Sections

Pediatric Enterococcal Infection

Sections Pediatric Enterococcal Infection
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
References

Workup

Laboratory Studies

See the list below:

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 and studies have not supported the need for empiric enterococcal antimicrobial coverage for these organisms in managing bowel perforations. 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.

Imaging Studies

See the list below:

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)

Procedures

See the list below:

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

Treatment & Management

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Bitsori M, Maraki S, Raissaki M, Bakantaki A, Galanakis E. Community-acquired enterococcal urinary tract infections. Pediatr Nephrol. 2005 Nov. 20(11):1583-6. [Medline]. [Full Text].
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Christie C, Hammond J, Reising S, Evans-Patterson J. Clinical and molecular epidemiology of enterococcal bacteremia in a pediatric teaching hospital. J Pediatr. 1994 Sep. 125(3):392-9. [Medline].
Matar MJ, Safdar A, Rolston KV. Relationship of colonization with vancomycin-resistant enterococci and risk of systemic infection in patients with cancer. Clin Infect Dis. 2006 May 15. 42(10):1506-7. [Medline]. [Full Text].
Bonadio WA. Group D streptococcal bacteremia in children. A review of 72 cases in 12 years. Clin Pediatr (Phila). 1993 Jan. 32(1):20-4. [Medline].
Tebruegge M, Pantazidou A, Clifford V, Gonis G, Ritz N, Connell T, et al. The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One. 2011. 6(11):e26576. [Medline]. [Full Text].
Lubell TR, Schnadower D, Freedman SB, Macias CG, Agrawal D, Kuppermann N, et al. Comparison of Febrile Infants With Enterococcal and Gram-negative Urinary Tract Infections. Pediatr Infect Dis J. 2016 Sep. 35 (9):943-8. [Medline].
[Guideline] Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections. Clinical Infectious Diseases. 2003. 37:997-1005. [Medline]. [Full Text].
Mave V, Garcia-Diaz J, Islam T, Hasbun R. Vancomycin-resistant enterococcal bacteraemia: is daptomycin as effective as linezolid?. J Antimicrob Chemother. 2009 Jul. 64(1):175-80. [Medline].
Santos BA, Oliveira JS, Cardoso NT, Barbosa AV, Superti SV, Teixeira LM, et al. Major globally disseminated clonal complexes of antimicrobial resistant enterococci associated with infections in cancer patients in Brazil. Infect Genet Evol. 2017 Sep 1. 55:56-62. [Medline].
de Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009 Jan 1. 360(1):20-31. [Medline].
Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals. Circulation. 2005 Jun 14. 111(23):e394-434. [Medline]. [Full Text].
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Kawecki D, Chmura A, Pacholczyk M, et al. Surgical site infections in liver recipients in the early posttransplantation period: etiological agents and susceptibility profiles. Transplant Proc. 2007 Nov. 39(9):2800-6. [Medline].
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Media Gallery

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

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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, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Pfizer, Sanofi<br/>Received research grant from: Merck; MedImmune; Regenron; Pfizer;Novartis; Sanof; GSK<br/>Received honoraria from phamaceutical companies for speaking and teaching; Received grant/research funds from phamaceutical companies for clinical trials research.

Coauthor(s)

Archana Chatterjee, MD, PhD Professor and Chair, Department of Pediatrics, Senior Associate Dean for Faculty Development, Sanford School of Medicine, The University of South Dakota

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

Disclosure: Nothing to disclose.

Walid Abuhammour, MD, MBA, CIC, FAAP, FIDSA Professor of Pediatrics, Michigan State University College of Human Medicine; Adjunct Professor, Department of Pediatrics, Hashemite University, Jordan; Head of Pediatric Infectious Diseases, Department of Pediatrics, Al Jalila Children's Hospital, UAE

Walid Abuhammour, MD, MBA, CIC, FAAP, FIDSA is a member of the following medical societies: American Academy of Pediatrics, International Society for Infectious Diseases, International Society for Infectious Diseases, Jordan Medical Association, Jordan Pediatric Society, Michigan Infectious Disease Society, Michigan State Medical Society, National Arab American Medical Association, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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, FACP Editor-in-Chief, ID Cases; Moderator, Program for Monitoring Emerging Diseases; Adjunct Professor of Medicine, State University of New York Downstate College of Medicine

Larry I Lutwick, MD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American Association for the Study of Liver Diseases, American College of Physicians, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, Infectious Diseases Society of New York, International Society for Infectious Diseases, New York Academy of Sciences, Veterans Affairs Society of Practitioners in Infectious Diseases

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

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, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

Sections Pediatric Enterococcal Infection
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
References

Pediatric Enterococcal Infection Workup

Laboratory Studies

Imaging Studies

Procedures

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Laboratory Studies

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