Pediatric Brain Abscesses, Epidural Empyemas, and Subdural Empyemas Associated With Streptococcus Species

United States, January 2016-August 2022

Emma K. Accorsi, PhD; Sopio Chochua, MD, PhD; Heidi L. Moline, MD; Matt Hall, PhD; Adam L. Hersh, MD, PhD; Samir S. Shah, MD; Amadea Britton, MD; Paulina A. Hawkins, MPH; Wei Xing, MSTAT; Jennifer Onukwube Okaro, MPH; Lindsay Zielinski, DO; Lesley McGee, PhD; Stephanie Schrag, DPhil; Adam L. Cohen, MD


Morbidity and Mortality Weekly Report. 2022;71(37):1169-1173. 

In This Article

Abstract and Introduction


In May 2022, CDC learned of three children in California hospitalized concurrently for brain abscess, epidural empyema, or subdural empyema caused by Streptococcus intermedius. Discussions with clinicians in multiple states raised concerns about a possible increase in pediatric intracranial infections, particularly those caused by Streptococcus bacteria, during the past year and the possible contributing role of SARS-CoV-2 infection.[1] Pediatric bacterial brain abscesses, epidural empyemas, and subdural empyemas, rare complications of respiratory infections and sinusitis, are often caused by Streptococcus species but might also be polymicrobial or caused by other genera, such as Staphylococcus. On June 9, CDC asked clinicians and health departments to report possible cases of these conditions and to submit clinical specimens for laboratory testing. Through collaboration with the Children's Hospital Association (CHA), CDC analyzed nationally representative pediatric hospitalizations for brain abscess and empyema. Hospitalizations declined after the onset of the COVID-19 pandemic in March 2020, increased during summer 2021 to a peak in March 2022, and then declined to baseline levels. After the increase in summer 2021, no evidence of higher levels of intensive care unit (ICU) admission, mortality, genetic relatedness of isolates from different patients, or increased antimicrobial resistance of isolates was observed. The peak in cases in March 2022 was consistent with historical seasonal fluctuations observed since 2016. Based on these findings, initial reports from clinicians[1] are consistent with seasonal fluctuations and a redistribution of cases over time during the COVID-19 pandemic. CDC will continue to work with investigation partners to monitor ongoing trends in pediatric brain abscesses and empyemas.

Two data sources were analyzed: 1) pediatric hospitalizations for brain abscesses, epidural empyemas, and subdural empyemas reported to CHA's Pediatric Health Information System (PHIS) and 2) cases reported to CDC in response to a national call for cases. With CHA, CDC examined hospitalizations at 40 tertiary referral children's hospitals across the United States that consistently reported data to PHIS during January 1, 2016–May 31, 2022 (the most recent data available when the analysis was performed). All inpatient encounters from patients aged ≤18 years with a primary or secondary discharge diagnosis of International Classification of Diseases, Tenth Revision, Clinical Modification code G06.0 (intracranial abscess and granuloma) or G06.2 (extradural and subdural abscess, unspecified) during the study period were included. Concurrent COVID-19 diagnosis was defined as having International Classification of Diseases, Tenth Revision codes U07.1 or B97.29 on the discharge diagnosis list. Medical complexity was classified according to the Pediatric Medical Complexity Algorithm.[2]

In CDC's national call for cases, a case was defined as the diagnosis of brain abscess, epidural empyema, or subdural empyema in a person aged ≤18 years without a previous neurosurgical procedure or history of head trauma, hospitalized on or after June 1, 2021, irrespective of etiology. The call for cases was shared with health departments and two provider listservs.* Reports received after August 10, 2022, were excluded. Available Streptococcus specimens isolated from a brain abscess, epidural empyema, subdural empyema, blood, or cerebrospinal fluid were collected for antimicrobial susceptibility testing and whole-genome sequencing at CDC's Streptococcus reference laboratory to identify microbiological features shared among cases. Genomic sequences were generated with an Illumina Miseq[3] instrument, and single-nucleotide polymorphisms (SNPs) were identified for core genomes employing kSNP3.0 with k-mer size of 19.[4] Pairwise comparisons were generated employing Mega7.[5] Minimal inhibitory concentrations (MICs) were determined by broth microdilution methods according to the Clinical and Laboratory Standards Institute.[6] The agar diffusion gradient method (Etest, bioMérieux) was used for isolates that did not grow in broth. Analyses were conducted using SAS (version 9.4; SAS Institute) or R (version 4.0.3; R Foundation) with R Studio (version 1.3.1093; RStudio, PBC).This study was reviewed by CDC and was conducted consistent with federal law and CDC policy.

*The Pediatric Infectious Diseases Society and the Section of Pediatric Neurosurgeons, a joint section of the American Association of Neurologic Surgeons and Congress of Neurologic Surgeons.
45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.