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

Cases Identified Through CDC's National Call for Cases

Among the 94 possible cases of pediatric brain abscesses, epidural empyemas, or subdural empyemas reported after CDC's national call for cases, 81 met the case definition. The median patient age was 11 years (IQR = 6–13 years) (Table). Cases were most frequently reported in males (61.3%) and White (54.5%) children. Forty-five percent of cases occurred in children with underlying health conditions, with asthma (11.5%) being the most common. Among patients, 61.0% had a diagnosis of at least one respiratory infection in the 6 weeks before hospitalization, most commonly sinusitis (26.0%) or COVID-19 (18.2%). Most patients (81.8%) sought outpatient care for the illness episode before hospitalization. Subdural empyema was the most common case presentation (53.1%), followed by brain abscess (37.0%) and epidural empyema (33.3%). Among 71 patients who were no longer hospitalized at the time of reporting, two (2.8%) died. Case report data indicated that streptococcal species were identified in most (92.1%) isolates, commonly S. intermedius (41.6%) and Streptococcus anginosus (18.4%). Nonstreptococcal species, including 15 unique pathogens, were isolated in 28.9% of cases and in all cases with polymicrobial infections.

Antimicrobial susceptibility testing was performed on available Streptococcus specimens (two Streptococcus constellatus and 16 S. intermedius) to identify shared microbiological features among cases. Both S. constellatus isolates were intermediately resistant to ampicillin, but susceptible to other antimicrobials tested. Nine S. intermedius isolates were pan-susceptible. One isolate was resistant to tetracycline only. Four S. intermedius isolates displayed a 1.5 μg/mL MIC against vancomycin, slightly above the clinical breakpoint for susceptibility (≤1 μg/mL) and were susceptible to other antimicrobials tested. Two isolates were resistant to multiple antibiotics (erythromycin, clindamycin, and tetracycline) and intermediately resistant to quinupristin-dalfopristin, one of which also displayed a 1.5 μg/mL MIC against vancomycin. Among 15 sequenced S. intermedius isolates, the average core genome pairwise distance was approximately 6,200 SNPs, indicating genetic unrelatedness.

Antimicrobials tested include ampicillin, cefotaxime, ceftriaxone, chloramphenicol, clindamycin, daptomycin, erythromycin, levofloxacin, linezolid, meropenem, penicillin, quinupristin-dalfopristin, tetracycline, and vancomycin.