Staphylococcus epidermidis bacteremia after small bowel enteroscopy

A 61-year-old man with a 6-month history of recurrent hematochezia was admitted to our hospital for the management of symptomatic anemia. Upon admission, his hemoglobin level was 60 g/L. Esophagogastroduodenoscopy and colonoscopy were performed but did not reveal the cause of his anemia. Subsequently, single-balloon enteroscopy (SBE) was conducted, which identified an actively bleeding angioectasia in the distal jejunum, approximately 300 cm from the incisors ([Fig. 1] a, [Video 1]). Hemostasis was achieved using argon plasma coagulation and hemoclip placement at the bleeding site ([Fig. 1] b, c). The SBE procedure time was approximately 13 min. Two days post-SBE, the patient developed a fever, peaking at 39°C, along with leukocytosis (white blood cell count: 21 × 10⁹/L). A computed tomography (CT) scan of the chest and abdomen did not reveal any source of infection.

Fig. 1 Single balloon enteroscopy (SBE) was performed to evaluate the cause of anemia in a 61-year-old ma. a SBE showed an active bleeding angioectasia in the distal jejunum. b Hemostasis was achieved using argon plasma coagulation. c Wound closure after hemostasis using endoclips. d Peripheral venous blood culture revealed growth of Staphylococcus epidermidis.

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Single balloon enteroscopy showing an active bleeding angioectasia in the distal jejunum in a 61-year-old man with anemia.Video 1

Blood cultures grew Staphylococcus epidermidis in three consecutive samples ([Fig. 1] d). The patient was treated with an initial intravenous dose of tigecycline at 100 mg, followed by 50 mg every 12 h. He became afebrile 2 days after starting antibiotics. At the 3-month follow-up, the patient remained afebrile with no recurrence of bacteremia.

SBE is commonly performed for both diagnostic and therapeutic interventions in the small intestine [1]. Despite disinfection and processing of endoscopes, device-associated infections can still occur. Notably, an overtube is used during SBE, which is placed on the endoscope in a non-sterile environment. Inflation of the balloon used to advance the enteroscope can compress the intestinal wall, and prolonged balloon inflation (> 10 min) may cause intestinal wall hypoxia, potentially disrupting the mucosal barrier and increasing the risk of bacterial translocation, which can result in bacteremia [1] [2] [3]. Additionally, mucosal injury is frequently encountered during SBE, further facilitating bacterial translocation [4].

The incidence of S. epidermidis infections has risen with the increased use of medical instrumentation. Our patient had no cutaneous lesions or evidence of accompanying gastrointestinal or respiratory infections. Therefore, we attributed the S. epidermidis bacteremia to the introduction of the bacteria into the digestive tract during the SBE procedure, followed by translocation through the damaged intestinal mucosa.

Given the increased use of balloon-assisted enteroscopy, our case highlights the importance of being aware of the potential for enteroscopy-associated bacteremia. Early recognition of this complication can facilitate timely initiation and discontinuation of antimicrobial therapy.

Endoscopy_UCTN_Code_CPL_1AI_2AD

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Lee TC, Huang YC, Lu YZ. et al. Hypoxia-induced intestinal barrier changes in balloon-assisted enteroscopy. J Physiol 2018; 596: 3411-3424
• 2 Huang CY, Hsiao JK, Lu YZ. et al. Anti-apoptotic PI3K/Akt signaling by sodium/glucose transporter 1 reduces epithelial barrier damage and bacterial translocation in intestinal ischemia. Lab Invest 2011; 91: 294-309
• 3 Lu YZ, Huang CY, Huang YC. et al. Tumor necrosis factor α-dependent neutrophil priming prevents intestinal ischemia/reperfusion-induced bacterial translocation. Dig Dis Sci 2017; 62: 1498-1510
• 4 Abu Taleb AMF, Mohamed MS, Abdel-Latif RS. et al. The role of ica operon and biofilm formation in coagulase negative staphylococcal infection. Egyptian J Med Microbiol 2012; 21: 21-32

Publication History

Article published online:
14 October 2024