methotrexate. One month after the removal of a dental implant, she complained of a disturbance of consciousness and suffered a convulsion. A cerebrospinal fluid culture was found to be positive for both S. mitis and N. subflava. After 14 days of antibiotic treatment with 4 g/day ceftriaxone, her stiff neck, somnolence, and laboratory data greatly improved, and she was successfully discharged at 27 days after admission. Although both S. mitis and N. subflava are generally considered to be benign bacteria, they can cause meningitis in patients with the following risk factors: older age, on immunosuppressive treatment, DM, or dental treatment.

The purpose of this study was to describe the distribution of streptococci causing infective endocarditis (IE). A total of 296 patients with definite IE admitted from July 2007 to December 2014 were identified, with microbial identification done by a combination of blood culture, valve culture, and valve polymerase chain reaction (PCR). The overall distribution of streptococci was 76% viridans (n = 224), 17% pyogenic (50), 6% nutritionally variant (17), and 2% anaerobic (5). Sixty-three (21%) viridans group streptococci were not identified further. The distribution of the remaining 161 viridans group streptococci was Streptococcus mitis group 61%, S. bovis group 15%, S. mutans group 13%, S. anginosus group 9%, and S. salivarius group 1%. Of the 50 pyogenic streptococci, 78% were S. agalactiae and 16% were S. dysgalactiae. PCR was significantly more sensitive than culture in identifying streptococci in excised heart valves.

Purpose: To raise awareness of a possible association between continuous positive airway pressure (CPAP) devices and postoperative bleb-related infection. Observations: A 57-year old patient on CPAP presented with unilateral bleb-associated endophthalmitis 32 months after routine ExPress Trabeculectomy with mitomycin C. The offending organism, Streptococcus mitis, is a nonmotile and generally non-virulent pathogen which predominates in the normal human respiratory flora. Conclusions and importance: This conceptual report underscores a potential relationship between CPAP use and bleb-associated endophthalmitis. Streptococcal species are the most commonly reported causative organisms in bleb-associated endophthalmitis, and S. mitis is of particular concern as the most abundant microbe among all human oral flora. A logical risk factor for infection, the CPAP device may inadvertently deliver such organisms to the vulnerable conjunctival filtering bleb. Keywords: Endophthalmitis, Bleb, Mitomycin C, Express trabeculectomy, Continuous positive airway pressure, Streptococcus mitis

The aetiology of erysipelas remains poorly defined though beta-haemolytic streptococci are considered as the main causative pathogens. We describe a case of a 70-year-old woman with recurrent erysipelas in her left arm due to infection with streptococci of the mitis group. Her past medical history includes lymphoedema of the left arm secondary to lymph node dissection due to breast cancer surgery. On seven different occasions during a decade, she has presented a clinical picture of erysipelas and in three of them with Streptococcus mitis group bacteraemia. The results indicate that two cases were caused by Streptococcus mitis and one case was caused by Streptococcus oralis. This is, to our knowledge, the first reported cases of S. mitis and of S. oralis as the causative agents of erysipelas.

Objectives Chlorhexidine is seen as the golden standard of disinfectants. It is widely used to clean surgical sites; however, many studies indicate resistance of pathogens to chlorhexidine. One study indicated that pathogenic microorganisms were isolated from the soft palate cleft region in 57% of patients with facial clefts. The objectives of our study were to determine (1) if chlorhexidine application is effective in removing pathogens from the surgical site in these patients, and (2) if any pathogens are isolated, determine if they are resistant to other antimicrobials. Design A descriptive observational study. Settings A private practice that specializes in facial cleft surgery, with a country-wide patient base. All procedures were executed by one oral and maxillofacial surgeon. Participants All patients (N=50) who presented for primary repair of the soft palate cleft were included in the study. Inclusion criteria written consent from parent(s), and patient cleared as systemically healthy by a pediatric physician. Exclusion criteria patient(s) with systemic infections (eg, flu) and/or any local infections (eg, tonsillitis). There were 25 males and 25 females with an average age of 7 months and 16 days included in the study. Methods Swabs were taken from the surgical site of all 50 patients with cleft soft palate and were sent for culture, identification and antimicrobial sensitivity. The swabs were taken before disinfecting the site as well as after 2 minutes of disinfecting the surgical site with chlorhexidine. Results were compared against each other. Results Positive cultures with 28 different pathogenic microorganisms that were identified in 47 patients before cleaning the surgical site with the chlorhexidine. The most dominant pathogens were K. pneumonia (n=22), H. influenza (n=18) and S. aureus (n=10). Of the pathogens found, 13 (46%) were still present on the swabs taken after disinfecting with chlorhexidine. K. pneumonia (n= 13), H. influenza (n=11) and S. aureus (n=9) were still the most prevalent pathogens. Conclusions This study demonstrated that 61 of the total of 113 pathogens isolated (54%), survived after 2 minutes of disinfecting the surgical and surrounding area with chlorhexidine, thus intensifying the chances of post-operative infection.

Background Subdural empyema can present as a spinal subdural empyema (SSE) or a cranial subdural empyema (CSE). Although they differ somewhat in epidemiology, etiology, pathophysiology, and symptomatology and occur separately, they rarely manifest together. The aim of this article is to review the literature concerning the clinical presentation, clinical course, and treatment options for managing concurrently occurring SSE and CSE. Methods The literature in the Medline database was reviewed with key words including but not limited to subdural empyema, retroclival empyema, and Streptococcus mitis . No similar reports were found in the database involving infection with this type of microorganism in this anatomical region. Results Only 3 cases with concurrent CSE and SSE were found in the literature caused by various etiologic agents. Two of the patients recovered with no neurologic deficit, whereas one fatality was reported. One new illustrative case caused by Streptococcus mitis is also presented. Conclusions CSE and SSE are neurosurgical emergencies, often requiring prompt surgical evacuation. Although very rare, Streptococcus mitis can cause spinal subdural empyema or retroclival abscesses. Natural history of this disease is grave without treatment. Delays in diagnosis and treatment are directly related to mortality and severe morbidity in patients with intracranial and spinal subdural empyema. Prompt recognition and treatment are essential to preclude severe neurologic disabilities or in rare cases a fatal outcome. A treatment paradigm for cranio-spinal empyema is proposed.

A 52-year-old man presented with a fever and malaise. Transthoracic echocardiogram was performed because of a holosystolic murmur, which showed mitral valve prolapse and a regurgitation jet toward the posterior wall of the left atrium. There was no apparent vegetation at any valves. Blood cultures were positive for Streptococcus mitis/oralis. Transesophageal echocardiogram revealed vegetation only at the posterior wall of the left atrium exposed to the mitral regurgitant jet. We diagnosed this condition as infective mural endocarditis. This case highlighted the need for a detailed observation of the valves and the atrial wall when infective endocarditis is suspected.

Patient: Male, 47 Final Diagnosis: Pulmonic valve endocarditis Symptoms: Fever • myalgia Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Infective endocarditis (IE) has a high mortality rate, even when treated with appropriate antibiotic therapy and surgical intervention. Right-sided endocarditis is in itself rare, with some studies reporting an incidence of 5–10%. The majority of these cases involve the tricuspid valve, and isolated pulmonary valve endocarditis (PVE) is an extremely rare entity affecting less than 2% of patients with infective endocarditis. Identification and early management are crucial to prevent long-term complications and reduce mortality. Case Report: We present a patient with a history of essential hypertension and no underlying valvular disease, who underwent dental cleaning and subsequently developed low-grade fever, myalgia, and malaise. This occurred during the flu season, and was initially diagnosed and treated as flu, without any improvement. The patient was later found to be bacteremic with S. mitis, with no identifiable source, and a normal transthoracic echocardiogram (TTE). He was later hospitalized, had a transesophageal echocardiogram, and was found to have a large pulmonic valve vegetation. Conclusions: This case presents an interesting and rare finding of endocarditis, isolated to the pulmonic valve, in an otherwise healthy individual with no predisposing risk factors. The lack of peripheral stigmata, as well as an unremarkable initial outpatient TTE, made the diagnosis more difficult. It should also be noted that current guidelines do not specifically address right-sided endocarditis, and do not specify the role of surgical intervention.

Background The amniotic membrane (AM) is used in ocular surface reconstruction and is effective at promoting epithelialization and preventing corneal perforation in cases of acute microbial keratitis. Here, we report a case of isolated AM infection after AM transplantation for a persistent epithelial defect following tectonic penetrating keratoplasty. Case presentation A 47-year-old man with poorly controlled type 2 diabetes mellitus presented to the emergency department with a referral for perforated microbial keratitis. After ophthalmic examination, corneal scraping was performed, and corneal gluing was attempted and failed. Hence, the patient underwent tectonic penetrating keratoplasty. After keratoplasty, the patient developed a persistent epithelial defect that required AM transplantation as an overlay. Thirty days post-AM transplant, the patient presented with signs and symptoms resembling granular microbial infection of the cornea. After two days, the granular findings began dislodging from the corneal surface and were sent for culture, sensitivity, and histopathological identification. Histological analysis of the granular material indicated it to be a small piece of AM stroma infiltrated with mixed-type inflammatory cells. Corneal scraping cultures indicated Streptococcus mitis and Streptococcus oralis. Conclusion The infiltrate was localized to the basement membrane of the AM as, despite the anti-inflammatory effects of AM, it can also act as a barrier against polymorphonuclear leukocyte infiltration from the tear film and microbial invasion into the cornea.