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PEDIATRICS Vol. 107 No. 4 April 2001, pp. 775-776
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ABSTRACT |
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Top
Abstract
Introduction
Discussion
References
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Pediococci are recently recognized Gram-positive human pathogens, resistant to vancomycin and generally susceptible to penicillin. Infection in adults has been seen in patients with chronic underlying conditions as well as those with previous abdominal surgery. Two previous infants with congenital gastrointestinal malformations requiring surgical correction have been reported with sepsis attributable to Pediococcus sp. We report a third infant born with gastroschisis who developed Pediococcus bacteremia and meningitis 3 months after surgery, and speculate regarding the role of probiotics in the pathogenesis of this infection.
Key words: Pediococcus, vancomycin resistance, bacteremia, lactobacilli, gastroschisis, probiotics.
Pediococci, recently recognized human pathogens, are
members of the lactic acid-producing family of facultatively anaerobic bacteria.1,2 This group of organisms, which also includes
Lactobacillus and Leuconostoc species,
importantly is resistant to vancomycin and may be misidentified as
viridans streptococci.3,4 We present an infant born with
gastroschisis who developed Pediococcus sp septicemia, and
probable meningitis, to alert pediatricians to these pathogens and
their apparent association with underlying gastrointestinal
abnormalities.
A 34-week gestation female was delivered by cesarean section to
a 22-year-old, group B streptococcal bacteriuric woman. The pregnancy
was complicated by the presence of fetal gastroschisis. The infant had
Apgar scores of 4 and 9, at 1 and 5 minutes, respectively. She was
intubated and ventilated; intravenous fluids were begun. Blood cultures
were obtained and parenteral ampicillin and gentamicin initiated.
Physical examination on admission to the neonatal intensive care unit
revealed an infant weighing 2108 g, a head circumference of 31.5 cm, and length of 44.5 cm. Her exteriorized bowel was wrapped with
saline-soaked lap pads. At 2 hours of age, repair of the infant's
gastroschisis, release of constricting Ladd's bands, resection of
ischemic, atretic ascending colon, and placement of colostomy, and
Broviac catheter were performed.
At 2 days of life, the infant was taken back to the operating room,
where additional necrotic colon and distal ileum were resected.
Antibiotics were changed to vancomycin, cefotaxime, and clindamycin,
which were administered for a total of 10 days. Enteral feedings with
Pregestimil (Mead Johnson, Evansville, IN) were begun on the infant's
ninth day of life, but interrupted on multiple occasions because of
bilious emesis and gastrointestinal hemorrhage.
On day 43 of life, blood culture yielded Enterococcus
faecalis, for which the infant received 10 days of ampicillin and
gentamicin therapy. When she was 2 months old, stool culture revealed
no normal enteric Gram-negative rods. Oral lactobacilli (Bacid) from capsules were added to her formula in an attempt to reintroduce normal
bowel flora. Two episodes of coagulase-negative staphylococcal sepsis
were treated with vancomycin and subsequent replacement of the Broviac
catheter.
At 3 months of age, the infant now without a Broviac catheter in place,
developed lethargy and irritability, marked icterus associated with
elevated direct bilirubin (peak: 10.9 mg/dL) and alanine
aminotransferase (peak: 268 units/L), and metabolic acidosis. Lumbar
puncture, after initiation of antibiotics, showed cloudy cerebrospinal
fluid (CSF) with 43 white blood cells/mm3 (42%
segmented and 32% band forms), protein of 47 mg/dL, and glucose of 60 mg/dL. Gram-positive cocci, sensitive (by Kirby-Bauer disk diffusion
test) to chloramphenicol and clindamycin, intermediate to penicillin
(minimal inhibitory concentration [MIC] = 1 µg/mL) and resistant to
vancomycin (MIC >1 µg/mL) and ceftriaxone (MIC >1 µg/mL), were
isolated from blood culture. The organisms were catalase-, pyrrolidone
carboylyl peptidase-, and arginine dihydrolase-negative; bile eusculin-
and group D streptococcal antigen-positive. They were identified as
Pediococcus sp. The CSF was sterile. The infant received 21 days of intravenous ampicillin and gentamicin with normalization of her
neurologic examination and improved hepatic function. Intercurrent
pseudomembranous enterocolitis was treated with a 10-day course of
metronidazole. She was discharged from the hospital on oral formula at
159 days of age, weighing 4416 g.
Subsequent culture of 2 Bacid capsules' contents obtained from the
hospital pharmacy yielded Lactobacillus acidophilus and E faecium, the latter susceptible to vancomycin. A sample of
the Pregestimil formula was sterile.
Pediococcus spp are Gram-positive, catalase- and
oxidase-negative cocci that may be either Originally thought to be clinically insignificant, pediococci have been
associated with human infection since 1987.1 Of the 14 previously reported cases of bacteremia,6-11 only 2 were
in children.7,10 A 2-week-old infant had jejunoileal
atresia and a 2-month-old had gastroschisis, as did the 3-month-old in
this report. Infection in adults has also been seen in individuals with
previous abdominal surgery and tube-feedings, as well as with chronic
underlying conditions including cancer, diabetes, pulmonary and
cardiovascular disease, and, most recently, pregnancy. We strongly
suspect that our infant had concomitant Pediococcus
meningitis based on her CSF pleocytosis and symptomatology, which
resolved with antibiotic therapy. This diagnosis remains speculative
because her CSF was obtained after initiation of antimicrobials and was
sterile.
Pediococci are found on fermenting vegetables and in silage, dairy
products, and beer. They have been used in the processing and
preservation of selected meats, vegetables, cheeses, and soy products.6,7 Human isolates have been obtained from
saliva, stool, urine, sputum, wounds, abscesses, and
blood.7,11 We attempted to delineate the source of our
patient's Pediococcus, but we were unsuccessful. Culture of
the Pregestimil was sterile. Cultures of the contents of 2 lactobacillus (Bacid) capsules (as had been added to her formula),
however, revealed L acidophilus as well as E
faecium. The latter isolate was of initial concern because of its
increasing association with both nosocomial infection and high-level
vancomycin resistance.4 Fortunately, this isolate was
vancomycin-susceptible. Unfortunately, however, the original formulae
and capsules administered to this patient were not available for these
cultures, performed 5 months after the episode of
Pediococcus bacteremia, 2 months after the infant's
discharge. Lactobacillus casei sps rhamnosus has previously been shown to decrease the incidence of traveler's diarrhea, duration and severity of rotavirus diarrhea, and incidence and duration of
antibiotic-associated diarrhea.12 We urge caution,
however, in using commercially available probiotics in children and
adults with gastrointestinal abnormalities, pending additional study.
We would also suggest that frequent use of vancomycin in hospitalized,
seriously ill patients may lead to increased recovery of
vancomycin-resistant organisms, including pediococci. Knowledge of
their unusual antimicrobial susceptibility pattern will facilitate
bacterial identification, allow institution of appropriate antibiotic
therapy, and prevent initiation of costly isolation procedures, as are
used for vancomycin-resistant enterococci.
We thank Marcia L. Lincoln and Dr Kenneth Ryan of the University
Medical Center Microbiology Laboratory in Tucson, Arizona, and Richard
Luoma, Lynn Williamson, and Patricia Fisher of Benefis HealthCare
Microbiology Laboratory in Great Falls, Montana, for their assistance
with laboratory studies. Amy O'Brien aided in manuscript preparation.
CASE REPORT
DISCUSSION
Top
Abstract
Introduction
Discussion
References
-hemolytic or
nonhemolytic.3 Because of their reaction with group D
streptococcal antisera, they may be overlooked and erroneously
identified as streptococci. Suspicion should be aroused, however, by
their susceptibility to penicillin and ampicillin (and generally
aminoglycosides) and resistance to vancomycin.1-5
ACKNOWLEDGMENTS
Department of Pediatrics
and Steele Memorial Children's Research Center
University of Arizona
Tucson, AZ 85724-5073
Benefis HealthCare and Great Falls Clinic
Great Falls, MT 59405
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FOOTNOTES |
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Received for publication Mar 23, 2000; accepted May 16, 2000.
Reprint requests to (L.L.B.) 1501 N Campbell Ave, Box 245073, Tucson, AZ 85724-5073. E-mail: llb{at}peds.arizona.edu
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ABBREVIATIONS |
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CSF, cerebrospinal fluid; MIC, minimal inhibitory concentration.
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REFERENCES |
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Abstract
Introduction
Discussion
References
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