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Nosocomial Infections
Medical tourism to Dominican Republic
results in multistate mycobacteria outbreak
A rash of mycobacteria surgical site in-
fections among travelers has been linked
to cosmetic procedures conducted in
Dominican surgical clinics, according
to an investigation recently published in
Emerging Infectious Diseases.
Interviews with the affected patients
suggested that many participated in
medical tourism to save money, accord-
ing to David Schnabel, MD, epidemic
intelligence officer for the CDC, and
colleagues, who are advising health care
providers and officials servicing immi-
grant populations to remain vigilant for
infections associated with this type of
travel.
“Infections with rapidly growing my-
cobacteria (RGM), which include the
species Mycobacterium abscessus, M.
chelonae and M. fortuitum, are difficult
to diagnose,” Schnabel and colleagues
wrote. “Infections by these organisms
acquired in health care settings are most
often associated with breeched sterile
technique and exposure to nonsterile
water. Outbreaks in these settings have
been reported and include those associ-
ated with cosmetic surgeries performed
in the United States and internationally.”
Cost of procedures influences
decision to travel
In August 2013, the Maryland De-
partment of Health and Mental Hy-
giene received reports of M. abscessus
complex-positive surgical site infections
New guideline for HAP, VAP recommends shortened
antibiotic therapy
The Infectious Diseases Society of
America and the American Thoracic
Society have released a new clinical
guideline for the diagnosis and treat-
ment of hospital-acquired pneumonia
and ventilator-associated pneumonia.
The guideline, which updates those
published in 2005, recommends short-
ening the duration of antibiotic thera-
pies for hospital-acquired pneumonia
(HAP) and ventilator-associated pneu-
monia (VAP) to 7 days, and advocates
the use of antibiograms to ensure appro-
priate antibiotics are selected for these
patients.
“Once clinicians are updated regu-
larly on what bugs are causing VAP
and HAP in their hospitals as well as
their sensitivities to specific antibiot-
ics, they can choose the most effective
treatment,” Andre C. Kalil, MD, MPH,
(SSIs) in two women who had recently
undergone cosmetic surgery at a private
clinic in the Dominican Republic. After
interviews with both women raised con-
cerns of additional unrecognized cases,
the CDC and other health departments
launched an investigation to determine
the scope of this potential RGM out-
break among medical travelers.
“Little systematically collected data
is available about the scope of and risks
for medical tourism,” the investigators
wrote. “Industry estimates regarding
the number of U.S. residents who travel
abroad for medical services vary widely
… [although] most reports indicate that
the frequency of medical tourist activi-
ties and subsequent public health effects
will likely increase in the future because
of ease of travel, increased marketing
and communications, and anticipated
cost savings.”
To locate additional cases, the inves-
tigation team distributed health alerts
to clinicians and public health officials
and disseminated general RGM infec-
tion warnings to clinicians and patients
through mainstream and social media
outlets. The team interviewed probable
case patients — defined as those who
had a cosmetic surgery procedure in the
Dominican Republic from March 2013
to February 2014 and were diagnosed
with soft tissue infection unresponsive
to standard therapy — to determine
common exposures or experiences and
professor of medicine in the infectious
diseases division and director of the
transplant infectious diseases program
at the University of Nebraska Medical
Center, Omaha, said in a press release.
“This helps individualize care, ensuring
patients will be treated with the correct
antibiotic as soon as possible.”
Kalil, along with Infectious
Disease News Editorial Board member
Thomas M. File Jr., MD, and a multi-
disciplinary team of
18 other experts,
reviewed published
data regarding the
diagnosis and treat-
ment of HAP and
VAP. They rated
evidence as either
“weak” or “strong”
Thomas M. File Jr. using the GRADE
Infectious Disease News | AUGUST 2016 | Healio.com/ID
better characterize the disease. Partici-
pating clinical and public health labora-
tories submitted patient wound culture
isolates to the CDC for organism confir-
mation and pulsed-field gel electropho-
resis (PFGE) testing in addition to those
from New York that were collected and
tested by the New York City Public
Health Laboratory.
The investigation revealed 18 con-
firmed and three probable cases living
in six northeastern states. The median
age of these patients was 40 years; all
were women. Fifteen were born in the
Dominican Republic, two in the U.S.,
three in other countries and one from
an unknown country. Sixty-two percent
learned of the clinic where they had sur-
gery from a friend or family member, and
15 of 16 responding patients reported
that cost had some impact on their deci-
sion to undergo procedures there.
More than half of the case-patients
underwent a surgical procedure at the
same clinic (clinic A). Patients most of-
ten received liposuction (71%); 18 un-
derwent more than one procedure.
Case-patients reported varying de-
grees of infection control and sanitation
after their surgeries, and the investiga-
tors identified no common exposures
upon return to the U.S. Among the 18
confirmed RGM infections, 16 were
M. abscessus complex, and two were M.
fortuitum. Eleven of the 15 M. abscessus
complex isolates analyzed using PFGE
system of evidence evaluation, and pro-
vided recommendations or suggestions
based on discussions of the data. All of
the panel’s recommendations were re-
viewed and endorsed by the two lead-
ing societies, as well as by the Society
of Critical Care Medicine and the So-
ciety for Healthcare Epidemiology of
America.
Although the previous recommen-
dations advocated different antibiotic
therapy durations depending on the
bacterium responsible for the infection,
the panel advised limiting HAP/VAP
patients’ therapies to 7 or fewer days and
only employing longer treatments when
necessary. This recommendation is
based on evidence suggesting no detri-
ment to shorter courses, Kalil said in the
release, and would reduce the impact of
various antibiotic-related side effects.
had indistinguishable patterns, and 10
of these came from clinic A.
Illness onset was a median 24 days
after surgery. Signs and symptoms
were more often wound-related than
systemic, and some patients required
multiple hospitalizations. Only one of
12 patients contacted 9 months after
their surgeries reported full recovery.
Schnabel and colleagues warned that
more cases may have been missed, and
that providers should remain vigilant
for similar outbreaks among at-risk
populations.
“Understanding the role of medi-
cal tourism in disease risk and increas-
ing patient protections in this context
will require an ongoing effort by the
international public health and medi-
cal communities,” the researchers wrote.
“Clinicians and public health officials,
particularly those service communities
with connections to immigrants from
medical tourism destinations, should be
vigilant and consider RGM infections
in the differential diagnosis for per-
sons who have wound infections after
surgery in these destinations.”
Xenotourism to blame for 2014
outbreak of Q fever
While the RGM investigation im-
plicated cost as a primary concern for
individuals considering surgery abroad,
interest in an unapproved procedure
Medical tourism continues on page 31
In addition, the experts recommend
the use of antibiograms specific to ICU
patients, describe the optimal therapies
for various HAP/VAP presentations,
offer guidance on the use of empiric
regimens and suggest dosing by phar-
macokinetic/pharmacodynamic data as
opposed to manufacturer’s prescribing
information.
The new guideline is not recommend-
ed for immunocompromised patients
with opportunistic pulmonary infection,
the panel members wrote, as these pa-
tients often require alternative diagnosis
and treatments. – by Dave Muoio n
Reference:
Kalil AC, et al. Clin Infect Dis. 2016;doi:10.1093/
cid/ciw353.
Disclosures: Kalil reports no relevant finan-
cial disclosures. File reports the receipt of FDA
grants during the study, as well as relationships
with Allergan, Cempra, Melinta, Merck, MotifBio,
Nabriva, Pfizer, Tetraphase and Sensor Kenesis
Group. Please see the full guideline for a list of
all other authors’ relevant financial disclosures.
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