BACKGROUND: In August 2013, the Maryland Department of Health and Mental Hygiene (MDHMH) learned of 2 residents with rapidly growing nontuberculous Mycobacterium surgical-site infections. During July 2013, both had undergone cosmetic surgery at a private surgical clinic (Clinic A) in Santo Domingo, Dominican Republic (DR). Multiple states and cities and the Centers for Disease Control and Prevention (CDC) joined MDHMH to initiate case finding and an investigation.
METHODS: Alerts were disseminated by health departments, Epi-X, the Emerging Infections Network, and the American Society of Plastic Surgeons. A probable case was defined as soft-tissue infection unresponsive to standard antibiotic therapy in a patient after cosmetic surgery in the DR after March 1, 2013; a confirmed case was also culture-positive for rapidly growing nontuberculous Mycobacterium. Patient interviews and chart abstractions were conducted. CDC and New York City Department of Health and Mental Hygiene performed pulsed-field gel electrophoresis of available isolates.
RESULTS: Overall, 21 cases were identified from New York (11), Massachusetts (4), Connecticut (2), Maryland (2), New Jersey (1), and Pennsylvania (1). Eighteen (86%) were confirmed; all patients were female, aged 18–59 years. Thirteen (62%) had had surgery at Clinic A; 7 (33%) reported surgery at 7 other surgical clinics; and 1 (5%) clinic was unidentified. The most frequent cosmetic surgical procedures were liposuction (71%) and abdominoplasty (52%); procedures were conducted March–November 2013. Of 20 patients with hospitalization information, 16 (80%) were hospitalized and required multiple therapeutic surgical procedures and prolonged courses of antibiotics. No deaths were reported. Of 20 patients who were interviewed, 15 (75%) had been born in the DR. Of 18 confirmed cases, 16 (89%) infections were caused by Mycobacterium abscessus and 2 (11%) by Mycobacterium fortuitum. Pulsed-field gel electrophoresis of 15 available case isolates indicates a clonal cluster involving 11 (73%) patients, 10 (91%) of whom were Clinic A patients.
CONCLUSIONS: This outbreak documents a potential risk of medical tourism. DR public health authorities temporarily closed Clinic A. All persons considering surgical care outside of the United States should verify that health care providers are licensed and facilities are accredited by an internationally recognized accreditation organization. Health departments should consider methods for communicating recommendations to medical tourists, especially foreign-born residents who might elect to have surgeries in their country of origin. Health care providers should consider nontuberculous Mycobacterium among patients who have undergone surgery in the DR and have surgical-site infections unresponsive to standard antibiotic therapy.