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Introduction Streptococcus bovis/equinus complex (SBEC) is a major cause of infective endocarditis (IE), although its incidence varies greatly depending on the geographical area. The characteristics of IE caused by Streptococcus gallolyticus susp. gallolyticus are well known; there are hardly any descriptions of IE caused by other species or biotypes. Methods Retrospective cohort study, from 1990 to 2019, of all SBEC IE in adults in three Spanish hospitals, Lugo (LH), Barcelona (BH) and Ferrol (FH) where the population is mainly rural, urban and mixed, respectively. The incidence of IE was analyzed in 3 areas. Clinical characteristics of IE (277 cases, 258 biotyped) were compared according to SBEC species and biotypes. Results There are significant differences between the incidence of SBEC IE in HL (27.9/106) vs. HF and HB (8.8 and 7,1, respectively, p Conclusions IE due to SBEC has geographical variations in incidence and different clinical characteristics among biotypes. The association with CRC was high.

Resumen Introduccion La infeccion por Streptococcus suis (S. suis) es una zoonosis poco descrita en nuestro pais, que se relaciona con la exposicion al ganado porcino o su carne. La forma de presentacion mas frecuente es la meningitis, mientras que la afectacion de la columna vertebral es rara. Metodos Presentamos 2 casos de infeccion por S. suis y realizamos una revision sistematica de los trabajos publicados sobre espondilodiscitis por S. suis entre enero de 1994 y mayo de 2020 con el objetivo de definir las caracteristicas clinicas, sus factores predisponentes y su evolucion. Resultados Se describen 17 casos, el 76,5% varones con una edad media de 57,6 anos, generalmente sin enfermedad de base asociada. El enolismo fue un factor presente en casi el 17,6% de los pacientes. Un 70,6% presentaron exposicion a ganado porcino o su carne y un 20% heridas en manos. La duracion media de los sintomas fue de 10,2 dias y el segmento mas afectado fue el lumbar. Un 70,6% curso con meningitis. Todos se trataron con betalactamicos con una duracion media de 53,2 dias. Hubo una recidiva y ninguno fallecio. Conclusion Existen pocos casos de espondilodiscitis por S. suis en la literatura. Cuando ocurre, se asocia a otro tipo de infeccion en la mayoria de los casos. Presentan buena respuesta al tratamiento medico y buen pronostico.

The role of colorectal neoplasms (CRN) as a common potential source of recurrentwe conducted a retrospective analysis of two prospective endocarditis cohorts (1979-2019) from two Spanish hospitals, providing descriptive analyses of the major features of the endocarditis episodes, colonoscopy findings, and histologic results.among 1552 IE episodes, 204 (13.1%) were caused by EF and 197 (12.7%) by SGG, respectively. There were 155 episodes (10%) of recurrent IE, 20 of which (12.9%) were due to a succession of SGG/EF IE in 10 patients (the first episode caused by SGG in eight cases, and by EF in two cases). The median follow-up was 86 (interquartile range 34-156) months. In 8/10 initial episodes, the causative microorganism was SGG, and all patients were diagnosed with CRN either during the initial episode or during follow-up. During the second episode of IE or follow-up, colonoscopies revealed CRN in six patients.There seems to be an association between SGG and EF in recurrent endocarditis that warrants further investigation. Our findings reinforce the need for systematically performing colonoscopy in the event of endocarditis caused by both microorganisms.

There are few data on the epidemiology of infections caused by Streptococcus bovis (Sb). Some studies suggest that both residence in rural areas and contact with livestock could be potential risk factors. We performed a retrospective study for the period 2005–2016 of all cases of bacteremia caused by Sb in Galicia (a region in the northwest of Spain). The association between the incidence rate of Sb bacteremia and the number of cattle by province and district was analyzed. 677 cases were included with a median age of 76 years, 69.3% males. The most frequent infections were endocarditis (234 cases, 34.5%), primary bacteremia (213 cases, 31.5%) and biliary infection (119 cases, 17.5%). In 252 patients, colon neoplasms were detected (37.2%). S. gallolyticus subsp. gallolyticus was the predominant species (52.3%). Mortality was 15.5% (105 cases). The annual incidence rate was 20.2 cases/106 inhabitants and was correlated with the density of cattle (p

Streptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spine's involvement is rare.We report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution.17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died.There are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis.

Objective Most of the data on Legionella pneumonia in our country come from the Mediterranean area, and there are few studies from the Northwest area. This study tries to assess the situation of this infection in this area. Method Retrospective study of all patients with positive Legionella antigenuria treated at the University Hospital Lucus Augusti in Lugo (Spain) from 2001, the year in which this test was introduced in our centre, until 2015. We analysed epidemiological data, risk factors, clinical, radiological and biochemical findings, and clinical outcome. Results The sampled included 136 patients. When comparing the first five years of the study with the last five, the incidence increased from 10.9 to 64.5 cases/1,000,000; the number of antigenuria requests increased 3.4 times, and compared to other pneumonia aetiologies Legionella increased from 0.9% to 15%. The mean age was 64.1 years and 84.6% were males; 74.3% had comorbidities. Males were significantly younger (62.7 ± 16.6 vs. 71.9 ± 17.3) and consumed more alcohol (26.1% vs. 0%) and tobacco (67.8% vs. 14.3%). Diagnosis was established within the first 72 h in 88.9% of cases and most received levofloxacin (95.6%). Hospitalisation was needed in 85% of cases, 11.7% in ICU and 4.4% died. Conclusions After the introduction of antigenuria there was an increase in the incidence of Legionella pneumonia recorded in our health area. Its rate in recent years has been one of the highest in our country. Despite the fact that the patients had advanced age and comorbidities, mortality was low.

Resumen Objetivo La mayoria de los datos de la neumonia por Legionella en nuestro pais proceden del area mediterranea, y apenas existen estudios en la zona del Noroeste. Con este trabajo se pretende conocer la situacion de la infeccion en nuestro medio. Metodo Estudio retrospectivo de todos los pacientes con antigenuria positiva para Legionella en el Hospital Universitario Lucus Augusti de Lugo desde 2001, ano en que se introdujo la antigenuria como prueba diagnostica en nuestro centro, hasta 2015. Se analizaron datos epidemiologicos, factores de riesgo, hallazgos clinicos, radiologicos, analiticos y evolutivos. Resultados Se registraron 136 pacientes. Si comparamos los primeros 5 anos del estudio con los 5 ultimos, la incidencia aumento de 10,9 a 64,5 casos/1.000.000, el numero de peticiones de antigenuria se incremento 3,4 veces, y con respecto a otras neumonias, Legionella paso del 0,9 al 15% de ellas. La edad media fue de 64,1 anos, y el 84,6% fueron varones. El 74,3% tenian comorbilidades. Los varones fueron significativamente mas jovenes (62,7 ± 16,6 vs 71,9 ± 17,3) y consumian mas alcohol (26,1% vs 0%) y tabaco (67,8% vs 14,3%). El 88,9% se diagnosticaron dentro de las primeras 72 h y la mayoria recibio levofloxacino (95,6%). El 85% necesitaron ingreso hospitalario, el 11,7% en UCI y el 4,4% fallecieron. Conclusiones Coincidiendo con la introduccion de la antigenuria, se observa un aumento de incidencia de neumonia por Legionella en nuestra area sanitaria, con tasas en los ultimos anos que se situan entre las mas altas de nuestro pais. A pesar de tener pacientes con elevada edad media y un alto porcentaje de comorbilidades, la mortalidad fue reducida.

Resumen Introduccion y objetivos Asi como la asociacion entre la endocarditis infecciosa por Streptococcus bovis y la neoplasia colorrectal (NCR) es bien conocida, no se han publicado hasta la fecha resultados de estudios que valoren dicha asociacion con la endocarditis infecciosa por Enterococcus faecalis (EIEF). El objetivo de este estudio es determinar si la prevalencia de NCR es mayor en los pacientes con EIEF de foco desconocido que en la poblacion general y en los pacientes con EIEF y foco conocido. Metodos Analisis retrospectivo de una cohorte de 154 pacientes con EIEF definitiva (109 con foco desconocido y 45 con foco definido) de 2 hospitales universitarios espanoles. Estudio de la prevalencia de NCR y otras enfermedades colorrectales. Resultados Se realizo colonoscopia a 61 pacientes (56%) con foco desconocido, y se diagnostico NCR a 31 (50,8%): adenoma colorrectal no avanzado en 22 casos (36%), adenoma avanzado en 5 (8,2%) y carcinoma colorrectal (CCR) en 4 (6,6%). Entre los supervivientes al episodio de endocarditis con seguimiento ≥ 2 anos, se diagnostico otro caso de CCR. Por otro lado, solo 6 colonoscopias (13,3%) se llevaron a cabo entre pacientes con foco claro de la EIEF, y se hallo NCR en 1 (16,7%). La prevalencia de adenomas era ligeramente mayor que en la poblacion general espanola de la misma franja de edad, mientras que la prevalencia del CCR resulto 17 veces mayor. Conclusiones Se diagnostico NCR a mas de la mitad de los pacientes con EIEF y foco desconocido a los que se realizo una colonoscopia. Estos resultados indican que se debe recomendar la realizacion de una colonoscopia a todo paciente con EIEF y foco no claro.

Introduction and objectives The association between Streptococcus bovis group infective endocarditis and colorectal neoplasm (CRN) is well-known. However, no studies have assessed the association between Enterococcus faecalis infective endocarditis (EFIE) and CRN. We aimed to determine whether the prevalence of CRN is higher in patients with EFIE and an unclear source of infection than in patients with EFIE and a known source of infection or in the general population. Methods Retrospective analysis of a cohort of 154 patients with definite EFIE (109 with an unclear source of infection and 45 with an identified source) from 2 Spanish teaching hospitals to determine the prevalence of CRN and other colorectal diseases. Results In the group with an unknown source of infection, 61 patients (56%) underwent colonoscopy; of these, 31 (50.8%) had CRN. Nonadvanced colorectal adenoma was detected in 22 patients (36%), advanced adenoma in 5 (8.2%), and colorectal carcinoma (CRC) in 4 (6.6%). Among patients who survived the EFIE episode with ≥ 2 years of follow-up, 1 case of CRC was subsequently diagnosed. Only 6 patients (13.3%) with an identified focus of infection underwent colonoscopy; 1 of these patients (16.7%) was diagnosed with CRN. The prevalence of adenomas was slightly higher than that of the Spanish population in the same age range, whereas that of CRC was 17-fold higher. Conclusions CRN was found in more than half of patients with EFIE and an unclear focus of infection who underwent colonoscopy. Colonoscopy should be recommended in patients with EFIE and an unclear source of infection.

Streptococcus bovis was described early last century as an inhabitant of the digestive tract of ruminants. Long ignored in the medical literature, in recent years, its importance has been increasingly recognized. Although S. bovis causes only a small proportion of streptococcal infections, the special interest in the organism is due to two fundamental facts. On one hand, S. bovis is a frequent cause of endocarditis, and on the other hand, it is an organism that has been associated unambiguously with colon cancer, along with Clostridium septicum . In addition, new infections caused by these organisms have been described in recent years, including meningitis, bone and joint infections, and neonatal sepsis, as well as an association with non-colorectal cancer. S. bovis consists of several biotypes or (sub)species with different clinical associations. However, microbiology laboratories do not always distinguish S. bovis to the biotype or subspecies level consistently. On the other hand, there have been continuous changes in the taxonomy and nomenclature of these microorganisms. All this has caused confusion among clinicians, which is reflected in the medical literature. This article reviews the clinical and microbiological aspects most relevant for this group of microorganisms.

To determine the incidence of Streptococcus bovis (Sb) biotypes causing bacteraemia and associated malignancies.This is a retrospective analysis of patients with Sb bacteraemia, pulled out from a prospective surveillance protocol of bacteraemia cases, in three areas of Spain (1990-2013): a cattle area (Lugo), a fishing area (Ferrol) and an urban area (Barcelona). Colonoscopy and Sb biotypes (Sb-I and Sb-II) were determined in most cases.506 patients with Sb bacteraemia; mean age 68.1 (±14.1) years, and 66.2% were males. The cattle area, compared with the fishing and urban areas, had higher incidence of bacteraemia by SbI (40.29 vs 9.38 vs 6.15 cases/10(6) person-years, P0.001) and bacteraemia by Sb-II (29.07 vs 9.84 vs 13.37 cases/10(6) person-years, P0.001). The Sb-I cases (n = 224), compared with Sb-II cases (n = 270), had greater rates of endocarditis (77.6% vs 9.6%, P0.001) and colorectal neoplasm (CRN) (50.9% vs 16.6%, P0.001), and smaller rates of biliary tract infection (2.2% vs 29.6%, P0.001) and non-colorectal malignancy (8.9% vs 31.4%, P0.001).There was a link between the cattle area and higher incidence of Sb bacteraemia. Sb-I differed from Sb-II cases in clinical findings and associated malignancies. Colonoscopy is mandatory in cases of endocarditis or bacteraemia caused by Sb-I.

Most of the data on Legionella pneumonia in our country come from the Mediterranean area, and there are few studies from the Northwest area. This study tries to assess the situation of this infection in this area.Retrospective study of all patients with positive Legionella antigenuria treated at the University Hospital Lucus Augusti in Lugo (Spain) from 2001, the year in which this test was introduced in our centre, until 2015. We analysed epidemiological data, risk factors, clinical, radiological and biochemical findings, and clinical outcome.The sampled included 136 patients. When comparing the first five years of the study with the last five, the incidence increased from 10.9 to 64.5 cases/1,000,000; the number of antigenuria requests increased 3.4 times, and compared to other pneumonia aetiologies Legionella increased from 0.9% to 15%. The mean age was 64.1years and 84.6% were males; 74.3% had comorbidities. Males were significantly younger (62.7±16.6 vs 71.9±17.3) and consumed more alcohol (26.1% vs 0%) and tobacco (67.8% vs 14.3%). Diagnosis was established within the first 72hours in 88.9% of cases and most received levofloxacin (95.6%). Hospitalisation was needed in 85% of cases, 11.7% in ICU and 4.4% died.After the introduction of antigenuria there was an increase in the incidence of Legionella pneumonia recorded in our health area. Its rate in recent years has been one of the highest in our country. Despite the fact that the patients had advanced age and comorbidities, mortality was low.

Item does not contain fulltext BACKGROUND: Bacteremia with Clostridium septicum (CS) and Streptococcus gallolyticus subsp. gallolyticus (SGG) have both been associated with colorectal neoplasms (CRN) and colonoscopic examination is advised, however the differences and similarities in colorectal findings are not well known. METHODS: This is a multicenter, comparative study of patients with CS bacteremia [44 of 664 cases (6.6%) of Clostridium spp.] and SGG bacteremia [257 of 596 cases (44.2%) of S. bovis group], carried out in three hospitals from Spain. Clinical findings related to bacteremia and associated CRN were collected. RESULTS: The main sources of infection were abdominal (77.7%) for CS bacteremia and endovascular (75%) for SGG bacteremia. CS bacteremia was more often associated with malignancies, (72.6% vs. 19.4%) and neutropenia (29.5% vs. 3.1%), and was more acute, with shock at presentation (63.6% vs. 3.9%) and higher 30-day mortality (47.7% vs. 9.7%) compared to SGG (P

Background. The association between bacteremia by Streptococcus gallolyticus subsp. gallolyticus (SGG) and colorectal neoplasia (CRN) is well established but the frequency of the association varies widely in different studies. We conducted a case-control study to assess the association between SGG bacteremia and CRN. Methods. An analysis of all SGG bacteremias was performed during the period 1988–2011. The frequency of CRN in patients with SGG bacteremia was compared with the frequency of CRN in a symptomatic control group of patients matched at a 1:2 ratio for gender and age (±3 years) without S. bovis bacteremia and personal history of CRN and with increased risk of CRN (by the presence of symptoms, signs, or test suspicious of colonic pathology or by family history of CRN). Results. One hundred nine cases of SGG bacteremia were detected (mean age, 66 years; 87% male). Colonoscopy was performed in 98 cases, diagnosing 69 cases of CRN: 57 adenomas (39 advanced adenomas) and 12 invasive carcinomas. Only 4 cases had suspected CRN before the blood culture. The prevalence of CRN was higher in patients with SGG bacteremia than in the 196 control patients (70% vs 32%; odds ratio [OR], 5.1; 95% confidence interval [CI], 3.0–8.6). This difference was not significant when comparing nonadvanced adenomas (19% vs 12%), but we found significant differences in advanced adenomas (40% vs 16%; OR, 3.5; 95% CI, 2.0–6.1) and invasive carcinomas (12% vs 5%; OR, 2.9; 95% CI, 1.2–6.9). Conclusions. The frequency of CRN among SGG infected patients is significantly increased compared with symptomatic age-matched controls, indicating that SGG infection is a strong indicator for underlying occult malignancy.

Background The Streptococcus bovis group (SBG) is a well-known cause of endocarditis, but its role in osteoarticular infections (OAIs) has not been well described. Methods We analyzed all patients with OAIs by SBG diagnosed in our hospital (1988–2014). We selected those cases with septic arthritis and osteomyelitis, as defined according to clinical, microbiological, and imaging studies. Identification of the strains was performed by using the API 20 Strep and the GP card of the Vitek 2 system, and confirmed the identification by molecular methods. In addition, we reviewed the literature to select all cases of OAI by SBG during the period 1980–2015. Results From the 83 cases of OAI included in the analysis (21 from our center and 62 from the literature review), 59 were osteomyelitis (57 of them spondylodiscitis) and 24 were arthritis (2 with associated spondylodiscitis). The mean age was 66.9 years, and 79.2% of the patients were men. Endocarditis (IE) was associated with 59% of the cases and this association was greater for osteomyelitis than for arthritis (78.9% vs. 13.6%; P = 0.001). OAI was a presenting symptom in 63% of the cases of IE. Colonoscopy was performed in 64 cases, which detected colorectal neoplasm (CRN) in 46 patients (71.8%), almost all asymptomatic. Some 69.5% of these neoplasm were carcinomas or advanced adenomas. The blood cultures were positive in 78.3% cases. In 45 cases, the S. bovis species was identified; in 82.2% of the cases the cause was Streptococcus gallolyticus subsp. gallolyticus . The mortality was 7.2%, which in no case was attributable to the OAI. Conclusions OAIs are frequently the initial manifestation of IE caused by SBG. S. gallolyticus causes most of these infections. Echocardiogram and colonoscopy are therefore mandatory, given the species' close association with IE and CRN.

Objectives Methicillin-resistant Staphylococcus aureus (MRSA) strains carrying the mecC gene have been reported from humans and animals from several European countries, but never from Spain. We describe the first isolates of mecC-positive MRSA of human origin collected in Spain and report a fatal case of bacteraemia. Methods Isolates were tested for phenotypic resistance using cefoxitin, tested for the mecA/mecC genes and toxin genes by PCR, and typed by staphylococcal cassette chromosome mec (SCCmec), PFGE, spa, multilocus sequence typing and agr. Results During 2008-13 five MRSA isolates showing resistance to cefoxitin and carrying the mecC gene were recovered at one hospital in Spain. In a review of 5505 S. aureus strains received at the Spanish National Reference Centre for Staphylococci from the same period, we found two additional mecC-positive isolates. The isolates were recovered from blood (two), wounds (two), joint fluid (one), urine (one) and a nasal swab (one). All MRSA were mecA negative, presented SCCmecXI, belonged to agr group III and to clonal complex 130, and were negative for the production of the toxin genes tst1, eta, etb, etd and Panton-Valentine leucocidin. Six isolates belonged to spa type t843 (ST130 and ST1945, where ST stands for sequence type) and one to spa type t6220 (ST1945). One patient with mecC-positive MRSA sepsis died in the emergency department. Conclusions We confirm the presence of MRSA carrying the mecC gene in Spain, the ability of this livestock-associated MRSA to cause severe infections in humans and the need to perform culture-based susceptibility testing methods in order to detect these emerging strains.

Controversy frequently exists about the actual frequency of Streptococcus bovis infective endocarditis (IE), its incidence of malignancy and its outcome. Consequently, the characteristics of S bovis IE were examined in an unselected population of nondrug-addicted patients. The literature was also reviewed.Nondrug-addicted patients with S bovis IE were retrospectively reviewed. Clinically definite IE was diagnosed according to the Duke classification criteria at the single reference hospital for a defined population in northwestern Spain over a 13-year period. The clinical features, need for surgery and mortality rate of these patients were compared with those of other nondrug-addicted patients with IE examined during the same time period.Between 1987 and 1999, S bovis IE was diagnosed in 20 consecutive patients. This pathogen was responsible for 16.8% of the cases of definite IE in nondrug-addicted patients. Underlying conditions and embolic septic events were common. The aortic valve was the most common site of IE. Simultaneous involvement of two cardiac valves and moderate to severe regurgitation were more common in patients with S bovis IE. Colonic neoplasms were observed in 77% of patients. However, in-hospital mortality rate, need for in-hospital surgery and surgery during follow-up did not differ between patients with S bovis IE and the other nondrug-addicted patients with IE.In unselected patients, the rate of mortality due to S bovis IE is similar to that observed in IE due to other microorganisms. However, colonoscopic evaluation during admission and follow-up is required.

Epididymoorchitis is a focal form of human brucellosis described in 2%-20% of patients with brucellosis. We assessed 59 cases of Brucella epididymoorchitis (BEO) between 1991 and 1999. The median age of patients was 34 years (range, 15-75 years). The onset of symptoms was acute in 46 patients (78%). Scrotal pain and swelling (100% of patients), fever (88%), and sweating (73%) were the most common symptoms. Brucella species was isolated from blood cultures in 41 patients (69%) and from epididymal aspiration in 4 patients. Treatment consisted of a combination of a doxycycline and an aminoglycoside (n=39) or rifampin (n=10); trimethoprim-sulfamethoxazole with rifampin (n=3); or trimethoprim-sulfamethoxazole as monotherapy (n=7). The median duration of therapy was 45 days (range, 21-90 days). The infections of 9 patients (15%) failed to respond to therapy, and 15 patients relapsed (25%). Three patients with necrotizing orchitis whose infections were unresponsive to antibiotics required an orchiectomy. In general, classical brucellosis therapy is adequate for BEO.

For 16 years we prospectively observed 530 adult patients with brucellosis to analyze the characteristics of and risk factors for relapse. Clinical and laboratory findings from 86 relapsed patients were milder during the relapse episode when compared with those for the same patients during the initial disease. Blood cultures were positive for Brucella melitensis in 65% of cases during relapse and in approximately 80% of cases during the initial disease. Risk factors that were identified as being independently associated with relapse (by logistic regression analysis) were "less-effective" antibiotic therapy (OR, 8.3; 95% CI, 4.6-15.1), positive blood cultures during initial disease (OR, 2.7; 95% CI, 1.2-6.2), < or = 10-day duration of the disease before treatment (OR, 1.9; 95% CI, 1.1-3.6), male sex (OR, 1.8; 95% CI, 1.02-3.8) and a platelet count of < or = 150 x 10(3)/mm3 (OR, 1.7; 95% CI, 1.1-2.8). These data show that relapse of brucellosis is sometimes difficult to diagnose and that it can be an insidious disease. In addition to inappropriate antibiotic therapy, other factors, such as those indicating a more aggressive disease and/or a deficient immunologic response, seem to play an important role in the relapse of brucellosis.

To compare the effectiveness of doxycycline-rifampin (DR) combination therapy with that of the classic doxycycline-streptomycin (DS) combination in patients with brucellosis.A randomized, double-blind study, with a mean follow-up of 15.7 months.A 1000-bed teaching hospital in Barcelona, Spain.Ninety-five patients (68 men and 27 women; mean age, 39 years) diagnosed with brucellosis on the basis of both clinical and serologic findings; 81 of these patients had blood cultures positive for Brucella melitensis.Forty-four patients received doxycycline, 100 mg every 12 hours, and rifampin, 15 mg/kg body weight per day in a single morning dose, for 45 days; 51 patients received the same dose of doxycycline for 45 days plus streptomycin, 1 g/d for 15 days.Therapeutic failure and relapse during the follow-up period.The mean time to defervescence was 4.2 days for the DR group and 3.2 days for the DS group (P greater than 0.2). The actuarial probability of therapeutic failure or relapse at 12 months of follow-up (Kaplan-Meier) was 14.4% in the DR group and 5.9% in the DS group (difference, 8.5%; 95% Cl, -4.8% to 21.6%; P greater than 0.2). All three patients with spondylitis in the DR group failed therapy compared with one of four patients in the DS group. Excluding patients with spondylitis, the actuarial failure rate was 4.9% and 4.3% in the DR and DS groups, respectively, at 12 months of follow-up (difference, 0.6%; Cl, -8.1% to 9.4%; P greater than 0.2).Doxycycline-rifampin combination therapy for 45 days is as effective as the classic DS combination in most patients with brucellosis; however, DR therapy might be less effective in those patients with spondylitis.

Streptococci other than Streptococcus pneumoniae are a rare cause of bacterial meningitis in adults. We report 29 cases of streptococcal meningitis (1977-1997). The patients comprised 19 men and 10 women, with a mean age +/- standard deviation of 47 +/- 18 years. Nine cases were secondary to neurosurgical procedures, seven to brain abscess, five to cerebrospinal fluid pericranial fistula, and three to endocarditis. Causative microorganisms included the following: viridans group streptococci, 20 cases; anaerobic streptococci, 3; Streptococcus agalactiae, 3; Streptococcus bovis, 2; and Streptococcus pyogenes, 1. Four Streptococcus mitis strains showed decreased susceptibility to penicillin (MIC, 0.5-2 microg/mL). Five patients (17%) died. The infection is increasing in the hospital setting. Streptococci resistant to penicillin should be considered in the empirical treatment of nosocomial meningitis. In cases of community-acquired infection, anaerobic streptococci or streptococci of the Streptococcus milleri group should alert the clinician to the presence of an undiagnosed brain abscess, whereas oral streptococci of the viridans group suggest the diagnosis of bacterial endocarditis.

Introduction Bacterial infections may appear as sequelae of remote tuberculous infections, especially thoracic infections. The simultaneous appearance of tuberculosis and bacterial infection is not common, and, to our knowledge, the association of infection by Streptococcus anginosus and Mycobacterium tuberculosis has not been reported previously in the literature. Case presentation We report three cases of dual infection with Streptococcus anginosus and Mycobacterium tuberculosis that were first diagnosed as pyogenic abscesses because of an isolation of Streptococcus anginosus. Despite a course of antibiotics and drainage, the outcome of this initial treatment was unfavourable. A re-evaluation yielded a diagnosis of mixed infection with Streptococcus anginosus and Mycobacterium tuberculosis. Conclusion In a geographical area with a high prevalence of tuberculous disease, the rare possibility of dual infection with Streptococcus anginosus and Mycobacterium tuberculosis should be considered.