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

Disclosures

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

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.

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Abstract and Introduction
Cases Identified Through CHA's PHIS Database
Cases Identified Through CDC's National Call for Cases
Discussion
References
Sidebar

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

Table. Demographic and clinical characteristics, and microbiology results in patients aged ≤18 years with brain abscess, epidural empyema, or subdural empyema reported to CDC in response to a June 2022 national call for cases (N = 81) — United States, June 2021–August 2022
Characteristic (no. with available information)	No. (%)*
Demographic
Age, yrs, median (IQR)	11.0 (6.0–13.0)
Race or ethnicity (66)
White, non-Hispanic	36 (54.5)
Black or African American, non-Hispanic	21 (31.8)
Hispanic or Latino	7 (10.6)
Asian, non-Hispanic	1 (1.5)
Multiple races, non-Hispanic	1 (1.5)
Sex assigned at birth (80)
Male	49 (61.3)
Female	31 (38.8)
Current gender identity (63)
Male	35 (55.6)
Female	28 (44.4)
Underlying health conditions
Any underlying health condition (78)	35 (44.9)
Asthma or reactive airway disease (78)	9 (11.5)
Obesity (78)	4 (5.1)
Seizures/Seizure disorder (78)	3 (3.8)
Congenital heart disease (78)	2 (2.6)
Dental caries or periodontal disease (78)	1 (1.3)
Diabetes mellitus (type 1 or 2) (78)	1 (1.3)
Other underlying condition^† (78)	20 (25.6)
Vaccination information
Previous pneumococcal conjugate vaccine (65)	55 (84.6)
Previous SARS-CoV-2 vaccine (59)	15 (25.4)
Recent medical history
Diagnosis in 6 wks preceding hospitalization
Respiratory infection ^§ (77)	47 (61.0)
COVID-19 (77)	14 (18.2)
Influenza (77)	1 (1.3)
Sinusitis (77)	20 (26.0)
Upper respiratory infection (77)	12 (15.6)
Other respiratory infection^¶ (77)	11 (14.3)
Sought prehospitalization care (77)**	63 (81.8)
Hospitalization
Length of stay, days (IQR) (71)	10.0 (6.0–21.0)
Outcome of hospitalization (80)
Discharged to home	59 (73.8)
Discharged to rehab facility	10 (12.5)
Currently hospitalized	9 (11.2)
Deceased	2 (2.5)
During hospitalization
Brain abscess (81)	30 (37.0)
Subdural empyema (81)	43 (53.1)
Epidural empyema (81)	27 (33.3)
Sinusitis (77)	47 (61.0)
Osteomyelitis, including Pott's puffy tumor (77)	24 (31.2)
Bacterial meningitis (77)	20 (26.0)
Orbital/Periorbital cellulitis (77)	13 (16.9)
Mastoiditis (77)	8 (10.4)
Otitis media (77)	4 (5.2)
Vancomycin received during hospitalization (80)	73 (91.2)
Ceftriaxone received during hospitalization (80)	71 (88.8)
Metronidazole received during hospitalization (80)	65 (81.2)
Detection of viral respiratory pathogens (52)
No pathogens identified	38 (73.1)
Pathogens identified^††	14 (26.9)
Microbiology
Pathogens identified (76)
Eikenella corrodens	5 (6.6)
Fusobacterium nucleatum	2 (2.6)
Parvimonas micra	5 (6.6)
Staphylococcus aureus	4 (5.2)
Staphylococcus epidermidis	3 (3.9)
Streptococcus intermedius	35 (46.1)
Streptococcus anginosus	14 (18.4)
Streptococcus pneumoniae	9 (11.8)
Streptococcus constellatus	7 (9.2)
Streptococcus agalactiae	1 (1.3)
Streptococcus pasteurianus	1 (1.3)
Other^§§	13 (17.1)
Polymicrobial specimens (76)	16 (21.1)
Isolate source (75)
Brain abscess	13 (17.3)
Epidural empyema	10 (13.3)
Subdural empyema	17 (22.7)
Blood	10 (13.3)
Cerebrospinal fluid	9 (12.0)
Other^¶¶	16 (21.3)

Abbreviations: ED = emergency department; MRSA = methicillin-resistant Staphylococcus aureus; RSV = respiratory syncytial virus; URI = upper respiratory infection.
*Percentages calculated using nonmissing data.
^†Other underlying conditions included: Alice in Wonderland syndrome (i.e., dysmetropsia, a rare neurologic disorder characterized by distortions in perception, especially of body image); allergies (seasonal, nonseasonal, and peanut); autism; Castleman disease; cerebral palsy (including spastic quadriplegic); cerebral infarction; chronic nasal congestion; cystic encephalomalacia; epilepsy; frequent nosebleeds; gallstone pancreatitis; global developmental delay; Hashimoto disease; headaches, insomnia; intellectual disability; microcephaly; migraines; MRSA infection; myringotomy tubes; neurofibromatosis type 1; nonaccidental trauma to child; oropharyngeal dysphagia; retinal hemorrhage of both eyes; right spastic hemiparesis; sinusitis; snoring; traumatic brain injury at birth; and Trisomy 21.
^§Including COVID-19, influenza, sinusitis, upper respiratory infection, and other respiratory infections.
^¶Other respiratory infections included otitis media (five); parainfluenza (two); cough and fever of unspecified cause (one); URI symptoms but no diagnosis (one); RSV (one); and otitis externa (one).
**In ED, outpatient primary care, or urgent care.
^††Viral respiratory pathogens detected during hospitalization included: SARS-CoV-2 (nine), rhinovirus/enterovirus (four), RSV (two), influenza virus (one), adenovirus (one), and parainfluenza virus (one).
^§§ Actinomyces sp. (one), Clostridium sp. (one), Candida parapsilosis (one), Cutibacterium acnes (one), Haemophilus influenzae (one), Klebsiella pneumoniae (one), Mycoplasma hominis (one), Staphylococcus capitis (one), Staphylococcus hominis (one), Gemella morbillorum (one), and unspecified streptococci (three).
^¶¶Orbital abscess (two), forehead abscess (one), middle meatus (one), ear aspirate (two), and sinuses (eight).