Rapidly Growing Mycobacterial Infection Following Liposuction and Liposculpture -- Caracas, Venezuela, 1996-1998

During October 1996-March 1998, nine patients in eight hospitals in Caracas, Venezuela, acquired surgical-site infections (SSI) caused by rapidly growing mycobacteria (RGM). All episodes of RGM infection occurred within 2 months after liposuction or liposculpture (aesthetic surgical procedures). This report describes the findings of an epidemiologic investigation of this cluster by the Venezuelan Ministry of Health and underscores the importance of sterilizing surgical equipment to prevent nosocomial infections.

A confirmed case was defined as RGM in a patient who underwent liposuction or liposculpture during October 1996-March 1998 (study period) in a surgical facility in Caracas, in whom local signs of SSI were present and for whom cultures of surgical site drainage grew RGM. A probable case was defined as RGM in a patient who underwent liposuction or liposculpture in a surgical facility in Caracas during the study period, who had local signs of infection at the surgical site, and for whom microscopic examination of stained smears of surgical site drainage were positive for acid-fast bacilli.

Seven confirmed and two probable cases from eight hospitals were identified. All case-patients were previously healthy women aged 28-49 years (median: 37.5 years). Eight surgeons and surgical teams performed the cosmetic surgery on the women. All nine case-patients underwent general anesthesia during their surgical procedure; procedures consisted of abdominal liposuction (seven patients), anterior and posterior thigh liposuction (three), or bilateral nasolabial fold liposculpture (two). The median time from surgical procedure to onset of infection was 15 days (range: 4-45 days). Clinical findings included fever, local inflammation, microabscesses, purulent drainage from the wound, or fistulae.

Seven case-patients had culture-confirmed RGM; species identified were Mycobacterium chelonae (four patients), M. fortuitum (two), and M. abscessus (one). Molecular typing of RGM isolates were not performed.

All hospitals cleaned surgical instruments (i.e., liposuction and liposculpture cannulae) with tap water and soap followed by low-level disinfection with a commercial quaternary ammonium solution. Environmental cultures, including cultures of tap water, at two surgical units did not yield bacteria or mycobacteria. The epidemiologic investigation did not reveal risk factors such as exposure to certain persons, cleaning solutions, medical supplies, or contaminated quaternary ammonium compounds.

Following the outbreak in Caracas, two of the affected surgical facilities modified their reprocessing procedures for surgical instruments (including suction cannulae) used in cosmetic surgical procedures by replacing quaternary ammonium compounds used for low-level disinfection with either high-level disinfection using 2% gluteraldehyde or ethylene oxide gas sterilization. No further cases of RGM infections complicating cosmetic surgical procedures in Caracas have been reported.

Reported by: J Torres, J Murillo, L Bofill, A Rĉos, E Irausquin, R Isturiz, M Guzman, L Rubino, M Cordido, Venezuelan Collaborative Infectious Diseases and Tropical Medicine Study Group, Caracas; Ministry of Health, Venezuela. Hospital Infections Program, National Center for Infectious Diseases; and an EIS Officer, CDC.

Editorial Note

Editorial Note: This is the first official report to CDC of SSI caused by RGM following liposuction or liposculpture. Both surgical procedures involve small surgical wounds with limited environmental exposure; both require using cannulae for tissue suction. The underlying mechanism for the cluster of SSI described in this report was not determined. However, potential causes included contaminated tap water used in cleaning cannulae during liposuction or liposculpture or contamination of the quaternary ammonium solution used to disinfect these instruments.

Nosocomial infections associated with contaminated quaternary ammonium compounds that were used to disinfect patient-care supplies or equipment (e.g., cysto-scopes, cardiac catheters, or surgical instruments) have been reported; none of these infections were caused by RGM. Quaternary ammonium compounds are used widely as low-level disinfectants (1). Surgical instruments used in liposuction and liposculpture procedures are critical items (i.e., intended to enter a normally sterile environment, sterile tissue, or the vasculature) according to the Spaulding Classification (2). Critical items should be sterilized between patient procedures.

Based on the risk for contamination of postsurgical wounds, aesthetic surgical procedures such as liposuction or liposculpture are considered clean wounds according to the classification system developed by the National Research Council (3). National Nosocomial Infections Surveillance (NNIS) system data indicate that among 5652 integumental surgical procedures (including aesthetic surgical procedures with risk index=0) performed during 1986-1996 in the United States, only 1.4% were complicated by SSI.

SSI caused by RGM following aesthetic surgical procedures is rare. Reports include infection following augmentation mammoplasty procedures (4,5) and an outbreak of infection following either face-lift or augmentation mammoplasty procedures that implicated using contaminated gentian violet skin-marking solution as the source of infection (6).

The Venezuelan Ministry of Health operates a national program for surveillance of antimicrobial resistance, and some of the large university hospitals occasionally provide rates of specific hospital-acquired infections. However, no active surveillance programs exist for SSI or systematic monitoring of tap water for microorganisms in health-care settings.

To prevent SSI in health-care settings, all surgical instruments used in liposuction or liposculpture procedures should be cleaned carefully after the procedure and sterilized in accordance with a validated reprocessing protocol provided by the medical device manufacturer. The exclusive use of low- or intermediate-level disinfectants to reprocess surgical instruments between patient procedures is inconsistent with the Food and Drug Administration guidance and recommended standards of practice (1,2).

References

1. Rutala W. Disinfection and sterilization of patient-care items. Infect Control Hosp Epidemiol 1996;17:377-84.

2. Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence CA, Block SS, eds. Disinfection, sterilization, and preservation. Philadelphia, Pennsylvania: Lea & Febiger, 1968:517-31.

3. National Academy of Sciences, National Research Council, Division of Medical Sciences, Ad Hoc Committee on Trauma. Postoperative wound infections: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964;160:1-192.

4. Clegg HW, Foster MT, Sanders WE Jr, Baine WB. Infection due to organisms of the Mycobacterium fortuitum complex after augmentation mammaplasty: clinical and epidemiologic features. J Infect Dis 1983;147:427-33.

5. Wallace RJ, Steele LC, Labidi A, Silcox VA. Heterogeneity among isolates of rapidly growing mycobacteria responsible for infections following augmentation mammaplasty despite case clustering in Texas and other southern coastal states. J Infect Dis 1989;160:281-8.

6. 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.

   
   

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