Skin and soft tissue infections caused by nontuberculous mycobacteria

Successful treatment of infections caused by mycobacterium abscessus complex following aesthetic procedures: A case series in China

BACKGROUND

Aesthetic procedure-associated infections caused by Mycobacterium abscessus complex (MABC) have been an emerging concern. However, limited evidence is available on this topic, and there are no standard treatments. The selection of antimicrobial regimens for the effective treatment of MABC infections poses a significant challenge.

CASE PRESENTATION

In this case series, we present three patients in China who developed MABC infections following various aesthetic procedures. Two patients presented with localized skin and soft tissue infections, whereas one patient developed a disseminated infection. Treatment involved a combination of intravenous amikacin and cefoxitin for more than two weeks, followed by an oral regimen comprising clarithromycin, linezolid, and moxifloxacin based on drug susceptibility testing results. Despite the treatment's efficacy, the patients experienced adverse reactions to the antibiotics, including gastrointestinal symptoms, anaemia, and hearing loss. All patients achieved successful outcomes with shorter treatment courses and no relapse during the 3-year follow-up period.

CONCLUSION

This case series emphasizes the importance of employing appropriate combination antibiotic therapies based on drug susceptibility testing results for aesthetic procedure-associated infection caused by MABC when specific subspecies are unidentified. The combination of intravenous aminoglycosides and cefoxitin, followed by oral sequential therapy, with the course of treatment specifically tailored to the severity of the infection, provides a valuable treatment reference for patients with MABC infections in China.

Demographic and clinical features of nontuberculous mycobacteria infection resulting from cosmetic procedures: a systematic review

OBJECTIVES

This systematic review aims to (1) summarize the demographic and clinical characteristics of patients with nontuberculous mycobacterial (NTM) infections following cosmetic procedures; (2) summarize the frequency of pathogenic NTM species; and (3) review and analyze the antibiotics choice as well as treatment outcomes.

METHODS

We conducted a systematic search of three electronic databases (Scopus, Embase, and PubMed) from inception to March 31, 2024. We presented demographic and clinical features and the main antibiotic strategy, along with etiological information.

RESULTS

A total of 200 patients were included in the analysis, with a median onset age of 38.0 years. The median latency period before the illness was 28 days. Nodules were the most frequently reported type of lesion, occurring in 31.0% (n = 62/200) of cases. Mycobacterium abscessus was the most commonly found NTM (45%). Clarithromycin was the most commonly applied (64.0%, n = 128/200), followed by amikacin (31.0%, n = 62/200). The median treatment duration was 6 months (0.25, 24). The overall treatment effectiveness rate was 97.4% (n = 148/152).

CONCLUSION

NTM infections caused by cosmetic procedures are rapidly increasing worldwide and present diagnostic and treatment challenges. Dermatologists and aesthetic practitioners should be aware of this relatively uncommon disease. Further research is needed to standardize management algorithms.

Skin and Soft Tissue Nontuberculous Mycobacteria Infection: A Retrospective Case Series of 49 Patients

BACKGROUND

The incidence of skin and soft tissue nontuberculous mycobacteria infection (SSTNI) is increasing. But it may be challenging to diagnose and treat SSTNI.

OBJECTIVE

To summarize course, clinical features, diagnosis and treatment of SSTNI and discuss the association between SSTNI and procedures.

METHODS

A retrospective case series study was conducted among patients diagnosed with SSTNI after surgical procedures. Medical history was collected, disease course and characteristics were analyzed.

RESULTS

49 patients were collected. Among them, 39 (80%) patients were infected with Mycobacterium abscesses. 40 (82%) patients had a history of fat-related procedures. The median and interquartile range of onset time were 15 and 43 days (1-100). Time from first visit to diagnosis was 82±57 days (23-308). Wound healing time was 161±92 days (30-545). The most common symptom were redness (96%), followed by swelling (96%), abscess (84%), pain (80%) and induration (76%). The most common infected site were head and neck (56%), followed by breasts (20%). 6 (12.5%) patients were diagnosed clearly before admission to our department. 10 (28%) patients showed positive acid-fast bacilli (AFB) smears among 36 patients. Treatment included debridement surgeries, drainage and antibiotics.

CONCLUSION

Patient with the above symptoms should be considered as SSTNI. Results of AFB smears are frequently negative after empirical antibiotic treatment so that molecular diagnostic techniques are required for rapid and accurate identification. Debridement surgeries, drainage and sensitive antibiotics are effective. Drug safety and psychological status should be paid attention.

LEVEL OF EVIDENCE IV

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 .

The Price of Beauty: A Literature Review on Non-Tuberculous Mycobacteria Infection After Cosmetic Procedures

Non-tuberculous mycobacteria (NTM) infection of the skin and soft tissues is a complication of cosmetic procedures. The incidence of cutaneous NTM infections has increased significantly as aesthetic operations have become more commonplace. With the rise of cosmetic tourism, the geographic expansion of NTM infections is a major concern. Due to the unique pathogenesis of NTM infections, diagnosis and treatment remain significant challenges for clinicians. Clinical management relies on a combination of antibiotic therapy with drug susceptibility testing and appropriate surgical debridement. Some new drugs, photodynamic therapy, and bacteriophage therapy have been developed in recent years, and may improve the aesthetic outcomes. This review summarizes the cosmetic procedures prone to NTM infections in recent years and their clinical features. We propose a 2-stage treatment procedure, including a hospitalization phase and a follow-up phase. We aim to increase the alertness of clinicians to NTM infections for timely detection and treatment.

LEVEL OF EVIDENCE: 3

A case report of Mycobacterium fortuitum infection after muscle injection

RATIONALE

Injection-related abscesses are a common complication in clinical practice, but the identification of infected bacteria might be difficult.

PATIENT CONCERNS

A 51-year-old female patient was admitted to the hospital due to a lump on her right buttock that emerged after receiving intramuscular injections to treat left shoulder joint pain. The lump gradually enlarged into a 3.0 to 4.5 cm mass at the time of admission with symptoms such as skin redness, itching, and pain.

DIAGNOSES

The patient received ultrasonic and other laboratory examinations. Laboratory results from the drainage indicated that the infection was caused by a rapidly growing mycobacteria and was confirmed as Mycobacterium fortuitum by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

INTERVENTIONS

The patient was treated with antibiotics for 12 days after incision and drainage of the abscess in the right buttock. Local dressings were changed regularly. A migration lesion that appeared 3 days after treatment was drained and cleaned when it matured.

OUTCOMES

The lesion substantially decreased in size and the patient was discharged after 2 months of treatment.

LESSONS

Rapidly growing mycobacteria are rare but important pathogens that should be considered in patients with injection-related abscesses. Early identification and appropriate treatment can result in a favorable prognosis.

Identification of Significant Pathogenic Nontuberculous Mycobacteria Species from Presumptive TB Patients Using Partial hsp65 Gene Sequencing

Purpose

To date, the diagnosis of nontuberculous mycobacteria (NTM) disease primarily relies on clinical symptoms and radiological features. Our objective was to apply a sequence-based analysis method by using partial gene sequencing of heat shock protein 65 (hsp65) to identify NTM species.

Patients and Methods

A total of 32 stored isolates obtained from individuals suspected of having pulmonary NTM infection were subjected to solid Ogawa culture. Genomic DNA from each sample was extracted and used in a conventional polymerase chain reaction (PCR) targeting a specific region of hsp65 gene. Identified amplicons from the PCR were then subjected to targeted sequencing. Analysis of the obtained hsp65 sequence was performed using DNA Baser tool. The consensus sequences obtained were compared to references in the GenBank NCBI database to determine NTM species.

Results

We identified several important NTM species which posses opportunistic characteristics. M. abscessus and M. chelonae are the most frequent NTM species identified in this study (40.63% and 18.75%, respectively). These two species have the potential to cause significant infections in human, ranging from opportunistic pulmonary infection to localized skin infection. Additionally, pathogenic NTM members of M. fortuitum group (MFG), M. avium, M. intracellulare, M. kansasii, and M. celatum were also found among all identified species.

Conclusion

Sequence-based analysis is a promising method for identifying species of NTM. The hsp65 gene has a high discriminatory power to identify opportunistic pathogen NTM species in specimens in Indonesia. Consequently, hsp65 partial gene sequencing is considerable as an alternative and reliable approach for NTM speciation.

Non-tuberculous mycobacterial skin and soft tissue infections in the Northern Territory, Australia, 1989-2021

BACKGROUND

A previous review demonstrated that the majority of NTM infections in the Northern Territory (NT) are pulmonary in nature [1], however skin and soft tissue (SST) are likely the next most common sites of disease. The current epidemiology of NTM SST infections across the NT is not known. We aimed to establish the current and historical incidence rates, and the organisms involved.

METHODS

All NTM cases reported to the Centre for Disease Control in Darwin from 1989-2021 were retrospectively reviewed.

RESULTS

226 NTM notifications were reviewed. 73 (32%) cases were SST infections. The incidence of SST cases increased over the study period. Female cases were more common (p=0·002). Disease occurred across a wide age range (1-85 years). Only 16% of cases occurred in Aboriginal individuals which may reflect immunological factors requiring further investigation. Many cases had no clear provocation, but localised skin trauma was the most common risk factor. The most common organism identified was M. fortuitum (41%). Diagnosis was often delayed, with a median time to diagnosis of 69 days (IQR=31-149). Most cases (60%) underwent surgical intervention with adjunctive anti-mycobacterial medical therapy.

CONCLUSION

NTM SST incidence rates increased over the study period. NTM SST infections are a rare but important differential diagnosis for non-healing cutaneous wounds.

Nontuberculous mycobacterial skin and soft tissue infection in Hawai'i

Background

Hawaiʻi has the highest nontuberculous mycobacterial (NTM) lung infection prevalence in the United States. Limited data regarding skin and soft tissue infections (SSTI) due to NTM in Hawaiʻi exists. This study describes patient demographics, clinical courses of infection, treatment patterns, and clinical outcomes of NTM SSTIs in Hawaiʻi.

Methods

A retrospective chart review (n = 50) of patients diagnosed and treated at Hawaiʻi Pacific Health facilities for NTM SSTIs between January 2010 and July 2021 was conducted. Patient demographics, clinical course, and treatment data were collected from electronic medical records.

Results

Half of the patient population consisted of females, and the average age of patients during infection was 49 years (SD = 25.6). The majority of cases (80%) were caused by rapidly growing mycobacteria (RGM), most commonly Mycobacterium abscessus. NTM SSTI by race were Asian (48%), White (28%), and Native Hawaiian and Other Pacific Islanders (16%). Almost all Asian patients with NTM SSTI were Filipino or Japanese. Diagnosis was frequently delayed. The average time to diagnosis was 116 days. Most patients achieved complete resolution (72%) following a prolonged course of antimicrobial treatment (mean = 196 days) with surgical debridement.

Conclusion

Increased awareness among physicians and the community of non-mycobacterial skin infections is essential in Hawaiʻi due to the high prevalence of NTM and the high percentage of predisposed populations. Increased awareness of NTM could reduce delayed diagnosis and improve patient care. Further studies are required to inform optimal treatment and diagnostic strategies, improve patient outcomes, and aid public health surveillance efforts.

A cold-blooded tiptoer: non-resolving cellulitis in an immunocompromised patient

Mycobacterium haemophilum is a nontuberculous mycobacteria (NTM) with a predilection for skin and soft tissue infection (SSTI) in the immunocompromised host. We report a case of disseminated M haemophilum infection initially presenting as a nonresolving subacute cellulitis of bilateral lower extremities. Genetic sequencing was used for final identification, while a commercially available polymerase chain reaction test returned a false-positive result for Mycobacterium intracellulare. Consequently, we highlight the importance of M haemophilum as a major differential diagnosis of SSTI in the immunocompromised host and the need for careful interpretation of rapid diagnostic tests.

Methods for Detecting Mycobacterial Mixed Strain Infections-A Systematic Review

Mixed strain infection (MSI) refers to the concurrent infection of a susceptible host with multiple strains of a single pathogenic species. Known to occur in humans and animals, MSIs deserve special consideration when studying transmission dynamics, evolution, and treatment of mycobacterial diseases, notably tuberculosis in humans and paratuberculosis (or Johne's disease) in ruminants. Therefore, a systematic review was conducted to examine how MSIs are defined in the literature, how widespread the phenomenon is across the host species spectrum, and to document common methods used to detect such infections. Our search strategy identified 121 articles reporting MSIs in both humans and animals, the majority (78.5%) of which involved members of the Mycobacterium tuberculosis complex, while only a few (21.5%) examined non-tuberculous mycobacteria (NTM). In addition, MSIs exist across various host species, but most reports focused on humans due to the extensive amount of work done on tuberculosis. We reviewed the strain typing methods that allowed for MSI detection and found a few that were commonly employed but were associated with specific challenges. Our review notes the need for standardization, as some highly discriminatory methods are not adapted to distinguish between microevolution of one strain and concurrent infection with multiple strains. Further research is also warranted to examine the prevalence of NTM MSIs in both humans and animals. In addition, it is envisioned that the accurate identification and a better understanding of the distribution of MSIs in the future will lead to important information on the epidemiology and pathophysiology of mycobacterial diseases.

Patients with Idiopathic Pulmonary Nontuberculous Mycobacterial Disease Have Normal Th1/Th2 Cytokine Responses but Diminished Th17 Cytokine and Enhanced Granulocyte-Macrophage Colony-Stimulating Factor Production

Objective

Although disseminated nontuberculous mycobacterial infection is attributed to defects in the interleukin (IL)-12/interferon-γ circuit, the immunophenotype of idiopathic pulmonary nontuberculous mycobacterial (PNTM) disease is not well defined.

Method

We phenotyped Th1, Th2, Th17, and Treg cytokines and colony-stimulating factor production from patients with idiopathic PNTM disease. Data were compared with healthy donors, cystic fibrosis (CF), and primary ciliary dyskinesia (PCD) patients with PNTM disease. Both supernatant cytokine production and intracellular cytokines expressed by various leukocyte subpopulations following mitogen and antigen stimulation were assayed by electrochemiluminescence-based multiplex immunoassay and flow cytometry, respectively.

Results

Regardless of antigen or mitogen stimulation, neither intracellular nor extracellular Th1, Th2, and Treg cytokine levels differed between patients and controls. Th17 cells and IL-17A levels were lower in idiopathic PNTM patients, whereas monocyte granulocyte-macrophage colony-stimulating factor (GM-CSF) expression in response to NTM stimulation was higher compared with healthy donors. Besides, distinct cytokine responses following stimulation by Mycobacterium abscessus and Mycobacterium avium were observed consistently within each group.

Conclusions

The IL-12/IFN-γ circuit appeared intact in patients with idiopathic PNTM disease. However, idiopathic PNTM patients had reduced Th17 response and higher mycobacteria-induced monocyte GM-CSF expression.

HMGN2 regulates non-tuberculous mycobacteria survival via modulation of M1 macrophage polarization

Non‐tuberculous mycobacteria (NTM), also known as an environmental and atypical mycobacteria, can cause the chronic pulmonary infectious diseases. Macrophages have been suggested as the main host cell to initiate the innate immune responses to NTM infection. However, the molecular mechanism to regulate the antimicrobial immune responses to NTM is still largely unknown. Current study showed that the NTM clinical groups, Mycobacterium abscessus and Mycobacterium smegmatis, significantly induced the M1 macrophage polarization with the characteristic production of nitric oxide (NO) and marker gene expression of iNOS, IFNγ, TNF‐α, IL1‐β and IL‐6. Interestingly, a non‐histone nuclear protein, HMGN2 (high‐mobility group N2), was found to be spontaneously induced during NTM‐activated M1 macrophage polarization. Functional studies revealed that HMGN2 deficiency in NTM‐infected macrophage promotes the expression of M1 markers and the production of NO via the enhanced activation of NF‐κB and MAPK signalling. Further studies exhibited that HMGN2 knock‐down also enhanced IFNγ‐induced M1 macrophage polarization. Finally, we observed that silencing HMGN2 affected the survival of NTM in macrophage, which might largely relevant to enhanced macrophage polarization into M1 phenotype under the NTM infection. Collectively, current studies thus suggested a novel function of HMGN2 in regulating the anti‐non‐tuberculous mycobacteria innate immunity of macrophage.

Physiopathology and current treatments of androgenetic alopecia: Going beyond androgens and anti-androgens

Androgenetic alopecia (AGA) is the most diagnosed hair loss dysfunction. Its physiopathology comprises a genetic predisposition affording an exacerbated response of the hair follicles cells to androgens aggravated by scalp inflammation and extrinsic factors. This paper presents a review of the mechanisms and extrinsic factors involved in the AGA physiopathology as well as its conventional and emerging treatments. The research focused on reports regarding AGA physiopathology and treatments published between January 2001 and July 2019 in medical and related journals. The most used medical treatments for AGA-minoxidil and finasteride-present non satisfactory results in some cases. Currently, the low-level laser therapy is recognized as a safe and effective treatment for AGA. Some minimally invasive techniques-mesotherapy, microneedling, carboxytherapy, and platelet-rich plasma-are also used to stimulate hair growth. Pharmaceutical substances with mechanisms differing from the anti-androgen activity are under current investigation and many of them have botanical origins; however, formulations with higher performance are required, and the hair follicles ability of being a drug and nanoparticle reservoir has been researched. The association of different strategies, that is, substances with synergic mechanisms and the use of advantageous technologies associated with lifestyle changes could improve the treatment outcomes.

Cutaneous nontuberculous mycobacteria infections: A retrospective case series of 78 patients from the Texas Gulf Coast region

BACKGROUND

The incidence of cutaneous nontuberculous mycobacteria (NTM) infections is increasing. These infections are a diagnostic and therapeutic challenge.

OBJECTIVE

We investigated the clinical features, diagnosis, and management of cutaneous NTM infections.

METHODS

A retrospective case series studied 78 patients from a Gulf Coast tertiary referral center diagnosed with cutaneous NTM infection by culture or stain of a skin biopsy specimen.

RESULTS

A history of trauma, procedure, or environmental exposure was common. The mean time between the initial evaluation and diagnosis was 12 weeks. Only 15% of acid-fast bacillus-positive cultures had a positive acid-fast bacillus smear, and only 43% of those accompanied by skin biopsy specimen had a positive Fite stain. Immunosuppressed patients were more likely to have a positive Fite stain. Treatment included surgery and multiple antibiotics. Immunosuppressed patients and Mycobacterium abscessus group infections were more likely to have persistent disease.

LIMITATIONS

M chelonae and M abscessus isolates were indistinguishable and therefore were reported together. Five cases were not confirmed by culture.

CONCLUSIONS

Even with clinical suspicion, the diagnosis of NTM infection can be difficult. Results of acid-fast bacillus smears and special stains are frequently negative. Antibiotic resistance is common. Multidrug treatment is often required, and surgical therapy may be needed.

Chronic Mycobacterium avium skin and soft tissue infection complicated with scalp osteomyelitis possibly secondary to anti-interferon-γ autoantibody formation

Background

Nontuberculous mycobacterial (NTM) disease is commonly an opportunistic infection frequently found in immunocompromised individuals, but sometimes can also be found in the immunocompetent hosts, especially in East Asians. The NTM separation rate in China is increasing, which reminds us to focus on NTM infections in immunocompromised populations.

Case presentation

A 43-year-old woman with a recurrent fever for more than 8-month and a right forehead surgical wounds unhealed for more than 6-month was admitted to our hospital on February 22, 2018. On arrival, several elliptic ulcers were obvious on the right forehead with pus and fibrin exudation, and the skin around the lesions was tender, reddish, no sense of fluctuation. The result of HIV serology test was negative. CD4+ T cell count was normal and tuberculosis antibody was negative. CT of the chest and head showed bone destruction. Skin biopsy on the right forehead was performed on March 13, 2018, and pathological examination of the excisional biopsy specimen found inflammatory granuloma and suppurative inflammatory changes. Broad-spectrum antibiotics were treated but the effect seemed discontent. Then debridement and skin grafting were performed on the right frontal ulcer under general anesthesia on April 3, 2018. The skin tissue culture that resected on March 13, 2018 found Nontuberculous mycobacteria grown after 78 days, so clarithromycin, ethambutol, protionamide, and amoxicillin clavulanate potassium were prescribed for anti-nontuberculous mycobacteria treatment beginning on May 31, 2018. In reviewing the case, Mycobacterium avium (M. avium) was identified in the skin tissue resected on April 3, 2018 by polymerase chain reaction (PCR) and the serum test of anti-interferon-γ autoantibodies was positive.

Conclusions

This is a case report of “Mycobacterium avium SSTI (skin and soft tissue infection) and OM (osteomyelitis) with possible secondary immunodeficiency syndrome induced by anti-interferon-γ autoantibody”.

Infections and outbreaks of nontuberculous mycobacteria in hospital settings

Purpose of review

Non-tuberculous mycobacterial [NTM] infections in the hospital setting are a complex and often challenging entity. The goal of this review is to discuss diagnostic and treatment strategies for established as well as emerging nosocomial NTM infections.

Recent findings

NTM outbreaks have been documented in a variety of hospital settings. Contamination of medical devices or aqueous solutions is often implicated in the spread of infection. More recently, the slow grower M. chimaera has been reported in the setting of contaminated heater-cooler devices used for cardiopulmonary bypass and extracorporeal membrane oxygenation. In addition, increases in medical tourism for cosmetic surgery have led to outbreaks of rapidly growing mycobacteria.

Summary

Diagnosis and treatment of nosocomial NTM pose many challenges for the clinician. Surgical resection or debridement as well as combination antimycobacterial therapy are a mainstay in therapeutic management. Strict infection control and prevention practices are critical to the identification and cessation of outbreaks.

Dermatological Complications After Solid Organ Transplantation

Organ transplant recipients (OTRs) are a population at high risk for cutaneous adverse events. Their early recognition and appropriate treatment is an important component of the clinical management of OTRs and should be optimally dealt with by dermatologists working in the context of a transplant dermatology clinic. Skin examination should be a standard procedure before performing organ transplantation to assess conditions which may be difficult to manage after the transplant procedure has been performed or which may represent a contraindication to transplantation, e.g., malignant melanoma. It also offers an opportunity to educate patients on skin care after organ transplantation. Skin infections can occur at any time after organ transplantation and include viral, bacterial, and fungal opportunistic infections. The risk of reactivation of latent viruses, such as varicella-zoster virus (VZV) and cytomegalovirus (CMV), is high. Bacterial infections are frequent and may be caused by unusual agents such Actinomyces, Mycobacteria, Legionella, or Nocardia. A large spectrum of fungal infections may occur, ranging from superficial (e.g., dermatophytes) to deeper and more severe ones (Alternaria, Aspergillus, Cryptococcus, Histoplasma). Drug-related idiosyncratic reactions usually occur early after the introduction of the causative drug, e.g., hypersensitivity reaction to azathioprine. On the long-term run, cutaneous effects due to cumulative drug toxicity, e.g., sebaceous hyperplasia from cyclosporine, may appear. Rare immunologically driven inflammatory reactions may occur in OTRs such as GVH or autoimmune disease. Tumors are particularly frequent. Kaposi's sarcoma, associated with persistent human herpes virus 8 (HHV8) infection, and cutaneous anaplastic large-cell lymphoma (ALCL) occur early after transplantation. Other cancers, such as nonmelanoma skin cancer (NMSCs), associated with persistent human papillomavirus (HPV) infections, malignant melanoma, Merkel cell carcinoma, or adnexal tumors, manifest later with an incidence which is much higher than observed in the general population. The incidence increases further after a first NMSC occurs.

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.

In Vitro Evaluation of Povidone-Iodine and Chlorhexidine against Outbreak and Nonoutbreak Strains of Mycobacterium abscessus Using Standard Quantitative Suspension and Carrier Testing

Povidone-iodine (PI) and chlorhexidine (CHX) are widely used antiseptics active against conventional Staphylococcus aureus, Enterobacteriaceae, Candida species, and viruses, but their efficacy against Mycobacterium abscessus remains unproven. We determined the in vitro potency of alcoholic PI and CHX against M. abscessus subsp. abscessus (ATCC 19977), M. abscessus subsp. bolletii (BCRC 16915), and our outbreak strain of M. abscessus subsp. massiliense (TPE 101) in reference to Staphylococcus aureus (ATCC 29213) by standard quantitative suspension and carrier methods (EN 14563). By suspension, all mycobacterial strains compared to S. aureus were significantly more resistant to CHX, but not PI. By carrier, the mean logarithmic reductions (LR) achieved by PI under clean (dirty) conditions were 6.575 (2.482), 5.540 (2.298), 4.595 (1.967), and 1.173 (0.889), while those achieved by CHX under clean (dirty) conditions were 3.164 (5.445), 5.307 (2.564), 3.844 (2.232), and 0.863 (0.389) for S. aureus, M. abscessus subsp. bolletii, M. abscessus subsp. abscessus, and M. abscessus subsp. massiliense, respectively. M. abscessus subsp. massiliense (outbreak strain) was significantly more resistant than the other tested strains to PI and CHX. By both methods, the mean LR achieved by PI was higher than for CHX for all mycobacterial strains, but under dirty conditions, neither antiseptic was effectively mycobactericidal (LR < 5). These preliminary findings caution against the universal replacement of PI with CHX as the first-line skin antiseptic, since all M. abscessus isolates were resistant to CHX. More studies are needed to establish the best practice for skin antisepsis if mycobacterial infections are also to be prevented.

Nontuberculous Mycobacterial Infections After Silicone Breast Implant Reconstruction Emphasize a Diversity of Infecting Mycobacteria

Postsurgical skin and soft tissue infections (SSTIs) caused by nontuberculous mycobacteria (NTM) are uncommon, indolent, difficult to treat, and often mimic pyogenic bacterial infections. Here we present 3 cases of NTM infections following placement of silicone implants for reconstructive breast surgery. These cases emphasize the importance of a high index of suspicion for NTM in patients with SSI after a prosthetic reconstruction refractory to conventional antibiotic therapy and the importance of early investigation with mycobacterial-specific diagnostics.

Nontuberculous Mycobacterial Infections in a French Hospital: A 12-Year Retrospective Study

Background

Nontuberculous mycobacteria (NTM) are environmental organisms associated with a range of infections. Reports of NTM epidemiology are mainly focused on pulmonary infections and isolations, and extrapulmonary infections are less frequently described.

Methods

We conducted a retrospective study of NTM infections at the Bordeaux University Hospital, France, between January 2002 and December 2013. We used the microbiologic component of the American Thoracic Society/Infectious Diseases Society of America's pulmonary NTM disease criteria to define cases of pulmonary NTM, and patients with isolates from a normally sterile site were classified as having extrapulmonary disease.

Results

In our setting, 170 patients were included. Pulmonary cases predominated (54.1%), followed by skin and soft tissue infections (22.9%), disseminated cases (10.6%), lymphadenitis (7.7%), bone and joint infections (2.9%) and the remaining 1.8% catheter-related infections. Overall, 16 NTM species were isolated. Mycobacterium avium (31.8%) and M. intracellulare (20%) were the most common species identified, followed by M. marinum (13.5%), M. kansasii (10.6%), M. xenopi (9.4%), rapidly growing mycobacteria (9.4%) and other slowly growing mycobacteria (5.3%). In general, NTM isolates were largely prevalent in people older than 50 (62.4%); patients aged 1–10 year-old exclusively yielded M. avium from lymph nodes, almost cases having being diagnosed after 2007. Among the 121 patients with complete follow-up, 78 (64.5%), 24 (19.8%), and 19 (15.7%) were cured, experienced relapse, or died, respectively.

Conclusion

In our study, extrapulmonary NTM infections represented almost half of cases, consisting mainly in skin and soft tissue infections. The increase lymphadenitis cases in children after 2007 could be linked to the cessation of mandatory BCG vaccination in France. We observed similar cure rates (64%) between pulmonary and extrapulmonary infections.

Mycobacterium fortuitum empyema associated with an indwelling pleural catheter: Case report and review of the literature

Mycobacterium fortuitum is a rapidly growing mycobacterium (RGM) that is an uncommon cause of healthcare-associated infections. The most common infections caused by M. fortuitum include skin, soft tissue, and catheter-related infections. Although occasionally cultured from sputum samples, M. fortuitum is a rare cause of pulmonary disease. We report a case of M. fortuitum empyema associated with an infected pleural catheter and review M. fortuitum pulmonary infections.

Prolonged postprocedural outbreak of Mycobacterium massiliense infections associated with ultrasound transmission gel

Postprocedural infections by Mycobacterium abscessus complex are increasing worldwide, and the source and route of transmission are infrequently identified. Here the extension of a previous clustering of paediatric patients with surgical site infections due to a single strain of the subspecies M. massiliense is reported. The investigation was conducted at a 2200-bed teaching hospital in Taiwan and included microbial surveillance of the environment (water, air, equipment and supplies) and a case-control study. We performed molecular identification and typing of the isolates by a trilocus sequencing scheme, confirmed by multilocus sequencing typing and pulsed-field gel electrophoresis. We investigated 40 patients who developed postprocedure soft tissue or bloodstream infections by M. massiliense (TPE101) during a 3-year period. Thirty-eight patients were identified at hospital A, and one newborn and her mother were identified at hospital B (185 km from hospital A). A case-control study identified the association of invasive procedures (adjusted odds ratio, 9.13) and ultrasonography (adjusted odds ratio, 2.97) (both p <0.05) with acquiring the outbreak strain. Isolates from the cases and unopened bottles of ultrasound transmission gel were all of strain ST48 and indistinguishable or closely related by pulsed-field gel electrophoresis. After replacement of contaminated gel, no new cases were detected during 18 months' follow-up. This investigation identified the use of contaminated gel as the common source causing an outbreak on a larger scale than had been recognized. Our findings halted production by the manufacturer and prompted revision of hospital guidelines.

Nontuberculous mycobacterial infections: a potential complication of cosmetic procedures

Interest in surgical and non-surgical cosmetic procedures has increased significantly over the last few decades. Billions of dollars are spent on these procedures annually. Although the associated risk is generally low, multiple cases of skin and soft tissue infections have been reported. Nontuberculous mycobacteria (NTM), in particular M. chelonae, M. fortuitum, and M. abscessus, have been increasingly identified as causative of numerous cosmetic procedure–related infections worldwide. This has therefore become a public health concern. Delays in diagnosis and appropriate management may occur given subtleties in diagnostic methods. The purpose of this review is to highlight the NTM-related skin and soft tissue infections associated with more common cosmetic procedures, describe methods of identification, and outline best treatment practices.

Mycobacterial skin and soft tissue infection

Mycobacterial skin and soft tissue infection (SSTI) includes nontuberculous mycobacterial (NTM) infections, tuberculosis (TB), and leprosy. Diagnosis of mycobacterial SSTI can be challenging due to diverse clinical presentation, low yield from cultured specimens, and nonspecific histopathology on tissue biopsy. In addition, immunosuppressed patients may present with atypical or disseminated disease. Despite aggressive medical treatment and often with surgical intervention, results may be suboptimal with poor outcomes. Regimens typically require multiple antibiotics for extended periods of time and are often complicated by medication side effects and drug-drug interactions. Biopsy with culture is the gold standard for diagnosis, but newer molecular diagnostics and proteomics such as matrix-assisted laser desorption ionization-time of flight mass spectrometry have improved diagnosis with increased identification of clinically significant mycobacteria species in clinically relevant time frames. We will review updates in diagnostic tests along with clinical presentation and treatment of mycobacterial SSTI for NTM, TB, and leprosy.