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Pablo Elpidio García-Granja, Javier López, Isidre Vilacosta, Cristina Sarriá, Raquel Ladrón, Carmen Olmos, Itziar Gómez, J Alberto San Román, ENDOVAL Group, Nutritionally Variant Streptococci Infective Endocarditis: A Different View, Clinical Infectious Diseases, Volume 67, Issue 11, 1 December 2018, Pages 1800–1801, https://doi.org/10.1093/cid/ciy444
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To the Editor—We have read with great interest the article by Tellez et al [1] regarding infective endocarditis (IE) due to Abiotrophia and Granulicatella species (GA-IE). Simultaneously, we did another systematic review of this entity from 2000 to 2017 and found 73 cases. Although the article by Tellez et al summarizes the main features of GA-IE, we think that it would be interesting for the readers to access the information of each individual case; therefore, we have built up a table with this information (Supplemental Table 1).
We have reviewed our own database of 1399 IE episodes, which is shared by 3 tertiary hospitals in Spain since 1996 and only identified 5 cases of GA-IE (0.4%). It is interesting the difference in the frequency among the 2 groups (0.4% vs 1.5%, P = .005); the particularly difficult growth requirements may provoke their treatment as a culture negative IE [2].
Tellez et al compared the main features of viridans group streptococci IE (VGS-IE) and GA-IE but only using their own institutional patients. We consider that it would be even more interesting to use the total population depicted in table 4 of the article. In such case, patients with GA-IE are younger (42 vs 65.5 years old, P < .001) than patients with VGS-IE, and the rate of intravenous drug use is lower than the stated 16.7% without statistically significant difference among groups (5.3% vs 0.8%, P = .061). In addition, prosthetic location, which previously was more frequent in GA-IE (33.3% vs 24.2%, P = .230), now is less (14.5% vs 24.2%, P = .111). Tellez et al reported an incidence of periannular complications in GA-IE of 72.7% (P = .008 vs 22% in VGS-IE); however, when including all the patients, the rate is more realistic (28.9% vs 22%, P = .084). In addition, in our series of 176 cases of VGS-IE, the rate of periannular complication is 44% (P = .025), even higher than GA-IE. The rate of cardiac surgery remains unchanged, but the difference is now statistically significant (65.8% vs 50%, P = .003), and the mortality, which was nearly 2-fold the mortality of VGS-IE (16.7% vs 9.6%, P = .590), now is similar (9.2% vs 9.6%, P = .999) and even lower than the mortality of our population of VGS-IE (20%, P = .043). This is an interesting aspect, as information on prognosis was contradictory in the literature, with some reports suggesting higher mortality than VGS-IE but other reports without mortality [3, 4].
Finally, we would like to add 2 interesting points from our systematic review. Previous dental manipulation is reported in 32% of GA-IE cases, which could justify a putative impact of antibiotic prophylaxis in this subgroup of patients, and long-term follow-up, which is reported in 50 patients (mean 13.3 months), shows 4 recurrences (8%) and a nonrelated death (2%).
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.
Note
Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
