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

Discussion

Postoperative complications among medical tourists are a growing problem. In a retrospective review by Klein et al.,[21] an increased incidence of complications related to cosmetic surgery tourism was observed in their clinic between 2010 and 2014. Of 109 cases identified during that time, postoperative infections were the main complication, involving 25 percent of patients. With postoperative infections among medical tourists becoming more prevalent, making a timely diagnosis remains a challenge.[32] Rapidly growing mycobacterial infections are not communicable, so they are not reportable diseases in the United States.[33] This may perhaps contribute to a lack of awareness or underestimation of the prevalence and burden of rapidly growing mycobacteria in the population.[8] Singh et al.[18] presented three cases where the mean time between initial symptoms and correct diagnosis of rapidly growing mycobacteria was 11.7 weeks. Reasons for the delay included failure to obtain wound cultures, misdiagnosis and treatment for typical wound infections, and time to obtain culture results for atypical mycobacteria.[18] Rapidly growing mycobacteria can grow within 1 week, whereas other species of mycobacteria can take up to 6 weeks to grow in culture.[18] Although rapidly growing mycobacteria grow rapidly compared with other mycobacteria, they have a slower replication rate than other typical bacterial pathogens.[8] It is therefore important to have a high clinical suspicion for rapidly growing mycobacteria when treating someone with a history of medical tourism and treatment-refractory infection. Medical tourists are also susceptible to more common postoperative skin flora infections caused by Staphylococcus or Streptococcus. These infections are likely treated readily with antibiotics and are not reported in the literature as difficult-to-treat infections.

Rapidly growing mycobacterial infections may be caused by many factors. Risk factors usually include trauma and contamination of the surgical wound.[34,35] Rapidly growing mycobacteria are difficult to eradicate with common decontamination methods and are relatively resistant to disinfectants such as chlorine, formaldehyde, organomercurials, and alkaline glutaraldehydes.[36–39] This enables growth in water distribution systems, soil, dust, and aerosol samples.[40] Another unique characteristic of rapidly growing mycobacteria is that these organisms possess a hydrophobic, lipid-rich cell wall that facilitates the formation of a biofilm on solid surfaces such as water pipes, catheters, and theoretically breast implants or tissue expanders.[40] Rapidly growing mycobacteria are ubiquitous environmental contaminants reported worldwide.[41] Their presence in water allows for iatrogenic infections with rapidly growing mycobacteria in freestanding medical offices or surgical centers that do not have regulated oversight of sanitary measures.[42,43] Although outbreaks of rapidly growing mycobacteria are more common in developing countries, there is no evidence to support that this type of mycobacterium is more prevalent in these geographic regions. Based on case reports and outbreaks, inadequate sterilization techniques in developing countries are thought to be largely responsible for these surgical infections.[8,31,44–46] In 2002, Meyers et al.[31] published a retrospective cohort study regarding an outbreak of M. chelonae at a single facility within a 6-month period. Twelve patients were confirmed to have culture-positive infections, and the source of the mycobacterium was the facility's potable water system. Other cases of rapidly growing mycobacteria growing in tap water from hospital storage tanks have been reported.[44] In addition, there have been reports of rapidly growing mycobacteria growing in bottles of topical antiseptics such as gentian violet solution and merbromin solution.[47,48] Ineffective sterilization of surgical instruments and injectable solutions has also been hypothesized to contribute to numerous mycobacterial outbreaks.[18,49,50] The increased frequency of rapidly growing mycobacteria infections may be associated with the growing popularity of medical tourism in freestanding surgical centers not routinely monitored by infection control committees.[37]

Early surgical intervention and aggressive débridement are important in treating postoperative infections among medical tourists. Cai et al.[20] reported on two cases of M. abscessus infections where one patient consented to early surgical débridement and had a shorter clinical course with fewer complications than the patient who chose to treat the infection conservatively with wound care. For accurate diagnosis of rapidly growing mycobacteria, both wound drainage and tissue biopsy specimens should be sent for acid-fast staining, mycobacterial culture, and routine surgical pathologic evaluation.[18] Rapidly growing mycobacteria can be isolated from a nonsterile specimen by means of inoculation into a liquid medium that is supplemented with polyantimicrobial mixtures, such as amphotericin B and nalidixic acid.[51] Optimally, two solid types of media such as a serum agar-based medium and an egg- and potato-based medium or the liquid medium BacT/Alert MB should be used for each specimen.[51] The rapidly growing mycobacteria will grow on blood agar, MacConkey agar, and Lowenstein-Jensen medium in approximately 7 days.[52] The identification of rapidly growing mycobacteria can be made based on specific phenotypic characteristics.[51] Current recommendations for treating rapidly growing mycobacteria infections are to have an oral macrolide as the backbone agent in a multidrug therapy.[33] Clarithromycin is known to possess consistent activity against all members of the M. chelonae group and against most M. fortuitum strains.[53,54] Our review of the literature showed that 65 percent of rapidly growing mycobacteria cases were treated with clarithromycin or azithromycin. Amikacin and moxifloxacin were also commonly used agents, involving 40 percent and 38 percent of cases, respectively. A combination of other antimicrobials was also used parenterally and orally, but many were discontinued because of treatment failure or intolerable side effects.

The authors have used a treatment algorithm when encountering patients with surgical complications. Early surgical débridement is warranted, with a minimum of two quantitative tissue cultures. At our institution, we send a separate sample for acid-fast staining and mention specifically rapidly growing mycobacteria; thus, the above-mentioned protocol is used for rapid identification. An infectious disease consultation is warranted if difficult-to-treat or highly resistant organisms are encountered; in a multidisciplinary setting, we set long-term therapy and outpatient management on a case-by-case basis.

Aside from difficult-to-treat infections, other risks are associated with medical tourism. Complications such as wound dehiscence, pain or discomfort, implant rupture, wound contracture, and hematoma can all occur.[21,55] Venous thrombosis and pulmonary embolism are also concerns for surgical procedures preceding a long-haul flight back home.[56,57] Risk factors include duration of travel greater than 5 hours with immobility and preexisting conditions.[58] In 2006, there was a report of a medical tourist who suffered from a pulmonary embolism after undergoing bilateral breast augmentation 3 days before her 9-hour flight home.[59] Surprisingly, the patient had not received any sort of postoperative thrombosis prophylaxis, such as subcutaneous low-molecular-weight heparin or compressive stockings.[59] Because most patients undergoing plastic surgery tourism will be traveling after their procedure, it is crucial to provide adequate mechanical or chemoprophylaxis.[60] Specific recommendations for thromboprophylaxis are dependent on the patient's level of risk.[58]

The authors want to echo a comment by Ross et al.,[61] namely that complications occur when the best trained surgeons practice at any institution worldwide. The thorough discussion by Ross et al.[61] explains the ethical dilemma, and highlights the lack of standards or guidelines regulating medical tourism. Our review does not intend to indicate that all patients undergoing procedures abroad will suffer devastating complications; rather, we are trying to raise awareness of the potential complications patients can experience while showcasing different microbes not commonly encountered in the United States.

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