May 6, 2024 (by: Lawrence F Muscarella, PhD) – Fifteen patients in nine states developed mycobacterial infections following cosmetic surgical procedures performed in 2022 at the same Florida clinic, according to a recent report by the Centers for Disease Control and Prevention (CDC).
This brief article presents some of my perspectives and questions about a recent investigation by state and federal health officials of a cluster of mycobacterial infections linked to cosmetic surgical procedures performed in 2022 at a single clinic in south Florida.
This article is intended to bring attention to surgical infections of mycobacteria and their prevention, encourage critical thinking, and discuss that findings disclosed in a federal or state report discussing an investigation of healthcare-associated infections may not always be complete or consistent with other similar investigations, which in some instances can raise as many questions as the published report might answer.
This article appreciates the commitment and effort by state and federal public health officials to educate the public about the risk of post-surgical infections of following cosmetic surgery, understanding that some mycobacterial infections may not develop until months after surgery.
In January, the U.S. Centers for Disease Control and Prevention (CDC) published the findings of an investigation that identified 15 patients who had developed an infection of Mycobacterium abscessus after undergoing cosmetic surgical procedures in 2022 at the same clinic in south Florida.
The infected patients resided in nine different states, including California, Florida and Massachusetts. The CDC’s report identifies this Florida facility only as “clinic A.”
Last week, The Tampa Bay Times newspaper brought renewed attention to this cluster of cases by publishing an article that in addition to discussing these 15 M. abscessus infections, included an interview with the first author of the CDC report, who is an officer at the CDC.
M. abscessus is a species of nontuberculous mycobacteria (“NTM”). It is rapidly growing, opportunistic, and intrinsically multidrug–resistant. Water and soil are common reservoirs for M. abscessus, which along with M. chimaera has been linked to several other unrelated outbreaks involving contaminated medical equipment, including heater-cooler devices used during open-heart surgery.
Also referred to as environmental mycobacteria, NTM are distinguished from M. tuberculosis and M. leprae, which are the causative agents of tuberculosis and leprosy, respectively.
Forensic Case Reviews, Infection Investigations: LFM-Healthcare Solutions, LLC provides medical expertise for legal representatives, device manufacturers, and medical facilities specializing in healthcare-associated infections linked to contaminated reusable medical equipment.
COMMENTARY: The CDC’s January report discussing this cluster of M. abscessus infections in nine states, however, is as noteworthy for bringing the risks of M. abscessus infection following cosmetic surgery to the public’s attention as it is for some questions it raises.
1. Disclosure: The CDC’s report, for instance, does not identify the south Florida clinic linked to these 15 NTM infections by its name or address (only referring to it as “clinic A“). This decision raises a number of reasonable questions, including inquiries about its justification and whether the omission could conflict with the principles of transparency and impartiality in public health.
Disclosure of the location of an infection outbreak, whether in a medical facility or somewhere else in the community, can provide a more complete understanding of the outbreak, as well as contribute to safety by, for instance, allowing the public to take the necessary precautions to reduce the exposure risk.
In fact, some publications focusing on the key principles of public health — including a 2002 document whose development and dissemination was co-funded by the CDC itself — state that factors that build trust in public health and its institutions include “communication; truth telling; (and) transparency (i.e., not concealing information),” among other factors.
This stance if echoed in the “CDC Field Epidemiology Manual,” which states that: “Risk communication literature identifies four factors that determine whether an audience, including journalists, will perceive a messenger as trusted and credible,” including honesty and “openness.”
Consistent with these principles, the CDC has in other cases identified the outbreak’s facility, by name.
Last year, for instance, the CDC issued an advisory about an outbreak of suspected fungal meningitis among U.S. patients who had undergone cosmetic procedures in Mexico. The CDC’s advisory identified the facilities by name, writing that the patients “underwent procedures in at least two clinics in Matamoros, Mexico, including River Side Surgical Center and Clinica K-3. Other facilities might be identified through further investigation.”
Apparently adopting a different policy, however, a spokesperson for the state’s health department told the Tampa Bay Times last week, presumably in response to a question about the 15 NTM infections linked to the same Florida clinic, that the “agency doesn’t confirm or deny the existence of doctor licensure or epidemiological investigations.”
While discussions of the importance of openness to building trust in public health is well documented, the decision not to identify the surgery clinic by name in the CDC January report is not unique.
Last week, for instance, Long Beach officials declared a public health emergency after identifying 14 cases of tuberculosis in southern California. According to news reports, the deadly outbreak was localized to guests at a single-room occupancy hotel in Long Beach, “which health officials declined to identify.”
The rationale for federal and state investigations to identity a facility linked to an outbreak by name in some cases but to decline to do so in others can be confusing. More on this topic can be read in a document entitled, “Points to consider: Public disclosure of outbreaks and cases of infectious diseases.”
2. The outbreak’s source: According to the CDC’s January report, the source of the M. abscessus associated with clinic A’s cluster “has not yet been identified,” suggesting that the outbreak’s investigation, at least as of this past January, was ongoing. Presumably, the clinic’s tap water would have been evaluated as a possible source of the outbreak’s NTM.
No matter, the CDC report does not explain whether investigators microbiologically tested clinic A’s tap water, or its sinks, faucets, or ice machines, for M. abscessus, other than stating that “Clinic A was closed after identification of the cluster; the closure precluded environmental sampling during the investigation.”
3. “Gaps” in infection control: During their investigation, state health officials identified “gaps in infection control including cleaning practices, use of personal protective equipment, and surgical device disinfection, that can contribute to NTM transmission,” the CDC’s January report states.
Exactly what these cleaning and device disinfection gaps were that could pose an increased risk of NTM infection following cosmetic surgeries the report does not identify.
In general, publication of the specific infection control breaches identified during an outbreak investigation is important to the public’s learning about the potential causes of the infections while also providing an impetus and guide for healthcare staffers to audit their own infection control practices and to implement corrections when warranted.
Performing a type of case-control comparison, I randomly identified a CDC report discussing an investigation of an unrelated M. abscessus outbreak in Pennsylvania, in 2022. Unlike in this Florida case, however, the report clarifies the identified gaps — for example, that medical equipment (i.e., tracheostomy tubes) was not being cleaned and disinfected according to the manufacturer instructions.
A POSSIBLE CAUSE: Based in part on the CDC January report’s findings, it is reasonable to ask whether, in addition to other possible infection control lapses, a contributing factor to “clinic A’s” infections could have been — although this is conjecture and a consideration that has been neither confirmed nor negated to date — the inadequate cleaning and/or disinfection (instead of sterilization) of one or more reusable surgical instruments, possibly followed by rinsing the item with water (e.g., tap water) unknowingly contaminated with M. abscessus, and then using the wet instrument (if inadvertently) during a surgical procedure without first ensuring it was thoroughly dry.
Improper handling and/or storage of surgical instruments is also a consideration. Other possible causes of post-surgical M. abscessus infections include improper injection practices and exposure to contaminated medications or other solutions.
Food for thought.
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Article by: Lawrence F Muscarella, PhD. Copyright (2024). LFM Healthcare Solutions, LLC. All rights reserved. Dr. Muscarella is the president and founder of LFM Healthcare Solutions, LLC, an independent quality improvement company. Click here for a list of his quality improvement healthcare services. E: Larry@LFM-HCS.com. [LFM-ver-1.0]
Sponsorship: The research and writing of this article were self-sponsored by LFM-Healthcare Solutions, LLC.
Services: Details about the quality and expert services Dr. Muscarella provides healthcare facilities, patients, device manufacturers and legal representatives are available here.
Forensic Case Reviews, Infection Investigations: LFM-Healthcare Solutions, LLC provides medical expertise for healthcare facilities, device manufacturers and the public, specializing in healthcare-associated infections linked to contaminated reusable medical equipment.
Dr. Muscarella’s expertise, experience:
Dr. Muscarella is an expert in the causes and preventions of hospital infections linked to endoscopic and other types of medical procedures. He also specializes in forensic case reviews, medical errors, medical device designs, risk assessments and gap analyses. His “bio” is available here.
Dr. Muscarella is an independent safety expert with almost 30 years of professional experience in the relevant fields of medical device design, infection prevention, aseptic technique, risk management, disinfection and sterilization, and endoscope reprocessing.
He has authored more than 200 articles on these topics, including on the causes and prevention of endoscope-related bacterial outbreaks. Several of his peer-reviewed articles have been published in Chest, The American Journal of Infection Control, Gastrointestinal Endoscopy, Infection Control and Hospital Epidemiology, and The Journal of Hospital Infection.
Dr. Muscarella’s research, findings and perspectives on these topics have been discussed by more than two dozen news media outlets, including CNN, NBC’s The Today Show, NBC Nightly News, ABC World News Tonight, Al Jazeera America, and
the CBS Evening News.
Additionally, his guidance and advice have been discussed on the front pages of The Wall Street Journal, The Los Angeles Times, The Seattle Times, The San Juan Weekly, The Seattle Times, and The Denver Post, among other printed newspapers.
More about Dr. Muscarella “bio” may be read here. Copies of his curriculum vitae (c.v.) are available upon request.