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Preventing avoidable central line–associated bloodstream infections: Implications for probiotic administration and surveillance

      Central line–associated bloodstream infections (CLABSIs) are a source of morbidity and impose an important financial burden.
      • Blot S.I.
      • Depuydt P.
      • Annemans L.
      • Benoit D.
      • Hoste E.
      • De Waele J.J.
      • et al.
      Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.
      As a public safety net health system, we continually strive to improve the quality of our care and to minimize cost. Every health care–associated infection is scrutinized to assess whether it could have been prevented. To our surprise, one patient recently fulfilled the National Healthcare Safety Network (NHSN) surveillance definition for a CLABSI in a situation which could have been avoided if probiotics were more carefully handled.
      • National Center for Health Statistics
      CDC/NHSN surveillance definitions for specific types of infections.
      Consequently, by highlighting this case, we aim to demonstrate the necessity for standardized instructions for the administration of probiotics and propose that Lactobacillus GG be added to the NHSN list of commensals.
      A 78-year-old woman with type II diabetes mellitus underwent an urgent exploratory laparotomy for ischemic bowel from an incarcerated ventral hernia and volvulus. Postoperatively, her course was complicated by fever and hypotension; therefore, she was treated for septic shock with fluids, vasopressors, and empirical broad-spectrum antibiotics. Cultures from urine, respiratory tract, and abdominal cavity–draining Jackson-Pratt drains were all negative, as was a Clostridium difficile polymerase chain reaction of stool. Blood cultures were also persistently negative, except 1 of 2 sets which grew Lactobacillus. During this time, she had a central venous catheter (CVC) and was receiving Lactobacillus GG probiotic (Culturelle; i-Health, Cromwell, CT) for the prevention of antibiotic-associated diarrhea. The isolate was sent for gene sequencing and identified as Lactobacillus zeae (99.7% identity) and Lactobacillus rhamnosus (99.8% identity), thereby matching the bacteria identified on the Lactobacillus GG product label. In discussion with nursing staff, it was determined that the probiotic capsules were being opened in the patient's room, dissolved in sterile water, and administered via an orogastric tube. As a result, we believe there was inadvertent environmental contamination with aerosolized bacteria. Because Lactobacillus GG was isolated from a single blood culture, it was not believed to represent a clinically significant infection. Nonetheless, it was accounted for as a CLABSI for our hospital.
      Recommendations in the literature have been made regarding the proper administration of probiotics and allude to the potential risk of bloodstream infections.
      • Cohen S.H.
      • Gerding D.N.
      • Johnson S.
      • Kelly C.P.
      • Loo V.G.
      • McDonald L.C.
      • et al.
      Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).
      However, there are no formalinstructions or warnings to heighten awareness about the possibility of environmental contamination or cross-transmission from hands to other sites from Lactobacillus, specifically. Therefore, to prevent avoidable CLABSIs in patients receiving probiotics who have a CVC and a feeding tube, capsules must be opened in a room separate from the patient, and staff should engage in proper hand hygiene before and after administration.
      It is worth mentioning that prior studies of Lactobacillus bacteremia did not support an association with catheter-related bloodstream infections.
      • Antony S.J.
      • Dummer S.
      • Stratton C.
      Lactobacillus bacteremia and endocarditis.
      There have since been 2 reported cases of catheter-related Lactobacillus GG bacteremia: one was in a lung transplant recipient and another, interestingly, was in a child with short gut syndrome who was receiving Lactobacillus GG probiotic via a gastrojejunostomy tube.
      • Carretto E.
      • Barbarini D.
      • Marzani F.C.
      • Fumagalli P.
      • Monzillo V.
      • Marone P.
      • et al.
      Catheter-related bacteremia due to Lactobacillus rhamnosus in a single-lung transplant recipient.
      • De Groote M.A.
      • Frank D.N.
      • Dowell E.
      • Glode M.P.
      • Pace N.R.
      Lactobacillus rhamnosus GG bacteremia associated with probiotic use in a child with short gut syndrome.
      Similarly, there have been 6 cases of primary Lactobacillus bacteremia where the isolated strain was indistinguishable from the administered probiotic.
      • De Groote M.A.
      • Frank D.N.
      • Dowell E.
      • Glode M.P.
      • Pace N.R.
      Lactobacillus rhamnosus GG bacteremia associated with probiotic use in a child with short gut syndrome.
      • Vahabnezhad E.
      • Mochon A.B.
      • Wozniack L.J.
      • Ziring D.A.
      Lactobacillus bacteremia associated with probiotic use in a pediatric patient with ulcerative colitis.
      • Meini S.
      • Laureano R.
      • Fani L.
      • Tascini C.
      • Galano A.
      • Antonelli A.
      • et al.
      Lactobacillus rhamnosus GG bacteremia associated with priobiotic use in an adult patient with severe active ulcerative colitis: case report and review of the literature.
      Accordingly, we believe that Lactobacillus GG should be added to the NHSN list of commensals so that one positive blood culture does not result in a reportable CLABSI. This merits particular consideration given the increasing use of probiotics in patients with CVCs. Just one misclassified health care–associated infection has detrimental effects on staff morale, consumer confidence, and hospital reimbursement.

      References

        • Blot S.I.
        • Depuydt P.
        • Annemans L.
        • Benoit D.
        • Hoste E.
        • De Waele J.J.
        • et al.
        Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.
        Clin Infect Dis. 2005; 41: 1591-1598
        • National Center for Health Statistics
        CDC/NHSN surveillance definitions for specific types of infections.
        (Available from:) (Accessed May 25, 2016)
        • Cohen S.H.
        • Gerding D.N.
        • Johnson S.
        • Kelly C.P.
        • Loo V.G.
        • McDonald L.C.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).
        Infect Control Hosp Epidemiol. 2010; 31: 431-455
        • Antony S.J.
        • Dummer S.
        • Stratton C.
        Lactobacillus bacteremia and endocarditis.
        Clin Infect Dis. 1998; 26: 1483-1484
        • Carretto E.
        • Barbarini D.
        • Marzani F.C.
        • Fumagalli P.
        • Monzillo V.
        • Marone P.
        • et al.
        Catheter-related bacteremia due to Lactobacillus rhamnosus in a single-lung transplant recipient.
        Scan J Infect Dis. 2001; 33: 780-782
        • De Groote M.A.
        • Frank D.N.
        • Dowell E.
        • Glode M.P.
        • Pace N.R.
        Lactobacillus rhamnosus GG bacteremia associated with probiotic use in a child with short gut syndrome.
        Pediatr Infect Dis J. 2005; 24: 278-280
        • Vahabnezhad E.
        • Mochon A.B.
        • Wozniack L.J.
        • Ziring D.A.
        Lactobacillus bacteremia associated with probiotic use in a pediatric patient with ulcerative colitis.
        J Clin Gastroenterol. 2013; 47: 437-439
        • Meini S.
        • Laureano R.
        • Fani L.
        • Tascini C.
        • Galano A.
        • Antonelli A.
        • et al.
        Lactobacillus rhamnosus GG bacteremia associated with priobiotic use in an adult patient with severe active ulcerative colitis: case report and review of the literature.
        Infection. 2015; 43: 777-781