A case report recently published in the Journal of the Pediatric Infectious Diseases Society highlighted the first pediatric case of Enterococcus hirae in the United States, and the presentation was a catheter-associated bloodstream infection.
“This is an unusual organism never before detected in children, and only the second reported case in the United States,” John Williams, MD, chief of the division of pediatric infectious diseases at UPMC Children’s Hospital of Pittsburgh, told Infectious Diseases in Children. “Clinicians should not dismiss unusual organisms isolated from bloodstream infections as ‘contaminants,’ especially in high-risk patients.”
E. hirae — a gram-positive coccus rarely implicated in human disease — was reported in a male infant aged 7 months who was born prematurely in Puerto Rico at 33 weeks’ gestation, had a pre-existing central venous catheter (CVC) and presented to the hospital with fussiness and fever. He also had a history of gastroschisis and jejunal atresia that resulted in bowel resection and intestinal failure requiring long-term total parenteral nutrition. This was the patient’s fifth bloodstream infection, according to the researchers. He had also undergone eight CVC placements, with the most recent being a right internal jugular double-lumen tunneled catheter placed at 5 months of age. At presentation, he was under the third growth percentile for both weight and length, his CVC tunnel tract was nontender and the researchers found no erythema, edema, fluctuance or expressible fluid. The physical examination was “otherwise unremarkable,” the researchers noted.
The patient was treated with vancomycin and gentamicin with adjunctive vancomycin lock therapy, but his bacteremia persisted. Treatment was changed to dual beta-lactam therapy of ampicillin and ceftriaxone with synergistic gentamicin, which cleared the enterococcal bacteremia. As an outpatient, he received ertapenem and daptomycin via a new CVC.
Williams and colleagues reviewed cases of E. hirae infection in adults and found 13 reported cases globally. In these cases, the coccus was implicated in heart valve, urinary tract, biliary tract and solid organ infections, as well as ascites, vertebrae/intervertebral disc infections and bacteremia. All reported adult cases thus far have involved severe disease associated with bacteremia, “which underscores the importance of additional study of this clinically significant strain,” the researchers wrote.
“The bacteria can grow on standard mediums, but advanced techniques” — such as matrix-assisted laser desorption ionization time-of-flight mass spectrometry, or MALDI-TOF — “may be required to provide a definite identification,” Williams said. – by Joe Gramigna
Disclosure: Williams reports serving on a scientific advisory board for Quidel and an independent data monitoring committee for GlaxoSmithKline.