Medical Tourism and Postoperative Infections

A Systematic Literature Review of Causative Organisms and Empiric Treatment

Pablo Padilla, M.D.; Priscilla Ly, B.S.; Rachel Dillard, B.S.; Stefanos Boukovalas, M.D.; Ramon Zapata-Sirvent, M.D.; Linda G. Phillips, M.D.

Disclosures

Plast Reconstr Surg. 2018;142(6):1644-1651. 

In This Article

Abstract and Introduction

Abstract

Background: Medical tourism has become increasingly globalized as individuals travel abroad to receive medical care. Cosmetic patients in particular are more likely to seek surgery abroad to defray costs. Unfortunately, not all procedures performed abroad adhere to strict hygienic regulations, and bacterial flora vary. As a result, it is not uncommon for consumers to return home with difficult-to-treat postoperative infections.

Methods: A systematic literature review of PubMed, Ovid, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was performed to assess the microbiology patterns and medical management of patients with postoperative infections after undergoing elective surgery abroad.

Results: Forty-two cases of postoperative infections were reported among patients who underwent elective surgery abroad. Most cases were reported from the Dominican Republic, and the most common elective procedures were abdominoplasty, mastopexy, and liposuction. Rapidly growing mycobacteria such as Mycobacterium abscessus, Mycobacterium fortuitum, and Mycobacterium chelonae were among the most common causes of postoperative infection, with M. abscessus involving 74 percent of cases. Most cases were treated with surgical débridement and a combination of antibiotics. Clarithromycin, amikacin, and moxifloxacin were the most common drugs used for long-term treatment.

Conclusions: When encountering a patient with a history of medical tourism and treatment-refractory infection, rapidly growing mycobacteria must be considered. To increase the likelihood of yielding a diagnostic organism, multiple acid-fast bacilli cultures from fluid and débridement content should be performed. There has been reported success in treating rapidly growing mycobacterial infections with a combination of antibiotics including clarithromycin, amikacin, and moxifloxacin.

Introduction

Medical tourism has become a multibillion dollar industry, with millions of Americans seeking health care abroad each year.[1–5] Historically, the flow of medical tourists has been from low-income to high-income countries.[6] However, this trend is reversing as more medical facilities have developed abroad and are attracting tourists regionally.[6,7] A major draw for patients undergoing medical tourism is quality health care at a more affordable price.[8,9] Accounts of the ability to combine a vacation with a medical procedure have also contributed to its growing popularity.[10–12] Other factors include avoidance of long waits, opportunity to recover away from home, and incentives offered by employers.[13–17]

Patients who travel for cosmetic procedures have been referred to as "lipotourists."[18] Procedures commonly sought by these individuals include abdominoplasty, liposuction, and breast augmentation.[19,20] Cosmetic tourism is largely price-driven because procedures need to be paid out of pocket both at home and abroad. Finding the best "bang for the buck" is becoming easier for consumers who can perform a simple search on the Internet.[21–23] In fact, it is not surprising for someone to find procedures in different countries offered at half the price of what is available in the United States.[24,25] In addition, patients who are unfamiliar with medical facilities abroad can hire medical travel intermediaries who screen health care providers for quality and evaluate patients for medical fitness to travel.[24]

With medical tourism growing in popularity, physicians' abilities to shape the informed decision-making process with their patients becomes threatened.[26–29] Problems concerning the lack of regulation, medical complications and outcomes, and fragmented follow-up care are becoming more evident.[16] When medical tourists return from their destination, physicians in their home countries are left to deal with their postoperative complications and clinical course.[30] Postoperative infections are of particular concern because of the variability of bacterial flora in different countries.[18] Many regions with robust medical tourism programs are in areas of high background rates of mycobacteria and antibiotic resistance.[16] In recent years, there have been increasing reports of rapidly growing mycobacterial infections caused by Mycobacterium abscessus, Mycobacterium chelonae, and Mycobacterium fortuitum among medical tourists.[8] Infections caused by rapidly growing mycobacteria are relatively uncommon in the United States.[31] These infections are often diagnosed late because of a low clinical suspicion, and patients experience a prolonged clinical course involving multiple operations and medications.[8]

A review of the current literature revealed several case reports of medical tourists who presented with postoperative wound infections after undergoing elective surgery abroad. Early aggressive surgical débridement has been suggested to optimize the clinical course of these difficult-to-treat infections.[20] There is little to no evidence of an existing review of the antibiotic regimen used to treat the different types of microorganisms causing infection among medical tourists. This article presents a systematic review of the current literature on cases of medical tourism–related postoperative infections, with specific focus on causative organisms and empiric antibiotic treatment.

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