Gastric Banding Linked to Mycobacterium Infections

Veronica Hackethal, MD

September 10, 2014

An Australian study has linked rapidly growing mycobacterium infections to gastric banding surgery, but no clear source has been identified, according to an article published online September 10 in Emerging Infectious Diseases.

"Rapidly growing mycobacteria can infect both port and band and can occur as either an early perioperative or late infection. Combination antimicrobial therapy is used on the basis of in vitro susceptibilities. Device removal seems to be vital to successful therapy," write Hugh L. Wright, MD, from the Royal Brisbane and Women's Hospital, Queensland, and colleagues.

Gastric banding, the most common weight-reducing surgery in Australia and the United Kingdom, normally has low rates of complications, the authors note. The procedure involves insertion of a silicon band and a port used for adjusting the band.

Rapidly growing mycobacteria are environmental microbes found in soil and water. Recently, they have begun to appear as pathogens in postoperative surgical infections, especially those related to prosthetics.

The researchers identified cases of mycobacterial infections using various methods. They reviewed clinical notes and positive cultures linked to gastric banding. They found other cases by corresponding with clinicians, through direct clinical involvement, and by looking at epidemiologic data and medical records. They also performed speciation and strain typing.

In total, they identified 18 cases of infection caused by Mycobacterium fortuitum (n = 11; 61%) and Mycobacterium abscessus (n = 7; 39%) that were linked to gastric banding in Australia from 2005 to 2011. Overall, 83% of cases were women and 28% had diabetes. The port appeared to be the primary site of infection in 10 patients (56%), and such infections had "more indolent signs," according to the authors. Five cases (28%) had infection linked to the band.

Five cases appeared within 9 months of each other, suggesting a temporal trend, but researchers could not identify a point source.

Cultures grew a polymicrobial mix, with frequent coisolates including Staphylococcus spp., Candida albicans, and enteric gram-negative organisms. Among infections caused by M fortuitum, 91% had susceptibility to amikacin and 91% to ciprofloxacin. Among infections caused by M abscessus, 100% had susceptibility to amikacin and 100% to clarithromycin.

Infections were complicated by peritonitis, band erosion, and chronic ulcer at the port. Cure necessitated removal of the band device in all cases.

In addition, 44% of cases appeared less than 3 months after surgery, whereas 56% presented more than 3 months afterward. Early-appearing vs late-appearing cases could have different causes.

"M. fortuitum and M. abscessus should be considered as possible etiologic agents of infection associated with laparoscopic banding, from port or band," the authors conclude. "Infection can occur early during the perioperative period or many years after insertion. Prolonged therapy with combination antimicrobial agents is suggested in conjunction with complete removal of the device."

The authors note several limitations, including relying in part on physician and surgeon recall for case identification. In addition, review of positive cultures relied on adequate clinical notes, which could have missed some cases.

The authors have disclosed no relevant financial relationships.

Emerg Infect Dis. Published online September 10, 2014.

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