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A Case of Streptococcus intermedius Empyema

Clinical Assistant Professor of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Huntsville, AL

Victoria J McConnell, MD

Assistant Professor of Internal Medicine, School of Medicine, University of Alabama—Birmingham; Department of Internal Medicine, Huntsville Regional Medical Campus

Steven A Higginbotham, PharmD Student

Harrison School of Pharmacy, Auburn University

Reprints: Dr. Wargo, 301 Governors Dr., Huntsville, AL 35801-5123, fax 256/551-4542, wargoka{at}auburn.edu

OBJECTIVE: To report a case of empyema caused by Streptococcus intermedius as a complication of community-acquired pneumonia (CAP).

CASE SUMMARY: An 85-year-old woman with a history of chronic obstructive pulmonary disease, asthma, heart failure, and hypothyroidism developed empyema as a result of 2 episodes of CAP and an acute exacerbation of chronic bronchitis within the past 2 months. Therapy with intravenous levofloxacin 750 mg every 48 hours was initiated. Culture results of the empyema fluid yielded pure growth of a rarely encountered microorganism, S. intermedius. Intravenous piperacillin/tazobactam 3.375 g every 6 hours was added to the antimicrobial therapy at that time. However, cultures continued to show S. intermedius. Surgical decortication was unsuccessful, and the patient died after a 30 day hospital stay.

DISCUSSION: Early, appropriate antimicrobial therapy is the mainstay of CAP treatment. Although rare, empyema or thoracic abscess can occur despite this therapy, due to mucosal changes caused by CAP. Historically, antimicrobial therapy used to treat organisms that typically cause CAP also has activity against S. intermedius. However, growth of this microorganism and failure to respond to therapy should alert clinicians to the possibility of empyema or abscess formation.

CONCLUSIONS: Despite historical in vitro susceptibility data of S. intermedius, antimicrobial therapy may be ineffective, and more extreme measures may be needed to achieve a successful outcome. Early, appropriate antimicrobial therapy needs to remain the mainstay of the treatment of CAP in an attempt to prevent fatal complications such as this from occurring.

Key Words: antimicrobial therapy, community-acquired pneumonia, empyema, Streptococcus intermedius

Published Online, May 30, 2006. www.theannals.com, DOI 10.1345/aph.1G704