Patient Case: 7-year-old male patient

Children’s Hospital Los Angeles

Pediatric hospital in Los Angeles, CA

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7-year-old male patient

7 yo male with history of gastroschisis and short gut syndrome on total parenteral nutrition presented at ED with acute fever, fatigue, and abdominal pain. Intermittent right sided-abdominal pain over previous 3 weeks. Morning prior to admission, he scraped right side of abdomen and same day developed chills, one episode of emesis and temp of 38.5°C. In ED, patient was tachycardic and had cool extremities, chills, blood pressure 97/61.

Empiric therapyCefepime and vancomycin
ID/AST methodAccelerate PhenoTest® BC kit
ID resultEnterobacter spp.
AST resultsPan-susceptible to all agents tested
Therapy changeDiscontinue vancomycin, continue cefepime
Time to AST results7h 44min post +BC with Accelerate PhenoTest® BC kit
Patient outcomePatient was discharged after 14-day course of cefepime

Case Discussion

A 7-year-old male with a history of gastroschisis and short gut syndrome on total parenteral nutrition presented to the emergency department (ED) with acute fever, fatigue, and abdominal pain. Over the past 3 weeks he experienced intermittent right-sided abdominal pain with no diarrhea or changes in bowel movements. On the morning prior to admission, he fell down and scraped the right side of his abdomen. That evening, he developed chills, had one episode of emesis and was febrile at 38.5°C. There were concerns for sepsis related to a broviac line infection. Upon presentation in the ED, the patient became more tachycardic with heart rate at 160 beats/minute, cool extremities, chills and blood pressure of 97/61 mmHg. One set of blood cultures were collected and patient was started on intravenous (IV) cefepime (50 mg/kg, Q8H) and IV vancomycin (15 mg/kg, Q6H). The patient also presented with a cough and sore throat with nasal congestion for the past week and molecular respiratory viral panel was ordered on a nasopharyngeal (NP) swab sample collected in universal viral transport medium.

Initial laboratory findings include, low white blood cell (3.26 K/uL), with 70% neutrophils, 27.9% lymphocytes and 0.9% monocytes and elevated hemoglobin at 14.7 g/dL. Low potassium (3.3 mEq/L), creatinine (0.37 mg/dL) and total CO2 levels (16 mEq/L) were also reported. Molecular respiratory viral testing of the nasopharyngeal swab confirmed adenovirus upper respiratory tract infection.

Anaerobic blood culture was positive after 6 hours of incubation in the BACTEC™ automated blood culture system, STAT Gram stain was performed and Gram-negative bacilli was called to the provider and reported in the electronic medical records (EMR). The aerobic blood culture bottle was also positive with the identical organism after 8 hours of incubation, hence further workup was only performed from the anaerobic blood culture bottle. Accelerate PhenoTest BC kit analysis was performed directly from the positive blood culture and Enterobacter species was called to the provider and reported 1 hour and 26 minutes after the Gram-stain result. Further identification of the organism as Enterobacter cloacae complex was carried out using MALDI-TOF MS directly from positive blood culture. Susceptibility results by the Accelerate PhenoTest BC kit were available in the EMR within 7 hours and 44 minutes and the organism was found to be pan-susceptible to all anti-microbial agents included in the panel. Vancomycin was discontinued within 9 hours of the Accelerate PhenoTest BC kit susceptibility results and the patient was maintained on IV cefepime due to the increased risk of AmpC production in Enterobacter cloacae. The patient was found to be clinically stable and was discharged after completion of 14-day course of IV cefepime.

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