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Plastic Surgery Dominican Republic: Wound Infections with Highly Resistant Bacteria

Outbreak of Mycobacterium abscessus wound infections among “lipotourists” from the United States who underwent abdominoplasty in the Dominican Republic.

Clin Infect Dis. 2008 Apr 15;46(8):1181-8.

Furuya EY, Paez A, Srinivasan A, Cooksey R, Augenbraun M, Baron M, Brudney K, Della-Latta P, Estivariz C, Fischer S, Flood M, Kellner P, Roman C, Yakrus M, Weiss D, Granowitz EV.

Department of Medicine, New York-Presbyterian Hospital-Columbia University Medical Center, New York, New York, USA.

BACKGROUND:

Some US residents travel abroad to undergo cosmetic plastic surgery Dominican Republic for fat removal, a practice referred to as “lipotourism.” Mycobacterium abscessus can cause postsurgical wound infection.

METHODS:

US residents who developed M. abscessus wound infection after undergoing cosmetic surgery in the Dominican Republic in 2003 and 2004 were identified using the Emerging Infections Network listserv.

RESULTS:

Twenty returning US travelers with M. abscessus infection were detected after plastic surgery Dominican Republic. Eight patients had matching isolates, as determined by pulsed-field gel electrophoresis and repetitive element polymerase chain reaction. All 8 patients, who had previously been healthy Hispanic women, underwent abdominoplasties at the same clinic in the Dominican Republic. Symptoms first developed 2-18 weeks after the procedure (median interval, 7 weeks). Only 2 of the 8 patients received a correct diagnosis at the initial presentation. Most patients presented with painful, erythematous, draining subcutaneous abdominal nodules. Seven patients underwent drainage procedures. Six patients received a combination of antibiotics that included a macrolide plus cefoxitin, imipenem, amikacin, and/or linezolid; 2 received clarithromycin monotherapy. All patients but 1 were cured after a median of 9 months of therapy (range, 2-12 months). Because of a lack of access to the surgical clinic, the cause of the outbreak of infection was not identified. The patients who were infected with nonmatching isolates underwent surgeries in different facilities for plastic surgery Dominican Republic but otherwise had demographic characteristics and clinical presentations similar to those of the 8 patients infected with matching isolates.

CONCLUSIONS:

This case series of M. abscessus infection in US “lipotourists” highlights the risks of traveling abroad for surgery and the potential role of the Internet in identifying and investigating outbreaks.

{ 1 comment… add one }

  • hansaplast October 24, 2012, 6:22 am

    What is Mycobacterium abscessus ?

    A very good link is http://www.hopkinsguides.com/hopkins/ub/view/Johns_Hopkins_ABX_Guide/540360/all/Mycobacterium_abscessus.
    In brief:
    – it is an environmental pathogen (like almost all Mycobacteriae)
    – it is slow growing
    – it requires AFB staining
    – cultures take long to turn positive, and if culture for mycobacteria is not performed the pathogen likely goes undetected and the cultures come back “sterile”
    – sensitivity analysis should always be performed, as resistance against the first line treatment with macrolid antibiotics (erm gene expression) is not infrequent; clarithromycin +/- linezolid, amikacin + impipenem are treatment recognized treatment schemes;

    Mycobacterium abscessus is primarliy a lung pathogen. Soft tissue infections like after plastic surgery Dominican Republic also well recognized (injections, liposcution, abdominoplasty, breast reduction, reconstruction or augmentation, post cardiac surgery).
    Interestingly, most major reports state outbreaks in Central and South America, while isolated cases are reported worldwide including the US, France and China amongst others.

    How do healthcare outbreaks occur ? According to the Center of Disease Control (quoting http://www.cdc.gov/hai/organisms/mycobacterium.html):
    “Transmission of M. abscessus can occur in several ways. Infection with M. abscessus is usually caused by injections of substances contaminated with the bacterium or through invasive medical procedures employing contaminated equipment or material. Infection can also occur after accidental injury where the wound is contaminated by soil. There is very little risk of transmission from person to person.”

    This was proven in the case of the largest documented outbreak in plastic surgery Venezuela for contaminated injections (Enferm Infecc Microbiol Clin. 2011 Aug-Sep;29(7):510-4. Epub 2011 Jun 17.).

    In the plastic surgery Dominican Republic outbreak the culprit is likely inadequate cleaning and sterilization of liposuction cannula or tubing or surgical instruments.

    Good infection control is not cheap (e. g. like PIP breast implants) and is likely not performed at all at these so called clinics, which often resemble more a garage than a healthcare facility and also have the infection control practices of a dumpster.