Aesth Plast Surg (2014) 38:1138–1142 DOI 10.1007/s00266-014-0410-7
CASE REPORT
GENERAL RECONSTRUCTION
Management of Mycobacterium abscessus Post Abdominoplasty R. Engdahl • L. Cohen • S. Pouch • C. Rohde
Received: 14 May 2014 / Accepted: 28 September 2014 / Published online: 23 October 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Atypical mycobacterium is the source of a recent outbreak of cosmetic surgery infections [1]. Such an infection is difficult to eradicate and presents unique challenges in its management after esthetic surgery. Delays in appropriate treatment are frequent because of difficulty in diagnosis and unfamiliarity with this type of infection. We present cases of our management of Mycobacterial abscessus abdominoplasty infections following cosmetic surgery in the Dominican Republic. Rapid initial recognition of this problem and the frequent need for surgical treatment of atypical mycobacterium abdominoplasty infection may aid in the treatment of this rare but increasingly encountered infection. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Mycobacteria Abdominoplasty Breast implants Liposuction Complication
R. Engdahl (&) L. Cohen C. Rohde Division of Plastic and Reconstructive Surgery, New YorkPresbyterian Hospital, 161 Fort Washington Avenue, Rm. 511, New York, NY 10032, USA e-mail: [email protected] C. Rohde e-mail: [email protected] S. Pouch Division of Infectious Diseases, Columbia University Medical Center, New York, USA
123
Introduction Atypical mycobacterium infection is on the rise worldwide and is the source of recent outbreaks [1, 2]. These infections present unique challenges in their management after esthetic surgery. Frequently, initial cultures are negative or a patient fails to respond to standard empiric antibiotic regimens, which can delay appropriate treatment and compromise outcomes [2]. We present recent cases of abdominoplasty infection after surgery in the Dominican Republic (DR). We discuss the difficulty of initial recognition of this problem, the requirement for long-term antibiotic therapy, and the frequent need for surgical treatment of atypical mycobacterium abdominoplasty infections.
Cases Over the past 6 months, we have treated a total of nine patients with mycobacterial infections after abdominoplasty. All patients had an indolent course of wound drainage for 3–5 months prior to presentation at Columbia University Medical Center for evaluation. Generally, the patients had been inadequately treated with short courses of antibiotics or local drainage procedures by their initial surgeons. Overt signs of fever and infection were variable. All exhibited open wounds and yellowish serous-appearing drainage. To completely eradicate abdominoplasty infection, all required surgery. Our treatment included elevation of the abdominoplasty flap, fluid drainage and debridement, and removal of plication sutures. Contents were sent for acid-fast bacilli (AFB) testing and culture. Mycobacterium abscessus cultures became positive at 6 days to 2 weeks post-op. All received infectious disease consults and a 6-month course of antibiotics. Three recent cases are discussed in detail.
Aesth Plast Surg (2014) 38:1138–1142
1139
Fig. 1 Mycobacterium abscessus abdominoplasty infection with draining open wounds and without erythema. Right image shows close-up view of umbilicus (Case 1)
Fig. 2 CT scan demonstrating multiple areas of abdominal wall abscesses and a large amount of fluid around breast implants (Case 1). Similar CT findings in the abdominoplasty sites were noted for cases 2 and 3 (not shown)
Case 1
Case 2
A 42-year-old woman 5 months post-operative from an abdominoplasty, breast augmentation, and back and flank liposuction in the DR presented in New York with fevers, breast pain and swelling, and mild abdominal pain with a small amount of serous drainage from the umbilicus and lower abdominal incision (Fig. 1). There was no erythema overlying her abdomen or breasts. A CT scan showed a large amount of fluid surrounding the bilateral breast implants and abdominal wall fat stranding (Fig. 2). She underwent removal of her breast implants with drainage of a large amount of seropurulent fluid, as well as an abdominal wall washout. Her abdominal wall and umbilical area were accessed with elevation of the entire abdominoplasty flap. Multiple abscesses were encountered within the soft tissue flap, within the fascia, and around the prolene plication sutures. Fluid and debridement contents were sent for AFB and culture. All areas of granulation tissue and prolene plication sutures were removed, followed by copious pulse-irrigation. Drains were placed. Cultures isolated a ‘‘fast-grower’’ on post-op day six and final results were M. abscessus. She was discharged with 6 months of antibiotic therapy with ampicillin and cefoxitin. She has been followed in the office with no signs of infection and has healed well.
A 40-year-old female 4 months post-operative from an abdominoplasty, liposuction, and gluteal fat augmentation in the DR presented with chronic drainage from her incisions. Clinical exam revealed serous-appearing drainage from the umbilical incision and areas of scar breakdown, but no erythema or fluctuance (Fig. 3a). She underwent excision of the entire abdominoplasty scar, elevation of the abdominoplasty flap, wound washout, and removal of all plication sutures. Multiple areas of murky yellowish fluid were drained from the left lower abdomen and epigastric area. The midline plication suture had fluid around it as well. AFB cultures isolated M. abscessus on post-operative day 13. Antibiotic therapy consisted of clarithomycin, bactrim, and levaquin for 6 months. She has recovered well and has been followed in the office with healed suture lines and no additional wound drainage. Case 3 A 50-year-old female presented 4 months after breast augmentation and abdominoplasty in the DR with wound drainage and pain. She stated that initially after surgery her incision healed, but 1 month later she developed fever, chills, and yellowish clear liquid drainage from the umbilicus. Her surgeon revised the scar, and she was started on a
123
1140
course of Ciprofloxacin and Bactrim for cultures that were positive for M. abscessus. A month after this, she returned to New York with continued abdominal pain and drainage. She never had any problems with her breast surgical sites.
Aesth Plast Surg (2014) 38:1138–1142
The exam was similar to cases 1 and 2 with yellow, serousappearing drainage at the umbilicus and no appreciable erythema (Fig. 3b). She was started on cefoxitin and clarithromycin and taken to the operating room for excision of the entire abdominoplasty scar, elevation of the abdominoplasty flap, debridement and washout, with removal of all plication sutures (Fig. 4).
Discussion
Fig. 3 Infection with scar breakdown. Drainage from the umbilicus and abdominal scars were noted without erythema (Cases 2 & 3)
Fig. 4 Intra-operative photograph of Case 3. Abdominoplasty scar and open wound excised and yellow thick fluid encountered in multiple areas. Second photo Pockets of purulence noted along and under the rectus plication
123
The reported incidence of surgical site infection after abdominoplasty is 3–5 % [3]. Typical treatment plans target common skin organisms such as streptococcus or staphylococcus, which cause post-operative infections common to most plastic surgeons. For post-operative infections that are initially culture negative or failing to respond to typical antimicrobials and treatment, a mycobacterial infection should be considered. This is especially important when treating patients who had surgery in areas of endemic atypical mycobacterium such as the DR [4]. Complications from esthetic surgery tourism arising from overseas, such as that from the DR, may lead to serious consequences [5]. Atypical mycobacterium infection after cosmetic surgery has been seen in recent outbreaks in New York after cosmetic surgery procedures in DR [1]. Managing this infection after cosmetic surgery presents unique challenges. Clinical presentations of M. abscessus abdominoplasty infections in our patients demonstrate an indolent course of initial wound healing and subsequent draining sinuses with associated deeper abscesses along the abdominal wall. Clinical cases 1–3 had umbilical wound openings with drainage of yellowappearing serous fluid (Figs. 1 and 3). All three patients
Aesth Plast Surg (2014) 38:1138–1142
healed the abdominoplasty incision, but then developed blistering or open wounds that drained yellow fluid. Figure 1 demonstrates typical M. abscessus wounds with chronic-appearing yellow serous drainage. In our series, drainage from the umbilicus was a common sign of abdominoplasty M. abscessus infection. The drainage can be malodorous or odor-free, non-purulent appearing, and can be mistaken for other causes to those unfamiliar with this type of infection. Marked erythema and tenderness are often absent and no patient in our series demonstrated these findings. Systemic signs of infection are variable. Case 1 demonstrates a more acute presentation with fevers and tachycardia, while the other cases demonstrate subjective fevers over a course of months prior to treatment, as well as chronic draining wounds. The most common atypical mycobacterium isolated at our institution is M. abscessus [4], a rapid-growing mycobacterium type (RGM) which also includes M. fortuitum and M. chelonae [6–8]. They typically grow in sub-culture within 1 week which is in contrast to other mycobacterial species that can take up to 6 weeks to grow in culture. M. abscessus wound infection after esthetic surgery has been associated with contaminated irrigation solutions, injectables, instruments and even marking dyes [9–14]. Detection can be difficult since Gram stains and cultures are frequently negative. Dedicated AFB cultures are often required for diagnosis. In our experience, multiple AFB cultures should be sent from fluid and debridement contents in order to maximize culture yield. Intraoperative cultures become positive for M. abscessus between 6 days and 2 weeks. We strongly recommend including appropriate laboratory testing and treatment for those with a high-index of suspicion. Unlike the situation with breast augmentations, where the need to remove the foreign bodies makes surgical washout the obvious treatment, there might be the temptation to treat abdominoplasty mycobacterial infections with antibiotics and localized drainage procedures only. However, this limited approach is generally inadequate to treat these infections. Abdominoplasty infections with M. abscessus are difficult to eradicate and usually require complete removal of infectious foci along with adjunctive antibiotic therapy. When there is high clinical suspicion and radiographic evidence of multiple subcutaneous fluid collections, we completely elevate the entire abdominoplasty flap and excise the involved scar. Fluid and debridement contents are sent for routine and AFB cultures. All areas of granulation tissue and plication sutures are removed followed by copious saline pulse-irrigation. Drains are placed and removed when output is less than 30 cc a day for consecutive days and signs of infection are resolved. A combined treatment approach between plastic surgery and infectious diseases is recommended to optimize the
1141
management of post-operative M. abscessus infections. It is generally considered to be the most pathogenic and drugresistant of the RGM [15]. Resistance to standard antituberculous therapy is typical. Limited susceptibility to antibiotics including imipenem, doxycycline, and trimethoprim-sulfamethoxazole is seen [16]. M. abscessus is often susceptible to clarithromycin and amikacin with sensitivity to these agents in M. abscessus bloodstream ranging from 79 to 100 % among published studies [16– 19]. There is variable sensitivity to cefoxitin, ranging from 7 to 75 % [20], and M. abscessus may display inducible resistance to clarithromycin and other macrolide antibiotics [21]. With the complexity of antimicrobial resistance in M. abscessus isolates, empiric therapy should generally be deferred until the organism is confirmed by the laboratory. Collaboration with infectious disease colleagues regarding antibiotic choices and timing of therapy is strongly recommended. Combination therapy with two or more agents is generally used in the treatment of M. abscessus infections. Specific regimens are normally addressed on a caseby-case basis. M. abscessus responds slowly to antibiotics and the duration of therapy, while typically lasting at least 6 months, is largely driven by each patient’s clinical course.
Conclusions A high-index of suspicion is needed in patients who had surgery overseas with chronic drainage from wounds in order to quickly diagnose atypical mycobacterial infection. AFB testing cultures are recommended for patients suspected of atypical mycobacterial infection after cosmetic surgery. Atypical mycobacterial infections may initially have negative cultures or fail to respond to standard empiric antibiotic regimens, which can delay appropriate treatment and compromise outcomes. Abdominoplasty sites will usually require thorough debridement and operative washout. Cultures are frequently negative and can take a long time to grow out atypical mycobacterium. An infectious disease consult is recommended to determine the best course of antibiotic treatment and duration. Further study is ongoing into the public health and economic implications of mycobacterial infections contracted from overseas cosmetic surgery. Conflict of interest The authors declared no conflict of interests with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article.
123
1142
References 1. NYC Department of Health 2013 ALERT # 38 (12/5/2013). Outbreak on east coast of rapidly-growing mycobacterium infections following cosmetic surgery performed in the Dominican Republic 2. Newman M, Camberos A, Ascherman J (2005) Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter. Ann Plast Surg 55:107–110 3. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N (2006) Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 59:1152–1155 4. 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 (2008) Outbreak of Mycobacterium abscessus wound infections among ‘‘lipotourists’’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 46(8):1181–1188 5. Retrieved July 26, 2014 from http://www.smartbrief.com/07/11/ 14/ny-woman-dies-after-getting-plastic-surgery-abroad 6. Brickman M, Parsa AA, Parsa FD (2005) Mycobacterium cheloneae infection after breast augmentation. Aesthetic Plast Surg 29(2):116–118 7. Pereira LH, Sterodimas A (2010) Autologous fat transplantation and delayed silicone implant insertion in a case of Mycobacterium avium breast infection. Aesthetic Plast Surg 34(1):1–4 8. Dessy LA, Mazzocchi M, Fioramonti P, Scuderi N (2006) Conservative management of local Mycobacterium chelonae infection after combined liposuction and lipofilling. Aesthetic Plast Surg 30(6):717–722 9. Safranek TJ, Jarvis WR, Carson LA (1987) Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 317:197–201
123
Aesth Plast Surg (2014) 38:1138–1142 10. Toy BR, Frank PJ (2003) Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg 29: 971–973 11. De Groote MA, Huitt G (2006) Infections due to rapidly growing mycobacteria. Clin Infect Dis 42:1756–1763 12. Chadha R, Grover M, Sharma A (1998) An outbreak of postsurgical wound infections due to Mycobacterium abscessus. Pediatr Surg Int 13:406–410 13. Kevitch R, Guyuron B (1991) Mycobacterial infection following blepharoplasty. Aesthetic Plast Surg 15(3):229–232 14. Inman PM, Beck A, Brown AE, Stanford JL (1969) Outbreak of injection abscesses due to Mycobacterium abscessus. Arch Dermatol 100:141–147 15. Petrini B (2006) Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS 114:319–328 16. Han XY, De I, Jacobson KL (2007) Rapidly growing mycobacteria: clinical and microbiologic studies of 115 cases. Am J Clin Pathol 128:612–621 17. Griffith DE, Aksamit T, Brown-Elliott BA et al (2007) An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 175:367–416 18. El Helou G, Hachem R, Viola GM et al (2013) Management of rapidly growing mycobacteria bacteremia in cancer patients. Clin Infect Dis 56:843–846 19. Huang YC, Liu MF, Shen GH et al (2010) Clinical outcome of Mycobacterium abscessus infection and antimicrobial susceptibility testing. J Microbiol Immunol Infect 43:401–406 20. El Helou G, Viola GM, Hachem R et al (2013) Rapidly growing mycobacterial bloodstream infections. Lancet Infect Dis 13: 166–174 21. Nash KA, Brown-Elliott BA, Wallace RJ Jr (2009) A novel gene, erm(41), confers inducible macrolide resistance to clinical isolates of Mycobacterium abscessus but is absent from Mycobacterium chelonae. Antimicrob Agents Chemother 53:1367–1376
CASE REPORT
GENERAL RECONSTRUCTION
Management of Mycobacterium abscessus Post Abdominoplasty R. Engdahl • L. Cohen • S. Pouch • C. Rohde
Received: 14 May 2014 / Accepted: 28 September 2014 / Published online: 23 October 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Atypical mycobacterium is the source of a recent outbreak of cosmetic surgery infections [1]. Such an infection is difficult to eradicate and presents unique challenges in its management after esthetic surgery. Delays in appropriate treatment are frequent because of difficulty in diagnosis and unfamiliarity with this type of infection. We present cases of our management of Mycobacterial abscessus abdominoplasty infections following cosmetic surgery in the Dominican Republic. Rapid initial recognition of this problem and the frequent need for surgical treatment of atypical mycobacterium abdominoplasty infection may aid in the treatment of this rare but increasingly encountered infection. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Mycobacteria Abdominoplasty Breast implants Liposuction Complication
R. Engdahl (&) L. Cohen C. Rohde Division of Plastic and Reconstructive Surgery, New YorkPresbyterian Hospital, 161 Fort Washington Avenue, Rm. 511, New York, NY 10032, USA e-mail: [email protected] C. Rohde e-mail: [email protected] S. Pouch Division of Infectious Diseases, Columbia University Medical Center, New York, USA
123
Introduction Atypical mycobacterium infection is on the rise worldwide and is the source of recent outbreaks [1, 2]. These infections present unique challenges in their management after esthetic surgery. Frequently, initial cultures are negative or a patient fails to respond to standard empiric antibiotic regimens, which can delay appropriate treatment and compromise outcomes [2]. We present recent cases of abdominoplasty infection after surgery in the Dominican Republic (DR). We discuss the difficulty of initial recognition of this problem, the requirement for long-term antibiotic therapy, and the frequent need for surgical treatment of atypical mycobacterium abdominoplasty infections.
Cases Over the past 6 months, we have treated a total of nine patients with mycobacterial infections after abdominoplasty. All patients had an indolent course of wound drainage for 3–5 months prior to presentation at Columbia University Medical Center for evaluation. Generally, the patients had been inadequately treated with short courses of antibiotics or local drainage procedures by their initial surgeons. Overt signs of fever and infection were variable. All exhibited open wounds and yellowish serous-appearing drainage. To completely eradicate abdominoplasty infection, all required surgery. Our treatment included elevation of the abdominoplasty flap, fluid drainage and debridement, and removal of plication sutures. Contents were sent for acid-fast bacilli (AFB) testing and culture. Mycobacterium abscessus cultures became positive at 6 days to 2 weeks post-op. All received infectious disease consults and a 6-month course of antibiotics. Three recent cases are discussed in detail.
Aesth Plast Surg (2014) 38:1138–1142
1139
Fig. 1 Mycobacterium abscessus abdominoplasty infection with draining open wounds and without erythema. Right image shows close-up view of umbilicus (Case 1)
Fig. 2 CT scan demonstrating multiple areas of abdominal wall abscesses and a large amount of fluid around breast implants (Case 1). Similar CT findings in the abdominoplasty sites were noted for cases 2 and 3 (not shown)
Case 1
Case 2
A 42-year-old woman 5 months post-operative from an abdominoplasty, breast augmentation, and back and flank liposuction in the DR presented in New York with fevers, breast pain and swelling, and mild abdominal pain with a small amount of serous drainage from the umbilicus and lower abdominal incision (Fig. 1). There was no erythema overlying her abdomen or breasts. A CT scan showed a large amount of fluid surrounding the bilateral breast implants and abdominal wall fat stranding (Fig. 2). She underwent removal of her breast implants with drainage of a large amount of seropurulent fluid, as well as an abdominal wall washout. Her abdominal wall and umbilical area were accessed with elevation of the entire abdominoplasty flap. Multiple abscesses were encountered within the soft tissue flap, within the fascia, and around the prolene plication sutures. Fluid and debridement contents were sent for AFB and culture. All areas of granulation tissue and prolene plication sutures were removed, followed by copious pulse-irrigation. Drains were placed. Cultures isolated a ‘‘fast-grower’’ on post-op day six and final results were M. abscessus. She was discharged with 6 months of antibiotic therapy with ampicillin and cefoxitin. She has been followed in the office with no signs of infection and has healed well.
A 40-year-old female 4 months post-operative from an abdominoplasty, liposuction, and gluteal fat augmentation in the DR presented with chronic drainage from her incisions. Clinical exam revealed serous-appearing drainage from the umbilical incision and areas of scar breakdown, but no erythema or fluctuance (Fig. 3a). She underwent excision of the entire abdominoplasty scar, elevation of the abdominoplasty flap, wound washout, and removal of all plication sutures. Multiple areas of murky yellowish fluid were drained from the left lower abdomen and epigastric area. The midline plication suture had fluid around it as well. AFB cultures isolated M. abscessus on post-operative day 13. Antibiotic therapy consisted of clarithomycin, bactrim, and levaquin for 6 months. She has recovered well and has been followed in the office with healed suture lines and no additional wound drainage. Case 3 A 50-year-old female presented 4 months after breast augmentation and abdominoplasty in the DR with wound drainage and pain. She stated that initially after surgery her incision healed, but 1 month later she developed fever, chills, and yellowish clear liquid drainage from the umbilicus. Her surgeon revised the scar, and she was started on a
123
1140
course of Ciprofloxacin and Bactrim for cultures that were positive for M. abscessus. A month after this, she returned to New York with continued abdominal pain and drainage. She never had any problems with her breast surgical sites.
Aesth Plast Surg (2014) 38:1138–1142
The exam was similar to cases 1 and 2 with yellow, serousappearing drainage at the umbilicus and no appreciable erythema (Fig. 3b). She was started on cefoxitin and clarithromycin and taken to the operating room for excision of the entire abdominoplasty scar, elevation of the abdominoplasty flap, debridement and washout, with removal of all plication sutures (Fig. 4).
Discussion
Fig. 3 Infection with scar breakdown. Drainage from the umbilicus and abdominal scars were noted without erythema (Cases 2 & 3)
Fig. 4 Intra-operative photograph of Case 3. Abdominoplasty scar and open wound excised and yellow thick fluid encountered in multiple areas. Second photo Pockets of purulence noted along and under the rectus plication
123
The reported incidence of surgical site infection after abdominoplasty is 3–5 % [3]. Typical treatment plans target common skin organisms such as streptococcus or staphylococcus, which cause post-operative infections common to most plastic surgeons. For post-operative infections that are initially culture negative or failing to respond to typical antimicrobials and treatment, a mycobacterial infection should be considered. This is especially important when treating patients who had surgery in areas of endemic atypical mycobacterium such as the DR [4]. Complications from esthetic surgery tourism arising from overseas, such as that from the DR, may lead to serious consequences [5]. Atypical mycobacterium infection after cosmetic surgery has been seen in recent outbreaks in New York after cosmetic surgery procedures in DR [1]. Managing this infection after cosmetic surgery presents unique challenges. Clinical presentations of M. abscessus abdominoplasty infections in our patients demonstrate an indolent course of initial wound healing and subsequent draining sinuses with associated deeper abscesses along the abdominal wall. Clinical cases 1–3 had umbilical wound openings with drainage of yellowappearing serous fluid (Figs. 1 and 3). All three patients
Aesth Plast Surg (2014) 38:1138–1142
healed the abdominoplasty incision, but then developed blistering or open wounds that drained yellow fluid. Figure 1 demonstrates typical M. abscessus wounds with chronic-appearing yellow serous drainage. In our series, drainage from the umbilicus was a common sign of abdominoplasty M. abscessus infection. The drainage can be malodorous or odor-free, non-purulent appearing, and can be mistaken for other causes to those unfamiliar with this type of infection. Marked erythema and tenderness are often absent and no patient in our series demonstrated these findings. Systemic signs of infection are variable. Case 1 demonstrates a more acute presentation with fevers and tachycardia, while the other cases demonstrate subjective fevers over a course of months prior to treatment, as well as chronic draining wounds. The most common atypical mycobacterium isolated at our institution is M. abscessus [4], a rapid-growing mycobacterium type (RGM) which also includes M. fortuitum and M. chelonae [6–8]. They typically grow in sub-culture within 1 week which is in contrast to other mycobacterial species that can take up to 6 weeks to grow in culture. M. abscessus wound infection after esthetic surgery has been associated with contaminated irrigation solutions, injectables, instruments and even marking dyes [9–14]. Detection can be difficult since Gram stains and cultures are frequently negative. Dedicated AFB cultures are often required for diagnosis. In our experience, multiple AFB cultures should be sent from fluid and debridement contents in order to maximize culture yield. Intraoperative cultures become positive for M. abscessus between 6 days and 2 weeks. We strongly recommend including appropriate laboratory testing and treatment for those with a high-index of suspicion. Unlike the situation with breast augmentations, where the need to remove the foreign bodies makes surgical washout the obvious treatment, there might be the temptation to treat abdominoplasty mycobacterial infections with antibiotics and localized drainage procedures only. However, this limited approach is generally inadequate to treat these infections. Abdominoplasty infections with M. abscessus are difficult to eradicate and usually require complete removal of infectious foci along with adjunctive antibiotic therapy. When there is high clinical suspicion and radiographic evidence of multiple subcutaneous fluid collections, we completely elevate the entire abdominoplasty flap and excise the involved scar. Fluid and debridement contents are sent for routine and AFB cultures. All areas of granulation tissue and plication sutures are removed followed by copious saline pulse-irrigation. Drains are placed and removed when output is less than 30 cc a day for consecutive days and signs of infection are resolved. A combined treatment approach between plastic surgery and infectious diseases is recommended to optimize the
1141
management of post-operative M. abscessus infections. It is generally considered to be the most pathogenic and drugresistant of the RGM [15]. Resistance to standard antituberculous therapy is typical. Limited susceptibility to antibiotics including imipenem, doxycycline, and trimethoprim-sulfamethoxazole is seen [16]. M. abscessus is often susceptible to clarithromycin and amikacin with sensitivity to these agents in M. abscessus bloodstream ranging from 79 to 100 % among published studies [16– 19]. There is variable sensitivity to cefoxitin, ranging from 7 to 75 % [20], and M. abscessus may display inducible resistance to clarithromycin and other macrolide antibiotics [21]. With the complexity of antimicrobial resistance in M. abscessus isolates, empiric therapy should generally be deferred until the organism is confirmed by the laboratory. Collaboration with infectious disease colleagues regarding antibiotic choices and timing of therapy is strongly recommended. Combination therapy with two or more agents is generally used in the treatment of M. abscessus infections. Specific regimens are normally addressed on a caseby-case basis. M. abscessus responds slowly to antibiotics and the duration of therapy, while typically lasting at least 6 months, is largely driven by each patient’s clinical course.
Conclusions A high-index of suspicion is needed in patients who had surgery overseas with chronic drainage from wounds in order to quickly diagnose atypical mycobacterial infection. AFB testing cultures are recommended for patients suspected of atypical mycobacterial infection after cosmetic surgery. Atypical mycobacterial infections may initially have negative cultures or fail to respond to standard empiric antibiotic regimens, which can delay appropriate treatment and compromise outcomes. Abdominoplasty sites will usually require thorough debridement and operative washout. Cultures are frequently negative and can take a long time to grow out atypical mycobacterium. An infectious disease consult is recommended to determine the best course of antibiotic treatment and duration. Further study is ongoing into the public health and economic implications of mycobacterial infections contracted from overseas cosmetic surgery. Conflict of interest The authors declared no conflict of interests with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article.
123
1142
References 1. NYC Department of Health 2013 ALERT # 38 (12/5/2013). Outbreak on east coast of rapidly-growing mycobacterium infections following cosmetic surgery performed in the Dominican Republic 2. Newman M, Camberos A, Ascherman J (2005) Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter. Ann Plast Surg 55:107–110 3. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N (2006) Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 59:1152–1155 4. 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 (2008) Outbreak of Mycobacterium abscessus wound infections among ‘‘lipotourists’’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 46(8):1181–1188 5. Retrieved July 26, 2014 from http://www.smartbrief.com/07/11/ 14/ny-woman-dies-after-getting-plastic-surgery-abroad 6. Brickman M, Parsa AA, Parsa FD (2005) Mycobacterium cheloneae infection after breast augmentation. Aesthetic Plast Surg 29(2):116–118 7. Pereira LH, Sterodimas A (2010) Autologous fat transplantation and delayed silicone implant insertion in a case of Mycobacterium avium breast infection. Aesthetic Plast Surg 34(1):1–4 8. Dessy LA, Mazzocchi M, Fioramonti P, Scuderi N (2006) Conservative management of local Mycobacterium chelonae infection after combined liposuction and lipofilling. Aesthetic Plast Surg 30(6):717–722 9. Safranek TJ, Jarvis WR, Carson LA (1987) Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 317:197–201
123
Aesth Plast Surg (2014) 38:1138–1142 10. Toy BR, Frank PJ (2003) Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg 29: 971–973 11. De Groote MA, Huitt G (2006) Infections due to rapidly growing mycobacteria. Clin Infect Dis 42:1756–1763 12. Chadha R, Grover M, Sharma A (1998) An outbreak of postsurgical wound infections due to Mycobacterium abscessus. Pediatr Surg Int 13:406–410 13. Kevitch R, Guyuron B (1991) Mycobacterial infection following blepharoplasty. Aesthetic Plast Surg 15(3):229–232 14. Inman PM, Beck A, Brown AE, Stanford JL (1969) Outbreak of injection abscesses due to Mycobacterium abscessus. Arch Dermatol 100:141–147 15. Petrini B (2006) Mycobacterium abscessus: an emerging rapidgrowing potential pathogen. APMIS 114:319–328 16. Han XY, De I, Jacobson KL (2007) Rapidly growing mycobacteria: clinical and microbiologic studies of 115 cases. Am J Clin Pathol 128:612–621 17. Griffith DE, Aksamit T, Brown-Elliott BA et al (2007) An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 175:367–416 18. El Helou G, Hachem R, Viola GM et al (2013) Management of rapidly growing mycobacteria bacteremia in cancer patients. Clin Infect Dis 56:843–846 19. Huang YC, Liu MF, Shen GH et al (2010) Clinical outcome of Mycobacterium abscessus infection and antimicrobial susceptibility testing. J Microbiol Immunol Infect 43:401–406 20. El Helou G, Viola GM, Hachem R et al (2013) Rapidly growing mycobacterial bloodstream infections. Lancet Infect Dis 13: 166–174 21. Nash KA, Brown-Elliott BA, Wallace RJ Jr (2009) A novel gene, erm(41), confers inducible macrolide resistance to clinical isolates of Mycobacterium abscessus but is absent from Mycobacterium chelonae. Antimicrob Agents Chemother 53:1367–1376
