Enterococcal Bloodstream Infections in Children

Background: Enterococcal bloodstream infections have become increasingly common among adult patients.  Few studies have examined these phenomena in the pediatric population.    

Objective: Our study describes factors associated with enterococcal bloodstream infections in children cared for at the A. I. duPont Hospital for Children from 2004-2008. 

Methods: A retrospective descriptive study was performed using the electronic medical record of children cared for at the A. I. duPont Hospital for Children from 2004-2008.  Children identified as having had an enterococcal bloodstream infection constituted the cohort we employed.  Patients from whom the same enterococcus species was recovered on multiple consecutive days were counted once for study purposes.  Clinical data analyzed included antibiotic usage less than or equal to 2 weeks prior to the date of positive culture, source of blood culture (central line or peripheral venous line), organism speciation and antimicrobial susceptibility, 30-day crude mortality and community or nosocomial acquired infection (greater than or equal to 48 hours after admission).  Demographic data were collected and analyzed.

Results: 133 unique patients yielding 373 blood isolates were reviewed (128 central lines and 5 peripheral).  There were 68 males and 65 females.  Mean age was 4.7 years (median 2.3 years, range 8 days to 20 years).  There were 4 neonates (0-28 days), with 3 E. faecalis and 1 E. faecium.  Speciation of organisms isolated revealed E. faecalis (n=94, 71%), E. faecium (n=32, 24%), E. gallinarum (n=3, 2.2%) and other species (n=4, 3%).  Nosocomial infection accounted for 57% of the cases.  56% of the patients had prior cephalosporin exposure.  12 patients accounted for 15 VRE isolates.  There were 4 E. gallinarum, all of which were intermediate to vancomycin.  30-day crude mortality rate was 12%, all in the non-neonatal group.

Conclusions: Enterococci are significant causes of bloodstream infections in children.  As has been shown in previous studies, the majority of the bacteremias in our study were nosocomial.  Reinforcing strict infection control practices may play a role in decreasing enterococcal bloodstream infections.  The majority of the isolates were obtained from central lines.  Greater than half of the study patients had prior exposure ot cephalosporins.  Prudent antimicrobial usage may decrease the incidence of this infection.  The rate of VRE bacteremia, 11%, reported in our study presents a real therapeutic challenge.  Although our 30-day crude mortality rate is lower than that reported in adult studies, it nevertheless reinforces the severity of this infection in children.