Nontuberculous Mycobacterial Infection After Fractionated CO2 Laser Resurfacing

Donna A. Culton; Anne M. Lachiewicz; Becky A. Miller; Melissa B. Miller; Courteney MacKuen; Pamela Groben; Becky White; Gary M. Cox; Jason E. Stout


Emerging Infectious Diseases. 2013;19(3) 

In This Article

Epidemiologic Investigation

After case 1 was detected, an epidemiologic investigation was requested by the physician (dermatologist) who had performed the laser resurfacing to investigate possible sources of the infection within the clinic. The investigation was initiated 27 days after the procedure was performed. We interviewed the dermatologist and reviewed all steps of the procedure. Several items were obtained and cultured for nontuberculous mycobacteria: a multiuse jar of lidocaine/tetracaine ointment, a multiuse jar of emollient, a multiuse vial of 1% lidocaine used for nerve blockimg, a nonsterile package of gauze used to apply ointments to patients' skin, and a multiuse vial of sodium bicarbonate. Small amounts of samples were swabbed onto 7H10 Middlebrook medium supplemented with an additional 5 μg/mL of malachite green by using a sterile swab. A gauze square was immersed in ≈250 mL sterile water and agitated vigorously for ≈1 min. The water was then filtered through a 0.4-μ sterile filter, and the filter was plated directly onto the 7H10 Middlebrook medium. Approximately 0.1 mL of each of the other samples was placed directly onto a 7H10 Middlebrook medium plate and spread over the plate by using a sterile loop. Plates were incubated at 30°C, and no growth was observed on any plates after 3 months of incubation.

Although no obvious source of infection was identified, several changes to the routine fractionated CO2 resurfacing procedure were made after case 1 was detected. These changes included use of sterile gloves; sterile gauze; sterile tongue depressors for application of topical lidocaine/tetracaine ointment; conversion to single-use vials of lidocaine, epinephrine, and sterile saline used for tumescent anesthesia; and single-use postprocedure emollient. Chloroxylenol (3%) was also added in addition to 70% isopropanol for preprocedure cleansing. Postprocedure wound care was not changed.

After case 2 was detected, a second site visit was arranged 46 days after the procedure was performed. The dermatologist was interviewed again, and a complete sham procedure was performed while the investigators observed. Samples were collected from the 3% chloroxylenol, hand scrub, multiuse sodium bicarbonate vial, and single-use lidocaine/tetracaine ointment vial. The suction canister, connection tubing, and smoke filter were removed from the machine and cultured. Copious amounts of skin debris were identified in the long and short tubes of the connection tubing, along with an ≈2 to 3–cm layer of skin debris on top of the smoke filter. Environmental swabs of the countertops and walls in the procedure room were also collected. Water specimens (≈250 mL) were collected from the taps in the staff and patient bathrooms in the clinic (there was no water source in the procedure room or any other nearby procedure rooms) and from a fountain in the hallway. Patients were routinely instructed to wash the area with soap and water before coming to the office (i.e., they did not wash in the patient sink in the office).

The ointments were plated directly onto Lowenstein-Jensen (LJ) and modified 7H10 medium. The environmental swab was plated directly onto LJ medium only. Two 1 × 3–cm pieces of the paper filter from the filter canister were plated directly onto LJ medium. In addition, the multiuse lidocaine/tetracaine ointment from the first site visit was plated directly onto LJ medium by using a sterile swab. Approximately 100 mL of sterile water were passed through the canister/short tube and the long tube from the apparatus and collected in sterile bottles. The resultant suspensions were brown and contained large quantities of skin debris. Approximately 40 mL of each water sample and 10 mL of the sodium bicarbonate were passed through 0.4-μ filters; each specimen was processed in duplicate. One filter from each specimen was then plated directly onto LJ medium, and the other filter was plated onto malachite green–supplemented 7H10 medium. Medium plates were incubated at 30°C. After 1 week, mycobacterial colonies were identified on the medium containing the filtrate from the connector tubing and several of the tap water specimens (staff bathroom and patient bathroom).

Species identification of all isolates was performed at the Microbiology Laboratory of the University of North Carolina by using 16S rRNA and heat shock protein 65 gene sequencing. Results of sequence analysis showed that the 2 patient isolates did not match. They were identical by sequencing of part of the 16S rRNA gene but differed by heat shock protein 65 sequencing; the organism isolated from case-patient 1 was M. abscessus and that from case-patient 2 was M. chelonae. Analysis of clinic water isolates showed several different mycobacterial organisms. Four colony morphologies were isolated from the tap water in the patient bathroom, 2 of which were identified as M. mucogenicum, 1 as M. obuense/aurum, and 1 as M. chelonae. Three colonies isolated from the tap in the staff bathroom were identified as M. mucogenicum. The isolate from the large tubing leading to the smoke filter was M. smegmatis, which was not a match with either patient isolate.

Pulsed-field gel electrophoresis was performed at the University of Texas at Tyler to compare the M. chelonae isolate from the case-patient 2 with the isolate from the patient bathroom in the dermatology clinic. The 2 isolates did not match.

Environmental investigation of the homes of the 2 patients was not conducted because case-patient 1 refused and sampling of the home of case-patient 2 was not attempted. The bottles of vinegar used for postprocedure cleansing were not available for either patient. Neither patient had undergone fractionated CO2 laser resurfacing before the procedures described.