Pediatric Enterococcal Infection Clinical Presentation

  • Author: Meera Varman, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 12, 2012
 

History

  • Historical risk factors for acquisition of vancomycin-resistant Enterococcus (VRE) and enterococcal infections include history of the following[4] :
    • Prolonged hospitalization
    • Long stay in ICU
    • Surgical reexploration following liver transplantation
    • Prior use of antibiotics, mainly vancomycin and cephalosporins
    • Immunocompromised state
    • Breakdown of normal physical barriers (eg, GI tract, skin, urinary tract)
    • Neurosurgical procedures and use of neurosurgical devices
  • Recent surveillance by perirectal culture for VRE and nasal culture for methicillin-resistant Staphylococcus aureus (MRSA) conducted between 2002 and 2003 revealed a co-colonization rate of 2.7% in 65 of 2,440 patients in an ICU. Significant risk factors included older age, male sex, hospitalization in an ICU, and antibiotic use during previous hospitalization within a year.
  • The SENTRY Antimicrobial Surveillance Program, performed between 1997-2002 to assess blood stream infections (BSIs) in the United States, Europe, and Latin America, documented that the incidence of oxacillin-resistant S aureus (39.1%) and VRE (17.7%) were highest in the United States.[5]
  • In a review of 451 patients on chronic dialysis, 60 (13%) were found to be colonized with VRE associated with increased mortality of 50%, compared with 10% in noncolonized patients.[6] This also poses challenges to infection control measures and medical care for these patients.
  • In a 2-year study of 1330 ICU admissions, 638 patients were at risk for acquisition; any VRE-colonized room occupants within the previous 2 weeks and a positive room culture result were independent risk factors for the acquisition of VRE.[7] This reinforces the necessity of thoroughly cleaning rooms prior to admitting new patients.
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Physical

  • Urinary tract infections: VRE is an infrequent cause of urinary tract infection (UTI) in healthy children. When an enterococcal UTI occurs in children, it is usually acquired nosocomially. Risk factors for UTIs caused by enterococci include the following:
    • Indwelling urinary catheters
    • Instrumentation of the urinary tract
    • Structural abnormalities of the urinary tract: In a retrospective review of 257 episodes of UTI over 5 years, E faecalis was identified in 5.1% (13); 9 of these patients had significant underlying anatomic abnormality.[8, 9]
    • Bacteremia: This may be polymicrobial, probably reflecting the severity of the underlying disease. In adults, the genitourinary tract is the most common entry site for enterococcal bacteremia but is implicated much less frequently in the etiology of enterococcal bacteremia in children. However, in a study by Christie et al, urosepsis was the etiology of 12% of episodes of nosocomial enterococcal bacteremia in hospitalized children.[10]
    • BSI: BSI due to VRE is an independent predictor of mortality, and duration of hospital stay is prolonged in BSI secondary to VRE, compared with vancomycin-susceptible enterococci (VSE) (4.5 d vs < 1 d). In a study of more than 2000 hematology-oncology (including transplant) patients, rectal colonization of VRE was close to 5%, of which E faecium constituted 84%.[11] Among these patients with VRE, 29% eventually developed bacteremia. A negative predictive value as high as 99.9% for the risk of bacteremia was documented in this study.
  • Endocarditis: In contrast to adults, in whom enterococci cause as many as 15% of cases of endocarditis, these organisms rarely infect the heart valves of children.
  • Intra-abdominal infections: Enterococcus is often isolated from polymicrobial abdominal or pelvic abscesses. In a 1993 study by Bonadio, 5 cases of enterococcal bacteremia occurred in previously healthy infants with gastroenteritis, 6 cases were associated with bowel obstruction, and 1 case was associated with appendicitis without perforation.[12]
  • Meningitis: Although Enterococcus rarely causes meningitis in otherwise healthy children and adults, it is known to cause meningitis and ventriculitis in children with ventriculoperitoneal (VP) shunts.
  • Neonatal infections: Enterococci account for as many as 10% of cases of neonatal bacteremia and septicemia. Incidence of neonatal enterococcal septicemia increased from 0.12 per 1000 live births in 1982 to 0.8 per 1000 live births in 1986. Enterococcus may cause early onset (within 7 d of birth) or late-onset (>7 d) neonatal sepsis. Early onset sepsis caused by enterococci is milder than that caused by group B streptococcal sepsis. Most cases of enterococcal bacteremia in neonates are nosocomial. Central venous catheters, necrotizing enterocolitis, and intra-abdominal surgery are risk factors. Enterococcus may cause focal skin and soft tissue infections, meningitis, and conjunctivitis in the neonate.[13] Most neonatal infections are caused by E faecalis.
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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

Meera Varman, MD  Associate Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center

Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: phamaceutical companies Honoraria speaker; phamaceutical companies Grant/research funds clinical trials research

Coauthor(s)

Archana Chatterjee, MD, PhD  Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital

Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Walid Abuhammour, MD, FAAP  Professor of Pediatrics, Michigan State University College of Medicine; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center

Walid Abuhammour, MD, FAAP is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

José Rafael Romero, MD  Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center

José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD  Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Warren C Johnson III, MD, to the development and writing of this article.

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This photomicrograph reveals cocci-shaped Enterococcus species bacteria taken from a patient with pneumonia.
 
 
 
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