(64) Polymicrobial Bacteremia from Licking Syringe Plungers: A Case Report and Scoping Review

Background & Introduction

People who inject drugs are at an increased risk for infectious complications. Certain injection practices can lead to bacterial complications from oral flora including licking needles or using saliva to clean the skin.

Methods
The authors searched OVID Medline, Embase, and APA PsychINFO to identify case reports and case series of patients with infections related to salivary contamination in the injection process. Studies with suspected unsafe injection practices based on the pathogen but no specific injection practices reported were excluded. Artificial Intelligence (AI) was utilized to augment the traditional scoping review by refining search criteria for a repeated traditional search and conducting iterative AI literature searches using embedded links.

Results
9 sources were identified with AI-augmented embedded article searching that were not identified in the traditional scoping review. If only the traditional scoping review had been used, 3 of the 10 articles would have been identified. 4 sources were identified with AI-augmented search criteria.

Case Description
The patient was a 29-year-old man with severe opioid use disorder on methadone, ADHD, generalized anxiety disorder, and housing instability who presented to the hospital with fevers for the past 3 days. He was hospitalized 10 days prior to rule out bacteremia given similar symptoms of fevers, chills, and myalgias. Blood cultures at that time were negative, and he was discharged home after 48 hours of broad-spectrum antibiotics. Upon discharge, he started using 5 bags of fentanyl intravenously daily and injected cocaine once. He presented again to the hospital with subjective fevers, and blood cultures eventually grew Bacillus thuringiensis. A transthoracic echo was reassuring without evidence of vegetation. Blood cultures cleared within 24 hours, and he was continued on a course of Vancomycin for 14 days. Notably, over the preceding 9 months, the patient has had 3 distinct episodes of bacteremia. Five months prior, the patient was admitted with blood cultures growing Veillonella atypica, Streptococcus mitis, Rothia mucilaginosa, Streptococcus anginosus, and Actinomyces odontolyticus. Six months prior, during an admission his blood cultures grew Burkholderia cepacia complex and Atopobium parvulum. Eight months ago, during an admission blood cultures grew Candida dubliniensis, Actinomyces odontolyticus, Veillonella parvula, Streptococcus salivarius, and Rothia mucilaginosa.

In the setting of repeated episodes of multiple atypical organisms grown in this patient’s blood cultures over the past months, he was interviewed regarding injection habits. He primarily injected into his bilateral forearms and wrists. He denied difficulty with venous access and denied ever injecting into subcutaneous or muscle tissue. He reported that he used a needle, cooker, and cotton for an average of 6 total injections before using new equipment. He injected fentanyl 6 to 8 times per day. He licked the stopper of the syringe plunger prior to every injection to check via taste for the quality of the substance being injected, and he reports that this was a difficult pattern to stop due to the process being habitual in his injection practices. He used the cap of the plunger as a cooker. Between injections, he stored his used cotton in the cooker, re-capped the plunger, and placed the syringes in his pocket.

Conclusion
The patient unfortunately was re-admitted with Granulicatella adiacens and Gemella sanguinis bacteremia one month later and recurrent Streptococcal mitis/Streptococcal oralis bacteremia one month after that. On his most recent admission, he reported that after ongoing education from the inpatient addiction medicine team he was licking the plunger much less frequently, although he had difficulty quantifying the amount.

Discussion
The scoping review identified unexpected etiologies of oropharyngeal bacterial contamination not limited to licking needles, illustrating the importance of gaining an in-depth, step-by-step understanding of how each patient with intravenous drug use injects to identify potential modes of infection. This case also provides an example of potential advancements in artificial intelligence to augment research by improving search strategies such as MeSH terms and identifying articles.