Head and neck infections caused by Streptococcus milleri group: An analysis of 17 cases
Introduction
The nomenclature of Streptococcus milleri group (SMG) remains controversial. At the present time, Streptococcus intermedius, Streptococcus anginosus, and Streptococcus constellatus are collectively referred to as the “Streptococcus milleri” group [1].
SMG is a common commensal in the mouth and gastrointestinal tract [2]. It can be an aggressive pathogen and causes brain abscess [3], subperiosteal abscess of the orbit [4], lung abscess, pleural empyema, and intra-abdominal abscess [5]. On the other hand, there is a paucity of published data regarding this organism as a serious pathogen in head and neck infections.
We report 17 patients who developed head and neck infections with SMG during a 2-year period at Onomichi General Hospital. Here, we describe the clinical features and management of SMG in head and neck infection.
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Materials and methods
A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed. Organisms were isolated with a conventional biphasic aerobic/anaerobic blood culture system. Samples were cultured on sheep blood agar and incubated in a CO2-enriched atmosphere for 24 h. Microorganisms recovered from blood cultures were identified using BBL CRYSTAL GP and RGP (BECTON DICKINSON, Mountain View, CA).
Results
SMG was isolated from 77 patients over a period of 2 years. The sites of infection were as follows: head and neck (n = 17), abdominal cavity (n = 12), sputum (n = 10), lachrymal sac (n = 8), trachea (n = 4), thoracic cavity (n = 4), anus (n = 4), limbs (n = 3), urine (n = 2) and others (n = 13). Nineteen cases (26%) had abscess formation in the brain, spinal epidural cavity, bladder, anus, or subcutaneously. The strains were identified in 10 of the 77 cases (13%): S. anginosus (n = 3), S. constellatus (n = 4), S.
Discussion
SMG has been reported by some researchers to be an aggressive pathogen in the head and neck [6], [7], [8]. However, SMG is not well recognized as an important pathogen in head and neck infections. There are two factors responsible for this. First, culture of SMG requires some special methods; incubation must be performed in air containing carbon dioxide or in an anaerobic atmosphere [6], [9]. Second, SMG is a common inhabitant of the mouth and gastrointestinal tract, and so might be not
Conclusions
The key points in the management of head and neck abscess are early diagnosis, adequate drainage, and control of infection by appropriate agents. It is important to recognize SMG as a pathogen in head and neck infection and to be aware of its predisposing factors, especially the co-existence of anaerobes. In cases with gas gangrene caused by SMG, combination therapy consisting of surgical debridement, antibiotic therapy, and hyperbaric oxygen should be considered.
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