An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants

Mycobacterium wolinskyi infection after breast augmentation: A case report and comprehensive review

We present a case report about a 26-year-old female with a Mycobacterium wolinskyi surgical site infection after bilateral breast augmentation. In a unique approach compared with previously reported cases, the patient was successfully treated in an outpatient setting using only orally administered cotrimoxazole (trimethoprim-sulfamethoxazole) and ciprofloxacin with one-sided preservation of the breast prothesis. We also provide a comprehensive overview of all report cases of M. wolinskyi infections available in the PubMed database until December 2023 and compare the different diagnostic and therapeutic approaches.

Molecular epidemiology of nontuberculous mycobacteria isolated from tuberculosis-suspected patients

It is a growing problem around the world to deal with nontuberculous mycobacteria infection (NTM), but its clinical significance is still largely unknown. This study aims to investigate the epidemiology of NTM infections from various clinical samples and determine their clinical significance. From December 2020 to December 2021, 6125 clinical samples were collected. In addition to phenotypic detection, genotypic detection through multilocus sequence typing (hsp65, rpoB, and 16S rDNA genes) and sequencing was also conducted. Records of patients were consulted for clinical information, such as symptoms and radiological findings. Of the 6,125 patients, 351 (5.7%) were positive for acid-fast bacteria (AFB). Out of 351 AFB, 289 (82.3%) and 62 (17.7%) subjects were identified as M. tuberculosis complex (MTC) and NTM strains, respectively. Isolates of Mycobacterium simiae and M. fortuitum were the most frequent, followed by isolates of M. kansasii and M. marinum. We also isolated M. chelonae, M. canariasense, and M. jacuzzii, which are rarely reported. Symptoms (P = 0.048), radiographic findings (P = 0.013), and gender (P = 0.039) were associated with NTM isolates. M. Fortuitum, M. simiae, and M. kansasii presented with bronchiectasis, infiltration, and cavitary lesions most frequently, while cough was the most common symptom. In conclusion, Mycobacterium simiae and M. fortuitum were presented in seventeen and twelve NTM isolates from the collected samples. There is evidence that NTM infections in endemic settings may contribute to the dissemination of various diseases and the control of tuberculosis. In spite of this, further research is needed to evaluate the clinical significance of NTM isolates.

Investigation of a cluster of rapidly growing mycobacteria infections associated with joint replacement surgery in a Kentucky hospital, 2013-2014 with 8-year follow-up

BACKGROUND

We describe the investigation of a nosocomial outbreak of rapidly growing mycobacteria (RGM) infections and the results of mitigation efforts after 8 years.

METHODS

A cluster of RGM cases in a Kentucky hospital in 2013 prompted an investigation into RGM surgical site infections following joint replacement surgery. A case-control study was conducted to identify risk factors.

RESULTS

Eight cases were identified, 5 caused by M. wolinskyi and 3 by M. goodii. The case-control study showed the presence of a particular nurse in the operating room was significantly associated with infection. Environmental sampling at the nurse's home identified an outdoor hot tub as the likely source of M. wolinskyi, confirmed by pulsed-field gel electrophoresis and whole genome sequencing. The hot tub reservoir was eliminated, and hospital policies were revised to correct infection control lapses. No new cases of RGM infections have been identified as of 2021.

DISCUSSION

Breaches in infection control practices at multiple levels may have led to a chain of infection from a nurse's hot tub to surgical sites via indirect person-to-person transmission from a colonized health care worker (HCW).

CONCLUSIONS

The multifactorial nature of the outbreak's cause highlights the importance of overlapping or redundant layers of protection preventing patient harm. Future investigations of RGM outbreaks should consider the potential role of colonized HCWs as a transmission vector.

A case report of wrist synovial infection due to Mycobacterium jacuzzii, Iran

Background

Mycobacterium jacuzzii (M. jacuzzii) was first isolated in 2003 by insertion of breast implants in Tel Aviv, Israel. In this case report, we describe our experience in detection of M. jacuzzii using phenotypic and genotypic test of wrist synovial sample.

Case presentation

A 73-year-old woman complained of pain and swelling in the right wrist for 4 months. Her body temperature was 37–38 °C, and symptoms, such as pain, swelling, and some movement limitation, were reported. Clinical laboratory parameters showed an elevated C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), and white blood cells (WBC) count. The sequences of hsp65, rpoB, 16S rDNA, and sodA genes indicated very high homology to M. jacuzzii.

Conclusion

We report a case of synovial infection caused by M. jacuzzii in a patient with severe wrist pain in Iran, who was treated with amikacin, levofloxacin, and ethambutol. The outcomes of treatment after 8 months were positive, and no recurrence of infection was reported in the patient.

Surgical cure of clarithromycin resistant Mycobacterium chelonae breast implant infection: A case report and review of the literature

Clusters of patients who obtain cosmetic surgeries abroad have developed surgical site infections due to rapid growing non-tuberculous mycobacteria (NTM). These are usually treated with a combination of surgery and months of anti-mycobacterial therapy, but poor outcomes, including permanent scarring are common. We present a case of a 36-year-old female who developed a clarithromycin-resistant M. chelonae (CRMC) infection after undergoing breast augmentation in the Dominican Republic. She underwent debridement and explant of her silicone implants, but due to a series of complications including discordant antimicrobial susceptibility testing profiles, GI side effects, and then pregnancy, she was unable to receive typical multidrug anti-mycobacterial therapy after surgery. She received close clinical follow up and demonstrated full recovery without any evidence of recurrence of infection at 9 months of follow up. We searched the literature for cases of NTM surgical site infection after breast surgery. To our knowledge, this is the first case report of confirmed NTM breast implant infection being cured with surgery alone, and only the second report of clarithromycin resistant M. chelonae in a patient without disseminated infection or pre-exposure to macrolides. The increasing prevalence of drug resistant NTM infections is an emerging concern for clinicians treating patients with complications related to medical tourism.

Revisiting Perioperative Hair Removal Practices

The standard of practice for perioperative hair removal is largely based on research that is outdated and underpowered. Although there is evidence to support the practice of clipping instead of shaving, current recommendations are to remove hair only when absolutely necessary. Human hair is bacteria-laden and challenging to disinfect, and clipping can be a safe method of hair removal that does not damage the skin. This article considers the removal of hair at the incision site with clippers, either before the patient enters the OR or in a manner that completely contains clipped hair, for every procedure, not just when absolutely necessary. There have been only two studies to date comparing clipping with no hair removal; more research is needed on this subject.

Outbreak of Nontuberculous Mycobacteria Joint Prosthesis Infections, Oregon, USA, 2010-2016

We investigated a cluster of Mycobacterium fortuitum and M. goodii prosthetic joint surgical site infections occurring during 2010–2014. Cases were defined as culture-positive nontuberculous mycobacteria surgical site infections that had occurred within 1 year of joint replacement surgery performed on or after October 1, 2010. We identified 9 cases by case finding, chart review, interviews, surgical observations, matched case–control study, pulsed-field gel electrophoresis of isolates, and environmental investigation; 6 cases were diagnosed >90 days after surgery. Cases were associated with a surgical instrument vendor representative being in the operating room during surgery; other potential sources were ruled out. A tenth case occurred during 2016. This cluster of infections associated with a vendor reinforces that all personnel entering the operating suite should follow infection control guidelines; samples for mycobacterial culture should be collected early; and postoperative surveillance for <90 days can miss surgical site infections caused by slow-growing organisms requiring specialized cultures, like mycobacteria.

Breast Implant Infections: An Update

Prosthetic breast implantation is a common surgical procedure for augmentation and reconstruction after mastectomy. The incidence of implant infection is 1% to 2.5% and is higher for reconstruction following mastectomy compared with augmentation. Most infections are caused by gram-positive pathogens, such as coagulase-negative staphylococci, Cutibacterium species, Staphylococcus aureus, and streptococci. Acute infections are usually associated with fever and breast pain, erythema, and drainage. Subacute infections may present with chronic pain, persistent drainage, failed healing of the incision site, or migration of the implant. Depending on severity of infection, patients are started on empiric intravenous or oral antibiotics and closely monitored.

[Triclosan-coated sutures in colorectal surgery : Assessment and meta-analysis of the recommendations of the WHO guideline]

BACKGROUND

In the global guidelines for the prevention of surgical site infections (SSI), the World Health Organization (WHO) recommends the general use of triclosan-coated sutures irrespective of the type of surgical intervention.

OBJECTIVE

Can this recommendation on the use of triclosan-coated sutures be confirmed by a meta-analysis specifically for colorectal surgery?

METHODS

Randomized and non-randomized clinical trials comparing triclosan-coated and uncoated sutures for the efficacy in reducing the SSI rate in colorectal surgery were identified by a systematic literature review. In addition, various quality criteria were set for the studies to be included: SSI definition according to the Centers for Disease Control and Prevention (CDC), a priori sample size calculation and a maximum SSI rate of 20%. The odds ratios were pooled using a fixed and random effects model, the 95% confidence intervals (CI) were calculated and subgroup analyses were carried out.

RESULTS

Included in the meta-analysis were 3 prospective randomized trials (RCT) and 3 non-randomized trials involving a total of 2957 subjects. The average SSI rate was 6.90% (76/1101) in the triclosan group and 9.11% (169/1856) in the control group, resulting in an odds ratio of 0.62 (95% CI: 0.29-1.31). Subgroup analysis showed a decreased risk for SSI in monocentric trials (OR = 0.39, 95% CI: 0.25-0.60) but an increased SSI risk in multicenter trials (OR = 1.75, 95% CI: 1.11-2.77).

CONCLUSION

Against the background of a moderate to high risk of bias and the partially contradictory findings of the studies, the general recommendation of the WHO on the use of triclosan-coated sutures for colorectal surgery could not be confirmed.

Perioperative hair removal: A review of best practice and a practice improvement opportunity

The current practice of perioperative hair removal reflects research-driven changes designed to minimize the risk of surgical wound infection. An aspect of the practice which has received less scrutiny is the clean-up of the clipped hair. This process is critical. The loose fibers represent a potential infection risk because of the micro-organisms they can carry, but their clean-up can pose a logistical problem because of the time required to remove them. Research has demonstrated that the most commonly employed means of clean-up, the use of adhesive tape or sticky mitts, can be both ineffective and time-consuming in addition to posing an infection risk from cross-contamination. Recently published research evaluating surgical clippers fitted with a vacuum-assisted hair collection device highlights the potential for significant practice improvement in the perioperative hair removal clean-up process. These improvements include not only further mitigation of potential infection risk but also substantial OR time and cost savings.

Surgical Head Coverings: A Literature Review

Microorganisms that cause surgical site infections may either be present on the patient's skin or mucous membranes or transmitted to the patient by health care personnel, the environment, or other items in the perioperative setting. This literature review analyzes the evidence used to support the recommendation that perioperative personnel should cover their heads, hair, and ears in the semirestricted and restricted areas. A literature search produced 27 articles related to bacterial shedding from skin and hair, pathogenic organisms present on the hair and ears, and case reports of infectious organisms passed from health care providers to patients. Although there is no conclusive evidence that wearing a head covering can help prevent surgical site infections, the potential benefits to patients when compared with the risks suggest that perioperative team members should cover their heads, hair, and ears in the semirestricted and restricted areas to provide the best possible protection for surgical patients.

Invasive Nontuberculous Mycobacterial Infections among Cardiothoracic Surgical Patients Exposed to Heater-Cooler Devices1

Invasive nontuberculous mycobacteria (NTM) infections may result from a previously unrecognized source of transmission, heater–cooler devices (HCDs) used during cardiac surgery. In July 2015, the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention (CDC) about a cluster of NTM infections among cardiothoracic surgical patients at 1 hospital. We conducted a case–control study to identify exposures causing infection, examining 11 case-patients and 48 control-patients. Eight (73%) case-patients had a clinical specimen identified as Mycobacterium avium complex (MAC). HCD exposure was associated with increased odds of invasive NTM infection; laboratory testing identified patient isolates and HCD samples as closely related strains of M. chimaera, a MAC species. This investigation confirmed a large US outbreak of invasive MAC infections in a previously unaffected patient population and suggested transmission occurred by aerosolization from HCDs. Recommendations have been issued for enhanced surveillance to identify potential infections associated with HCDs and measures to mitigate transmission risk.

Percutaneous breast implant herniation: a rare complication of miliary TB

We describe the case of a 46-year-old female patient treated for disseminated tuberculosis (TB) infection involving the lungs, urinary tract and skin. Following initiation of antituberculous therapy, the patient's right breast implant eroded through the overlying skin and was seen to be herniating through the resulting defect. The breast implant was removed under local anaesthetic and histological analysis of the resected tissue demonstrated granuloma formation consistent with periprosthetic TB. Wound healing following implant removal was poor and future breast augmentation surgery was only considered following completion of 12 months anti-TB treatment. This case constitutes the first report in the literature of percutaneous breast implant herniation resulting from periprosthetic infection with TB. A high index of suspicion is required to ensure early detection and timely management of TB and, in cases where periprosthetic pus aspirate is sterile, mycobacterial infection must be actively excluded.

Diversity, community composition, and dynamics of nonpigmented and late-pigmenting rapidly growing mycobacteria in an urban tap water production and distribution system

Nonpigmented and late-pigmenting rapidly growing mycobacteria (RGM) have been reported to commonly colonize water production and distribution systems. However, there is little information about the nature and distribution of RGM species within the different parts of such complex networks or about their clustering into specific RGM species communities. We conducted a large-scale survey between 2007 and 2009 in the Parisian urban tap water production and distribution system. We analyzed 1,418 water samples from 36 sites, covering all production units, water storage tanks, and distribution units; RGM isolates were identified by using rpoB gene sequencing. We detected 18 RGM species and putative new species, with most isolates being Mycobacterium chelonae and Mycobacterium llatzerense. Using hierarchical clustering and principal-component analysis, we found that RGM were organized into various communities correlating with water origin (groundwater or surface water) and location within the distribution network. Water treatment plants were more specifically associated with species of the Mycobacterium septicum group. On average, M. chelonae dominated network sites fed by surface water, and M. llatzerense dominated those fed by groundwater. Overall, the M. chelonae prevalence index increased along the distribution network and was associated with a correlative decrease in the prevalence index of M. llatzerense, suggesting competitive or niche exclusion between these two dominant species. Our data describe the great diversity and complexity of RGM species living in the interconnected environments that constitute the water production and distribution system of a large city and highlight the prevalence index of the potentially pathogenic species M. chelonae in the distribution network.

Infections associated with body modification

Although exact statistics are lacking, body modifications for cosmetic purposes are performed in many countries. The commonest forms include tattooing, body piercing, and breast and facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, mesotherapy are also practiced in many countries. Infective complications of these procedures include local infections, transmission of bloodborne pathogens (viral hepatitis and human immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures.

Breast implant infections

Infection after breast implant surgery occurs in 1.1% to 2.5% of procedures performed for augmentation and up to 35% of procedures performed for reconstruction after mastectomy. Most infections result from skin organisms and occur in the immediate postoperative period, although infections can occasionally present after many years. Diagnosis of breast implant infection relies on the clinical presentation of breast pain, swelling, erythema, and drainage in conjunction with ultrasound-guided cultures of periprosthetic fluid. Management commonly involves implant removal, with device salvage attempted in select situations.

[Infections due to rapidly growing mycobacteria]

Rapidly growing mycobacteria (RGM) are ubiquitous in nature and widely distributed in water, soil and animals. During the past three decades we have observed a notable increment of infections caused by RGM, both localized and disseminated, as well as nosocomial outbreaks of contaminated medical equipment. The microbiological diagnosis of RGM infections includes direct microscopic observation and culture. The taxonomic identification is performed by phenotypic, biochemical, chromatographic and molecular biology techniques. The treatment differs from that of other mycobacteriosis like tuberculosis, owing to the variable in vitro susceptibility of the species of this group. The RGM are resistant to conventional antituberculous drugs, but can be susceptible to broad spectrum antimicrobial agents. In this study we comment on the significant aspects of human infections by RGM, including their biology, epidemiology, pathology, microbiological diagnosis, taxonomic identification, antimicrobial susceptibility and treatment.

Identification of Mycobacterium spp. of veterinary importance using rpoB gene sequencing

Background

Studies conducted on Mycobacterium spp. isolated from human patients indicate that sequencing of a 711 bp portion of the rpoB gene can be useful in assigning a species identity, particularly for members of the Mycobacterium avium complex (MAC). Given that MAC are important pathogens in livestock, companion animals, and zoo/exotic animals, we were interested in evaluating the use of rpoB sequencing for identification of Mycobacterium isolates of veterinary origin.

Results

A total of 386 isolates, collected over 2008 - June 2011 from 378 animals (amphibians, reptiles, birds, and mammals) underwent PCR and sequencing of a ~ 711 bp portion of the rpoB gene; 310 isolates (80%) were identified to the species level based on similarity at ≥ 98% with a reference sequence. The remaining 76 isolates (20%) displayed < 98% similarity with reference sequences and were assigned to a clade based on their location in a neighbor-joining tree containing reference sequences. For a subset of 236 isolates that received both 16S rRNA and rpoB sequencing, 167 (70%) displayed a similar species/clade assignation for both sequencing methods. For the remaining 69 isolates, species/clade identities were different with each sequencing method. Mycobacterium avium subsp. hominissuis was the species most frequently isolated from specimens from pigs, cervids, companion animals, cattle, and exotic/zoo animals.

Conclusions

rpoB sequencing proved useful in identifying Mycobacterium isolates of veterinary origin to clade, species, or subspecies levels, particularly for assemblages (such as the MAC) where 16S rRNA sequencing alone is not adequate to demarcate these taxa. rpoB sequencing can represent a cost-effective identification tool suitable for routine use in the veterinary diagnostic laboratory.

Epidemic of postsurgical infections caused by Mycobacterium massiliense

An epidemic of infections after video-assisted surgery (1,051 possible cases) caused by rapidly growing mycobacteria (RGM) and involving 63 hospitals in the state of Rio de Janeiro, Brazil, occurred between August 2006 and July 2007. One hundred ninety-seven cases were confirmed by positive acid-fast staining and/or culture techniques. Thirty-eight hospitals had cases confirmed by mycobacterial culture, with a total of 148 available isolates recovered from 146 patients. Most (n = 144; 97.2%) isolates presented a PRA-hsp65 restriction pattern suggestive of Mycobacterium bolletii or Mycobacterium massiliense. Seventy-four of these isolates were further identified by hsp65 or rpoB partial sequencing, confirming the species identification as M. massiliense. Epidemic isolates showed susceptibility to amikacin (MIC at which 90% of the tested isolates are inhibited [MIC(90)], 8 microg/ml) and clarithromycin (MIC(90), 0.25 microg/ml) but resistance to ciprofloxacin (MIC(90), >or=32 microg/ml), cefoxitin (MIC(90), 128 microg/ml), and doxycycline (MIC(90), >or=64 microg/ml). Representative epidemic M. massiliense isolates that were randomly selected, including at least one isolate from each hospital where confirmed cases were detected, belonged to a single clone, as indicated by the analysis of pulsed-field gel electrophoresis (PFGE) patterns. They also had the same PFGE pattern as that previously observed in two outbreaks that occurred in other Brazilian cities; we designated this clone BRA100. All five BRA100 M. massiliense isolates tested presented consistent tolerance to 2% glutaraldehyde. This is the largest epidemic of postsurgical infections caused by RGM reported in the literature to date in Brazil.

Seasonality of clinical isolation of rapidly growing mycobacteria

Rapidly growing mycobacteria (RGM) are environmental organisms that have emerged as significant human pathogens. RGM infections show remarkable geographic variations. In this study, based on data from Houston, Texas, RGM were isolated from clinical cultures year-round, although peaks in the summer and autumn correlating with the seasonal variation of temperature and rainfall also were noted. These results may offer some explanation for the summer occurrence of RGM outbreaks at diverse locations.

Outbreak of surgical infection caused by non-tuberculous mycobacteria in breast implants in Brazil

SUMMARY

We investigated an outbreak caused by non-tuberculous mycobacteria (NTM) related to breast implant surgery in the city of Campinas, Brazil, by means of a retrospective cohort and molecular epidemiological study. A total of 492 records of individuals having breast surgery in 12 hospitals were evaluated. Twelve isolates were analysed using four different molecular typing methods. There were 14 confirmed cases, 14 possible cases and one probable case. One probable, nine possible and 12 confirmed cases were included in a cohort study; all occurred in eight of the hospitals and the confirmed cases in five. Univariate analysis showed that patients who had had breast reconstruction surgery in hospitals A and B were more likely to have NTM infections. No risk factor was independently associated with NTM infection in the multivariate model. The isolates obtained from patients at each hospital showed different molecular patterns, excluding isolates from hospital C that repeatedly showed the same genotype for approximately one year. In conclusion, this outbreak was caused by polyclonal strains at different institutions, and in one hospital a unique genotype caused most cases. No specific risk factors were found.

Mycobacterium barrassiae sp. nov., a Mycobacterium moriokaense group species associated with chronic pneumonia

Three identical isolates of new rapidly growing mycobacteria (RGM) were recovered from the bronchial aspirate and sputum from a 49-year-old woman presenting with lung lesions. The case met the American Thoracic Society criteria for the diagnosis of nontuberculous mycobacterial infection. The three isolates grew in 3 days at 24 to 42 degrees C. The 16S rRNA gene sequence analysis indicated that the sequences of the isolates were identical and shared 99.7% and 98.1% similarities with those of Mycobacterium moriokaense and Mycobacterium gadium, respectively. Partial 723-bp rpoB sequence analyses indicated that the sequences of the isolates shared 95.8% and 92.3% similarities with those of M. moriokaense and M. gadium, respectively. Polyphasic identification (including biochemical tests; antimicrobial susceptibility profiling; and hsp65, recA, and sodA gene sequence analyses, as well as G+C content determination and cell wall fatty acid composition analysis) supported the evidence that these isolates were representative of a new species. Phylogenetic analyses confirmed the close relationships of the isolates with M. moriokaense and the defined M. moriokaense group. These isolates were susceptible to the antimicrobials currently recommended for the treatment of RGM infections. These isolates differed from M. moriokaense by their susceptibility to vancomycin. We propose the name Mycobacterium barrassiae sp. nov. for this new species. The type strain is N7T (CIP 108545T and CCUG 50398T).