Pediatric Enterococcal Infection Workup

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

Laboratory Studies

  • Diagnosis
    • Enterococcal infections are diagnosed once the organism has been isolated from a blood culture or other normally sterile site. Isolation from a stool culture is not evidence of invasive infection. The significance of isolating Enterococcus from polymicrobial intra-abdominal, wound, and pelvic infections has yet to be determined. Test all isolated organisms for resistance to beta-lactam antibiotics, aminoglycosides, and glycopeptides. Multiple antibiotic-resistant isolates also may need to be tested for resistance to fluoroquinolones, quinupristin/dalfopristin, doxycycline, and chloramphenicol.
    • Test ampicillin resistance by determining the minimal inhibitory concentration (MIC) and detecting beta-lactamase production. Although isolates with an MIC of greater than 16 mcg/mL are considered resistant, high doses of ampicillin (≤ 20 g/d in adults) may be effective for MICs as much as 64 mcg/mL. Enterococcus with gentamicin MICs of greater than 500 mcg/mL and streptomycin MICs of greater than 1000-2000 mcg/mL (depending on method used) are considered highly resistant and nonsynergistic for use of the aminoglycoside as part of combination therapy. Vancomycin MICs are difficult to determine, but agar dilution screening using brain-heart infusion agar supplemented with 16 mcg/mL vancomycin is reliable, as is the standard broth microdilution method.
  • Antimicrobial resistance and susceptibility
    • Enterococcus demonstrates 2 types of resistance.
      • Intrinsic resistance (low-level resistance) is chromosomally mediated and nontransferable.
      • Acquired resistance (high-level resistance) is mediated by plasmids and transposons and can be transferred from one bacterium to another.
    • Beta-lactam resistance is due to production of low-affinity penicillin-binding proteins. Enterococci are inherently resistant to cephalosporins, clindamycin, and semisynthetic penicillins, such as nafcillin, oxacillin, and methicillin. All enterococci have intrinsic low-level resistance to aminoglycosides.
    • Vancomycin-resistant enterococci: Three major phenotypes of vancomycin resistance have been described in enterococci.
      • Van A is characterized by high-level resistance to vancomycin (MIC >64 mcg/mL) and teicoplanins (MIC >32 mcg/mL). This phenotype is mediated by a transposon (Tn 1546) that carries 7 genes and is usually seen in E faecium.
      • Van B phenotype has variable levels of resistance to vancomycin (MIC 4-1000 mcg/mL) but not teicoplanin. It is mediated by transposons (Tn 1547). This phenotype usually is seen in E faecium but is also seen in E faecalis.
      • Van C phenotype is limited to certain species of enterococci. This phenotype demonstrates low-level vancomycin resistance (MIC 8-32 mcg/mL) and is susceptible to teicoplanin.
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Imaging Studies

  • According to the site and type of infection, the following imaging studies may be considered:
    • Brain CT scanning
    • Abdominal CT scanning
    • Renal ultrasonography
    • Heart echocardiography
    • Plain film radiography (eg, chest radiography)
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Procedures

  • Lumbar puncture or shunt aspiration is recommended to evaluate for meningitis or ventriculoperitoneal (VP) shunt infection.
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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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