Sphingomonas paucimobilis infection among a patient with a history of injection drug use: An opportunity for improvement of medical chart documentation

To the Editor—At our level 1 academic trauma center in northeastern Florida, a patient developed a central-line–associated bloodstream infection (CLABSI) with Sphingomonas paucimobilis, an aerobic gram-negative bacillus that more commonly occurs in immunocompromised persons and is less commonly associated with nosocomial transmission. ^1–3 This patient was a female in her late twenties who was admitted for multifocal pneumonia after several days of cough and shortness of breath. Her medical history was remarkable for Hodgkin’s lymphoma, chronic hepatitis C infection, thrombocytopenia, neutropenia, excoriation, tobacco use, and injection drug use (oxycodone). She denied current drug use. A double-lumen power peripherally inserted central catheter (PICC) was placed and dressed with a transparent dressing and chlorhexidine-gluconate impregnated antimicrobial disc (BioPatch) according to hospital policy. Approximately 1 month into her stay, blood cultures were positive for S. paucimobilis. Medical staff had documented patient noncompliance with hospital polices, such as dressing changes, on multiple occasions. After a 57-day stay, the patient was discharged to home hospice.

Whether the patient acquired S. paucimobilis due to her immunocompromised state and/or noncompliance with hospital policies is unknown. There was a paucity of information regarding her past history of injection drug use, as documented by clinical staff during her admission. Current injection drug use may have contributed to the development of the CLABSI. Walayat et al ⁴ noted the isolation of S. paucimobilis in an injection drug user, which presented itself as acute phlebitis; these authors suspected the patient acquired the organism from using toilet water to mix heroin prior to injecting. ⁴ We urge clinicians to thoroughly document past drug use, especially among past and current injection drug users, to note when suspected drug use has occurred, and/or to note suspicion if a patient has accessed their own vascular catheter. This is critical in wake of the ongoing opioid epidemic linked to injection drug use, which has affected many states across the United States, including Florida, which has also been facing an ongoing outbreak of the hepatitis A virus. Since January 2018, more than one-third of reported cases in the state have reported injection drug use. ⁵ According to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network definitions, even if a patient accesses their own vascular catheter during their hospital stay, whether through injection drug use or other means, and it meets the CLABSI case definition, it is still attributed to the reporting facility. ⁶ The CDC recommend that risk mitigation include a sitter for the patient and/or removing the tunneled catheter as soon as clinically possible. Providing a sitter may not always be feasible, especially in light of ongoing novel coronavirus pandemic. ⁶