{'fraction_non_alphanumeric': 0.030798240100565682, 'fraction_numerical': 0.017913262099308613, 'mean_word_length': 5.290513833992095, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Antimicrobial Therapy for Pyogenic Liver Abscess Secondary to Streptococcus intermedius Bacteremia.

To the Editor: Streptococcus intermedius, S. constellatus, and S. anginosus are 3 bacterial species of the Streptococcus anginosus group (SAG) also known as the Streptococcus milleri group. These rare pathogens are normally found in oropharynx and gastrointestinal tract. A variety of purulent infections and abscesses have been reported in brain, heart, liver, lungs, spleen, peritoneum, and appendix.1 Infections caused by these bacteria are increased in patients with multiple comorbidities like malignancy and diabetes. Liver abscess due to portal bacteremia has been described as a rare complication of abdominal conditions.2,3 We describe a rare of liver abscess due to S. intermedius bacteremia that was acquired from acute cholangitis. An 80-year-old man with a medical history of diabetes, coronary artery disease, and hypertension presented with severe abdominal pain. He was admitted in ICU for septic shock secondary to acute cholangitis. Vancomycin and piperacillin-tazobactam were started empirically. Blood cultures grew S. intermedius for which piperacillin-tazobactum was started. After adequate volume resuscitation, care was de-escalated to medical floor. Repeat blood cultures after 48 hours of therapy were negative. The patient was discharged after completing antibiotic therapy. Two weeks later, he returned feeling weak with decreased appetite and weight loss of approximately 30 lbs. Vitals were stable. Laboratory results were significant for leukocytosis 14.2K/mL, thrombocytosis 443 K/mL, International Normalized Ratio 1.26, Blood Urea Nitrogen 35, creatinine 2.72 mg/dL, alkaline phosphatase 149 m/L, aspartate aminotransferase 40 m/L, and alanine aminotransferase 79 m/L. Computed tomography of the abdomen with contrast revealed a largest abscess of 5.5 3 4.3 cm. Entamebic hystolitica antibody was negative. Vancomycin and piperacillin-tazobactum was started but switched to ertapenem after culture sensitivity. Patient clinically improved and was discharged on ertapenem to be continued for 4 weeks. Repeat computed tomography with contrast after 1 month showed reduction in size of the abscess to 4.0 3 3.9 cm. Streptococcus intermedius is the most pathogenic species of SAG but is very rare in previously healthy individuals without any identifiable risk factors.4,5 The susceptibilities of each SAG strain to penicillin, erythromycin, vancomycin, gentamicin, and streptomycin show a decrease of 12.5% of S. anginosus, 5.5% of S. constellatus, and 33.3% of S. intermedius.6 All SAG members are susceptible to usual dose of penicillin, amoxicillin, cefotaxime, or ceftriaxone.7 The susceptibility to tetracycline, clindamycin, and erythromycin has been reported to be varaible.8 The use of carbapenems, especially ertapenem is recommended in patients with high risk of resistance organism and has been shown to be very effective.9 This case illustrates potential risk of liver abscess even after S. intermedius bacteremia is adequately treated. Early recognition and timely intervention is important for successful treatment and better prognosis.