MYCOBACTERIUM INFECTIONS

January 27, 2013

CDC urges plastic surgeons to be alert for rapidly growing Mycobacterium infections from cases performed in the Dominican Republic

The Division of Global Migration and Quarantine and the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control (CDC) are investigating cases of surgical-site infections caused by rapidly growing Mycobacterial species (e.g. M. abscessus and M. chelonae) following plastic surgery in the Dominican Republic.

Fifteen cases – all resulting from procedures performed in the Dominican Republic – have been identified in five states, prompting several state and local health departments in the northeast United States to issue an advisory for health-care providers to be aware of the condition, and to notify their local health department in the event they should identify or suspect a case.

“Though the cases so far appear to have been identified only in the northeast, it’s important for all ASPS members to be alert to the potential of this infection,” says ASPS President Robert X. Murphy Jr., MD. “Ease of travel has turned medical tourism into a booming industry. Unfortunately, people often don’t think of the downside of medical tourism – you’re not guaranteed the same quality of safety measures that exist in this country, and should you have problems after you return, your surgeon is not there to take care of you.”

The advisory is aimed at all plastic surgery; dermatology; primary care; family, emergency and internal medicine; general surgery; infectious disease; laboratory medicine (including Mycobacteriology laboratory and staff) and infection control staff.

The American Society of Plastic Surgeons is now collaborating with the CDC, in order to effectively disseminate this information to the ASPS membership.

“These surgical-site infections represent a serious public health problem affecting patients who opt for low-cost cosmetic plastic surgery procedures overseas, in this case, the Dominican Republic,” says ASPS Patient Safety Committee Chair C. Bob Basu, MD, MPH.  “Medical tourism may attract patients with ‘cheap deals,’ but unfortunately, these deals may compromise, or worse, completely ignore recognized quality and safety standards.

“It underscores why it is vital for patients to choose a board-certified plastic surgeon who is an ASPS member,” he adds. “Our members only perform procedures in fully accredited facilities that ensure the highest standards for infection control and patient safety.“

Initial cases were reported by the Maryland Department of Health and Mental Hygiene in August 2013, with additional cases identified since then in Connecticut, Massachusetts, New York and Pennsylvania. All patients were women in the 18-50 age range who had undergone elective procedures that include abdominoplasty, mammaplasty and liposuction in the Dominican Republic from April through September in 2013. Symptoms have included abdominal abscess, pain, fever and wound discharge.

No deaths have occurred.

“At least nine of the case-patients had surgery at the same surgical center and were attended by the same surgeon,” notes Duc Nguyen of the CDC’s Prevention and Response branch of the DHQP, via e-mail. “Symptoms of infection developed after return to the United States; several patients consulted with plastic surgeons after their return who, in turn, notified their state and local health departments.”

“Given that at least nine of the cases are arising from the same surgery center in the Dominican Republic,” adds Dr. Basu, “it raises deep concerns about the violation of sterilization procedures and the quality of the sterile products utilized.”

Others who may have undergone surgical procedures in the Dominican Republic may be at risk for the “rapidly growing non-tuberculous mycobacterium” (RG-NTM) infections.

“It is possible that additional infected patients have not yet been reported,” notes Nguyen.

Healthcare providers should be aware of these cases and obtain cultures for mycobacterial culture from patients with cellulitis, soft tissue infection or cutaneous abscess who had a surgical procedure in the Dominican Republic after April 1, 2013.

RISKS OF TESTOSTERONE

Testosterone supplements linked to increased heart attack risk in men. The CBS Evening News (1/29, story 9, 1:45, Pelley) reported that new research suggests “a link between testosterone supplements and heart attacks.”         USA Today (1/30, Szabo) reports that the study, published in PLOS One, found that “taking testosterone therapy doubled the risk of heart attack among men over age 65 and nearly tripled the risk in younger men with a history of heart disease.” This research, “which involved 56,000 men, is the latest in a series of studies raising concerns about the heart attack risk from testosterone therapy, whose popularity has ballooned in recent years.”         On its website, NBC News (1/30, Fox) reports that “to be sure,” the researchers “compared the men getting testosterone to those getting prescriptions for erectile dysfunction drugs, as the two groups are similar in many ways.” The investigators found that the ED medications “only very slightly raised the risk of heart attack.”         The New York Times (1/30, O'Connor) “Well” blog reports, “By itself, the new study, which was not a randomized trial...’may not tell us very much,’ said Dr. Michael Lauer, the director of cardiovascular sciences at the National Heart, Lung and Blood Institute, who was not involved in the study.” However, added Dr. Lauer, “when you put this together with the rest of the medical literature, this tells us that we potentially have a problem.” Meanwhile, “in a statement, Andrea Fischer, an F.D.A. spokeswoman, said the agency was reviewing the new findings.”         On its website, TIME (1/30, Sifferlin) reports that although it is unclear “why testosterone can harm the heart, some studies suggest that it can lower levels of HDL, or good cholesterol, and therefore increase the risk of heart disease.”         Meanwhile, on the CBS News (1/30) website, CBS’ Dr. Jon Lapook writes that a “possible way testosterone might be causing problems is by increasing clotting within arteries supplying the heart.”         Forbes (1/30) contributor Ed Silverman points out that these “findings come amid years of aggressive promotion of testosterone treatments.” Research “published last fall in the Journal of the American Medical Association noted that annual prescriptions for these elixirs rose more than five-fold from 2000 to 2011, reaching 5.3 million prescriptions.”         The Los Angeles Times (1/30, Healy) “Science Now” blog also covers the story.

TANNING BEDS

Study: More people using tanning beds than previously believed.

USA Today (1/30, Szabo) reports that research published in JAMA Dermatology indicates that more people are using tanning beds than previously believed. Researchers found that “more than 35% of American adults report ever using a tanning bed, along with 59% of college students and 17% of teens in the analysis.” Additionally, “the percentage of Americans who have used a tanning bed in the past year also was high – 13% of adults, 43% of university students and 10% of teens.” The article points out some groups, including the American Medical Association and the American Academy of Dermatology “have called on states to bar children under 18 from tanning salons.”

        HealthDay (1/30) quotes Dr. Mark Lebwohl, incoming president-elect of the American Academy of Dermatology, as saying, “It is appalling how often exposure to indoor tanning takes place in presumably educated populations and particularly worrisome that we allow adolescents to be exposed to this carcinogen.” Dr. Lebwohl added, “We must do a much better job at educating people of all ages about the risks of indoor tanning.”

DOCTOR'S DRESS CODE AIMED AT HALTING GERMS

A new dress code for doctors, nurses and other health care workers calls for outfits that may be short on style, but long on what it takes to keep dangerous germs from spreading among patients. Short sleeves, bare hands and forearms and white coats that are laundered at least once a week – if not more often – are the keys to keeping nasty bugs such as Staphylococcus aureus from hitching a ride on a doctor's wrist. Neckties are questionable. Watches and rings have to go. It's not clear what to do about name tags, lanyards, necklaces and cell phones, but when in doubt, it’s best to clean the offending items – or get rid of them. That's according to new guidance on hospital attire released Monday by the Society for Healthcare Epidemiology of America, or SHEA. The group obsessed with stopping infections in hospitals and health care settings turned its attention to dozens of studies that suggest that grimy hospital garb might be responsible for spreading germs

CIGARETTES MORE ADDICTIVE

Study: Cigarettes increased nicotine content over last 15 years.

The Boston Globe (1/16, Kotz) reports a Massachusetts Department of Public Health and University of Massachusetts Medical School study published online in the journal Nicotine and Tobacco Research indicates that particular cigarette manufacturers have increased the nicotine in their product. Researchers found the average cigarette contained 1.65 milligrams of the substance in 1999, but increased 15% to 1.89 milligrams in 2011. Study leader Thomas Land believes the increase may have resulted from redesigning several brands with alterations on filters or product length.

        The Springfield (MA) Republican (1/16, Flynn) also quotes Land as saying, “Cigarettes are getting more efficient at delivering nicotine to smokers. This could make it more difficult for a current smoker who is trying to quit, and easier for a young smoker to become addicted.”

FDA - LIMIT ACETAMINOPHEN

FDA asks physicians to curb usage of medications with high levels of acetaminophen.

In continuing coverage, CBS Evening News (1/15, story 12, 0:20, Pelley) reports that “there is a warning tonight about acetaminophen, the active ingredient in Tylenol. It’s also found in prescription painkillers such as codeine and hydrocodone.” CBS says the FDA is asking “doctors to stop prescribing medication that contains more than 325 milligrams of acetaminophen per pill” because in high doses it can cause severe liver damage.

        NBC Nightly News (1/15, story 8, 2:00, Williams) reports the FDA “was very pointed today” in why it is taking this action “and it has to do with the fact that so many people don’t know that acetaminophen is a common component in prescription pain killers like Vicodin and Percoset.” NBC says that many a time patients take an additional OTC acetaminophen “without realizing that they are at risk for liver damage and that is why the agency is asking doctors to stop prescribing combination medications with more than 325 milligrams of acetaminophen per dose.”

        USA Today (1/15, Painter) reports the step by the agency is one of several moves by the FDA to curb “high-dose use of the popular painkiller.” USA Today also notes that the agency has said “it soon will withdraw approval for any of those medications” that have more than 325 mg of acetaminophen. The FDA also plans to unveil “new regulatory action on over-the-counter acetaminophen,” though it didn’t provide details.

        The Los Angeles Times (1/15, Kaplan) says pharmacists getting requests to fill prescriptions for medications “with more than 325 mg of acetaminophen should contact the” prescribing doctor or dentist to check if “lower dose would suffice,” the agency has recommended. TIME (1/15), Alabama Live (1/16, Lord) reports and FOX News (1/15) also cover the news.

SURIGCAL EXPERIENCE IS MOST IMPORTANT

Arlington Heights, Ill. - What do patients look for when choosing a surgeon to perform their facelift, nose job, or other cosmetic plastic surgery procedure? Surgeon experience and a personal recommendation from a doctor or friend are the most influential factors, reports a study in the January issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

MELANOMA AND CHEMOTHERAPY

FDA approves combination treatment for melanoma.

Reuters (1/9, Hirschler) reports that the FDA has granted accelerated approval to a combination treatment for melanoma offered by GlaxoSmithKline. According to the article, both dabrafenib and trametinib are approved for treatment of melanoma, but GSK believes they will last longer when given together.

SURGICAL ADHESIVES

Researchers develop surgical glue for heart patients.

The Boston Globe (1/9, Weintraub) reports that researchers have developed a “surgical glue” for heart patients that “is nontoxic, biodegradable, and fast-drying even in the presence of blood, forming a bond that is strong enough to close a hole on a beating heart.” Research published in Science Translational Medicine shows “that the glue works in the harsh conditions of a surgical site.”

        The NPR (1/9, Doucleff) “Shots” blog reports that thus far, the product has only been tested on animals, so it “is far from reaching the operating room or battlefield.” However, one of the researchers “hopes the adhesive will eventually replace traditional sutures and staples for some operations, especially heart surgery.”

        HealthDay (1/9, Preidt) reports that “the adhesive is activated by ultraviolet light and provides an anti-bleeding seal within five seconds of UV light application when applied to high-pressure large blood vessels and heart wall defects, according to the study.”

STDs ON THE RISE NATIONWIDE

 

The Washington Times (1/9, Wetzstein) reports that the Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance 2012 report (pdf) released yesterday shows that gonorrhea rates increased in 2012 and syphilis rose 11%, while chlamydia remained relatively flat, although a record 1.4 million cases existed. The report states, “This is the largest number of cases ever reported to the CDC for any condition,” with the National Coalition of STD Directors adding that “rising STD rates have a major negative impact on our ability to address the HIV epidemic.” Public health officials are encouraging sexually active individuals to undergo annual STD screenings, with men who have sex with men (MSM) screened at shorter intervals if partners are not monogamous or use illicit drugs.