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Eikenella Corrodens infections in children
E i k e n e l l a Corrodens Infections in Children By John G. Raffensperger Chicago, Illinois 9 Techniques for obtaining, transporting, and culturing bacteriologic specimens have improved in recent years. The laboratory is n o w identifying rare fastidious organisms in surgical infections, which w e r e previously unknown to clinicians. One of these organisms, Eikenella corrodens, was found in 28 children over 5 years. It was most commonly found in patients with perforated appendices or in wounds with oral contamination. Eikenella most often occurs in multibacterial infections but has also been grown in pure culture. W h e n this bacteria is found in a patient with a serious surgical infection the wound must be widely opened and debrided of necrotic tissue. Prolonged antibiotic therapy based on culture and sensitivity is necessary to prevent prolonged or recurrent infection. 9 1 9 8 6 by Grune & S t r a t t o n , Inc. INDEX W O R D S : Surgical infections; Eikenella corrodens.
URGICAL BACTERIOLOGY continues to
S evolve. Organisms that were previously little known are now being found in postoperative wounds and other surgical infections. For example, our increased awareness of the role of anaerobes in abdominal infections led to greater care in the taking and transporting of specimens. Sterile anaerobic tubes have supplanted the candle in the jar and enable the delivery of viable bacteria to the laboratory. Furthermore, bacteriologists have developed improved techniques for culturing fastidious organisms. The isolation from several patients of Eikenella corrodens, an organism previously unknown to me, led to this study. MATERIALS A N D METHODS i reviewed the daily bacteriology laboratory logbook for a period of 5 years to find Eikenella corrodens infections. This organism was cultured from 28 children, aged 4 months to 14 years (Table 1). There were 17 boys and 1 I girls. Specimens of purulent material from wounds or abscesses were taken on sterile swabs and placed in disposable culturettes for aerobic culture. A second specimen was placed in a double-stopper oxygen-free anaerobic culturette tube. Aerobic specimens are plated on chocolate, 5% sheep's blood, and EMB agar and placed in thioglycal broth. They are then placed in an
From the Division of Pediatric Surgery, Children's Memorial Hospital, and the Department of Surgery, Northwestern University Medical School, Chicago. Presented at the 34th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, San Antonio, Texas, October 19-20, 1985. Address reprint requests to John G. Raffensperger, MD, 2300 Children's Plaza. Chicago, IL 60614. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2107~9020503.00/0
644
atmosphere of 5% to 10% carbon dioxide. Anaerobic specimens are plated on 5% sheep's blood and kept in an oxygen-free atmosphere. Eikenella grows to pinpoint colonies on 5% sheep's blood agar in the carbon dioxide atmosphere. In 50% of the cases, "pitting" of the agar may be seen in reflective light by 24 hours. In others, identification depends on biochemical characteristics and may require 4 to 5 days. Eikenella corrodens was found in pure culture or as the predominant organism in six patients. These included one conjunctivitis, an empyema, a neck abscess, a severe case of gingivitis, and two appendiceal infections. The remaining 22 patients had infections with from 3 to 11 different organisms. Eikenella corrodens was cultured from I1 children who had complications of appendicitis. All had been ill for 2 days to 2 weeks prior to their operation. Most had suffered with a perforated appendix for a minimum of four days. In seven, the organism was obtained at the original operation and the remaining four from postoperative wound abscesses. From 3 to 9 organisms were found in nine patients. Six had one or more anaerobic organisms in addition to Eikenella corrodens. The postoperative hospitalization in these I 1 patients varied from 4 to 15 days, or an average of 9.5 days. All were treated with appropriate drainage together with intraperitoneal and intravenous antibiotics. The most frequently used antibiotic combination consisted of ampicillin, amikacin, and clindamycin. Ten children had infections related to oral contamination. Three followed craniofacial reconstructions for Crouzon's disease or hypertelorism They became febrile within three days postoperatively, required multiple drainage and debridement procedures, and 3~/2 weeks to 4 months for total healing. Two children had substernal esophageal bypasses, one for atresia and one for a lye stricture. The ileocolic bypass for lye stricture sloughed secondary to venous congestion and was removed. The mediastinum was drained on two occasions for a purulent mediastinitis that lasted 3 weeks. This child also had severe dental caries. The child with a gastric tube had a cervical leak and required drainage of both his upper and lower mediastinum. At various times, I1 organisms that are commonly found in the oral cavity were cultured form his mediastinum. The remaining patients with infections related to oral contamination included 2 human bites, 2 paronychias in thumbsuckers, and 1 gingivitis. One child with a human bite had a concomitant scalp wound puncture. This infected wound was initially drained, but he returned 3 months later with a second abscess which also grew
Eikenella. Eikenella corrodens, a normal inhabitant of the respiratory tract, was incidentally cultured from tracheotomy secretions in two children who had other serious diseases. Two patients with empyemas both had serious underlying lung pathology. One was a threeyear-old child who underwent a middle and lower lobe lobectomy for bronchiectasis. He required drainage of an empyema 14 days later. Eikenella corrodens and Haemophilus influenzae were found in both the preoperative sputum cultures and the empyema fluid. The other child with an empyema was a 14-year-old boy who had a history of progressive weight loss, cough, expectoration, and chest pain. He had been given intensive antibiotic therapy for pneumonia 1 month prior to his operation for empyema. At an open thoractomy, there was 500 mL of pus and fibrinous material in a chronic empyema cavity. This fluid grew a pure culture of Eikenella corrodens. The empyema cavity had the appearance of raw granula-
Journal of Pediatric Surgery, Vol 21, No 7 (July), 1986: pp 644-646
EIKENELLA CORRODENS INFECTIONS
645
Table 1. Location of Eikenella Corroden= Infections
Intra-abdorninal (appendicitis) Oral contamination Respiratory tract Miscellaneous (neck abscess, pefineal wound, conlunctivitis) Total
I1 10 4 3 28
tion tissue. He required a reexploration to control diffuse bleeding several hours after the drainage operation. Seven years later, he has hemoptysis and has continued to cough bu! refuses further studies. Infection occurred in three other areas. One was a neck abscess that involved the sternocleidomastoid muscle and adjacent tissues after blunt trauma. The abscess contained necrotic tissue as well as pus. After drainage, the wound developed purulent exuberant granulation tissue. Fie required two further drainage operations over 2 months and the wound did not heal until he had had prolonged antibiotic therapy and wound debridement. One child had a purulent conjunctivitis. The last infection occurred in a perineal biopsy wound in a boy with extensive metastatic Wilms" tumor. This child and the two with tracheotomies died. The Eikenella corrodens infection did not contribute to their ultimate deaths.
DISCUSSION
Eikenella corrodens was named for Eiken, a Danish pediatrician who studied colonies of an anaerobic organism that pitted or "corroded" agar. ~ Eiken cultured 1,007 samples of pus or sputum from 708 patients on blood agar plates under anaerobic conditions. In 61 instances, he found colonies of a small gram negative rod that made minute impressions on the agar surface wthin 36 to 48 hours. He recognized atypical variations of these organisms in cultures and determined their biochemical and morphologic characteristics. He classified the organism as an anaerobe and named it Bacteroides corrodens. The organism described by Eiken has since been shown to be a facultative aerobe that grows best on 5% sheep's blood agar in an atmosphere of 3% to 8% carbon dioxide. 2'3 Eikenella corrodens is identical to an organism previously called HB}, which is not a strict anaerobe and should not be in the genus Bacteroides. 4 Jackson and Goodman renamed it Eikenella, a new genus, and placed it in the Brucelaceae family because of a similar D N A base composition. 5 The difficulties in its isolation, particularly in pure culture, delayed its recognition as a human pathogen. In 1971, Marsden and Hyde reported six children with serious infections from whom they isolated this corroding bacteria. One child had a pure culture from a fatal subdural abscess. 6 Eikenella infections in adults are usually found in patients with advanced carcinoma, a ruptured viscus, or in drug addicts. 7'8 Human bite or fist injuries may be infected with Eikenella, in association with other oral bacteria. 9"~~ It is a normal inhabitant of the oral
pharynx, has been cultured from a patient with parotitis, and has caused endocarditis after oral surgery. ~'12 In children, Eikenella has been found in empyemas secondary to chronic lung infections, in thyroid abscesses, otitis media, meningitis, wound infections, and intra-abdominal abscesses. In these infections it is most often associated with other organisms, but in a review of 16 cases it was found in pure culture in three. ~ Our patients confirmed previous studies in that infections fell into three broad groups, ie, those with intra-abdominal infections, those due to oral contamination, and those secondary to chronic respiratory disease. Unlike experience with adults, only three of our patients had a fatal underlying systemic disease. The soft tissue infections and the empyema in our first patient appeared to be associated with more tissue necrosis and the formation of more exuberant granulation tissue than is seen with common organisms. Morbidity was particularly prolonged in the three craniofacial infections, the cervical abscess, and the scalp wound, These patients required repeated wound drainage, debridement, and prolonged antibiotic therapy. On the other hand, the morbidity seen in children with abdominal infections did not seem unusual considering the duration of their initial infections. Perhaps this is because we regularly use a combination of amikacin, ampicillin, and clindamycin for major intra-abdominal infections. Our culture results, as well as those of others, indicate excellent sensitivity of Eikenella to ampicillin, penicillin, tetracycline, and carbenicillin. Aminoglycosides will also inhibit the organism, but Eikenella shows a striking resistance to clindomycin. In fact, when clindomycin is added to a culture medium, the growth of Eikenella is enhanced, s4 SUMMARY
Eikenella corrodens is an unusual facultative anaerobic organism, which may require five days for accurate identification. When it is found, it should not be taken lightly. Antibiotic sensitivity should be carefully studied, the wound must be extensively debrided or opened widely and drained. Antibiotic coverage should be provided for a minimum of ten days and perhaps longer, At this time, ampicillin seems to be the antibiotic of choice. REFERENCES
1. Eiken M: Studies on an anaerobic, rod-shaped, gram negative microorganism: Bacteroides corrodens N. SP. Acta Patho] Microbiol Scand 43:404-416, 1958 2. Tatum HW, Ewing WA, Weaver RE: Manual of Clinical Microbiology (ed 2), Lennett EH, Spaulding EH, Fruant JP: Washington. DC, American Society of Microbiology. 1974, pp 270-294
646
3. Henriksen SD: Corroding bacteria from the respiratory tract--Bacteroides corrodens. Acta Pathol Microbiol Scand 75:9196, 1969 4. Riley PS, Tatum HW, Weaver RE: Identity of HB-I of King and Eikenella corrodens. (Eiken) Jackson and Goodman, lnt J Syst Bacteriol 23:75-76, 1973 5. Jackson FL, Goodman YE: Transfer of the facultative anaerobic organism Bacteroides corrodens Eiken to a new genus, Eikenella. Int J Syst Bacteriol 22:73-77, 1972 6. Marsden HB, Hyde WA: Isolation of Bacteroides corrodens from infections in children. J Clin Pathol 24:117-119, 1971 7. Dorff GJ, Jackson L J, Rytel MW: Infections with Eikenella corrodens. Ann Int Med 80:305-309, 1974 8. Brooks GF, O'Donoghue JM, Smith JW: Eikenella corrodens: A new pathogen. Clin Res 21:841,1973 9. Goldstein EJ, Miller TA, Citron DM, et ah Infections follow-
JOHN G. RAFFENSPERGER
ing clenched fist injury: A new perspective. J Hand Surg 3:455~,57, 1978 10. Johnson SM, Pankey GA: Eikenella corrodens osteomyelitis, arthritis and cellulitis of the hand. South Med J 69:535-539, 1976 I 1. Geraci JE, tlermans PE, Washington JA: Eikenella corrodens endocarditis: Report of a cure in two cases. Mayo Clin Proc 49:950-953, 1974 12. Bissell P, Glew RH, Liland JB: Parotitis associated with Eikenella corrodens in a healthy adult. Arch Otolaryngol 109:772773, 1983 13. St John MA, Belda AA, Matlow A, et al: Eikenella corrodens empyema in children. Am J Dis Child 135:415-417, 1981 14. Brooks GF, O'Donoghue JM, Rissing JP, et al: Eikenella corrodens: A recently recognized pathogen. Medicine 53:325-342, 1974
URGICAL BACTERIOLOGY continues to
S evolve. Organisms that were previously little known are now being found in postoperative wounds and other surgical infections. For example, our increased awareness of the role of anaerobes in abdominal infections led to greater care in the taking and transporting of specimens. Sterile anaerobic tubes have supplanted the candle in the jar and enable the delivery of viable bacteria to the laboratory. Furthermore, bacteriologists have developed improved techniques for culturing fastidious organisms. The isolation from several patients of Eikenella corrodens, an organism previously unknown to me, led to this study. MATERIALS A N D METHODS i reviewed the daily bacteriology laboratory logbook for a period of 5 years to find Eikenella corrodens infections. This organism was cultured from 28 children, aged 4 months to 14 years (Table 1). There were 17 boys and 1 I girls. Specimens of purulent material from wounds or abscesses were taken on sterile swabs and placed in disposable culturettes for aerobic culture. A second specimen was placed in a double-stopper oxygen-free anaerobic culturette tube. Aerobic specimens are plated on chocolate, 5% sheep's blood, and EMB agar and placed in thioglycal broth. They are then placed in an
From the Division of Pediatric Surgery, Children's Memorial Hospital, and the Department of Surgery, Northwestern University Medical School, Chicago. Presented at the 34th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, San Antonio, Texas, October 19-20, 1985. Address reprint requests to John G. Raffensperger, MD, 2300 Children's Plaza. Chicago, IL 60614. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2107~9020503.00/0
644
atmosphere of 5% to 10% carbon dioxide. Anaerobic specimens are plated on 5% sheep's blood and kept in an oxygen-free atmosphere. Eikenella grows to pinpoint colonies on 5% sheep's blood agar in the carbon dioxide atmosphere. In 50% of the cases, "pitting" of the agar may be seen in reflective light by 24 hours. In others, identification depends on biochemical characteristics and may require 4 to 5 days. Eikenella corrodens was found in pure culture or as the predominant organism in six patients. These included one conjunctivitis, an empyema, a neck abscess, a severe case of gingivitis, and two appendiceal infections. The remaining 22 patients had infections with from 3 to 11 different organisms. Eikenella corrodens was cultured from I1 children who had complications of appendicitis. All had been ill for 2 days to 2 weeks prior to their operation. Most had suffered with a perforated appendix for a minimum of four days. In seven, the organism was obtained at the original operation and the remaining four from postoperative wound abscesses. From 3 to 9 organisms were found in nine patients. Six had one or more anaerobic organisms in addition to Eikenella corrodens. The postoperative hospitalization in these I 1 patients varied from 4 to 15 days, or an average of 9.5 days. All were treated with appropriate drainage together with intraperitoneal and intravenous antibiotics. The most frequently used antibiotic combination consisted of ampicillin, amikacin, and clindamycin. Ten children had infections related to oral contamination. Three followed craniofacial reconstructions for Crouzon's disease or hypertelorism They became febrile within three days postoperatively, required multiple drainage and debridement procedures, and 3~/2 weeks to 4 months for total healing. Two children had substernal esophageal bypasses, one for atresia and one for a lye stricture. The ileocolic bypass for lye stricture sloughed secondary to venous congestion and was removed. The mediastinum was drained on two occasions for a purulent mediastinitis that lasted 3 weeks. This child also had severe dental caries. The child with a gastric tube had a cervical leak and required drainage of both his upper and lower mediastinum. At various times, I1 organisms that are commonly found in the oral cavity were cultured form his mediastinum. The remaining patients with infections related to oral contamination included 2 human bites, 2 paronychias in thumbsuckers, and 1 gingivitis. One child with a human bite had a concomitant scalp wound puncture. This infected wound was initially drained, but he returned 3 months later with a second abscess which also grew
Eikenella. Eikenella corrodens, a normal inhabitant of the respiratory tract, was incidentally cultured from tracheotomy secretions in two children who had other serious diseases. Two patients with empyemas both had serious underlying lung pathology. One was a threeyear-old child who underwent a middle and lower lobe lobectomy for bronchiectasis. He required drainage of an empyema 14 days later. Eikenella corrodens and Haemophilus influenzae were found in both the preoperative sputum cultures and the empyema fluid. The other child with an empyema was a 14-year-old boy who had a history of progressive weight loss, cough, expectoration, and chest pain. He had been given intensive antibiotic therapy for pneumonia 1 month prior to his operation for empyema. At an open thoractomy, there was 500 mL of pus and fibrinous material in a chronic empyema cavity. This fluid grew a pure culture of Eikenella corrodens. The empyema cavity had the appearance of raw granula-
Journal of Pediatric Surgery, Vol 21, No 7 (July), 1986: pp 644-646
EIKENELLA CORRODENS INFECTIONS
645
Table 1. Location of Eikenella Corroden= Infections
Intra-abdorninal (appendicitis) Oral contamination Respiratory tract Miscellaneous (neck abscess, pefineal wound, conlunctivitis) Total
I1 10 4 3 28
tion tissue. He required a reexploration to control diffuse bleeding several hours after the drainage operation. Seven years later, he has hemoptysis and has continued to cough bu! refuses further studies. Infection occurred in three other areas. One was a neck abscess that involved the sternocleidomastoid muscle and adjacent tissues after blunt trauma. The abscess contained necrotic tissue as well as pus. After drainage, the wound developed purulent exuberant granulation tissue. Fie required two further drainage operations over 2 months and the wound did not heal until he had had prolonged antibiotic therapy and wound debridement. One child had a purulent conjunctivitis. The last infection occurred in a perineal biopsy wound in a boy with extensive metastatic Wilms" tumor. This child and the two with tracheotomies died. The Eikenella corrodens infection did not contribute to their ultimate deaths.
DISCUSSION
Eikenella corrodens was named for Eiken, a Danish pediatrician who studied colonies of an anaerobic organism that pitted or "corroded" agar. ~ Eiken cultured 1,007 samples of pus or sputum from 708 patients on blood agar plates under anaerobic conditions. In 61 instances, he found colonies of a small gram negative rod that made minute impressions on the agar surface wthin 36 to 48 hours. He recognized atypical variations of these organisms in cultures and determined their biochemical and morphologic characteristics. He classified the organism as an anaerobe and named it Bacteroides corrodens. The organism described by Eiken has since been shown to be a facultative aerobe that grows best on 5% sheep's blood agar in an atmosphere of 3% to 8% carbon dioxide. 2'3 Eikenella corrodens is identical to an organism previously called HB}, which is not a strict anaerobe and should not be in the genus Bacteroides. 4 Jackson and Goodman renamed it Eikenella, a new genus, and placed it in the Brucelaceae family because of a similar D N A base composition. 5 The difficulties in its isolation, particularly in pure culture, delayed its recognition as a human pathogen. In 1971, Marsden and Hyde reported six children with serious infections from whom they isolated this corroding bacteria. One child had a pure culture from a fatal subdural abscess. 6 Eikenella infections in adults are usually found in patients with advanced carcinoma, a ruptured viscus, or in drug addicts. 7'8 Human bite or fist injuries may be infected with Eikenella, in association with other oral bacteria. 9"~~ It is a normal inhabitant of the oral
pharynx, has been cultured from a patient with parotitis, and has caused endocarditis after oral surgery. ~'12 In children, Eikenella has been found in empyemas secondary to chronic lung infections, in thyroid abscesses, otitis media, meningitis, wound infections, and intra-abdominal abscesses. In these infections it is most often associated with other organisms, but in a review of 16 cases it was found in pure culture in three. ~ Our patients confirmed previous studies in that infections fell into three broad groups, ie, those with intra-abdominal infections, those due to oral contamination, and those secondary to chronic respiratory disease. Unlike experience with adults, only three of our patients had a fatal underlying systemic disease. The soft tissue infections and the empyema in our first patient appeared to be associated with more tissue necrosis and the formation of more exuberant granulation tissue than is seen with common organisms. Morbidity was particularly prolonged in the three craniofacial infections, the cervical abscess, and the scalp wound, These patients required repeated wound drainage, debridement, and prolonged antibiotic therapy. On the other hand, the morbidity seen in children with abdominal infections did not seem unusual considering the duration of their initial infections. Perhaps this is because we regularly use a combination of amikacin, ampicillin, and clindamycin for major intra-abdominal infections. Our culture results, as well as those of others, indicate excellent sensitivity of Eikenella to ampicillin, penicillin, tetracycline, and carbenicillin. Aminoglycosides will also inhibit the organism, but Eikenella shows a striking resistance to clindomycin. In fact, when clindomycin is added to a culture medium, the growth of Eikenella is enhanced, s4 SUMMARY
Eikenella corrodens is an unusual facultative anaerobic organism, which may require five days for accurate identification. When it is found, it should not be taken lightly. Antibiotic sensitivity should be carefully studied, the wound must be extensively debrided or opened widely and drained. Antibiotic coverage should be provided for a minimum of ten days and perhaps longer, At this time, ampicillin seems to be the antibiotic of choice. REFERENCES
1. Eiken M: Studies on an anaerobic, rod-shaped, gram negative microorganism: Bacteroides corrodens N. SP. Acta Patho] Microbiol Scand 43:404-416, 1958 2. Tatum HW, Ewing WA, Weaver RE: Manual of Clinical Microbiology (ed 2), Lennett EH, Spaulding EH, Fruant JP: Washington. DC, American Society of Microbiology. 1974, pp 270-294
646
3. Henriksen SD: Corroding bacteria from the respiratory tract--Bacteroides corrodens. Acta Pathol Microbiol Scand 75:9196, 1969 4. Riley PS, Tatum HW, Weaver RE: Identity of HB-I of King and Eikenella corrodens. (Eiken) Jackson and Goodman, lnt J Syst Bacteriol 23:75-76, 1973 5. Jackson FL, Goodman YE: Transfer of the facultative anaerobic organism Bacteroides corrodens Eiken to a new genus, Eikenella. Int J Syst Bacteriol 22:73-77, 1972 6. Marsden HB, Hyde WA: Isolation of Bacteroides corrodens from infections in children. J Clin Pathol 24:117-119, 1971 7. Dorff GJ, Jackson L J, Rytel MW: Infections with Eikenella corrodens. Ann Int Med 80:305-309, 1974 8. Brooks GF, O'Donoghue JM, Smith JW: Eikenella corrodens: A new pathogen. Clin Res 21:841,1973 9. Goldstein EJ, Miller TA, Citron DM, et ah Infections follow-
JOHN G. RAFFENSPERGER
ing clenched fist injury: A new perspective. J Hand Surg 3:455~,57, 1978 10. Johnson SM, Pankey GA: Eikenella corrodens osteomyelitis, arthritis and cellulitis of the hand. South Med J 69:535-539, 1976 I 1. Geraci JE, tlermans PE, Washington JA: Eikenella corrodens endocarditis: Report of a cure in two cases. Mayo Clin Proc 49:950-953, 1974 12. Bissell P, Glew RH, Liland JB: Parotitis associated with Eikenella corrodens in a healthy adult. Arch Otolaryngol 109:772773, 1983 13. St John MA, Belda AA, Matlow A, et al: Eikenella corrodens empyema in children. Am J Dis Child 135:415-417, 1981 14. Brooks GF, O'Donoghue JM, Rissing JP, et al: Eikenella corrodens: A recently recognized pathogen. Medicine 53:325-342, 1974