S5034 Short Bowel Syndrome and Parenteral Nutrition: A Challenging Case of Recurrent Bacteremia and Fungemia

Introduction: Short bowel syndrome (SBS) often necessitates chronic total parenteral nutrition (TPN) via central venous catheters, increasing the risk of catheter-related bloodstream infections (CRBSIs). We present a challenging case of a 76-year-old woman with SBS who developed multidrug-resistant Gram-positive bacteremia and fungemia, highlighting diagnostic and therapeutic complexities in TPN-dependent patients. Case Description/Methods: A 76-year-old woman with SBS (TPN-dependent via a peripherally inserted central catheter [PICC] placed almost 1 year ago), history of small bowel obstructions (status post colostomy and ileostomy also a year ago), atrial fibrillation (on apixaban), hypertension, hyperlipidemia, fibromyalgia, hypothyroidism, and GERD presented with fever (100.7°F), chills, rigors, and malaise. In the Emergency Department, she developed hypotensive septic shock. The PICC was identified as the likely infection source and removed, with a right internal jugular line placed for vasopressors and TPN continuation. Blood cultures revealed Staphylococcus epidermidis and Mycobacterium mucogenicum, both catheter associated. Skin cultures were negative, and transthoracic echocardiography ruled out endocarditis. Empiric therapy with meropenem and caspofungin was adjusted to minocycline for 7 days, followed by ciprofloxacin 500 mg orally every 12 hours for 4 weeks, based on susceptibility profiles showing multidrug resistance to antituberculous agents but sensitivity to ciprofloxacin, minocycline, and linezolid. Fevers resolved within 1 week, with clinical improvement achieved through multidisciplinary management involving gastroenterology, infectious disease, and nutrition services. Discussion: CRBSIs are a significant complication in SBS patients due to long-term TPN dependence. S. epidermidis, a common skin flora, and M. mucogenicum, a rare non-tuberculous mycobacterium, highlight the complexity of infections in this population. Multidrug resistance required tailored antibiotic therapy. Epidemiological data indicate M. mucogenicum accounts for ∼24% of rapidly growing mycobacteria (RGM) isolates, primarily in immunocompromised hosts, with a low incidence (0.04 cases per 100,000). Prompt catheter removal, targeted antimicrobials, and nutritional optimization were critical to recovery. This case underscores the need for multidisciplinary approaches to manage CRBSIs in SBS patients.