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E. coli common cause of bacteremia in febrile infants admitted to hospital
Escherichia coli appears to be the most common cause of bacteremia in previously healthy febrile infants with bacteremia, according to study findings.
Eric Biondi, MD, of the University of Rochester, and colleagues examined infants aged 90 days or younger who were admitted to a general care unit with positive blood cultures from 2006 to 2012.
Eric Biondi
Overall, there were 181 cases of bacteremia in 177 infants. Researchers found that E. coli was the most common pathogen (42%), followed by group B streptococcus (23%); Streptococcus pneumoniae (6%); and S. aureus (5%). Fifty-six percent of patients with S. aureus bacteremia had evidence of a skin and soft tissue infection at presentation. Older infants with bacteremia were more likely to have S. pneumoniae as the cause (P=.01). Low-risk bacteremic infants were less likely to have E. coli or group B streptococcus than non-low-risk infants.
"Clinicians need to really think about the bacteria with which they are concerned and the susceptibility patterns in their area when starting empiric antibiotics in febrile infants," Biondi told Infectious Diseases in Children. "While further study is needed, maybe it's time to being to rethink our current empiric antibiotic therapy in order to better adapt to the shift in bacterial epidemiology seen in the past two decades."
Eric Biondi, MD, can be reached at 601 Elmwood Ave, Box 777, Rochester, NY 14642; email: eric_biondi@urmc.rochester.edu.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Biondi and colleagues report that the epidemiology of bacteremia in generally healthy febrile infants in the first 90 days of life is dominated by Escherichia coli and group B streptococcus, with Streptococcus pneumoniae as a distant third. Evaluating 181 cases of bacteremia in a multicenter cohort over a 7-year period, there were no cases of Listeria monocytogenes bacteremia. Their findings question the utility of continued coverage of L. monocytogenes for “rule-out” sepsis evaluations in infants <90 days of age.
The empiric use of third-generation cephalosporin monotherapy for this age group seems reasonable, with the addition of Staphylococcus aureus coverage for infants with relevant risk factors and the severely ill. Most sepsis evaluations in young infants demonstrate no detectable pathogens. Whether ampicillin and gentamicin are prescribed- ampicillin’s primary purpose would be to empirically cover group B streptococcus and S. pneumoniae (with the potential consequence of nephrotoxicity) or a third-generation cephalosporin is prescribed (with the potential consequence of antibiotic-resistant organisms) is likely of minimal significance if therapy is limited to 48 hours. However, particularly in infants with early-onset sepsis, therapy is often prolonged to 7 or more days to treat “culture-negative sepsis.” While this is occasionally warranted, improvement is often seen by 24 hours in the setting of negative blood cultures - yet antibiotics continue. Although both of these regimens treat the most common pathogens in this age group and are likely to perform equally well as sepsis rule-out regimens, I believe the real effort should be focused on maximizing blood culture volumes so we can feel more comfortable decreasing the duration of antibiotic therapy for early-onset sepsis to 48 to 72 hours.