Introduction:
Since the emergence of community-acquired methicillin-resistant S. aureus (MRSA), severe manifestations of infection are encountered more frequently. Venous thrombosis (VT) has been previously reported in children with S. aureus infections. This study reviews our institutional experience and outcomes of children with VT and staphylococcal infections.
Methods:
A retrospective analysis of 15 pediatric patients (≤ 18 years) treated for VT and staphylococcal infections at Children’s Memorial Hermann Hospital between January 1, 2010 and December 31, 2014 was performed.
Results:
Fifteen patients were included (10 males, 5 females) with a median age at diagnosis of 8 years (range 2 mo-17yrs). Underlying infections included: osteomyelitis (n=7), soft tissue infection (n=3), aortitis (n=1), meningitis (n=1), septic arthritis (n=1), central line infection (n=1), septicemia (n=1). Primary presentation included: swelling (n=12), pain (n=11), tenderness (n= 8), and color changes (n=3). One patient had prior history of VT. Family history was positive for VT in one patient. Isolated organisms included: MRSA (n=9), MSSA (n=3), polymicrobial (n=2), and Staphylococcus non- aureus (n=1). Eight patients had central venous catheters (CVC) and 5 of them had thrombosis at the CVC site. VT sites identified by Doppler US (DUS) included: upper extremity (n= 5), lower extremity (n= 8), and neck (n=2). All thrombophilia work up was negative. The median D-dimer at diagnosis was 3 ug/ml (range: 0.31- 6.54 ug/ml). Median time elapsed between infection and VT diagnosis was 5.5 days (range: 0-35 days). All patients received anticoagulation using LMWH (1mg/kg/dose) except one who had superficial thrombophlebitis and was managed conservatively. Median time to achieve therapeutic anti- factor Xa level was 2.5 days (range 1- 6 days). Median duration of anticoagulation was 3 months. Three out of 13 patients (23%) had resolution of thrombosis within one week of anticoagulation. Four other patients had thrombus resolution by DUS at 3-6 months. Five patients did not have DUS at 3-6 months. None of the 15 patients required hospital re- admission for bleeding or thrombotic complications.
Discussion:
Staphylococcal infections may increase the risk of VT in children. Nine out of 15 patients (60%) with VT had a documented MRSA infection, which appears to confer an even higher risk for development of VT. Over half of the patients responded favorably to anticoagulation with resolution of VT within 6 months.
Conclusions:
A high index of suspicion for VT is warranted in children with Staphyloccoccal infections (particularly MRSA) to promptly diagnose and treat. This approach may improve outcomes and minimize complications including septic emboli and post-thrombotic syndrome. Prophylactic anticoagulation in presence of MRSA infection could be considered in future studies.
Keywords: Children, staphylococcal infection, venous thrombosis