Case Presentation: 35-year-old female with past medical history of mitochondrial disease, asthma, Fanconi syndrome, diabetes mellitus, and GERD presented to the hospital with a four-day history of dyspnea due to Rhinovirus seen on respiratory panel. The patient was managed in the intensive care unit for non-invasive ventilation support, and received solumedrol, albuterol, ipratropium, and azithromycin. Chest x-rays were negative. She continued her outpatient total parenteral nutrition (TPN) regimen through central venous catheter.She had been seen at an outside hospital for her mitochondrial disease. She was continued on her previous regimen of levocarinitine and a combination of insulin drip, dextrose and bicarbonate in saline, with adjustments based on her lactic acid and glucose levels. The patient experienced chills, diaphoresis, and body aches. She was febrile with leukocytosis. Blood, urine, and fungal cultures were drawn, and Daptomycin and Meropenem were started based on advice from the infectious disease team. One year prior, the patient had developed sepsis due to a port infection and was effectively treated with this same antibiotic regimen. One blood culture demonstrated alpha hemolytic streptococci (Streptococcus mitis). Meropenem was discontinued and she completed 7 days of Daptomycin. Despite antibiotics, the patient continued to have daily fevers. Blood cultures were repeated, and one out of two cultures grew Bifidobacterium spp with no specified species. There was no documented use of probiotics. Imaging demonstrated septic emboli, likely due to her port. This port was removed, and repeat blood cultures were negative. Ertapenem was initiated. The patient remained afebrile. Dextrose and insulin drip were discontinued. She was discharged after 27 days and prescribed Ertapenem for 3 weeks.
Discussion: Bifidobacterium is a strain of lactic acid bacilli that is used in some probiotics and helps to suppress growth or invasion by pathogenic bacteria. Bifidobacterium concentrations are decreased in celiac disease. Combination of Lactobacillus, Bifidobacterium, and Streptococcus thermophilus decreases acute dysentery bleeding and length of hospitalization. Bifidobacterium has been shown to improve bowel habits including frequency and consistency.Little has been studied in terms of probiotic complications. Risk factors include central venous catheters, gastric-acid suppressing medications, and disorders associated with increased bacterial translocation (sepsis, HIV, and C. difficile colitis). One systematic review demonstrated that probiotics, including Bifidobacterium, Saccharomyces, Lactobacillus, Bacillus, Pediococcus, and Escherichia, were associated with sepsis and fungemia. There is no reported statistic for Bifidobacterium bacteria. Another study that investigated the probiotic safety in patients receiving nutritional support demonstrated adverse events, such as bacteremia, in twenty of thirty-two case reports.
Conclusions: TPN is delivered through a central venous catheter and contains dextrose, amino acids, electrolytes, vitamins, and minerals. It is used in hospitalized patients with malnutrition, surgical intervention, or multi-organ disease. In immunocompromised patients with central venous catheters requiring TPN or consuming probiotics, bloodstream infections with the same should be kept in mind. TPN was as a risk factor in our patient. Early initiation and targeted therapy along with removal of foreign material leads to better outcomes.