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Infections due to the Streptococcus anginosus (Streptococcus milleri) group

INTRODUCTION

The S. anginosus group (also known as the S. milleri group) is a subgroup of viridans streptococci that consists of three distinct streptococcal species: S. anginosus, S. intermedius, and S. constellatus; S. constellatus has two subspecies, S. constellatus subsp. constellatus and S. constellatus subsp. pharyngis [1-6]. These non-hemolytic viridans streptococci were first described by Guthof in 1956 after being isolated from dental abscesses. He named these organisms "Streptococcus milleri" in honor of the microbiologist W. D. Miller [1,7].

The organisms were subsequently recognized as normal flora of the human oral cavity and gastrointestinal tract with the ability to cause abscesses and systemic infections [8-12]. The unique characteristic of the S. anginosus group that sets these streptococci apart from other pathogenic streptococci, such as S. pyogenes (group A streptococcus) and S. agalactiae (group B streptococcus), is their ability to cause abscesses [13]. Unlike less virulent members of the viridans streptococci, members of the S. anginosus group should be considered true pathogens when isolated from humans, including children [14-16].

The microbiology, pathogenesis, clinical manifestations, and treatment of infections caused by members of the S. anginosus group in both adults and children will be reviewed here.

MICROBIOLOGY

Members of the S. anginosus group are gram-positive, catalase-negative cocci (like other members of the genus Streptococcus). They are non-motile, facultative anaerobes that demonstrate variable hemolysis patterns (alpha, beta, or gamma) on sheep blood agar [17]. Colonies are typically small (colony size less than 0.5 mm) [18]. Many strains demonstrate enhanced growth in the presence of CO2, whereas some strains may require anaerobic conditions.

Members of the genus Streptococcus may be classified by hemolysis patterns, Lancefield antigens, growth properties, and biochemical reactions. However, hemolysis patterns and Lancefield antigens are highly variable for members of the S. anginosus group. Almost 40 percent of S. constellatus and 12 percent of S. anginosus are beta-hemolytic, whereas 93 percent of S. intermedius strains are not beta-hemolytic [4]. Beta-hemolytic strains of S. constellatus typically react with Lancefield serologic group F antibody. Members of S. anginosus group often exhibit Lancefield antigens A, C, F, or G; strains containing the group F antigen may cross-react with other grouping sera. Group C and G streptococcus that belong to the S. anginosus group consist of small colony isolates; large colony group C and G streptococcus are discussed further separately. (See "Group C and group G streptococcal infection".)

            

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Literature review current through: Sep 2014. | This topic last updated: Sep 16, 2013.
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References
Top
  1. Ruoff KL. Streptococcus anginosus ("Streptococcus milleri"): the unrecognized pathogen. Clin Microbiol Rev 1988; 1:102.
  2. Whiley RA, Beighton D. Emended descriptions and recognition of Streptococcus constellatus, Streptococcus intermedius, and Streptococcus anginosus as distinct species. Int J Syst Bacteriol 1991; 41:1.
  3. Whiley RA, Hall LM, Hardie JM, Beighton D. A study of small-colony, beta-haemolytic, Lancefield group C streptococci within the anginosus group: description of Streptococcus constellatus subsp. pharyngis subsp. nov., associated with the human throat and pharyngitis. Int J Syst Bacteriol 1999; 49 Pt 4:1443.
  4. Whiley RA, Fraser H, Hardie JM, Beighton D. Phenotypic differentiation of Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus strains within the "Streptococcus milleri group". J Clin Microbiol 1990; 28:1497.
  5. Whiley RA, Beighton D, Winstanley TG, et al. Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infections. J Clin Microbiol 1992; 30:243.
  6. Claridge JE 3rd, Attorri S, Musher DM, et al. Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus ("Streptococcus milleri group") are of different clinical importance and are not equally associated with abscess. Clin Infect Dis 2001; 32:1511.
  7. GUTHOF O. [Pathogenic strains of Streptococcus viridans; streptocci found in dental abscesses and infiltrates in the region of the oral cavity]. Zentralbl Bakteriol Orig 1956; 166:553.
  8. Mejàre B, Edwardsson S. Streptococcus milleri (Guthof); an indigenous organism of the human oral cavity. Arch Oral Biol 1975; 20:757.
  9. Mejàre B. Characteristics of Streptococcus milleri and Streptococcus mitior from infected dental root canals. Odontol Revy 1975; 26:291.
  10. Parker MT, Ball LC. Streptococci and aerococci associated with systemic infection in man. J Med Microbiol 1976; 9:275.
  11. Bateman NT, Eykyn SJ, Phillips I. Pyogenic liver abscess caused by Streptococcus milleri. Lancet 1975; 1:657.
  12. Melo JC, Raff MJ. Brain abscess due to Streptococcus MG-intermedius (Streptococcus milleri). J Clin Microbiol 1978; 7:529.
  13. Gossling J. Occurrence and pathogenicity of the Streptococcus milleri group. Rev Infect Dis 1988; 10:257.
  14. Jackson DS, Welch DF, Pickett DA, et al. Suppurative infections in children caused by non-beta-hemolytic members of the Streptococcus milleri group. Pediatr Infect Dis J 1995; 14:80.
  15. Belko J, Goldmann DA, Macone A, Zaidi AK. Clinically significant infections with organisms of the Streptococcus milleri group. Pediatr Infect Dis J 2002; 21:715.
  16. Doern CD, Burnham CA. It's not easy being green: the viridans group streptococci, with a focus on pediatric clinical manifestations. J Clin Microbiol 2010; 48:3829.
  17. Spellerberg B, Brandt C. Streptococcus. In: Manual of Clinical Microbiology, 9th ed, Murray PR, Baron EJ, Jorgenson JH, et al (Eds), ASM Press, Washington, DC 2009. Vol 1, p.412.
  18. Poole PM, Wilson G. Infection with minute-colony-forming beta-haemolytic streptococci. J Clin Pathol 1976; 29:740.
  19. Brogan O, Malone J, Fox C, Whyte AS. Lancefield grouping and smell of caramel for presumptive identification and assessment of pathogenicity in the Streptococcus milleri group. J Clin Pathol 1997; 50:332.
  20. Petti C, Stratton CW. Streptococcus anginosus group. In: Principles and Practice of Infectious Diseases, 7th Ed, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, New York, NY 2009. p.2681.
  21. Hinnebusch CJ, Nikolai DM, Bruckner DA. Comparison of API Rapid Strep, Baxter MicroScan Rapid Pos ID Panel, BBL Minitek Differential Identification System, IDS RapID STR System, and Vitek GPI to conventional biochemical tests for identification of viridans streptococci. Am J Clin Pathol 1991; 96:459.
  22. Hoshino T, Fujiwara T, Kilian M. Use of phylogenetic and phenotypic analyses to identify nonhemolytic streptococci isolated from bacteremic patients. J Clin Microbiol 2005; 43:6073.
  23. Brigante G, Luzzaro F, Bettaccini A, et al. Use of the Phoenix automated system for identification of Streptococcus and Enterococcus spp. J Clin Microbiol 2006; 44:3263.
  24. Summanen PH, Rowlinson MC, Wooton J, Finegold SM. Evaluation of genotypic and phenotypic methods for differentiation of the members of the Anginosus group streptococci. Eur J Clin Microbiol Infect Dis 2009; 28:1123.
  25. Nielsen XC, Justesen US, Dargis R, et al. Identification of clinically relevant nonhemolytic Streptococci on the basis of sequence analysis of 16S-23S intergenic spacer region and partial gdh gene. J Clin Microbiol 2009; 47:932.
  26. Friedrichs C, Rodloff AC, Chhatwal GS, et al. Rapid identification of viridans streptococci by mass spectrometric discrimination. J Clin Microbiol 2007; 45:2392.
  27. Petti CA, Simmon KE, Bender J, et al. Culture-Negative intracerebral abscesses in children and adolescents from Streptococcus anginosus group infection: a case series. Clin Infect Dis 2008; 46:1578.
  28. Willcox MD, Knox KW. Surface-associated properties of Streptococcus milleri group strains and their potential relation to pathogenesis. J Med Microbiol 1990; 31:259.
  29. Kitada K, Inoue M, Kitano M. Experimental endocarditis induction and platelet aggregation by Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedius. FEMS Immunol Med Microbiol 1997; 19:25.
  30. Toyoda K, Kusano N, Saito A. Pathogenicity of the Streptococcus milleri group in pulmonary infections--effect on phagocytic killing by human polymorphonuclear neutrophils. Kansenshogaku Zasshi 1995; 69:308.
  31. Shinzato T, Saito A. A mechanism of pathogenicity of "Streptococcus milleri group" in pulmonary infection: synergy with an anaerobe. J Med Microbiol 1994; 40:118.
  32. Young KA, Allaker RP, Hardie JM, Whiley RA. Interactions between Eikenella corrodens and 'Streptococcus milleri-group' organisms: possible mechanisms of pathogenicity in mixed infections. Antonie Van Leeuwenhoek 1996; 69:371.
  33. Nagashima H, Takao A, Maeda N. Abscess forming ability of streptococcus milleri group: synergistic effect with Fusobacterium nucleatum. Microbiol Immunol 1999; 43:207.
  34. Nagamune H, Whiley RA, Goto T, et al. Distribution of the intermedilysin gene among the anginosus group streptococci and correlation between intermedilysin production and deep-seated infection with Streptococcus intermedius. J Clin Microbiol 2000; 38:220.
  35. Jacobs JA, Stobberingh EE. Hydrolytic enzymes of Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedius in relation to infection. Eur J Clin Microbiol Infect Dis 1995; 14:818.
  36. Wanahita A, Goldsmith EA, Musher DM, et al. Interaction between human polymorphonuclear leukocytes and Streptococcus milleri group bacteria. J Infect Dis 2002; 185:85.
  37. Bert F, Bariou-Lancelin M, Lambert-Zechovsky N. Clinical significance of bacteremia involving the "Streptococcus milleri" group: 51 cases and review. Clin Infect Dis 1998; 27:385.
  38. Stelzmueller I, Pfausler B, Fille M, et al. Streptococcus milleri group isolates from blood cultures: consider surgical sepsis. Surg Infect (Larchmt) 2009; 10:259.
  39. Ruoff KL, Kunz LJ, Ferraro MJ. Occurrence of Streptococcus milleri among beta-hemolytic streptococci isolated from clinical specimens. J Clin Microbiol 1985; 22:149.
  40. Drucker DB, Green RM. Dental caries induced by Streptococcus milleri. J Dent Res 1977; 56:1062.
  41. Rawlinson A, Duerden BI, Goodwin L. New findings on the microbial flora associated with adult periodontitis. J Dent 1993; 21:179.
  42. Hidaka H, Kuriyama S, Yano H, et al. Precipitating factors in the pathogenesis of peritonsillar abscess and bacteriological significance of the Streptococcus milleri group. Eur J Clin Microbiol Infect Dis 2011; 30:527.
  43. Williams BL, McCann GF, Schoenknecht FD. Bacteriology of dental abscesses of endodontic origin. J Clin Microbiol 1983; 18:770.
  44. Bancescu G, Lofthus B, Hofstad T, et al. Isolation and characterization of "Streptococcus milleri" group strains from oral and maxillofacial infections. Adv Exp Med Biol 1997; 418:165.
  45. Cimolai N, MacCulloch L, Damm S. The epidemiology of beta-haemolytic non-group A streptococci isolated from the throats of children over a one-year period. Epidemiol Infect 1990; 104:119.
  46. Turner JC, Hayden GF, Kiselica D, et al. Association of group C beta-hemolytic streptococci with endemic pharyngitis among college students. JAMA 1990; 264:2644.
  47. Turner JC, Hayden FG, Lobo MC, et al. Epidemiologic evidence for Lancefield group C beta-hemolytic streptococci as a cause of exudative pharyngitis in college students. J Clin Microbiol 1997; 35:1.
  48. Hamrick HJ, Mangum ME. Beta-hemolytic Streptococcus milleri group misidentified as Streptococcus pyogenes on throat culture. Pediatr Infect Dis J 1999; 18:75.
  49. Jensen A, Hoshino T, Kilian M. Taxonomy of the Anginosus group of the genus Streptococcus and description of Streptococcus anginosus subsp. whileyi subsp. nov. and Streptococcus constellatus subsp. viborgensis subsp. nov. Int J Syst Evol Microbiol 2013; 63:2506.
  50. Salavert M, Gómez L, Rodriguez-Carballeira M, et al. Seven-year review of bacteremia caused by Streptococcus milleri and other viridans streptococci. Eur J Clin Microbiol Infect Dis 1996; 15:365.
  51. Casariego E, Rodriguez A, Corredoira JC, et al. Prospective study of Streptococcus milleri bacteremia. Eur J Clin Microbiol Infect Dis 1996; 15:194.
  52. Jacobs JA, Pietersen HG, Stobberingh EE, Soeters PB. Bacteremia involving the "Streptococcus milleri" group: analysis of 19 cases. Clin Infect Dis 1994; 19:704.
  53. Seifert H. The clinical importance of microbiological findings in the diagnosis and management of bloodstream infections. Clin Infect Dis 2009; 48 Suppl 4:S238.
  54. Felsenstein S, Williams B, Shingadia D, et al. Clinical and microbiologic features guiding treatment recommendations for brain abscesses in children. Pediatr Infect Dis J 2013; 32:129.
  55. Herr RD, Murdock RT, Davis RK. Serious soft tissue infections of the head and neck. Am Fam Physician 1991; 44:878.
  56. Johnson JT. Abscesses and deep space infections of the head and neck. Infect Dis Clin North Am 1992; 6:705.
  57. Han JK, Kerschner JE. Streptococcus milleri: an organism for head and neck infections and abscess. Arch Otolaryngol Head Neck Surg 2001; 127:650.
  58. Hirai T, Kimura S, Mori N. Head and neck infections caused by Streptococcus milleri group: an analysis of 17 cases. Auris Nasus Larynx 2005; 32:55.
  59. Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: a primer for critical care physicians. Lung 2009; 187:271.
  60. Pearson CR, Riden DK, Garth RJ, Thomas MR. Two cases of lateral sinus thrombosis presenting with extracranial head and neck abscesses. J Laryngol Otol 1994; 108:779.
  61. Watkins LM, Pasternack MS, Banks M, et al. Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri. Ophthalmology 2003; 110:569.
  62. Udaondo P, Garcia-Delpech S, Díaz-Llopis M, et al. Bilateral intraorbital abscesses and cavernous sinus thromboses secondary to Streptococcus milleri with a favorable outcome. Ophthal Plast Reconstr Surg 2008; 24:408.
  63. Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis 1997; 25:763.
  64. Jones RL, Violaris NS, Chavda SV, Pahor AL. Intracranial complications of sinusitis: the need for aggressive management. J Laryngol Otol 1995; 109:1061.
  65. Bair-Merritt MH, Shah SS, Zaoutis TE, et al. Suppurative intracranial complications of sinusitis in previously healthy children. Pediatr Infect Dis J 2005; 24:384.
  66. Deutschmann MW, Livingstone D, Cho JJ, et al. The significance of Streptococcus anginosus group in intracranial complications of pediatric rhinosinusitis. JAMA Otolaryngol Head Neck Surg 2013; 139:157.
  67. Oxford LE, McClay J. Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children. Int J Pediatr Otorhinolaryngol 2006; 70:1853.
  68. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007; 144:497.
  69. Beech T, Robinson A, McDermott AL, Sinha A. Paediatric periorbital cellulitis and its management. Rhinology 2007; 45:47.
  70. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited. Pediatr Neurosurg 2001; 35:82.
  71. Tsai BY, Lin KL, Lin TY, et al. Pott's puffy tumor in children. Childs Nerv Syst 2010; 26:53.
  72. Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. Pott's puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol 2012; 76:1274.
  73. Goldenberg NA, Knapp-Clevenger R, Hays T, Manco-Johnson MJ. Lemierre's and Lemierre's-like syndromes in children: survival and thromboembolic outcomes. Pediatrics 2005; 116:e543.
  74. Ridgway JM, Parikh DA, Wright R, et al. Lemierre syndrome: a pediatric case series and review of literature. Am J Otolaryngol 2010; 31:38.
  75. Brook I. Fusobacterial infections in children. J Infect 1994; 28:155.
  76. Centor RM, Geiger P, Waites KB. Fusobacterium necrophorum bacteremic tonsillitis: 2 Cases and a review of the literature. Anaerobe 2010; 16:626.
  77. Chun CH, Johnson JD, Hofstetter M, Raff MJ. Brain abscess. A study of 45 consecutive cases. Medicine (Baltimore) 1986; 65:415.
  78. Carpenter J, Stapleton S, Holliman R. Retrospective analysis of 49 cases of brain abscess and review of the literature. Eur J Clin Microbiol Infect Dis 2007; 26:1.
  79. Gelfand MS, Bakhtian BJ, Simmons BP. Spinal sepsis due to Streptococcus milleri: two cases and review. Rev Infect Dis 1991; 13:559.
  80. Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369.
  81. Dhariwal DK, Patton DW, Gregory MC. Epidural spinal abscess following dental extraction--a rare and potentially fatal complication. Br J Oral Maxillofac Surg 2003; 41:56.
  82. Greenlee JE. Subdural Empyema. Curr Treat Options Neurol 2003; 5:13.
  83. Cabellos C, Viladrich PF, Corredoira J, et al. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999; 28:1104.
  84. Ziai WC, Lewin JJ 3rd. Update in the diagnosis and management of central nervous system infections. Neurol Clin 2008; 26:427.
  85. Smith SJ, Ughratdar I, MacArthur DC. Never go to sleep on undrained pus: a retrospective review of surgery for intraparenchymal cerebral abscess. Br J Neurosurg 2009; 23:412.
  86. Jansson AK, Enblad P, Sjölin J. Efficacy and safety of cefotaxime in combination with metronidazole for empirical treatment of brain abscess in clinical practice: a retrospective study of 66 consecutive cases. Eur J Clin Microbiol Infect Dis 2004; 23:7.
  87. Kowlessar PI, O'Connell NH, Mitchell RD, et al. Management of patients with Streptococcus milleri brain abscesses. J Infect 2006; 52:443.
  88. Allison HF, Immelman EJ, Forder AA. Pyogenic liver abscess caused by Streptococcus milleri. Case reports. S Afr Med J 1984; 65:432.
  89. Corredoira J, Casariego E, Moreno C, et al. Prospective study of Streptococcus milleri hepatic abscess. Eur J Clin Microbiol Infect Dis 1998; 17:556.
  90. Molina JM, Leport C, Bure A, et al. Clinical and bacterial features of infections caused by Streptococcus milleri. Scand J Infect Dis 1991; 23:659.
  91. Poole PM, Wilson G. Streptococcus milleri in the appendix. J Clin Pathol 1977; 30:937.
  92. Madden NP, Hart CA. Streptococcus milleri in appendicitis in children. J Pediatr Surg 1985; 20:6.
  93. Hardwick RH, Taylor A, Thompson MH, et al. Association between Streptococcus milleri and abscess formation after appendicitis. Ann R Coll Surg Engl 2000; 82:24.
  94. Admon D, Gottehrer N, Leitersdorf E. Is "primary" subphrenic abscess caused by Streptococcus milleri a result of unrecognized gastrointestinal perforation? Klin Wochenschr 1986; 64:287.
  95. Rautio M, Saxén H, Siitonen A, et al. Bacteriology of histopathologically defined appendicitis in children. Pediatr Infect Dis J 2000; 19:1078.
  96. Guillet-Caruba C, Cheikhelard A, Guillet M, et al. Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagn Microbiol Infect Dis 2011; 69:376.
  97. Schmitt F, Clermidi P, Dorsi M, et al. Bacterial studies of complicated appendicitis over a 20-year period and their impact on empirical antibiotic treatment. J Pediatr Surg 2012; 47:2055.
  98. Seeto RK, Rockey DC. Pyogenic liver abscess. Changes in etiology, management, and outcome. Medicine (Baltimore) 1996; 75:99.
  99. Stelzmueller I, Biebl M, Berger N, et al. Relevance of group Milleri streptococci in thoracic surgery: a clinical update. Am Surg 2007; 73:492.
  100. Shinzato T, Saito A. The Streptococcus milleri group as a cause of pulmonary infections. Clin Infect Dis 1995; 21 Suppl 3:S238.
  101. Wong CA, Donald F, Macfarlane JT. Streptococcus milleri pulmonary disease: a review and clinical description of 25 patients. Thorax 1995; 50:1093.
  102. Porta G, Rodríguez-Carballeira M, Gómez L, et al. Thoracic infection caused by Streptococcus milleri. Eur Respir J 1998; 12:357.
  103. Marinella MA, Harrington GD, Standiford TJ. Empyema necessitans due to Streptococcus milleri. Clin Infect Dis 1996; 23:203.
  104. Shishido H, Watanabe K, Matsumoto K, et al. Primary purulent mediastinitis due to Streptococcus milleri. Respiration 1997; 64:313.
  105. Waite RD, Wareham DW, Gardiner S, Whiley RA. A simple, semiselective medium for anaerobic isolation of anginosus group streptococci from patients with chronic lung disease. J Clin Microbiol 2012; 50:1430.
  106. Sibley CD, Parkins MD, Rabin HR, et al. A polymicrobial perspective of pulmonary infections exposes an enigmatic pathogen in cystic fibrosis patients. Proc Natl Acad Sci U S A 2008; 105:15070.
  107. Parkins MD, Sibley CD, Surette MG, Rabin HR. The Streptococcus milleri group--an unrecognized cause of disease in cystic fibrosis: a case series and literature review. Pediatr Pulmonol 2008; 43:490.
  108. Parkins MD, Sibley CD, Surette MG, et al. Streptococcus milleri endobronchial colonization is associated with an increased rate of pulmonary disease in cystic fibrosis. Pediatr Pulmonol 2008; 43:S339.
  109. Rabin HR, Surette MG. The cystic fibrosis airway microbiome. Curr Opin Pulm Med 2012; 18:622.
  110. Sibley CD, Grinwis ME, Field TR, et al. McKay agar enables routine quantification of the 'Streptococcus milleri' group in cystic fibrosis patients. J Med Microbiol 2010; 59:534.
  111. Olson AB, Sibley CD, Schmidt L, et al. Development of real-time PCR assays for detection of the Streptococcus milleri group from cystic fibrosis clinical specimens by targeting the cpn60 and 16S rRNA genes. J Clin Microbiol 2010; 48:1150.
  112. Grinwis ME, Sibley CD, Parkins MD, et al. Characterization of Streptococcus milleri group isolates from expectorated sputum of adult patients with cystic fibrosis. J Clin Microbiol 2010; 48:395.
  113. Ripley RT, Cothren CC, Moore EE, et al. Streptococcus milleri infections of the pleural space: operative management predominates. Am J Surg 2006; 192:817.
  114. Reimel BA, Krishnadasen B, Cuschieri J, et al. Surgical management of acute necrotizing lung infections. Can Respir J 2006; 13:369.
  115. Lefort A, Lortholary O, Casassus P, et al. Comparison between adult endocarditis due to beta-hemolytic streptococci (serogroups A, B, C, and G) and Streptococcus milleri: a multicenter study in France. Arch Intern Med 2002; 162:2450.
  116. Woo PC, Tse H, Chan KM, et al. "Streptococcus milleri" endocarditis caused by Streptococcus anginosus. Diagn Microbiol Infect Dis 2004; 48:81.
  117. Levandowski RA. Streptococcus milleri endocarditis complicated by myocardial abscess. South Med J 1985; 78:892.
  118. Stocker E, Cortes E, Pema K, et al. Streptococcus milleri as a cause of antecubital abscess and bacteremia in intravenous drug abusers. South Med J 1994; 87:95.
  119. Calza L, Manfredi R, Briganti E, et al. Iliac osteomyelitis and gluteal muscle abscess caused by Streptococcus intermedius. J Med Microbiol 2001; 50:480.
  120. Ortel TL, Kallianos J, Gallis HA. Group C streptococcal arthritis: case report and review. Rev Infect Dis 1990; 12:829.
  121. Yassin M, Yadavalli GK, Alvarado N, Bonomo RA. Streptococcus anginosus (Streptococcus milleri Group) Pyomyositis in a 50-Year-Old Man with Acquired Immunodeficiency Syndrome: Case Report and Review of Literature. Infection 2010; 38:65.
  122. Tracy M, Wanahita A, Shuhatovich Y, et al. Antibiotic susceptibilities of genetically characterized Streptococcus milleri group strains. Antimicrob Agents Chemother 2001; 45:1511.
  123. Bantar C, Fernandez Canigia L, Relloso S, et al. Species belonging to the "Streptococcus milleri" group: antimicrobial susceptibility and comparative prevalence in significant clinical specimens. J Clin Microbiol 1996; 34:2020.
  124. Yamamoto N, Fujita J, Shinzato T, et al. In vitro activity of sitafloxacin compared with several fluoroquinolones against Streptococcus anginosus and Streptococcus constellatus. Int J Antimicrob Agents 2006; 27:171.
  125. Kaneko A, Sasaki J, Shimadzu M, et al. Comparison of gyrA and parC mutations and resistance levels among fluoroquinolone-resistant isolates and laboratory-derived mutants of oral streptococci. J Antimicrob Chemother 2000; 45:771.
  126. Jacobs JA, van Baar GJ, London NH, et al. Prevalence of macrolide resistance genes in clinical isolates of the Streptococcus anginosus ("S. milleri") group. Antimicrob Agents Chemother 2001; 45:2375.
  127. Asmah N, Eberspächer B, Regnath T, Arvand M. Prevalence of erythromycin and clindamycin resistance among clinical isolates of the Streptococcus anginosus group in Germany. J Med Microbiol 2009; 58:222.
  128. Limia A, Jiménez ML, Alarcón T, López-Brea M. Five-year analysis of antimicrobial susceptibility of the Streptococcus milleri group. Eur J Clin Microbiol Infect Dis 1999; 18:440.