Effective oral health in infective endocarditis: efficacy of high-street mouthwashes against the viridans group streptococci

Antibiotika im Rahmen der Endokarditisprophylaxe – Risiko und Nutzen

Für die Effektivität und Effizienz einer antibiotischen Prophylaxe vor zahnmedizinischen Eingriffen zum Schutz vor einer infektiösen Endokarditis liegt nur eine geringe Evidenz vor, die keine Rechtfertigung zur generalisierten Therapie von Patienten mit einem erhöhten Endokarditisrisiko darstellt. Aktuelle Leitlinien empfehlen daher, Antibiotika im Rahmen der Endokarditisprophylaxe auf Patienten zu beschränken, die zum einen ein hohes Risiko für die Entstehung einer infektiösen Endokarditis aufweisen und die sich zum anderen zahnärztlichen Eingriffen mit höchstem Endokarditisrisiko unterziehen. Einen hohen Stellwert besitzen allerdings auch Mund- und Hauthygienemaßnahmen, die nicht nur auf Risikopatienten, sondern auch auf die Allgemeinbevölkerung angewendet werden sollten, da die Inzidenz der infektiösen Endokarditis bei Patienten ohne anamnestisch bekannte Herzerkrankung zunehmend ansteigt.

Invasive pyogenic infection and infective endocarditis due to Streptococcus anginosus: A case report

RATIONALE

Streptococcus anginosus mostly colonizes the digestive and genitourinary system, including the oropharyngeal region. It commonly causes invasive pyogenic infection, but less likely causes infective endocarditis (IE).

PATIENT CONCERNS

An 18-year-old woman who had an underlying mitral valve prolapse without mitral regurgitation presented to our hospital with low-grade fever, left leg weakness, and left abdominal pain. She was diagnosed with brain infarction and microabscess as well as IE. The patient totally recovered after the 6-week course of intravenous antibiotics.

DIAGNOSIS

Brain magnetic resonance imaging revealed brain infarction and microabscess. Abdominal computed tomography revealed splenic and left renal infarction. Three sets of blood culture were positive for S anginosus. Transthoracic echocardiogram identified mitral valve prolapse with moderate eccentric mitral valve regurgitation, and a 0.3 × 0.6-cm vegetation was found on the left mitral valve. All of these results meet the modified Duke criteria.

INTERVENTIONS

The abdominal pain and left leg weakness were improving after 2 weeks of intravenous antibiotics treatment. No neurological sequelae were noted after completing the 6-week course of medical treatment.

OUTCOMES

The patient was successfully treated and discharged after completing the 6-week intravenous antibiotics treatment.

LESSONS

IE should be considered in young patients with native valve disease who have prolonged fever. Though S anginosus commonly causes invasive pyogenic infection, patients with native valve disease should be checked for IE.

Ineffective Antibiotic Prophylaxis: An Unusual Presentation of Infective Endocarditis with Insights into the Appropriateness of Prophylaxis

The practice of antibiotic prophylaxis for the prevention of infective endocarditis (IE) has undergone a major paradigm shift over the past few decades. From the earlier practice of antibiotic prophylaxis for all patients undergoing dental procedures, since 2006, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have now narrowed down the indications to use it only in patients at high risk for IE. A true concern for antibiotic resistance remains eminent when used without appropriate indications. Through this case presentation of IE and the associated preceding use of antibiotics, we take this opportunity to explain the appropriateness of prophylaxis in patients from different risk groups. We also shed some light on alternative, effective, and, yet, harmless measures for the prevention of IE in patients at low risk.

Efficacy of two mouth rinse sprays in inhibiting Streptococcus mutans growth on toothbrush bristles

Objective

To compare the efficacy of two types of mouth rinse sprays (Periogard and Plax) in inhibiting the growth of Streptococcus mutans (S. mutans) on toothbrush bristles used by children.

Methods

An experimental comparative study was performed. The sample included 60 children aged 6-8 years with high caries index. Children were divided randomly into 3 groups (20 each) according to materials applied on toothbrush. Each group was further subdivided into 2 subgroups A and B (10 each) according to the laboratory standards for processing microbiological specimens. Each toothbrush was placed in phosphate buffered saline, vortexed then serially diluted. Mitis salivarius bacitracin (MSB) agar plates were inoculated and incubated for 48 h. S. mutans colonies were identified by morphology, gram stain and biochemical tests.

Results

Statistically, significant difference was observed between the three groups either when toothbrushes were processed immediately or when processed after 24 h. Group I showed highest bacterial count followed by group III whereas group II showed least bacterial count. Bacterial counts were significantly decreased by time in group I and group III while in group II no significant decrease as both subgroups showed very low bacterial count.

Conclusions

Although both mouth rinses were effective against S. mutans toothbrush contamination, chlorhexidine gluconate proved to be better.

A case of isolated bicuspid pulmonary valve

We present a 73 years old woman who presented with pelvic cancer, ongoing sepsis and presumably a new diastolic murmur. Her transthoracic echocardiogram, as part of a sepsis screen, showed an abnormal pulmonary valve with moderate regurgitation. Trans-oesophageal echocardiography using 3D imaging showed a bicuspid pulmonary valve as the cause for the moderate regurgitation, but with no clear source of infection. Bicuspid pulmonary valve as an isolated clinical entity is a rare finding in clinical practice. Bicuspid pulmonary valves tend to be more commonly associated with other congenital cardiac anomalies. Whereas, the incidence of bicuspid aortic valve is estimated to be about 1-2%, the incidence of bicuspid pulmonary valve is thought to be much lower at around 0.1%. This could be an underestimate due to difficulty in visualising the pulmonary valve en-face on standard two-dimensional echocardiography. The true prevalence of the condition may be uncovered by the routine use of 3D echocardiography.

Investigating the candidacy of the serotype specific rhamnan polysaccharide based glycoconjugates to prevent disease caused by the dental pathogen Streptococcus mutans

Dental caries remains a major health issue and the Gram-positive bacterium Streptococcus mutans is considered as the major pathogen causing caries. More recently, S. mutans has been recognised as a cause of endocarditis, ulcerative colitis and fatty acid liver disease along with the likelihood of increased cerebral hemorrhage following a stroke if S. mutans is present systemically. We initiated this study to examine the vaccine candidacy of the serotype specific polysaccharides elaborated by S. mutans. We have confirmed the carbohydrate structures for the serotype specific rhamnan containing polysaccharides from serotypes c, f and k. We have prepared glycoconjugate vaccines using the rhamnan containing polymers from serotypes f and k and immunised mice and rabbits. We consistently obtained a robust immune response to the glycoconjugates with cross-reactivity consistent with the structural similarities of the polymers from the different serotypes. We developed an opsonophagocytic assay which illustrated the ability of the post-immune sera to facilitate opsonophagocytic killing of the homologous and heterologous serotypes at titers consistent with the structural homologies. We conclude that glycoconjugates of the rhamnan polymers of S. mutans are a potential vaccine candidate to target dental caries and other sequelae following the escape of S. mutans from the oral cavity.

Association of oral flora with orbital complications of acute sinusitis

BACKGROUND

Acute and chronic sinusitis in children and adults can spread to the orbit. Oral flora has been seen in orbital infections, but the extent of synergy between pathogens in such infections remains unknown.

METHODS

A retrospective case series of patients with complicated sinusitis that involved the orbit from acute sinusitis who were admitted to a tertiary care hospital from January 2000 to December 2014 and who had surgical cultures obtained. Patients were identified by the International Classification of Diseases, Ninth Revision code for periorbital cellulitis, subperiosteal abscess, or orbital abscess.

RESULTS

Sixteen patients underwent surgical drainage via external drainage or endoscopic sinus surgery of an orbital infection associated with sinusitis and had cultures obtained. Nine patients (56%) grew organisms that exist in oral flora, whereas seven patients (44%) grew common respiratory pathogens. The most common organisms recovered were viridans group streptococcus (VGS) (50%), Staphylococcus aureus (31%), Eikenella corrodens (25%), and Prevotella species (19%). Oral flora anaerobes were cultured alongside a VGS species in seven of eight patients (88%) as opposed to the respiratory pathogens, which were less frequently associated with concomitant VGS infection (29%) (p = 0.04).

CONCLUSION

There are two main sources for infectious orbital complications from acute sinusitis: respiratory pathogens and oral flora. The high prevalence of concurrent anaerobic oral flora and VGS infection supports a suspected synergy between VGS and other oral organisms.