Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context
Summary: Background: Streptococcal infective endocarditis (IE) is a devastating disease. In international guidance, the risk of IE from streptococci is considered the same regardless of species (excluding Streptococcus pyogenes and Streptococcus pneumoniae). However, the idea of homogenous risk has...
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Elsevier
2025-09-01
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S2589537025003578 |
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| author | Gavin Deas Todd C. Lee Julia Colston Mahableshwar Albur Julia Vasant Angela H. Nobbs Philip Williams Fergus Hamilton |
| author_facet | Gavin Deas Todd C. Lee Julia Colston Mahableshwar Albur Julia Vasant Angela H. Nobbs Philip Williams Fergus Hamilton |
| author_sort | Gavin Deas |
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| description | Summary: Background: Streptococcal infective endocarditis (IE) is a devastating disease. In international guidance, the risk of IE from streptococci is considered the same regardless of species (excluding Streptococcus pyogenes and Streptococcus pneumoniae). However, the idea of homogenous risk has been recently questioned. We aimed to evaluate the risk of IE across streptococcal species through meta-analysis of other published works and our own local data. Methods: We first conducted a scoping review for publications that reported cases of streptococcal bacteraemia differentiated by species and estimated the risk of IE between 1994 and October 2024. Then we supplemented this data with our own laboratory data from four large hospitals. We meta-analysed the risk of IE. Two sensitivity analyses were performed to deal with one manuscript which excluded cultures considered as contaminants: first, by excluding that publication, and second by adjusting for blood culture contamination using our local estimated contamination rates. Findings: Four studies met inclusion criteria comprising a total of 14,183 isolates with 1028 endocarditis cases (7.25% absolute risk of IE). The highest risk species were: Streptococcus mutans: 47% (95% CI 38–56%), Streptococcus cristatus: 41% (95% CI 21–62%), Streptococcus gordonii: 37% (95% CI 30–44%), Streptococcus sanguinis 33% (95% CI 28–39%), and Streptococcus gallolyticus: 31% (95% CI 27–36%). Combined, these species accounted for only 8.4% of bacteraemias but 38.6% of IE. The most common IE pathogen overall was Streptococcus mitis/oralis (23.6% of IE, 8% of bacteraemias) but these infections themselves only carried an IE risk of 12% (95% CI 11–13%). There was strong evidence of heterogeneity detected in S. mitis/oralis (I2 87%; Cochran’s Q: 30 p: <0.001) and S. gallolyticus (I2 90%; Q: 29 p: <0.001). Interpretation: The ‘small five’ streptococci: S. mutans, S. cristatus, S. gordonii, S. gallolyticus, and S. sanguinis account for only 8% of all streptococcal bloodstream infections but nearly 40% of all streptococcal IE with a risk of IE in individual infections as high as ∼50%. The risk of S. mitis/oralis appears heterogeneous, may depend on species or subspecies, and requires further study. Funding: FH was funded by the NIHR Clinical Lectureship Scheme. TL has salary support from Fonds de Recherche Québec - Santé. PW is funded by a Medical Research Council grant MR/T005408/1. |
| format | Article |
| id | doaj-art-9a7e7d5fe04347a190f64cc9c7ee6bb3 |
| institution | Kabale University |
| issn | 2589-5370 |
| language | English |
| publishDate | 2025-09-01 |
| publisher | Elsevier |
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| series | EClinicalMedicine |
| spelling | doaj-art-9a7e7d5fe04347a190f64cc9c7ee6bb32025-08-26T04:14:28ZengElsevierEClinicalMedicine2589-53702025-09-018710342510.1016/j.eclinm.2025.103425Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in contextGavin Deas0Todd C. Lee1Julia Colston2Mahableshwar Albur3Julia Vasant4Angela H. Nobbs5Philip Williams6Fergus Hamilton7University Hospitals Bristol & Weston NHS Trust, Marlborough Street, Bristol, BS2 8HW, UK; Corresponding author.Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, H4A 3S1, CanadaNorth Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, Avon, BS10 5NB, UKNorth Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, Avon, BS10 5NB, UKRoyal United Hospital Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UKOral Microbiology, Bristol Dental School Research Laboratories, University of Bristol, Bristol, BS1 3NY, UKUniversity Hospitals Bristol & Weston NHS Trust, Marlborough Street, Bristol, BS2 8HW, UKUniversity Hospitals Bristol & Weston NHS Trust, Marlborough Street, Bristol, BS2 8HW, UK; MRC Integrative Epidemiology Unit, University of Bristol, Bristol, BS6 5ES, UKSummary: Background: Streptococcal infective endocarditis (IE) is a devastating disease. In international guidance, the risk of IE from streptococci is considered the same regardless of species (excluding Streptococcus pyogenes and Streptococcus pneumoniae). However, the idea of homogenous risk has been recently questioned. We aimed to evaluate the risk of IE across streptococcal species through meta-analysis of other published works and our own local data. Methods: We first conducted a scoping review for publications that reported cases of streptococcal bacteraemia differentiated by species and estimated the risk of IE between 1994 and October 2024. Then we supplemented this data with our own laboratory data from four large hospitals. We meta-analysed the risk of IE. Two sensitivity analyses were performed to deal with one manuscript which excluded cultures considered as contaminants: first, by excluding that publication, and second by adjusting for blood culture contamination using our local estimated contamination rates. Findings: Four studies met inclusion criteria comprising a total of 14,183 isolates with 1028 endocarditis cases (7.25% absolute risk of IE). The highest risk species were: Streptococcus mutans: 47% (95% CI 38–56%), Streptococcus cristatus: 41% (95% CI 21–62%), Streptococcus gordonii: 37% (95% CI 30–44%), Streptococcus sanguinis 33% (95% CI 28–39%), and Streptococcus gallolyticus: 31% (95% CI 27–36%). Combined, these species accounted for only 8.4% of bacteraemias but 38.6% of IE. The most common IE pathogen overall was Streptococcus mitis/oralis (23.6% of IE, 8% of bacteraemias) but these infections themselves only carried an IE risk of 12% (95% CI 11–13%). There was strong evidence of heterogeneity detected in S. mitis/oralis (I2 87%; Cochran’s Q: 30 p: <0.001) and S. gallolyticus (I2 90%; Q: 29 p: <0.001). Interpretation: The ‘small five’ streptococci: S. mutans, S. cristatus, S. gordonii, S. gallolyticus, and S. sanguinis account for only 8% of all streptococcal bloodstream infections but nearly 40% of all streptococcal IE with a risk of IE in individual infections as high as ∼50%. The risk of S. mitis/oralis appears heterogeneous, may depend on species or subspecies, and requires further study. Funding: FH was funded by the NIHR Clinical Lectureship Scheme. TL has salary support from Fonds de Recherche Québec - Santé. PW is funded by a Medical Research Council grant MR/T005408/1.http://www.sciencedirect.com/science/article/pii/S2589537025003578EndocarditisInfectionStreptococcal speciesBacteraemia |
| spellingShingle | Gavin Deas Todd C. Lee Julia Colston Mahableshwar Albur Julia Vasant Angela H. Nobbs Philip Williams Fergus Hamilton Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context EClinicalMedicine Endocarditis Infection Streptococcal species Bacteraemia |
| title | Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context |
| title_full | Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context |
| title_fullStr | Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context |
| title_full_unstemmed | Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context |
| title_short | Streptococcal endocarditis: a meta-analysis of species dependant riskResearch in context |
| title_sort | streptococcal endocarditis a meta analysis of species dependant riskresearch in context |
| topic | Endocarditis Infection Streptococcal species Bacteraemia |
| url | http://www.sciencedirect.com/science/article/pii/S2589537025003578 |
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