Accidental Intravenous Administration of Oral Bacillus clausii Probiotic (Enterogermina) in a Toddler: A Case Report

Acute diarrheal illness is a common cause of hospitalization in toddlers, and probiotics such as oral Bacillus clausii suspension (Enterogermina) are frequently prescribed to restore gut flora. This report describes the first documented case in the United Arab Emirates of accidental intravenous administration of oral Bacillus clausii probiotic in a 17-month-old toddler. The previously healthy child presented with rotavirus-positive gastroenteritis and moderate dehydration. On the day of admission, 3 mL of Enterogermina containing approximately 2 billion spores was inadvertently given intravenously instead of orally. Within two hours, the toddler developed rigors and high-grade fever. He was immediately transferred to the pediatric intensive care unit, where empirical intravenous piperacillin-tazobactam and teicoplanin were started. Inflammatory markers rose sharply, but blood cultures remained sterile. The child became afebrile within 48 hours, markers normalized rapidly, and he was discharged in excellent condition after seven days of intravenous antibiotics with no long-term sequelae. This case demonstrates that even generally safe oral probiotics can trigger a significant but transient systemic inflammatory response when administered intravenously. Prompt recognition, intensive monitoring, and broad-spectrum antibiotics prevented serious complications. It highlights the urgent need for strict medication safety protocols, staff training, and clearer product labeling to avoid such preventable errors in pediatric practice.