Post liposuction infections by rapidly growing mycobacteria

Advances in diagnosis and management of atypical spinal infections: A comprehensive review

Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.

Complications of Medical Tourism in Aesthetic Surgery: A Systematic Review

INTRODUCTION

As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings attract many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short- and long-term follow-up, as well as the management and cost of complications.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses on complications that presented after cosmetic surgeries performed abroad. The literature search was performed on October 18, 2022, using the databases of PubMed, Google Scholar, and Embase.

RESULTS

From the 44 studies that were included, 589 patients were identified who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/hematoma, and tissue necrosis. Ninety-eight percent of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus.

CONCLUSIONS

Cosmetic tourism is a global phenomenon. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that the primary procedures took place in, and the countries of origin of the patients. To aid in reducing morbidity and mortality from cosmetic tourism, regulatory bodies should educate and empower the public to aid them in making educated medical conditions when seeking care.

Mycobacterium abscessus skin and soft tissue infection following autologous fat grafting in Kurdistan treated with an antibiotic combination including Imipenem-Relebactam and Rifabutin

Medical tourism is becoming increasingly popular. The most popularly sought operations are cosmetic procedures. With the increase in cosmetic tourism, it is unsurprising that there has also been a rise in skin and soft tissue infections caused by nontuberculous mycobacteria (NTM); in particular by the rapidly growing mycobacteria species. Here we provide a case of a 35 year-old woman who presented after autologous fat grafting with multiple painful, violaceous, and purulent nodules on her arms, legs, and breasts. Infection was found to be due to Mycobacterium abscessus. She was successfully treated with azithromycin, clofazimine, rifabutin, amikacin, imipenem-cilastatin-relebactam (Recarbrio™) and imipenem-cilastatin. This is the first described case of a M. abscessus infection successfully treated using this combination.

Evaluation of cleaning and sterilization of liposuction cannulas after intentional contamination with human fat, Mycobacterium abscessus subspecies bolletii and Geobacillus stearothermophilus

BACKGROUND

The complex design of cannulas is a major challenge for reprocessing due to the retention and accumulation of fat residues.

AIM

To evaluate the cleaning of liposuction cannulas and the protective effects of the remaining fat residues on Mycobacterium abscessus subspecies bolletii (MASB) and Geobacillus stearothermophilus inactivation during steam sterilization.

METHODS

In Phase 1, six standard operating procedures (SOP) were evaluated for cleaning of liposuction cannulas. In Phase 2, the sectioned lumens of the liposuction cannulas were contaminated with the largest and smallest volume of human fat found in Phase 1, with the addition of MASB. In Phase 3, the same volumes of human fat from Phase 2 were used to contaminate paper strips containing G. stearothermophilus.

FINDINGS

In phase 1 the residual amount of fat ranged from 6 to 52mg. In phases 2 and 3, the minimum and maximum amounts of fat (6 to 50mg) protected microorganisms during steam sterilization at 134ºC for 1.5 and 3min.

CONCLUSION

Effective cleaning and sterilization of liposuction cannulas intentionally contaminated with human fat, MASB and G. stearothermophilus could not be performed.

Nontuberculosis Mycobacteria Infection After Liposuction and Fat Grafting for Augmentation Mammoplasty: A Case Report and Literature Review

BACKGROUND

Nontuberculosis mycobacteria (NTM) commonly occur in nature. Although the infection rate is low, soft tissue infection with NTM after surgical procedures is possible in both immunocompromised and normal populations. For cosmetic surgery, NTM infection has emerged as a common infection in the recent years, and this indicates the need to pay more attention, especially to those with prolonged atypical uncertain wound problems.

AIM AND OBJECTIVES

We aimed to report a case of NTM infection after breast augmentation to share our experience on clinical appearance and process of diagnosis and treatment, and to review the existing literature.

MATERIALS AND METHODS

We retrospectively review a patient who suffered from NTM infection after liposuction and fat grafting for breast augmentation between 2019 and 2021 in our hospital. The baseline characteristics, operations, bacterial culture report, medications, and outpatient information were collected from medical records.

RESULTS

The patient suffered from purulent skin lesions after breast augmentation and was diagnosed with NTM infection according to the culture report. The NTM infection was resolved after a long-term course of treatment for around a year, including surgical debridement, serial aspirations, and prescriptions of antituberculosis medications.

CONCLUSIONS

The results of our study suggest that NTM must be considered when facing refractory infections after surgeries or invasive procedures without bacterial growth on routine cultures. Acid-fast stain and mycobacterial culture are strongly recommended. Treatment modalities include localized aspiration, surgical debridement, and multidrug antibiotics based on the sensitivity of the microorganism.

Nontuberculous Mycobacteria under Scrutiny in the Geneva Area (2015-2020)

BACKGROUND

Nontuberculous mycobacteria (NTM) are increasingly identified in industrialized countries, and their role as pathogens is more frequently recognized. The relative prevalence of NTM strains shows an important geographical variability. Thus, establishing the local relative prevalence of NTM strains is relevant and useful for clinicians.

METHODS

Retrospective analysis (2015-2020) of a comprehensive database was conducted including all results of cultures for mycobacteria in a University Hospital (Geneva, Switzerland), covering a population of approximately 500,000 inhabitants. All NTM culture-positive patients were included in the analyses. Patients' characteristics, NTM strains, and time to culture positivity were reported.

RESULTS

Among 38,065 samples analyzed during the study period, 411 were culture-positive for NTM, representing 236 strains, and 231 episodes of care which occurred in 222 patients. Patients in whom NTM were identified were predominantly female (55%), with a median age of 62 years, and a low BMI (median: 22.6 kg/m2). The Mycobacterium avium complex (MAC) was the most frequently identified group (37% of strains) followed by Mycobacterium gordonae (25%) and Mycobacterium xenopi (12%) among the slowly growing mycobacteria (SGM), while the Mycobacterium chelonae/abscessus group (11%) were the most frequently identified rapidly growing mycobacteria (RGM). Only 19% of all patients were treated, mostly for pulmonary infections: the MAC was the most frequently treated NTM (n = 19, 43% of cases in patients treated) followed by RGM (n = 15, 34%) and M. xenopi (n = 6, 14%). Among those treated, 23% were immunosuppressed, 12% had pulmonary comorbidities, and 5% systemic comorbidities. Cultures became positive after a median of 41 days (IQR: 23; 68) for SGM and 28 days (14; 35) for RGM.

CONCLUSIONS

In Western Switzerland, M. avium and M. gordonae were the most prevalent NTM identified. Positive cultures for NTM led to a specific treatment in 19% of subjects. Patients with a positive culture for NTM were mostly female, with a median age of 62 years, a low BMI, and a low prevalence of immunosuppression or associated severe comorbidities.

Chemical Sterilization of Lipoplasty Cannula and Nontuberculous Mycobacteria Disinfection: An Experimental Study

BACKGROUND

Nontuberculous mycobacteria are commonly found pathogens; however, skin and soft tissue infections due to nontuberculous mycobacteria are often associated with surgical procedures, particularly after lipoplasty. Although nontuberculous mycobacteria are resistant to some chemical disinfectants, glutaraldehyde, peracetic acid, povidone iodine, alcohol, and chlorine are still used for the sterilization of medical instruments. This study investigated the efficacy of various disinfectants in a fatty environment with adipose and a bloody environment without adipose. In addition, this study was also used to identify the most effective disinfectant against nontuberculous mycobacteria.

METHODS

Three nontuberculous mycobacteria (Mycobacterium avium, M. abscessus, and M. fortuitum), pathogens frequently found in skin and soft tissue infections, were used. Seven chemical disinfectants were tested in both fatty and bloody environments. The disinfectants used were considered to have a sterilization effect when the log10 reduction factor exceeded 5.

RESULTS

Most disinfectants had some sterilizing effects against nontuberculous mycobacteria; however, glutaraldehyde was the most effective against all 3. Chlorhexidine and povidone iodine also displayed sterilizing effects. Of the disinfectants tested, only alkyldiaminoethylglycine hydrochloride showed a diminished effect with statistical significance, specifically against M. fortuitum in a fatty environment, whereas it had effective results in a bloody environment.

CONCLUSIONS

Glutaraldehyde showed the greatest sterilizing effect on nontuberculous mycobacteria with a log10 reduction factor >5 in both fatty and bloody environments. However, some chemical disinfectants did not show sufficient sterilizing effects in a fatty environment and, therefore, should be used with caution for the sterilization of nontuberculous mycobacteria.

LEVEL OF EVIDENCE

Level II.

Clinical analysis of nontuberculous mycobacterial infection after minimally invasive plastic surgery and cosmetic surgery

OBJECTIVE

To investigate the clinical features, diagnosis, and treatment of nontuberculous mycobacterial infections after minimally invasive plastic surgery and cosmetic surgery, and to provide reference data for the management of affected patients.

METHOD

We retrospectively analyzed 12 cases of nontuberculous mycobacterial infection after minimally invasive plastic surgery and cosmetic surgery in our department from January 2014 to December 2020. The case data included baseline characteristics, morbidity, chronology of patient symptoms, diagnostic results, and treatment outcomes. Disease characteristics were summarized and objectively analyzed.

RESULTS

The 12 patients infected with nontuberculous mycobacteria after plastic surgery and cosmetic surgery received small incision or minimally invasive surgery. The onset time was 5-30 days after surgery, the clinical manifestations were non-specific, and ordinary antibiotics are ineffective.

CONCLUSIONS

Small incisions or minimally invasive plastic surgery and cosmetic surgery have hidden dangers of nontuberculous mycobacterial infection, and the detection and diagnosis are difficult, and the treatment time is long, which requires attention.

Infectious complications related to medical tourism

BACKGROUND

Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

METHODS

A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

RESULTS

The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

CONCLUSIONS

There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Medical Tourism and Postoperative Infections: A Systematic Literature Review of Causative Organisms and Empiric Treatment

BACKGROUND

Medical tourism has become increasingly globalized as individuals travel abroad to receive medical care. Cosmetic patients in particular are more likely to seek surgery abroad to defray costs. Unfortunately, not all procedures performed abroad adhere to strict hygienic regulations, and bacterial flora vary. As a result, it is not uncommon for consumers to return home with difficult-to-treat postoperative infections.

METHODS

A systematic literature review of PubMed, Ovid, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was performed to assess the microbiology patterns and medical management of patients with postoperative infections after undergoing elective surgery abroad.

RESULTS

Forty-two cases of postoperative infections were reported among patients who underwent elective surgery abroad. Most cases were reported from the Dominican Republic, and the most common elective procedures were abdominoplasty, mastopexy, and liposuction. Rapidly growing mycobacteria such as Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae were among the most common causes of postoperative infection, with M. abscessus involving 74 percent of cases. Most cases were treated with surgical débridement and a combination of antibiotics. Clarithromycin, amikacin, and moxifloxacin were the most common drugs used for long-term treatment.

CONCLUSIONS

When encountering a patient with a history of medical tourism and treatment-refractory infection, rapidly growing mycobacteria must be considered. To increase the likelihood of yielding a diagnostic organism, multiple acid-fast bacilli cultures from fluid and débridement content should be performed. There has been reported success in treating rapidly growing mycobacterial infections with a combination of antibiotics including clarithromycin, amikacin, and moxifloxacin.

Plastic Surgery Complications from Medical Tourism Treated in a U.S. Academic Medical Center

BACKGROUND

Medical tourism is a growing, multi-billion dollar industry fueled by improvements in the global transportation infrastructure. The authors studied patients living in the United States who travel to other countries for plastic surgical procedures and returned to have their complications treated in the authors' center.

METHODS

A retrospective patient evaluation was performed. Patients who had presented to an urban tertiary academic hospital plastic surgery service with complications or complaints associated with plastic surgery performed in a developing country were studied. The authors collected demographic information, types of surgery performed, destinations, insurance coverage, and complications.

RESULTS

Seventy-eight patients were identified over 7 years. Most commonly, complications were seen following abdominoplasty (n = 35), breast augmentation (n = 25), and foreign body injections (n = 15). Eighteen patients underwent multiple procedures in one operative setting. The most common destination country was the Dominican Republic (n = 59). Complications included surgical-site infections (n = 14), pain (n = 14), and wound healing complications (n = 12). Eighty-six percent of patients (n = 67) relied on their medical insurance to pay for their follow-up care or manage their complications, with the most common type of health insurance coverage being Massachusetts Medicaid (n = 48).

CONCLUSIONS

Cosmetic surgery performed in developing countries can carry substantial risks of complications that can be challenging to patients, primary care providers, insurers, and plastic surgical teams not associated with the original surgery. These complications pose significant burdens on our public health systems.

Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic, 2013-2014(1)

Infections in 6 states were linked to persons traveling to undergo cosmetic surgical procedures.

During 2013, the Maryland Department of Health and Mental Hygiene in Baltimore, MD, USA, received report of 2 Maryland residents whose surgical sites were infected with rapidly growing mycobacteria after cosmetic procedures at a clinic (clinic A) in the Dominican Republic. A multistate investigation was initiated; a probable case was defined as a surgical site infection unresponsive to therapy in a patient who had undergone cosmetic surgery in the Dominican Republic. We identified 21 case-patients in 6 states who had surgery in 1 of 5 Dominican Republic clinics; 13 (62%) had surgery at clinic A. Isolates from 12 (92%) of those patients were culture-positive for Mycobacterium abscessus complex. Of 9 clinic A case-patients with available data, all required therapeutic surgical intervention, 8 (92%) were hospitalized, and 7 (78%) required ≥3 months of antibacterial drug therapy. Healthcare providers should consider infection with rapidly growing mycobacteria in patients who have surgical site infections unresponsive to standard treatment.

Rapidly growing Mycobacterium infections after cosmetic surgery in medical tourists: the Bronx experience and a review of the literature

BACKGROUND

Medical tourism is increasingly popular for elective cosmetic surgical procedures. However, medical tourism has been accompanied by reports of post-surgical infections due to rapidly growing mycobacteria (RGM). The authors' experience working with patients with RGM infections who have returned to the USA after traveling abroad for cosmetic surgical procedures is described here.

METHODS

Patients who developed RGM infections after undergoing cosmetic surgeries abroad and who presented at the Montefiore Medical Center (Bronx, New York, USA) between August 2015 and June 2016 were identified. A review of patient medical records was performed.

RESULTS

Four patients who presented with culture-proven RGM infections at the sites of recent cosmetic procedures were identified. All patients were treated with a combination of antibiotics and aggressive surgical treatment.

CONCLUSIONS

This case series of RGM infections following recent cosmetic surgeries abroad highlights the risks of medical tourism. Close monitoring of affected patients by surgical and infectious disease specialties is necessary, as aggressive surgical debridement combined with appropriate antibiotic regimens is needed to achieve cure. Given the increasing reports of post-surgical RGM infections, consultants should have a low threshold for suspecting RGM, as rapid diagnosis may accelerate the initiation of targeted treatment and minimize morbidity.

Rapid-Growing Mycobacteria Infections in Medical Tourists: Our Experience and Literature Review

BACKGROUND

"Medical tourism" has gained popularity over the past few decades. This is particularly common with patients seeking elective cosmetic surgery in the developing world. However, the risk of severe and unusual infectious complications appears to be higher than for patients undergoing similar procedures in the United States.

OBJECTIVES

The authors describe their experience with atypical mycobacterial infections in cosmetic surgical patients returning to the United States postoperatively.

METHODS

A review of patient medical records presenting with infectious complications after cosmetic surgery between January 2010 and July 2015 was performed. Patients presenting with mycobacterial infections following cosmetic surgery were reviewed in detail. An extensive literature review was performed for rapid-growing mycobacteria (RGM) related to cosmetic procedures.

RESULTS

Between January 2010 and July 2015, three patients presented to our institution with culture-proven Mycobacterium abscessus at the sites of recent cosmetic surgery. All had surgery performed in the developing world. The mean age of these patients was 36 years (range, 29-44 years). There was a delay of up to 16 weeks between the initial presentation and correct diagnosis. All patients were treated with surgical drainage and combination antibiotics with complete resolution.

CONCLUSIONS

We present series of patients with mycobacterial infections after cosmetic surgery in the developing world. This may be related to the endemic nature of these bacteria and/or inadequate sterilization or sterile technique. Due to low domestic incidence of these infections, diagnosis may be difficult and/or delayed. Consulting physicians should have a low threshold to consider atypical etiologies in such scenarios.

LEVEL OF EVIDENCE

5 Therapeutic.

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient

Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).

Post Liposuction Mycobacterium Abscessus Surgical Site Infection in a Returned Medical tourist Complicated by a Paradoxical Reaction During Treatment

Rapidly growing mycobacterial skin and soft tissue infections are known to complicate cosmetic surgical procedures. Treatment consists of more surgery and prolonged antibiotic therapy guided by drug susceptibility testing. Paradoxical reactions occurring during antibiotic therapy can further complicate treatment of non-tuberculous mycobacterial infections. We report a case of post liposuction Mycobacterium abscessus surgical site infection in a returned medical tourist and occurrence of paradox during treatment.

Multilocus enzyme electrophoresis analysis of rapidly-growing mycobacteria: an alternative tool for identification and typing

OBJECTIVES

Rapidly growing mycobacteria (RGM) have emerged as important pathogens in clinical settings, associated with esthetic procedures and postsurgical infections, pulmonary infections among cystic fibrosis patients, and other structural pulmonary diseases. Microorganisms belonging to Mycobacterium abscessus-Mycobacterium chelonae and to Mycobacterium fortuitum groups have frequently been associated with outbreaks and various epidemics. In the present study, RGM strains were characterized in order to investigate molecular markers based on proteomic analysis.

METHODS

Multilocus enzyme electrophoresis (MLEE) was used for species identification and clonal analysis of RGM recovered from postsurgical wound infections during an epidemic. The study included 30M. abscessus subsp. bolletii clinical isolates, most belonging to the BRA100 clone (epidemic in Rio de Janeiro city), as well as 16 RGM ATCC reference strains.

RESULTS

Molecular typing allowed the detection of diversity in the studied population and revealed species-specific isoenzymatic patterns. Additionally, the clonal relationship among M. abscessus subsp. bolletii outbreak isolates, as examined using MLEE, was markedly consistent.

CONCLUSIONS

Isoenzymatic characterization was found to be a useful molecular tool to identify RGM species and to determine the relatedness among closely related M. abscessus subsp. bolletii isolates. This may be considered a powerful approach for epidemiological studies on RGM.

Nontuberculous mycobacterial osteomyelitis

Osteomyelitis caused by nontuberculous mycobacteria (NTM) can have severe consequences and a poor prognosis. Physicians therefore need to be alert to this condition, especially in immunocompromised patients. Although the pathogenesis of NTM osteomyelitis is still unclear, studies in immunodeficient individuals have revealed close relationships between NTM osteomyelitis and defects associated with the interleukin-12-interferon-γ-tumor necrosis factor-α axis, as well as human immunodeficiency virus infection, various immunosuppressive conditions, and diabetes mellitus. Culture and species identification from tissue biopsies or surgical debridement tissue play crucial roles in diagnosing NTM osteomyelitis. Suitable imaging examinations are also important. Adequate surgical debridement and the choice of appropriate, combined antibiotics for long-term anti-mycobacterial chemotherapy, based on in vitro drug susceptibility tests, are the main therapies for these bone infections. Bacillus Calmette-Guerin vaccination might have limited prophylactic value. The use of multiple drugs and long duration of treatment mean that the therapeutic process needs to be monitored closely to detect potential side effects. Adequate duration of anti-mycobacterial chemotherapy together with regular monitoring with blood and imaging tests are key factors determining the recovery outcome in patients with NTM osteomyelitis.

Multisite Infection with Mycobacterium abscessus after Replacement of Breast Implants and Gluteal Lipofilling

Introduction. Medical tourism for aesthetic surgery is popular. Nontuberculous mycobacteria (NTM) occasionally cause surgical-site infections. As NTM grow in biofilms, implantations of foreign bodies are at risk. Due to late manifestation, infections occur when patients are back home, where they must be managed properly. Case Report. A 39-year-old healthy female was referred for acute infection of the right gluteal area. Five months before, she had breast implants replacement, abdominal liposuction, and gluteal lipofilling in Mexico. Three months postoperatively, implants were removed for NTM-infection in Switzerland. Adequate antibiotic treatment was stopped after seven days for drug-related hepatitis. At entrance, gluteal puncture for bacterial analysis was performed. MRI showed large subcutaneous collection. Debridement under general anaesthesia was followed by open wound management. Total antibiotic treatment was 20 weeks. Methods. Bacterial analysis of periprosthetic and gluteal liquids included Gram-stain plus acid-fast stain, and aerobic, anaerobic and mycobacterial cultures.  Results. In periprosthetic fluid, Mycobacterium abscessus, Propionibacterium, and Staphylococcus epidermidis were identified. The same M. abscessus strain was found gluteally. The gluteal wound healed within six weeks. At ten months' follow-up, gluteal asymmetry persists for deep scarring. Conclusion. This case presents major complications of multisite aesthetic surgery. Surgical-site infections in context of medical tourism need appropriate bacteriological investigations, considering potential NTM-infections.