P3D331: Streptococcus Gallolyticus Urinary Tract Infection in a 2-day-old Term Infant

Introduction: Urinary tract infections are atypical among infants in the first 3 days of life. Therefore, neonatal sepsis protocols recommend against urine testing during this timeframe. Streptococcus gallolyticus is most often associated with endocarditis, or bacteremia in the setting of a primary intestinal disorder. S. gallolyticus is rarely isolated in neonates and has not previously been identified as a cause for neonatal urinary tract infection (UTI).

Case Description: A term, uncircumcised male presents to the emergency department at 52 hours of life with fever. He was discharged home 15 hours earlier following an uncomplicated nursery stay. There were no identified risk factors for neonatal infection and prenatal imaging was normal. He was exclusively breastfeeding with age-appropriate voiding and stooling. A neonatal sepsis evaluation is obtained with urinalysis demonstrating 16 white blood cells/ high power field and trace leukocyte esterase. His procalcitonin is 1.83ng/mL. Blood and urine cultures are collected. A lumbar puncture is attempted but not obtained. The infant is admitted to the pediatric ward while cultures are pending. His urine culture returns positive for >100,000 colony-forming units/mL of S. gallolyticus. All other testing is negative. Antibiotics are appropriately tailored, and he has an uncomplicated treatment course. Although a subsequent renal ultrasound is normal, further work-up reveals grade 4 vesicoureteral reflux of the right ureter.

Discussion: A literature review, published in 2022, reported on 30 cases of neonatal S. gallolyticus infections, including 19 with meningitis; 58% presented during the first week of life. A single case report describes a 28-day-old term infant who presented with fever and lethargy, where S. bovis (now S. gallolyticus) was isolated from blood, spinal fluid, and urine. Of note, this patient’s urinalysis was normal. There are no other reports of an infant with S. gallolyticus- UTI. S. gallolyticus has also been reported as a cause of chorioamnionitis. A case series published in 2022 describes five laboring mothers with intrapartum bacteremia with S. gallolyticus. All these mothers had histopathological or microbiological evidence of chorioamnionitis. All but one baby had clinical sepsis requiring neonatal intensive care unit stay. None of the babies had S. gallolyticus isolated from any cultures though urine samples were not obtained during any of their workups.

Conclusion: Sources suggest that S. gallolyticus is an emerging infection, both among laboring mothers and neonates. As pathogen predilections change, our workups must also evolve to match new threats. This case suggests that there may be a role for urine testing during infectious workup of newborns, particularly if Moms are found to be colonized or infected with S. gallolyticus. In the setting of gram-positive UTIs, significant pyuria is less sensitive as an indicator of infection. This pathogen has an obvious predilection for causing neonatal meningitis; early identification and treatment are paramount.