Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations, diagnosis, and treatment of infections due to group D streptococci (Streptococcus bovis/Streptococcus equinus complex)

Bruno Hoen, MD, PhD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


The Streptococcus bovis/Streptococcus equinus complex includes four major species that all belong to group D streptococci (GDS); this taxonomy was established in 2003 and is summarized in the Table (table 1) [1]. For simplicity, the Streptococcus bovis/Streptococcus equinus complex will be referred to as GDS in the discussion below.

GDS are gram-positive cocci that are an important cause of bacteremia and infective endocarditis in adults. Because there is a strong association between infections with GDS and colonic neoplasms and other lesions of the gastrointestinal tract, evaluation of the gastrointestinal tract with colonoscopy is important for patients with infections due to this organism [2].

GDS species and subspecies differ in their microbiology, pathogenesis, and epidemiology. Most clinical microbiology laboratories in the United States use automated testing equipment or other methods to identify these organisms to the species and subspecies level. However, some laboratories continue to report them under the common name S. bovis or S. bovis group [3].

Associations with endocarditis and colonic neoplasm are most closely linked to Streptococcus gallolyticus subspecies gallolyticus (S. bovis biotype I) [2,4-6]. S. bovis biotype II bacteremias may be more associated with biliary tract disease and more likely to be polymicrobial [4,7]. S. gallolyticus subspecies pasteurianus has been identified as a cause of infections in neonates and infants [8-10]. However, the published literature regarding these organisms does not always distinguish GDS isolates to the biotype and/or subspecies level consistently [2]. Regardless, in studies in which GDS isolates were identified using 16S rRNA sequencing, both endocarditis and colorectal tumors were observed with all GDS subspecies [11].

The clinical manifestations, diagnosis, and therapy of S. bovis infection will be reviewed here. The microbiology, pathogenesis, and epidemiology of GDS infection are discussed separately. (See "Microbiology, pathogenesis, and epidemiology of infections due to group D streptococci (Streptococcus bovis/Streptococcus equinus complex)".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Sep 26, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Klatte JM, Clarridge JE 3rd, Bratcher D, Selvarangan R. A longitudinal case series description of meningitis due to Streptococcus gallolyticus subsp. pasteurianus in infants. J Clin Microbiol 2012; 50:57.
  2. Boleij A, van Gelder MM, Swinkels DW, Tjalsma H. Clinical Importance of Streptococcus gallolyticus infection among colorectal cancer patients: systematic review and meta-analysis. Clin Infect Dis 2011; 53:870.
  3. van't Wout JW, Bijlmer HA. Bacteremia due to Streptococcus gallolyticus, or the perils of revised nomenclature in bacteriology. Clin Infect Dis 2005; 40:1070.
  4. Corredoira JC, Alonso MP, García JF, et al. Clinical characteristics and significance of Streptococcus salivarius bacteremia and Streptococcus bovis bacteremia: a prospective 16-year study. Eur J Clin Microbiol Infect Dis 2005; 24:250.
  5. Ruoff KL, Miller SI, Garner CV, et al. Bacteremia with Streptococcus bovis and Streptococcus salivarius: clinical correlates of more accurate identification of isolates. J Clin Microbiol 1989; 27:305.
  6. Corredoira-Sánchez J, García-Garrote F, Rabuñal R, et al. Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study. Clin Infect Dis 2012; 55:491.
  7. Fernández-Ruiz M, Villar-Silva J, Llenas-García J, et al. Streptococcus bovis bacteraemia revisited: clinical and microbiological correlates in a contemporary series of 59 patients. J Infect 2010; 61:307.
  8. Floret N, Bailly P, Thouverez M, et al. A cluster of bloodstream infections caused by Streptococcus gallolyticus subspecies pasteurianus that involved 5 preterm neonates in a university hospital during a 2-month period. Infect Control Hosp Epidemiol 2010; 31:194.
  9. Jans C, Meile L, Lacroix C, Stevens MJ. Genomics, evolution, and molecular epidemiology of the Streptococcus bovis/Streptococcus equinus complex (SBSEC). Infect Genet Evol 2015; 33:419.
  10. Saegeman V, Cossey V, Loens K, et al. Streptococcus Gallolyticus Subsp. Pasteurianus Infection In A Neonatal Intensive Care Unit. Pediatr Infect Dis J 2016; 35:1272.
  11. Ben-Chetrit E, Wiener-Well Y, Kashat L, et al. Streptococcus bovis new taxonomy: does subspecies distinction matter? Eur J Clin Microbiol Infect Dis 2017; 36:387.
  12. Pfaller MA, Jones RN, Marshall SA, et al. Nosocomial streptococcal blood stream infections in the SCOPE Program: species occurrence and antimicrobial resistance. The SCOPE Hospital Study Group. Diagn Microbiol Infect Dis 1997; 29:259.
  13. Eggers S, Beuth J. Etiology and antibiotic susceptibility of bloodstream Streptococcus sp. Zentralbl Bakteriol 1992; 276:521.
  14. Murray HW, Roberts RB. Streptococcus bovis bacteremia and underlying gastrointestinal disease. Arch Intern Med 1978; 138:1097.
  15. Zarkin BA, Lillemoe KD, Cameron JL, et al. The triad of Streptococcus bovis bacteremia, colonic pathology, and liver disease. Ann Surg 1990; 211:786.
  16. Corredoira J, Alonso MP, Coira A, et al. Characteristics of Streptococcus bovis endocarditis and its differences with Streptococcus viridans endocarditis. Eur J Clin Microbiol Infect Dis 2008; 27:285.
  17. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009; 169:463.
  18. Panwalker AP. Unusual infections associated with colorectal cancer. Rev Infect Dis 1988; 10:347.
  19. Klein RS, Recco RA, Catalano MT, et al. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med 1977; 297:800.
  20. Klein RS, Catalano MT, Edberg SC, et al. Streptococcus bovis septicemia and carcinoma of the colon. Ann Intern Med 1979; 91:560.
  21. Potter MA, Cunliffe NA, Smith M, et al. A prospective controlled study of the association of Streptococcus bovis with colorectal carcinoma. J Clin Pathol 1998; 51:473.
  22. Chirouze C, Patry I, Duval X, et al. Streptococcus bovis/Streptococcus equinus complex fecal carriage, colorectal carcinoma, and infective endocarditis: a new appraisal of a complex connection. Eur J Clin Microbiol Infect Dis 2013; 32:1171.
  23. Ballet M, Gevigney G, Garé JP, et al. Infective endocarditis due to Streptococcus bovis. A report of 53 cases. Eur Heart J 1995; 16:1975.
  24. Alazmi W, Bustamante M, O'Loughlin C, et al. The association of Streptococcus bovis bacteremia and gastrointestinal diseases: a retrospective analysis. Dig Dis Sci 2006; 51:732.
  25. Leport C, Bure A, Leport J, Vilde JL. Incidence of colonic lesions in Streptococcus bovis and enterococcal endocarditis. Lancet 1987; 1:748.
  26. Burns CA, McCaughey R, Lauter CB. The association of Streptococcus bovis fecal carriage and colon neoplasia: possible relationship with polyps and their premalignant potential. Am J Gastroenterol 1985; 80:42.
  27. Moshkowitz M, Arber N, Wajsman R, et al. Streptococcus bovis endocarditis as a presenting manifestation of idiopathic ulcerative colitis. Postgrad Med J 1992; 68:930.
  28. Boleij A, Schaeps RM, Tjalsma H. Association between Streptococcus bovis and colon cancer. J Clin Microbiol 2009; 47:516.
  29. Tripodi MF, Adinolfi LE, Ragone E, et al. Streptococcus bovis endocarditis and its association with chronic liver disease: an underestimated risk factor. Clin Infect Dis 2004; 38:1394.
  30. Lee RA, Woo PC, To AP, et al. Geographical difference of disease association in Streptococcus bovis bacteraemia. J Med Microbiol 2003; 52:903.
  31. Beck M, Frodl R, Funke G. Comprehensive study of strains previously designated Streptococcus bovis consecutively isolated from human blood cultures and emended description of Streptococcus gallolyticus and Streptococcus infantarius subsp. coli. J Clin Microbiol 2008; 46:2966.
  32. Hoen B, Chirouze C, Cabell CH, et al. Emergence of endocarditis due to group D streptococci: findings derived from the merged database of the International Collaboration on Endocarditis. Eur J Clin Microbiol Infect Dis 2005; 24:12.
  33. Ravreby WD, Bottone EJ, Keusch GT. Group D streptococcal bacteremia, with emphasis on the incidence and presentation of infections due to Streptococcus bovis. N Engl J Med 1973; 289:1400.
  34. Kupferwasser I, Darius H, Müller AM, et al. Clinical and morphological characteristics in Streptococcus bovis endocarditis: a comparison with other causative microorganisms in 177 cases. Heart 1998; 80:276.
  35. Duval X, Papastamopoulos V, Longuet P, et al. Definite streptococcus bovis endocarditis: characteristics in 20 patients. Clin Microbiol Infect 2001; 7:3.
  36. Moellering RC Jr, Watson BK, Kunz LJ. Endocarditis due to group D streptococci. Comparison of disease caused by streptococcus bovis with that produced by the enterococci. Am J Med 1974; 57:239.
  37. Bassetti M, Secchi G, Borziani S, et al. Successful treatment of four-valve native endocarditis caused by Streptococcus bovis. Int J Cardiol 2004; 97:159.
  38. Pergola V, Di Salvo G, Habib G, et al. Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens. Am J Cardiol 2001; 88:871.
  39. Hoen B, Alla F, Selton-Suty C, et al. Changing profile of infective endocarditis: results of a 1-year survey in France. JAMA 2002; 288:75.
  40. Gonzlez-Quintela A, Martínez-Rey C, Castroagudín JF, et al. Prevalence of liver disease in patients with Streptococcus bovis bacteraemia. J Infect 2001; 42:116.
  41. Gergaud JM, Breux JP, Roblot P, et al. [Neurologic complications of infectious endocarditis]. Ann Med Interne (Paris) 1995; 146:413.
  42. Giannitsioti E, Chirouze C, Bouvet A, et al. Characteristics and regional variations of group D streptococcal endocarditis in France. Clin Microbiol Infect 2007; 13:770.
  43. Hede SV. Diagnosis and Treatment of Childhood Meningitis Caused by Streptococcus bovis Group. Curr Infect Dis Rep 2016; 18:11.
  44. Beneteau A, Levy C, Foucaud P, et al. Childhood meningitis caused by Streptococcus bovis group: clinical and biologic data during a 12-year period in France. Pediatr Infect Dis J 2015; 34:136.
  45. Cohen LF, Dunbar SA, Sirbasku DM, Clarridge JE 3rd. Streptococcus bovis infection of the central nervous system: report of two cases and review. Clin Infect Dis 1997; 25:819.
  46. Jain AK, Agarwal SK, el-Sadr W. Streptococcus bovis bacteremia and meningitis associated with Strongyloides stercoralis colitis in a patient infected with human immunodeficiency virus. Clin Infect Dis 1994; 18:253.
  47. Coret Ferrer F, Vilchez Padilla JJ, Igual Adell R, Ferrando Ginestar J. Streptococcus bovis meningitis: no association with colonic malignancy. Clin Infect Dis 1993; 17:527.
  48. van Samkar A, Brouwer MC, Pannekoek Y, et al. Streptococcus gallolyticus meningitis in adults: report of five cases and review of the literature. Clin Microbiol Infect 2015; 21:1077.
  49. Gray JD, Wilson CJ. Streptococcus gallolyticus (bovis): a rare presentation of meningitis in the ED. Am J Emerg Med 2016; 34:677.e1.
  50. Grant RJ, Shang WY, Whitehead TR. Isolated septic arthritis due to Streptococcus bovis. Clin Infect Dis 1997; 24:1021.
  51. Emerton ME, Crook DW, Cooke PH. Streptococcus bovis-infected total hip arthroplasty. J Arthroplasty 1995; 10:554.
  52. Bajwa ZH, Ho C, Grush A, et al. Discitis associated with pregnancy and spinal anesthesia. Anesth Analg 2002; 94:415.
  53. Bleibel W, D'Silva K, Elhorr A, et al. Streptococcus bovis endophthalmitis: a unique presentation of colon cancer. Dig Dis Sci 2007; 52:2336.
  54. García-País MJ, Rabuñal R, Armesto V, et al. Streptococcus bovis septic arthritis and osteomyelitis: A report of 21 cases and a literature review. Semin Arthritis Rheum 2016; 45:738.
  55. Goumas PD, Naxakis SS, Rentzis GA, et al. Lateral neck abscess caused by Streptococcus bovis in a patient with undiagnosed colon cancer. J Laryngol Otol 1997; 111:666.
  56. Ackerman Z, Eliakim R, Stalnikowicz R. Spontaneous peritonitis caused by Streptococcus bovis: search for colonic neoplasia. J Clin Gastroenterol 1995; 21:263.
  57. Wong SS, Woo PC, Ho PL, Wang TK. Continuous ambulatory peritoneal dialysis-related peritonitis caused by Streptococcus bovis. Eur J Clin Microbiol Infect Dis 2003; 22:424.
  58. Eledrisi MS, Zuckerman MJ, Ho H. Spontaneous bacterial peritonitis caused by Streptococcus bovis. Am J Gastroenterol 2000; 95:1110.
  59. Genuth L. Re: Shad and Schindler's report on spontaneous peritonitis due to Streptococcus bovis. Am J Gastroenterol 2000; 95:840.
  60. Matesanz M, Rubal D, Iñiguez I, et al. Is Streptococcus bovis a urinary pathogen? Eur J Clin Microbiol Infect Dis 2015; 34:719.
  61. de Teresa-Alguacil J, Gutiérrez-Soto M, Rodríguez-Granger J, et al. Clinical interest of Streptococcus bovis isolates in urine. Rev Esp Quimioter 2016; 29:155.
  62. Gherardi G, Palmieri C, Marini E, et al. Identification, antimicrobial resistance and molecular characterization of the human emerging pathogen Streptococcus gallolyticus subsp. pasteurianus. Diagn Microbiol Infect Dis 2016; 86:329.
  63. Chuard C, Reller LB. Bile-esculin test for presumptive identification of enterococci and streptococci: effects of bile concentration, inoculation technique, and incubation time. J Clin Microbiol 1998; 36:1135.
  64. Clarridge JE 3rd, Attorri SM, Zhang Q, Bartell J. 16S ribosomal DNA sequence analysis distinguishes biotypes of Streptococcus bovis: Streptococcus bovis Biotype II/2 is a separate genospecies and the predominant clinical isolate in adult males. J Clin Microbiol 2001; 39:1549.
  65. Haanperä M, Jalava J, Huovinen P, et al. Identification of alpha-hemolytic streptococci by pyrosequencing the 16S rRNA gene and by use of VITEK 2. J Clin Microbiol 2007; 45:762.
  66. Dekker JP, Lau AF. An Update on the Streptococcus bovis Group: Classification, Identification, and Disease Associations. J Clin Microbiol 2016; 54:1694.
  67. Mouton JW, Endtz HP, den Hollander JG, et al. In-vitro activity of quinupristin/dalfopristin compared with other widely used antibiotics against strains isolated from patients with endocarditis. J Antimicrob Chemother 1997; 39 Suppl A:75.
  68. Matsumura M, Araki T, Yokogawa A. Streptococcus bovis discitis and possible endocarditis. Intern Med 2000; 39:677.
  69. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
  70. Thornsberry C, Baker CN, Facklam RR. Antibiotic susceptibility of Streptococcus bovis and other group D streptococci causing endocarditis. Antimicrob Agents Chemother 1974; 5:228.
  71. Fung JC, Gadbaw JJ Jr, Donta ST, Tilton RC. Infective endocarditis due to penicillin-tolerant Streptococcus bovis. Diagn Microbiol Infect Dis 1986; 5:171.
  72. Venditti M, Gelfusa V, Serra P, et al. 4-week treatment of streptococcal native valve endocarditis with high-dose teicoplanin. Antimicrob Agents Chemother 1992; 36:723.
  73. Leclercq R, Huet C, Picherot M, et al. Genetic basis of antibiotic resistance in clinical isolates of Streptococcus gallolyticus (Streptococcus bovis). Antimicrob Agents Chemother 2005; 49:1646.
  74. Rodríguez-Avial I, Rodríguez-Avial C, Culebras E, Picazo JJ. In vitro activity of telithromycin against viridans group streptococci and Streptococcus bovis isolated from blood: antimicrobial susceptibility patterns in different groups of species. Antimicrob Agents Chemother 2005; 49:820.
  75. Kaufhold A, Potgieter E. Chromosomally mediated high-level gentamicin resistance in Streptococcus mitis. Antimicrob Agents Chemother 1993; 37:2740.
  76. Teng LJ, Hsueh PR, Ho SW, Luh KT. High prevalence of inducible erythromycin resistance among Streptococcus bovis isolates in Taiwan. Antimicrob Agents Chemother 2001; 45:3362.
  77. Kerawala M, Ambler JE, Lee PY, Drabu YJ. In vitro activity of gemifloxacin (SB-265805) compared to eleven other antimicrobial agents against streptococcal isolates, excluding Streptococcus pneumoniae. Eur J Clin Microbiol Infect Dis 2001; 20:271.
  78. David F, de Céspèdes G, Delbos F, Horaud T. Diversity of chromosomal genetic elements and gene identification in antibiotic-resistant strains of Streptococcus pneumoniae and Streptococcus bovis. Plasmid 1993; 29:147.
  79. Hinse D, Vollmer T, Rückert C, et al. Complete genome and comparative analysis of Streptococcus gallolyticus subsp. gallolyticus, an emerging pathogen of infective endocarditis. BMC Genomics 2011; 12:400.
  80. Moet GJ, Dowzicky MJ, Jones RN. Tigecycline (GAR-936) activity against Streptococcus gallolyticus (bovis) and viridans group streptococci. Diagn Microbiol Infect Dis 2007; 57:333.
  81. Romero B, Morosini MI, Loza E, et al. Reidentification of Streptococcus bovis isolates causing bacteremia according to the new taxonomy criteria: still an issue? J Clin Microbiol 2011; 49:3228.
  82. Tripodi MF, Fortunato R, Utili R, et al. Molecular epidemiology of Streptococcus bovis causing endocarditis and bacteraemia in Italian patients. Clin Microbiol Infect 2005; 11:814.
  83. Roberts RB. Streptococcal endocarditis: The viridans and beta hemolytic streptococci. In: Infective Endocarditis, Kaye D (Ed), Raven Press, New York 1992. p.191.
  84. Hoogkamp-Korstanje JA, Roelofs-Willemse J. Comparative in vitro activity of moxifloxacin against Gram-positive clinical isolates. J Antimicrob Chemother 2000; 45:31.
  85. Streit JM, Steenbergen JN, Thorne GM, et al. Daptomycin tested against 915 bloodstream isolates of viridans group streptococci (eight species) and Streptococcus bovis. J Antimicrob Chemother 2005; 55:574.
  86. Francioli P, Ruch W, Stamboulian D. Treatment of streptococcal endocarditis with a single daily dose of ceftriaxone and netilmicin for 14 days: a prospective multicenter study. Clin Infect Dis 1995; 21:1406.
  87. Sexton DJ, Tenenbaum MJ, Wilson WR, et al. Ceftriaxone once daily for four weeks compared with ceftriaxone plus gentamicin once daily for two weeks for treatment of endocarditis due to penicillin-susceptible streptococci. Endocarditis Treatment Consortium Group. Clin Infect Dis 1998; 27:1470.
  88. Gold JS, Bayar S, Salem RR. Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy. Arch Surg 2004; 139:760.