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


Nationally representative hospitalizations during January 2016–May 2022, indicate that the number of pediatric brain abscess, epidural empyema, and subdural empyema cases in 2021 were within historical limits. High case counts in March 2022 were consistent with seasonal peaks in cases observed in March since 2016, but not previously reported. Cases declined in April 2022 and reached the median level by May 2022. 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. The finding that S. intermedius and S. constellatus isolates were largely susceptible to tested antimicrobials is consistent with published reports.[7,8]

Pediatric brain abscess, epidural empyema, and subdural empyema are often preceded by respiratory infection, including in 61.0% of cases reported to CDC, although previous COVID-19 was only reported in 18.2%. The extended period with case numbers below the January 2016–May 2022 median after the onset of the COVID-19 pandemic, followed by a peak in cases during late 2021–early 2022, might reflect altered patterns of respiratory pathogen transmission during the pandemic. Other studies have reported decreased incidences of respiratory and streptococcal infections in children coinciding with the implementation of pandemic-related nonpharmaceutical interventions, which were followed by returns to or rebounds past prepandemic baselines after COVID-19 mitigation measures were relaxed.[9,10] Pediatric brain abscesses and empyemas are serious infections always requiring hospitalization; thus, it is unlikely that the observed trends are the result of altered detection of cases from disruptions to the medical system during the COVID-19 pandemic.

The findings in this report are subject to at least five limitations. First, microbiologic etiology could not be identified from the PHIS hospitalization data. Second, PHIS data reported case numbers, not rates over time. Third, PHIS data from tertiary children's hospitals might not reflect all hospitals admitting children. Fourth, levels of completeness of case report form variables from CDC's call for cases varied. Whereas COVID-19 diagnosis before hospitalization was of particular interest, this information might not have been reliably available to medical record abstractors. Finally, selection bias could have occurred in the identification and reporting of cases from CDC's call for cases. In particular, the phrasing of the call for cases, which highlighted streptococcal species as a potential etiology, might have resulted in underreporting of cases with other etiologies.

Through collaboration with state and local health departments, clinicians, laboratorians, and academic partners, this investigation examined multiyear nationally representative hospitalization data, a large case series with detailed clinical information, and microbiologic features of Streptococcus sp. isolated from patients with a diagnosis of brain abscess, epidural empyema, or subdural empyema. After a comparative increase in cases from previous years that began in summer 2021, no evidence of increased case severity, genetic relatedness of streptococcal isolates from different cases, or antimicrobial resistance beyond what is typical for streptococcal species was identified. Case numbers peaked in March 2022, consistent with historical, seasonal fluctuations and declined to baseline in subsequent months. CDC will continue to work with investigation partners to monitor ongoing trends in pediatric brain abscesses and empyemas.