Two Cases of Lactobacillus Bacteremia During Probiotic Treatment of Short Gut Syndrome


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Lactobacillus, a gram-positive bacillus, is a constituent of the indigenous flora of the colon. Often used as a probiotic agent, it appears to help prevent both intestinal colonization by pathogenic organisms and bacterial overgrowth syndrome. Lactobacillus organisms in the intestine are thought to produce acetic acid, lactic acid, and hydrogen peroxide and to promote the secretion of antimicrobial substances. The production of short chain fatty acids and the resultant low luminal pH of the colon also appear to inhibit growth of bacterial pathogens (1). Lactobacillus may also compete with pathogenic organisms for mucosal surface receptors and may decrease the incidence of antibiotic-associated diarrhea and Clostridium difficile colitis (2).Although Lactobacillus generally is not considered a pathogen, it can cause disease in compromised hosts, including bacterial endocarditis, pleuropulmonary infections, gastrointestinal abscesses, urinary tract infection, conjunctivitis, dental caries, and endometritis (3). Lactobacillus bacteremia, presumably secondary to bacterial translocation from the gastrointestinal tract, has been reported in a patient with severe intestinal inflammation caused by ulcerative colitis (4). There are no published reports of bacteremia or sepsis secondary to Lactobacillus given as a probiotic agent. We report two cases of Lactobacillus GG sepsis occurring during the therapeutic use of this organism.CASE REPORTSCase 1Patient 1 was a 36-week-gestation male infant with short gut syndrome secondary to congenital intestinal atresia and volvulus. The patient was dependent on total parenteral nutrition (TPN) because of his very short residual intestine. He had experienced cholestasis. A regimen of Lactobacillus GG (Culturelle, ConAgra, Omaha, Nebraska) supplementation was started on the 95th day of life, with the patient receiving the contents of 1 capsule daily via gastrostomy tube without apparent complication. On the 23rd day of supplementation, the patient experienced fever and diarrhea, with signs and symptoms consistent with sepsis or infection. Blood cultures were obtained, and antibiotic therapy with ceftriaxone and ampicillin was initiated. Within 48 hours, blood cultures grew a Lactobacillus species sensitive to ampicillin. Blood cultures taken after 10 days of treatment with ampicillin were negative. Although fingerprinting of the isolate was not performed, we suspected that the source of the lactobacillus sepsis might have been the exogenous probiotic. Lactobacillus GG supplementation was discontinued, and the patient had no additional Lactobacillus bacteremia. On endoscopy, the patient’s intestine was inflamed and friable. We suspect that the fragility of the intestine may have promoted transmigration of the supplemental Lactobacillus GG.Case 2Patient 2 was a 34-week-gestation male infant with gastroschisis. At delivery, most of the intestine was infarcted, leaving the infant with approximately 16 cm of bowel distal to the ligament of Treitz. He underwent a gastrostomy and jejunostomy shortly after birth, was dependent on TPN, and rapidly developed cholestatic liver disease. He began a regimen of Lactobacillus GG, 1 capsule by mouth daily, on day of life 17. It was hoped the regimen would prevent bacterial overgrowth of the small intestine. He tolerated the preparation well. On day of life 186, he experienced an elevated temperature, tachycardia, and increased apneic events. Cultures were obtained, and ceftriaxone and ampicillin were administered. Within 48 hours, the blood cultures grew Lactobacillus sensitive to both antibiotics. The Lactobacillus GG supplement was discontinued, and the patient completed a 10-day course of ceftriaxone and ampicillin without complications. His repeat blood cultures while receiving antibiotics were negative, and he had no additional episodes of Lactobacillus bacteremia. Upper endoscopy after the sepsis episode revealed mild inflammation of the intestine.

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