Le Infezioni in Medicina, n. 1, 138-144, 2021

CASE REPORTS

A case of Corynebacterium striatum endocarditis successfully treated with an early switch to oral antimicrobial therapy

Simona Biscarini1, Marta Colaneri1, Bianca Mariani2, Teresa Chiara Pieri1, Raffaele Bruno1,3, Elena Seminari1

1Division of Infectious Diseases I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;

2Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;

3Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy

Corresponding author

Simona Biscarini

E-mail: simona.biscarini01@universitadipavia.it

SummaRY

Patients with Corynebacterium striatum endocarditis are usually managed with long-term intravenous antibiotic therapy and hospitalization. Here we describe a case of a 76-year-old woman with hepatitis C virus (HCV) related cirrhosis who developed endocarditis due to Corynebacterium striatum associated with severe aortic regurgitation. To our knowledge, this is the first case to be successfully treated with an early switch to oral linezolid after three weeks of vancomycin. We performed a literature review using the PubMed database and found 27 cases which showed the enhanced virulence of this pathogen especially for long-term hospitalized patients with a frequent need of surgical treatment (44.4%) and long course of parenteral antimicrobial therapy, with vancomycin as drug of choice. There are no studies confirming the possibility of using oral treatment in non-diphtheritic Corynebacteria infective endocarditis. This case report provides us with the evidence that once the patient is in a stable condition, the efficacy and safety of linezolid might be similar to vancomycin administration. New trials and prospective studies are needed to confirm the opportunity of an early switch to oral therapy in this specific setting.

Keywords: Corynebacterium striatum, endocarditis, linezolid, oral therapy.

INTRODUCTION

Infective Endocarditis (IE) is a potentially life-threatening disease, still characterized by increased morbidity and mortality which requires prolonged hospitalization.

We here report a case of native aortic valve endocarditis due to Corynebacterium striatum and review the literature about the therapeutic approach and outcomes of endocarditis caused by this emerging pathogen.

As far as we know, this is the first case report of C. striatum endocarditis successfully treated conservatively with an early switch to oral antibiotic therapy. Although the option of oral antibiotic therapy in treating infective endocarditis has been widely hinted at, its role is still not fully understood especially for multidrug-resistant bacteria as Corynebacteria.

CASE PRESENTATION

A 76-year-old woman presented to the Emergency Department due to lethargy and right lower limb erysipelas. She lived in a residential care home for the elderly and her medical comorbidities included Hepatitis C Virus (HCV) related cirrhosis (Model for End-Stage Liver Disease score 11), peripheral vascular disease with chronic venous stasis in the lower extremities and severe aortic regurgitation.

Physical examination revealed an axillary body temperature of 37.7°C, a pulse rate of 87 beats/minute, a blood arterial pressure of 115/50 mmHg, and a normal oxygen saturation breathing room air. The patient was lethargic but responsive to verbal stimuli. She had a previously unknown grade III holosystolic ejection murmur, best heard at the second right intercostal space. The patient’s lungs were clear on auscultation and no peripheral stigmata of endocarditis were found.

Laboratory evaluation showed anemia (hemoglobin 9.8 g/dL) and thrombocytopenia (platelet count 90,000/μL) with a normal leukocyte count of 7,400 μL. Further testing revealed liver enzymes within normal limits, but elevated blood ammonia levels (153 μg/dL) and slightly increased inflammatory markers (C-Reactive Protein 5.48 mg/dl, procalcitonin 1.15 ng/ml). The chest and abdominal X-ray and Computed Tomography (CT) scan of the brain were unremarkable.

Following blood cultures, an empiric antimicrobial treatment with amoxicillin/clavulanic acid 875/125 mg every 8 hours and trimethoprim/sulfamethoxazole 160/800 mg every 12 hours was promptly started. After 22 hours, blood cultures turned positive for Corynebacterium striatum.

Blood samples for cultures were collected in BD BACTEC culture aerobic/anaerobic vials and were incubated into BACTEC FX automated blood culture system (Becton, Dickinson and Company, Franklin Lakes, New Jersey, United States), according to the manufacturer’s instructions.

Positive blood cultures were subjected to Gram-staining and sub-cultured into aerobic sheep blood agar plates, chocolate agar plates, selective plates and into Schaedler agar and 5% sheep blood plates (bioMérieux SA, Marcy-L’Étoile, France) anaerobically and incubated at 37 °C overnight: the organisms were identified by Matrix-Assisted Laser Desorption Ionization time-of-flight (MALDI-TOF) (Bruker Daltonics GmbH, Bremen, Germany, Bruker Biotyper 3.1 database). Sensitivity tests for Corynebacterium striatum were performed using the Kirby Bauer method, according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints (version 9.0). The isolate resulted only susceptible to linezolid and vancomycin and, accordingly, vancomycin 1000 mg every 12 hours by intravenous route was started. After 48 hours, surveillance blood cultures were repeated and returned negative.

Afterwards, a trans-thoracic echocardiogram was performed and showed a small aortic valve vegetation of 4 mm with an associated severe aortic regurgitation. Due to the diagnosis of infective endocarditis, a total body Computed Tomography (CT) scan was also performed, showing no septic embolisms of the brain, thorax and abdomen.

After a total of 3 weeks of intravenous vancomycin, considering the significant improvement of the health conditions, the patient was discharged with an indication to continue linezolid 600 mg every 12 hours orally for an additional 7 days. One week after the discontinuation of the entire cycle of antimicrobial therapy, a trans-esophageal echocardiogram was performed and showed the disappearance of aortic valve vegetation with a residual structural alteration of the valve leaflets. She did not report any adverse effect to the medication. At 7 months follow-up, she was in good health condition, afebrile with no relapse.

MATERIALS AND METHODS

With the aim to better delving into outcomes and treatment options of C. striatum endocarditis we conducted a literature review of all published cases in the last 25 years. We performed a research in PubMed database using the terms “Corynebacterium striatum endocarditis” and “Corynebacterium striatum heart infection” excluding the studies involving patients <18 years. The search was limited to papers published in English only. In the articles examined, the bibliographical references were explored in order to report other cases that might have escaped the original query.

RESULTS

The review of the medical literature revealed 26 studies describing a total amount of 27 cases [2-27]. C. striatum endocarditis was reported more frequently in men (59.3%, 16 of 27), the average patients’ age was 61.8 years. Just one patient had no co-morbidities, confirming the enhanced virulence of this pathogen especially for long-term hospitalized patients with underlying disease [1]. Eight patients of 27 (29%) were diabetics, 6 patients (22.2%) suffered from chronic renal disease with 2 of 6 who underwent hemodialysis. Seven of 27 (25.9%) had a prosthetic valve, 2 a pacemaker and 1 a ventriculo-atrial shunt for a congenital hydrocephalus. Two patients’ past history was not reported.

The most affected valve was the mitral valve (51.8%, 14 of 27) followed by aortic valve (29.6%, 8 of 27). Six valves involved were prosthetic and in 2 cases there were found vegetations on pacemaker leads. Being a life threatening infection, among patients with a reported outcome, 24% (6 of 25) died and 76% (19 of 25) were discharged from the hospital. A high percentage of C. striatum endocarditis required surgical treatment (44.4%), 9 of 27 needed valve replacement and 3 of 27 underwent a procedure of leads or whole pacemaker removal.

Fourteen cases over 27 (51.9%) were treated with vancomycin for 4 or 6 weeks. One case has been switched after 4 weeks of vancomycin to oral linezolid for a further 28 days [2] (Table 1).

DISCUSSION

Intravenous vancomycin is currently the drug of choice as empiric treatment for C. striatum endocarditis. Hence, although C. striatum isolates are frequently susceptible to many antimicrobial drugs, resistance to penicillin, cephalosporins, ciprofloxacin, meropenem, tetracycline, and clindamycin has been recently reported [28-30]. Multidrug-resistant C. striatum outbreaks have occurred among patients with prolonged hospitalization and exposure to broad-spectrum antibiotics, in carriers of intracardiac or endovascular devices or immunocompromised individuals. Recently, several cases of patient-to-patient transmission in Intensive Care Unit have been described [31, 32]. In vitro resistance to vancomycin has not been reported yet in any of the Corynebacterium species [33, 34]. Daptomycin may be an alternative with a favorable side effect profile but rapid development of resistance has been described among a large sampling of isolates by McMullen et al. and the failure of a prolonged therapy with this antibiotic has been documented in case reports [35, 36].

According to Hahn et al. infections due to C. striatum are associated with a longer course of parenteral antimicrobial drugs compared to coagulase-negative staphylococci’s infections [33]. Nevertheless, an oral treatment option for multidrug-resistant C. striatum could be feasible with linezolid as drug of choice. Hence, a strain resistant to linezolid has never been reported [28, 37].

In the present review of the literature we found just one case treated with oral linezolid after 4 weeks of vancomycin. The therapy was continued for a long time, for further 28 days, which determined bone marrow toxicity differently from our case [2].

Emerging data suggest the potential benefit of oral switch strategy as an alternative to standard intravenous therapy in low-risk patients with uncomplicated Gram positive blood stream infection and endocarditis [38-41].

Linezolid has more than 99% of oral bioavailability and 30% of serum protein binding rate. It has activity against a wide range of antibiotic-susceptible and resistant Gram-positive bacteria and, due to its novel mechanism of action, it lacks cross-resistance with other antimicrobial therapies [42, 43].

Several studies have demonstrated that switching clinically stable patients to appropriate oral antibiotics is safe and effective and helps to reduce time of hospitalization and the consequent risk of acquiring nosocomial infections [44-47].

Choosing oral rather than parenteral therapy might be a key strategy in the struggle to decrease antimicrobial resistance. The reduction of length of stay associated with the use of oral linezolid, indeed, could diminish the reservoir of resistant Gram-positive infected patients from the hospital population and the potential transmission to non-infected patients. Secondly, limiting the utilization of vancomycin would decrease selective pressure for resistant organisms such as Vancomycin-Resistant Enterococci (VRE).

Evidence is lacking for oral treatment in Corynebacteria endocarditis and blood stream infections as streptococci and Staphylococcus aureus are the predominant microorganisms studied. The available trials which showed non-inferiority of partial oral therapy to intravenous therapy in endocarditis (POET) and bone and joint infections (OVIVA), have the important limitation that they include few multidrug resistant bacteria [41, 48].

In conclusion, the present is the first case report of endocarditis due to C. striatum which has been managed with an early switch to oral linezolid after 3 weeks of vancomycin with a good outcome and absence of relapse or reinfection at 7-months follow up. The review of the literature showed that C. striatum endocarditis is usually managed with a long course of parenteral antimicrobial drugs and studies are lacking about the opportunity to reduce hospital length of stay and duration of intravenous therapy using linezolid.

Once the patient is in stable condition, efficacy and safety of an oral effective treatment could be similar to vancomycin administration but new trials and prospective studies are needed to confirm this therapeutic strategy.

Acknowledgment

Thanks to the medical and nursing staff involved in patients care.

Conflict of interest

The authors report no conflict of interest.

Funding

None.

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