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Bacteremia in a pediatric hemodialysis unit secondary to Enterococcus fecalis
L C Hymes1, B L Warshaw, B Clowers
1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
Insights
Enterococcus bacteremia is an unusual but serious infection in children on hemodialysis. Flushing catheters with antibiotics after dialysis effectively prevented further Enterococcus infections in a pediatric unit.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Clinical Microbiology
Background:
- Bacteremia is a significant complication for pediatric patients undergoing hemodialysis, particularly those with central venous catheters.
- An outbreak of Enterococcus bacteremia occurred in a pediatric hemodialysis unit between June 1992 and June 1993.
Purpose of the Study:
- To investigate an outbreak of Enterococcus bacteremia in a pediatric hemodialysis unit.
- To identify the source and contributing factors of the outbreak.
- To evaluate the effectiveness of a new preventive measure.
Main Methods:
- Retrospective analysis of 18 bacteremia episodes in eight children over a 13-month period.
- Cultures of blood, catheter sites, and rectal swabs were performed.
- Enterococcus isolates were characterized by serotyping.
- A post-dialysis catheter flushing protocol with vancomycin or ampicillin was implemented.
Main Results:
- Enterococcus was the primary pathogen in 13 of 18 episodes, often in polymicrobial infections.
- All Enterococcus infections were associated with dual-lumen subclavian venous catheters.
- No common environmental or patient source was identified through cultures or serotyping.
- Catheter flushing with antibiotics led to the cessation of Enterococcus bacteremia episodes.
Conclusions:
- Enterococcus is an uncommon cause of bacteremia in pediatric hemodialysis patients.
- Dialysis catheters predispose children to Enterococcus infections.
- Preventive measures, such as antibiotic catheter flushing, can be effective in controlling outbreaks.
Unlabelled:
Bacteremia is often a serious and recurring problem in children with hemodialysis catheters. We report an outbreak of Enterococcus bacteremia in a pediatric hemodialysis unit occurring from June 1992 to June 1993. During this period, 18 episodes of bacteremia occurred in eight children; 11 infections were polymicrobial. Enterococcus fecalis was associated with 13 infections in five patients (8 polymicrobial). Other pathogens included Enterobacter cloacae (5 infections), Staphylococcus (3), Staphylococcus epidermidis (2), and Klebsiella pneumoniae (2). All Enterococcus infections occurred in patients with dual-lumen subclavian venous catheters. Skin and catheter sites were culture negative, except in one patient. Rectal swabs were positive for Enterococcus in five patients. Enterococcus was not isolated from any source within the unit. Serotypes of all Enterococcus isolates were different, except for 2 isolates in the same patient. Starting in June 1993, catheters were flushed after dialysis with vancomycin or ampicillin. Since initiating this procedure, further episodes of Enterococcus bacteremia have not occurred. A questionnaire sent to other pediatric hemodialysis units failed to identify Enterococcus among 26 cases of bacteremia.
In Conclusion:
(1) Enterococcus is an unusual pathogen for hemodialysis-related bacteremia in children; (2) patients with dialysis catheters were predisposed to this infection; (3) a common source for Enterococcus could not be identified by either culture or by serotyping; (4) flushing catheters with antibiotics after dialysis was effective prevention.