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BACKGROUND: In February 2015, the Toledo-Lucas County Health Department (TLCHD) in Toledo, Ohio learned of two cases of Mycobacterium chelonae infections associated with Laser-Assisted in situ Keratomileusis (LASIK) eye surgery. M. chelonaeis a rapidly growing mycobacterium that has been found in natural and potable freshwater, soil, and contaminated solutions. TLCHD notified the Outbreak Response and Bioterrorism Investigation Team (ORBIT) Bureau of Infectious Diseases (BID) at Ohio Department of Health to initiate investigation. The Federal Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) were also called upon to assist.
METHODS: TLCHD gathered information on all eye drops used during the procedure to provide to the FDA, and reviewed EpiCenter, Ohio’s syndromic reporting system, for eye related infections following surgery. Environmental sampling of the eye care center (Clinic A) was completed by TLCHD, with pulsed field gel electrophoresis (PFGE) of patient and environmental isolates performed by the CDC. A confirmed case was defined as a laboratory-confirmed case of Mycobacterium chelonaeisolated from the eye following eye surgery; a probable case was defined as a gram stain consistent with Mycobacterial eye infection following eye surgery. Interviews of case patients and a case-control questionnaire of patients having eye surgery at Clinic A were completed by TLCHD.
RESULTS: Overall, four confirmed cases of M. chelonaefollowing LASIK eye surgery at Clinic A were reported. All cases were between the ages of 30-55, 75% were female. All received LASIK eye surgery by Clinic A during the months of January and February 2015. Susceptibility testing of the organism determined the antibiotic course administered to the four cases. Vigamox and fortified Tobramycin eye drops were prescribed; in addition one case was prescribed oral Clarithromycin. Clinic A was given the recommendation from TLCHD and ODH to refrain from all LASIK and Advanced Surface Treatment (AST) surgeries until the source of infection could be identified from the environmental samples.
CONCLUSIONS: M. chelonae is a hydrophobic mycobacterium that presents a clear risk of infection from contaminated sources. This mycobacterium is capable of producing a biofilm when adhering to surfaces dramatically increasing the difficulty of removing it from the environment. Additionally, it is one of the most drug resistant organisms in the non-tuberculosis mycobacterium group rendering it immune to the most common antibiotic therapies. This outbreak highlights the importance of routine cleaning, and careful disinfection of the surgical room environment in LASIK surgery centers.