Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic, 2013-2014(1)

Abstract

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.

Keywords: Dominican Republic; Mycobacteria; Mycobacterium abscessus complex; Mycobacterium chelonae; Mycobacterium fortuitum; United States; antibacterial drugs; antibiotic; antimicrobial resistance; bacteria; cosmetic surgery; healthcare-associated infections; medical tourism; nontuberculous mycobacteria; nosocomial infections; rapidly growing mycobacteria; tourist.

Figure 1

Dendrogram of rapidly growing mycobacteria in surgical site infections among patients in the US associated with medical tourism to the Dominican Republic, 2013–2014. Patients were exposed in 5 known clinics and 1 unknown clinic (data not shown). Pulsed-field gel electrophoresis band patterns for available Mycobacterium abscessus complex isolates were restricted with the Asel enzyme and run at 3 and 20 seconds for 20 hours. Isolates with indistinguishable band patterns are labelled cluster A. Case ID indicates US location and patient case number. ID, identification; NYC, New York City; NYS, state of New York.

Figure 2

Number of case-patients in the United States who were infected in surgical sites with rapidly growing mycobacteria associated with medical tourism to the Dominican Republic, by procedure week, March 2013–February 2014 (N = 21). Weeks are defined uniformly as week 1, days 1–7 of the month; week 2, days 8–15; week 3, days 16–23; week 4, days 24–28/30/31. Pulsed-field electrophoresis pattern of the Mycobacterium abscessus isolate from the clinic A case-patient diagnosed during week 2 of June 2003 differed from those of remaining clinic A case-patients who were infected with M. abscessus.