Infections caused by Fusobacterium in children: a 14-year single-center experience

A Pediatric Case of Fusobacterium necrophorum Mastoiditis and Meningitis Case Report in a Healthy Child and Review of the Literature

In infants and children, bacterial meningitis caused by anaerobic bacteria is rare. However, a serious infection with the anaerobe Fusobacterium necrophorum can occur in previously healthy children with a peak incidence in preschool children and in adolescents. As the clinical presentation can be very similar to meningitis caused by aerobic bacteria, one should consider Fusobacterium necrophorum as the causative agent when preceded by or associated with otitis media with purulent otorrhea or mastoiditis, in combination with minimal or no improvement on empiric antibiotic treatment. As this pathogen can be difficult to culture, anaerobic cultures should be obtained. Prompt treatment with a third-generation cephalosporin and metronidazole should be initiated once suspected or confirmed. Surgical source control is often necessary, but even with adequate and prompt treatment, the morbidity and mortality in children with a Fusobacterium necrophorum meningitis remains high. In this report, we describe a case of Fusobacterium necrophorum meningitis in a previously healthy child and review the available literature.

The Clinical Value of Cranial CT Venography for Predicting Fusobacterium necrophorum as the Causative Agent in Children with Complicated Acute Mastoiditis

BACKGROUND AND PURPOSE

Fusobacterium necrophorum (F necrophorum) is an anaerobic bacteria that causes invasive head and neck infections in children. Several studies have demonstrated an increasing prevalence of F necrophorum as the causative agent in acute mastoiditis in children, with associated high rates of intracranial complications such as epidural abscess and sinus venous thrombosis, to name a few. F necrophorum requires a treatment protocol that differs from the empiric treatment that is tailored to more common pathogens (eg, group A streptococci, Streptococcus pneumonia), and hence expediting the diagnosis is important. For evaluating complicated acute mastoiditis in children, cranial CT venography remains the imaging study of choice in most medical centers due to its availability in emergency situations. Based on our clinical experience, our hypothesis is that children with F necrophorum-associated complicated acute mastoiditis can be differentiated from those with other etiologies using CT venography.

MATERIALS AND METHODS

CT venography studies of 76 children hospitalized and treated for complicated acute mastoiditis were retrospectively reviewed. Retrieved imaging data included intracranial complications (epidural abscess, sinus venous thrombosis), cranial bone-related complications, and extracranial complications (subperiosteal abscess, temporomandibular joint abscess, and soft-tissue inflammation). The cohort was divided into children with F necrophorum-related disease (study group) and those with non-F necrophorum-related disease (control group).

RESULTS

Thirty-seven children (49%) comprised the study group, and 39 children in whom the causative agents were other bacteria comprised the control group. There were significantly higher rates of complications in the study group: sinus venous thrombosis (P < .001), perisigmoid epidural abscess (P = .036), and extramastoid osteomyelitis (P < .001). Thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with an otogenic variant of Lemierre syndrome) and emphysematous osteomyelitis were found only among children in the F necrophorum-related study group (32% and 22% accordingly).

CONCLUSIONS

In children with complicated acute mastoiditis, CT venography findings of emphysematous osteomyelitis and/or thrombosis in venous sites beyond the sigmoid sinus and jugular foramen (a pattern consistent with the otogenic variant of Lemierre syndrome) should lead the radiologist to suggest F necrophorum-related mastoiditis.

Otogenic Cerebral Sinus Thrombosis in Children: A Narrative Review

Cerebral venous thrombosis (CVT) is a rare entity that remains a diagnostic challenge due to various clinical manifestations and a wide variety of causative agents. Local infections, such as acute (AOM) or chronic otitis media, can play a role in the pathogenesis of CVT. The proximity of the tympanic cavity and temporal bone air cells to the dural venous sinuses predisposes them to secondary thrombosis. The release of inflammatory cytokines and activation of the coagulation pathway in the middle ear space in response to infection may trigger the thrombotic mechanism in venous sinuses of the central nervous system. There is no consensus in the literature concerning the treatment of otogenic cerebral venous sinus thrombosis (CVST). Both the extent of the surgery and the use of anticoagulants are disputable. The aim of the study was to provide a thorough analysis of the literature concerning CVST in patients with AOM and acute mastoiditis (AM). The current surgical and conventional treatment strategies are presented. Special attention has been attached to the predisposing factors, the extent of the surgery, and the role of anticoagulants in the treatment of septic otogenic CVST.

Invasive Fusobacterium Infections in Children: A Retrospective Multicenter Study

BACKGROUND

The past decade has witnessed a rise in Fusobacterium infections. This study aimed to describe the epidemiology, clinical and demographic characteristics and outcomes associated with Fusobacterium infections in hospitalized children in central Israel.

METHODS

We retrospectively analyzed the medical records of children <18 years old who had been admitted with a diagnosis of invasive Fusobacterium infection (IFI) between January 2010 and April 2020. Clinical, laboratory and microbiologic data were retrieved. IFI diagnosis was based upon microbiological identification in any specimen by culture or by 16S ribosomal RNA polymerase chain reaction.

RESULTS

Fifty-one children (26 boys) with a median age of 3 years (range, 5-16 years) were included. Hospitalizations for IFI increased from 19 of 100,000 admissions between 2010 and 2015 to 50 of 100,000 between 2016 and 2020, representing a 2.5-fold increase. Most of the infections were from an otogenic source (n = 28, 55%) followed by an oropharyngeal/respiratory source (n = 21, 41%). The most common complications were subperiosteal and epidural abscesses (41% and 37%, respectively). Thrombosis was diagnosed in 11 children, 10 of whom had sinus vein thrombosis. All had an otogenic source. Children with otogenic compared with all other infection sources were significantly younger (median age of 1.9 vs. 3 years; P < 0.001). Forty-seven children (92%) underwent a surgical intervention. All patients survived, one with neurologic sequelae.

CONCLUSIONS

The admissions for IFI in children increased 2.5-fold during the last decade. The most common source is otogenic, especially among younger children, and it is associated with high complication rates. Current management, including combinations of antibiotics and surgical interventions, leads to favorable outcome.

Prospective Study of the Detection of Bacterial Pathogens in Pediatric Clinical Specimens Using the Melting Temperature Mapping Method

The melting temperature (Tm) mapping method is a novel technique that uses seven primer sets without sequencing to detect dominant bacteria. This method can identify pathogenic bacteria in adults within 3 h of blood collection without using conventional culture methods. However, no studies have examined whether pathogenic bacteria can be detected in clinical specimens from pediatric patients with bacterial infections. Here, we designed a new primer set for commercial use, constructed a database with more bacterial species, and examined the agreement rate of bacterial species in vitro. Moreover, we investigated whether our system could detect pathogenic bacteria from pediatric patients using the Tm mapping method and compared the detection rates of the Tm mapping and culture methods. A total of 256 pediatric clinical specimens from 156 patients (94 males and 62 females; median age, 2 years [<18 years of age]) were used. The observed concordance rates between the Tm mapping method and the culture method for both positive and negative samples were 76.4% (126/165) in blood samples and 79.1% (72/91) in other clinical specimens. The Tm mapping detection rate was higher than that of culture using both blood and other clinical specimens. In addition, using the Tm mapping method, we identified causative bacteria in pediatric clinical specimens quicker than when using blood cultures. Hence, the Tm mapping method could be a useful adjunct for diagnosing bacterial infections in pediatric patients and may be valuable in antimicrobial stewardship for patients with bacterial infections, especially in culture-negative cases. IMPORTANCE This study provides novel insights regarding the use of the melting temperature (Tm) mapping method to identify the dominant bacteria in samples collected from pediatric patients. We designed a new set of primers for commercial use and developed a database of different bacteria that can be identified using these primers. We show that the Tm mapping method could identify bacteria from blood samples and other clinical specimens. Moreover, we provide evidence that the Tm mapping method has a higher detection rate than that of the culture-based methods and can achieve a relatively high agreement rate. We believe that our study makes a significant contribution to this field because rapid identification of the source of bacterial infections can drastically improve patient outcomes and impede the development of antibiotic-resistant bacteria.

Antimicrobial susceptibility profiles of invasive isolates of anaerobic bacteria from a large Canadian reference laboratory: 2012-2019

Anaerobic bacteria can cause severe and life threatening infections. Susceptibility data are relatively limited on anaerobic organisms despite the clinical importance in guiding empiric treatment of infections. To determine antimicrobial susceptibility profiles of clinically significant anaerobic bacteria, isolates obtained from sterile sites submitted to Public Health Ontario Laboratory (2012-2019) were included in this study (N = 5712). Cefoxitin, clindamycin, metronidazole, meropenem, penicillin and piperacillin-tazobactam were tested using the gradient strip method with MICs interpreted based on Clinical and Laboratory Standards Institute guidelines. Bacteroides spp. (N = 958; 16.7%), Clostridium spp. (N = 798; 14.0%), Cutibacterium spp. (N =659; 11.5%) and Actinomyces spp. (N = 551; 7.0%) were the most commonly isolated genera. Bacteroides fragilis isolates were susceptible to cefoxitin (88.4%), clindamycin (68.4%), metronidazole (96.0%), meropenem (99.0%) and piperacillin-tazobactam (98.4%). Other Bacteroides spp. showed reduced susceptibility to several antimicrobials. Clostridium spp. isolates were susceptible to penicillin (69.7%), clindamycin (69.7%) and cefoxitin (76.3%); C. perfringens and C. ramosum showed distinct susceptibility profiles. Susceptibility rates among anaerobes remained relatively unchanged over 8 years with a few exceptions: C. perfringens susceptibility to clindamycin decreased from 91.3% to 60% (p = 0.03); Clostridium spp. susceptibility to penicillin similarly decreased from 82.1% to 65.9% (p = 0.03); Eggerthella spp. susceptibility to piperacillin-tazobactam decreased from 100% to 24.3% (p < 0.001); B. fragilis group susceptibility to cefoxitin decreased from 70.4% to 48.2% (p = 0.05); and Parabacteroides spp. susceptibility to piperacillin-tazobactam decreased from 100% to 25% (p = 0.01). Our findings underscore the need for ongoing surveillance and periodic monitoring of antimicrobial resistance in order to guide empiric therapy.

Case Report: Cerebrovascular Events Associated With Bacterial and SARS-CoV-2 Infections in an Adolescent

Neurologic manifestations associated with Covid-19 are increasingly reported, especially stroke and acute cerebrovascular events. Beyond cardiovascular risk factors associated with age, some young adults without medical or cardiovascular history had stroke as a presenting feature of Covid-19. Suggested stroke mechanisms in this setting are inflammatory storm, subsequent hypercoagulability, and vasculitis. To date, a handful of pediatric stroke cases associated with Covid-19 have been reported, either with a cardioembolic mechanism or a focal cerebral arteriopathy. We report the case of an adolescent who presented with febrile meningism and stupor. Clinical, biological, and radiological features favored the diagnosis of Lemierre syndrome (LS), with Fusobacterium necrophorum infection (sphenoid sinusitis and meningitis) and intracranial vasculitis. The patient had concurrent SARS-CoV-2 infection. Despite medical and surgical antimicrobial treatment, stroke prevention, and venous thrombosis prevention, he presented with severe cerebrovascular complications. Venous thrombosis and stroke were observed, with an extension of intracranial vasculitis, and lead to death. As both F. necrophorum and SARS-CoV-2 enhance inflammation, coagulation, and activate endothelial cells, we discuss how this coinfection may have potentiated and aggravated the usual course of LS. The potentiation by SARS-CoV-2 of vascular and thrombotic effects of a bacterial infection may represent an underreported cerebrovascular injury mechanism in Covid-19 patients. These findings emphasize the variety of mechanisms underlying stroke in this disease. Moreover, in the setting of SARS-CoV-2 pandemic, we discuss in what extent sanitary measures, namely, lockdown and fear to attend medical facilities, may have delayed diagnosis and influenced outcomes. This case also emphasizes the role of clinical assessment and the limits of telemedicine for acute neurological condition diagnosis.

Oral Pathogen Fusobacterium nucleatum Coaggregates With Pseudomonas aeruginosa to Modulate the Inflammatory Cytotoxicity of Pulmonary Epithelial Cells

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality worldwide, and inflammatory damage induced by bacterial infections is an important contributor to the etiology of COPD. Fusobacterium nucleatum, a recognized periodontal pathogen, is considered as a biomarker of lung function deterioration of COPD patients coinfected with Pseudomonas aerugionsa, but the underlying mechanism is still unclear. This study established single- and dual-species infection models, bacterial simultaneous and sequential infection models, and found that F. nucleatum could coaggregate with P. aeruginosa to synergistically invade into pulmonary epithelial cells and transiently resist P. aeruginosa-induced cytotoxic damage to amplify IL-6 and TNF-α associated inflammation in pulmonary epithelial cells simultaneously infected with P. aeruginosa and F. nucleatum. Furthermore, F. nucleatum pretreatment or subsequential infection could maintain or even aggravate P. aeruginosa-induced inflammatory cytotoxicity of pulmonary epithelial cells. These results indicate that oral pathogen F. nucleatum coaggregates with P. aeruginosa to facilitate bacterial invasion and modulates the inflammatory cytotoxicity of pulmonary epithelial cells, which may contribute to lung function deterioration of COPD patients accompanied with P. aeruginosa and F. nucleatum coinfection.

Medical and surgical characteristics of fusobacterium necrophorum mastoiditis in children

OBJECTIVES

To evaluate and compare characteristics of Fusobacterium necrophorum mastoiditis (FnM) to characteristics of acute mastoiditis (AM) caused by other bacteria in tertiary children hospital Methods : Children with FnM (N=43) and non FnM (N=88). Assess medical, microbiologic and imaging characteristics, surgical findings and postoperative recovery.

RESULTS

Children with FnM had a positive history of otitis media, ear discharge and sub-periosteal abscess (p=0.0004, 0.09, 0.0003, respectively) at presentation. Their temperature, WBC and CRP were significantly higher (39.8 vs. 37.9, 19.4K vs. 16.1K, 21 vs. 8.7, p=0.0001). Positive culture was found in 46% of patients; 64% were diagnosed by PCR. CT scan was indicated in 95% and surgical intervention in 93% of children with FnM, compared to 15% and 9.7% of children in the non-FnM group (p=0.0001). Complex post-operative course was frequent for the FnM group: 88% of children had persistent fever, 46% had additional imaging and 14% additional surgical intervention. Children with FnM were treated with IV antibiotics for an average of 22 compared to seven days for non-FnM children (p=0.0001).

CONCLUSIONS

Fusobacterium should be suspect in a child presenting with AM, a septic appearance, high fever and increased inflammation markers. A regimen of two antibiotics should be empirically started, then proceed to imaging and early surgical intervention. A relatively slow post-operative recovery process should be expected; however, prognosis is good.

Fusobacterium necrophorum, a major provider of sinus thrombosis in acute mastoiditis: A retrospective multicentre paediatric study

OBJECTIVE

To evaluate in children the clinical severity and evolution of otogenic lateral sinus thrombosis (OLST) due to Fusobacterium necrophorum compared with other bacterial otogenic thrombosis and propose a specific management flowchart for Fusobacterium OLST.

DESIGN

A retrospective multicentre cohort study.

SETTINGS

Four French ENT paediatric departments.

PARTICIPANTS

A total of 260 under 18 years old admitted for acute mastoiditis were included. Initial imaging was reviewed to focus on complicated mastoiditis and 52 OLST were identified. Children were then divided into two groups according to bacteriological results: 28 in the "OLST Fusobacterium group" and 24 in the "OLST other bacteria group".

RESULTS

There was a significant association between F necrophorum and OLST (P < .001). When compared to the OLST other bacteria group, children in the OLST Fusobacterium group were significantly younger (61 months vs 23 months, P < .01) and had a more severe clinical presentation: higher CRP (113 mg/L vs 175.7 mg/L, P = .02) and larger subperiosteal abscess (14 mm vs 21 mm, P < .01). Medical management was also more intensive in the OLST Fusobacterium group than in the OLST other bacteria group: increased number of conservative surgeries (66.7% vs 92.9%, P = .03) and longer hospital stay (13.7 days vs 19.8 days, P = .02). At the end of follow-up, the clinical course was good in both groups without any neurological sequelae.

CONCLUSIONS

Thrombotic complications are very frequent in case of Fusobacterium mastoiditis and clinicians should be aware of the initial severity of the clinical presentation. Under appropriate management, the clinical course of Fusobacterium OLST is as good as that of other bacterial otogenic thrombosis.

Mastoiditis with concomitant Lemierre's syndrome

Otalgia with mastoiditis is an infrequently encountered complication of acute otitis media (Pfaff and Moore, 2018). Even more rare is the development of infected jugular venous thrombosis, Lemierre's disease. We present a case of a six year-old girl with otalgia for over two months who presented to our Emergency Department (ED) with clinical mastoiditis, confirmed on CT scan, as well as an incidental diagnosis of complete thrombosis of the internal jugular (IJ) vein, Lemierre's syndrome. The true prevalence of Lemierre's from mastoiditis is difficult to discern. This clinical case highlights the importance of the consideration of these pathologies by the emergency physician.

Fusobacterium necrophorum as an Emerging Pathogen of Acute Mastoiditis

BACKGROUND

Recent reports have reported an increase in the incidence of acute mastoiditis because of Fusobacterium necrophorum. However, the crude incidence and the specific clinical and laboratory characteristics of F. necrophorum mastoiditis in children have not been described. Our aim was to describe these features to identify high-risk patients.

METHODS

The electronic medical records of all children with acute mastoiditis at a tertiary medical center between July 2011 and December 2015 were analyzed. Using a stepwise logistic regression to identify independent risk factors for F. necrophorum, we formulated a predictive model.

RESULTS

F. necrophorum was identified in 13% (19/149) of mastoiditis cases with an identifiable agent. Its incidence increased 7-fold from 2.8% in 2012 to 20.4% in 2015 (P = 0.02). F. necrophorum infection had unique clinical, laboratory and prognostic features. The vast majority had complications and underwent surgical intervention. The predictive model used 4 parameters to define high-risk patients for F. necrophorum infection at admission: females, winter/spring season, prior antibiotic treatment and a C-reactive protein value >20 mg/dL (area under receiver operating characteristic curve 0.929).

CONCLUSIONS

Clinicians should be aware of the increasing incidence of F. necrophorum mastoiditis and consider anaerobic cultures and specific anaerobic coverage in high-risk patients.

Fusobacterium necrophorum otitis and mastoiditis in infants and young toddlers

There is an increased recovery of Fusobacterium necrophorum from cases of otitis media and mastoiditis in the pediatric population. These infections may be highly severe, causing local osteomyelitis, bacteremia, and Lemierre's syndrome. The severity and difficulties in providing optimal treatment for these infections may be especially difficult in this age group due to immunological immaturity and delayed presentation. In this review of literature, we present and analyze the clinical presentation, management, and outcome of otic infections caused by F. necrophorum in infants and young toddlers less than 2 years old. Search in Pubmed was conducted for reported cases in the English literature for the time period of the last 50 years. Twelve well-described cases were retrieved with F. necrophorum otitis and mastoiditis and complications reported in all cases. Treatment included both intravenously with antimicrobial agents (beta lactams plus metronidazole) and mastoidectomy. Lemierre's syndrome and Lemierre's syndrome variants developed in 60 % of the patients. Dissemination of the infection as distal osteomyelitis and septic shock were also reported. The outcome was favorable in all the cases. Otitis and mastoiditis infections in children less then 2 years old are invasive infections, and severe complications can occur.

Fusobacterium nucleatum infections: clinical spectrum and bacteriological features of 78 cases

PURPOSE

Few series describe the clinical spectrum of Fusobacterium spp. infections. Among them, fewer discuss F. nucleatum, even though there are many clinical cases.

METHODS

We performed a retrospective study over 8 years (from 2007 to 2014) in Limoges University Hospital, France, to assess clinical and bacteriological aspects of infections due to F. nucleatum.

RESULTS

Eighty-one patients with F. nucleatum positive cultures were included in this study, irrespective of sample origin. Abscesses (n = 43), bacteraemia (n = 18) and bone infections (n = 8) were the most common types of infections, Abscesses were found in various organs (mostly skin, brain, pleura, liver). Co-morbidities were found in 38 patients (47 %) with neoplasia, diabetes, and alcoholism and history of smoking. There were more neoplasms in patients with bacteraemia than in patients with abscesses (p = 0.007). In 51 cases (65.4 %), infection was polymicrobial, either during bacteraemia or abscesses. Main associations were with Streptococcus spp., Peptostreptococcus spp. and/or Prevotella spp. The sources of infection, when found, were either dental or gastrointestinal. All isolates were susceptible to penicillin, clindamycin and metronidazole.

CONCLUSIONS

Infections involving F. nucleatum are uncommon and potentially severe, with many abscesses requiring surgery. Bacteraemia was mainly associated with co-morbidities such as cancer. Polymicrobial infections were very common and there is probably interaction and/or synergy between F. nucleatum and some other commensal bacteria to cause infections and abscesses.