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Mycobacterium chelonae Infections Associated with Face Lifts --- New Jersey, 2002--2003

Please note: An erratum has been published for this article. To view the erratum, please click here.

In March 2003, the New Jersey Department of Health and Senior Services (NJDHSS) was notified about three patients who acquired surgical-site infections caused by Mycobacterium chelonae after having face lifts (i.e., rhytidectomies) performed at an outpatient surgical center. NJDHSS learned subsequently of another patient with M. chelonae infection who had a rhytidectomy performed at a second surgical center. The four patients received diagnoses of M. chelonae infection during March 2002--February 2003. NJDHSS conducted an epidemiologic, environmental, and microbiologic investigation. This report summarizes the results of that investigation, which identified contaminated methylene blue used as a tissue-marking agent as the source of infection. Surgeons should use only sterile, single-use, tissue-marking agents during procedures that require aseptic technique, and clinicians should consider M. chelonae when evaluating surgical-site infections.

To search for additional cases of M. chelonae infection, NJDHSS interviewed surgical center staff, reviewed logs maintained at the two surgical centers to identify postoperative infections, and interviewed clinicians who performed procedures at these surgical centers about cases of mycobacterial infection. A clinical case was defined as a case involving a nonhealing surgical incision lasting >30 days or a surgical-site infection unresponsive to empiric antibiotic therapy in a patient who had an operation during February 2002--March 2003 at either center. Cases were classified as confirmed, probable, or suspect. A patient with a confirmed case had cutaneous signs of infection (e.g., erythema, swelling, or drainage) consistent with the clinical case definition and isolation of M. chelonae from surgical-site drainage. A patient with a probable case had cutaneous signs of infection consistent with the clinical case definition and evidence of acid-fast bacilli on a smear prepared from surgical-site drainage but lacked culture confirmation. A patient with a suspect case had cutaneous signs of infection consistent with the clinical case definition but lacked laboratory evidence of bacterial infection.

Of the four cases identified initially, three were confirmed, and one was suspect; no additional cases were identified. All patients had been treated by the same surgeon, who performed 55 procedures (including six face lifts) at the two surgical centers during the study period. Two patients had rhytidectomies only, one patient had a combined rhytidectomy and blepharoplasty, and one had a rhytidectomy combined with blepharoplasty and liposuction of the lower extremities. All patients were female. The median age of the women was 56 years (range: 44--69 years). Two patients had had previous facial cosmetic surgery; none had an immunocompromising medical condition. The median time from surgical procedure to onset of clinically apparent infection was 30 days (range: 18--34 days). The median time from illness onset to presumptive diagnosis of mycobacterial infection was approximately 21 days (range: 8--38 days). Clinical findings included erythema, tenderness, nodular lesions, and drainage localized to the area of the surgical incision. No patient reported systemic manifestations (e.g., fever or chills).

One patient's infection resolved without sequelae after 8 months of treatment with clarithromycin. Another patient had areas of hyperpigmentation at the surgical site despite 9 months of clarithromycin and 6 months of concurrent ciprofloxacin therapy. This patient also underwent incision and drainage of her surgical wound. Of the remaining two patients, one had hyperpigmentation and scarring after taking an antibiotic regimen that consisted of varying courses of imipenem-cilastatin, linezolid, and clarithromycin during a 9-month period, and one patient was lost to follow-up.

Investigation of this cluster included an onsite review of the patients' surgical records and the surgical centers' infection-control policies. An environmental investigation did not identify substantial breaches in cleaning, disinfectant, or sterilization practices. Environmental samples obtained included the swabbed surface of a surgical instrument, wastewater from a steam sterilizer, and tap water from lines supplying a steam sterilizer and ultrasonic cleaner. None of the samples yielded mycobacteria.

Interviews with surgical center staff indicated that the patients' surgeon used a water-based solution of methylene blue to mark incisions on exposed muscle during rhytidectomies. No other surgeons affiliated with the surgical centers used methylene blue in this manner. In addition, the surgeon used this dye only during rhytidectomies. All sources of methylene blue that were available when the patients had their rhytidectomies were removed from circulation and tested at the New Jersey Public Health and Environmental Laboratories. These sources included 1) a 4-ounce bottle of 0.5% unsterile methylene blue that was prepared commercially in September 1999 and found in an office at the surgical center where three cases occurred, 2) a tube containing dye, 3) a single syringe used to dispense dye into a cup during multiple rhytidectomy procedures, and 4) an opened, single-use vial of 1% methylene blue. Mycobacteria identified as M. chelonae were isolated from each source.

Wound isolates from the three patients with culture-confirmed infections and the isolates from the four sources of methylene blue were sent to CDC for species confirmation and molecular typing. On the basis of the results of high-performance liquid chromatography, the isolates were confirmed to be M. chelonae. Molecular typing, using random amplification of polymorphic DNA, indicated that the methylene blue and wound isolates were the same strain. No additional cases were reported after the surgical centers replaced their stock of methylene blue with sterile, single-use vials.

Reported by: G Knackmuhs, MD, Ridgewood Infectious Disease Associates, Ridgewood; M Gerwel, MD, C Patterson, N Cipollone, M Navitski, R Lawler, A Monaco, MA, M Dillon, E Bresnitz, MD, C Tan, MD, New Jersey Dept of Health and Senior Svcs. R Cooksey, PhD, Div of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases; CA Robertson, MD, EIS Officer, CDC.

Editorial Note:

M. chelonae (formerly known as M. chelonae subspecies chelonae) is one of a group of rapidly growing mycobacteria that can cause localized soft-tissue and skeletal infections in otherwise healthy persons and disseminated disease in patients with impaired immune function (1). Soft-tissue infections caused by M. chelonae typically manifest initially as slightly tender nodules with scant drainage and minimal surrounding cellulitis; systemic manifestations often are absent (2). The indolent course typical of these infections, together with a low index of suspicion and failure to request or perform the appropriate diagnostic tests (e.g., acid-fast staining), can make timely diagnosis of M. chelonae infections difficult (3).

Clarithromycin is effective against M. chelonae, but a course of treatment for >6 months might be necessary for cure (4). Because monotherapy can lead to antimicrobial resistance, clarithromycin might be used in conjunction with another antibiotic that is effective against M. chelonae (e.g., amikacin, imipenem, or tobramycin) (4). Even with antibiotic therapy, abscess and ulcer formation can occur, which might require surgical debridement (3). Scarring also is a potential outcome of infection caused by rapidly growing mycobacteria after cosmetic surgery (5).

In the United States, the burden of disease caused by M. chelonae is unknown. Clinicians and laboratories are not required to report infections caused by nontuberculous mycobacteria. Because M. abscessus was classified previously as a subspecies of M. chelonae, determining which pathogen was responsible for RGM infections described in older reports is difficult. Limited information about disease trends is available through CDC's Public Health Laboratory Information System (PHLIS), which receives voluntary reports of nontuberculous species suspected to be involved in disease. During 1993--1996, the rate of M. chelonae reports received by PHLIS increased from 0.93 to 2.64 per million population, suggesting that M. chelonae might be recognized increasingly as a cause of disease (6).

M. chelonae has been identified as the cause of approximately 10% of nosocomial outbreaks attributed to rapidly growing mycobacteria (1). M. chelonae might be less virulent than or not as widespread in the environment as other rapidly growing mycobacteria that are commonly responsible for such outbreaks (e.g., M. abscessus and M. fortuitum) (1).

The findings in this report indicate the risks associated with multiuse supplies, specifically the use of unsterile, methylene blue to outline surgical incisions. Because methylene blue is a potential reservoir for M. chelonae, surgeons should use only sterile, single-use, tissue-marking agents during procedures that require aseptic technique, and clinicians should consider M. chelonae when evaluating surgical-site infections.

References

  1. Wallace RJ Jr, Brown BA, Onyi GO. Skin, soft tissue, and bone infections due to Mycobacterium chelonae: importance of prior corticosteroid therapy, frequency of disseminated infections, and resistance to oral antimicrobials other than clarithromycin. J Infect Dis 1992;166:405--12.
  2. McFarland EJ, Kuritzkes DR. Clinical features and treatment of infection due to Mycobacterium fortuitum/chelonae complex. Curr Clin Top Infect Dis 1993;13:188--202.
  3. Kullavanijaya P. Atypical mycobacterial cutaneous infection. Clin Dermatol 1999;17:153--8.
  4. Wallace RJ Jr, Tanner D, Brennan PJ, Brown BA. Clinical trial of clarithromycin for cutaneous (disseminated) infection due to Mycobacterium chelonae. Ann Intern Med 1993;119:482--6.
  5. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 1987;317:197--201.
  6. CDC. Nontuberculous mycobacteria reported to the Public Health Laboratory Information System by state public health laboratories, 1993--1996. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 1999. Available at http://www.cdc.gov/ncidod/dastlr/tb/ntmfinal.pdf.

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