PC2166: Elizabethkingia Miricola: A First Report of bacteremia in an At-risk Pediatric Patient

Introduction: Children with short-bowel syndrome (SBS) are at increased risk for polymicrobial bloodstream infections (pBSI). Enteric gram-negative rods predominate but typical central-line associated organisms, fungi, and other less commonly pathogenic bacteria have been implicated. In 2003, Elizabethkingia miricola was first isolated and identified from the Mir space station. Herein we describe the presentation and management of a young child with SBS and pBSI with Elizabethkingia miricola bacteremia. Additionally, we provide whole genome sequencing (WGS) species confirmation as well as antibiotic susceptibilities to inform future management decisions. This is the first reported case of an invasive Elizabethkingia miricola infection in the pediatric population.

Case Description: A 16-month-old girl presented to the emergency department with fever and signs of septic shock. Her medical history is notable for tracheostomy and ventilator dependence, gastrostomy tube, central venous catheter (CVC), and short-bowel-syndrome due to complications from prematurity and necrotizing enterocolitis. Physical examination was unrevealing. Volume resuscitation, cultures of blood, urine, and respiratory sources, and broad-spectrum empiric antibiotics were implemented. Culture results are highlighted in Table 1. She required central line removal and tailoring of antibiotics to target culture results. Table 2 provides a microbiological description of the Elizabethkingia miricola isolate. A 7-day course of vancomycin plus levofloxacin was completed following line removal with positive clinical response.

Discussion: Members of the genus Elizabethkingia are emerging pathogens found in the environment and typically affect the immunocompromised. Intrinsic antibiotic resistance results in limited therapeutic options and complicates management. Additionally, pBSI’s are associated with high rates of morbidity and mortality. While pBSI are common in patients with SBS, unique to our patient is the identification of E. miricola, which has been rarely associated with invasive infections. There has only been one pediatric case described in the literature from a non-pulmonary isolate. Due to its rarity, we had WGS completed at the Department of Defense’s Multidrug-Resistant Organism Repository and Surveillance Network. WGS confirmed E. miricola and identified three distinct intrinsic genes conferring resistance to carbapenems and extended-spectrum cephalosporins. Adult case reports and the single other pediatric case report describe successful treatment using a fluoroquinolone regimen. Our patient similarly responded favorably to treatment with levofloxacin.

Conclusion: SBS predisposes children to polymicrobial bloodstream infections which can include a broad range of pathogens. E. miricola is a rare opportunistic gram-negative bacillus that has the ability to cause invasive infections in susceptible hosts. Management is complicated by resistance to multiple beta-lactam antibiotics to include carbapenems, but typically susceptible to fluoroquinolones. By describing the first, to our knowledge, case of invasive E. miricola infection in a pediatric patient, we hope to raise awareness and promote further research into this new pathogen.