Mycobacterium fortuitum wound infection following laparoscopy
Sethi, Sunil
During a six week period in 1999, seven patients who underwent laparoscopic tubectomies at small town health centres near Chandigarh developed chronic discharging sinuses at the site of incision. Mycobacterium fortuitum was isolated from wound discharge of five patients by standard methods and two patients were smear positive. Environmental samples e.g., tap water, and a variety of fluids did not yield any mycobacteria and swabs from different parts of the laparoscope were sterile. All patients responded to ciprofloxacin and amikacin therapy. Our observation demonstrates that M. fortuitum is a clinically important nosocomial pathogen in setting of surgical wound infection in our country.
Key words Mycobacterium fortuitum – wound infection
Mycobacterium fortuitum is known for producing a wide spectrum of clinical disease. The most frequently reported infections are postsurgical, primary cutaneous and pulmonary . We describe here the occurrence of M. fortuitum surgical wound infection developing within one month after a laparoscopic procedure. During a six weeks period in August-September 1999, 20 patients in three health centres (located near Chandigarh) underwent laparoscopic procedures under local anaesthesia (2% xylocaine). In these health centres, no surgical procedures other than laparoscopic tubectomies are performed. In all the patients, medical check up and basic investigations like blood count, hepatic and renal functions were carried out and were found to be within normal limits. Postoperatively all the patients had healthy wounds and the stitches were removed on day 7. Seven of these 20 patients had come for follow up and all seven presented with nodular swellings progressing to chronic discharging sinus at the site of incision (near umbilicus). There was chronic watery discharge from the wound and all the patients had mild pain but no fever or any other constitutional symptoms. Emperical treatment schedules with different antibiotics (cloxacillin and cephalexin) failed to resolve the infection. All the patients were previously healthy women aged 32-45 yr (median 33.5 yr) and clinical examination did not reveal lymph node involvement or hepatosplenomegaly. In these patients, the discharge persisted. The patients were subsequently brought to the Medical Microbiology Department of the Postgraduate Institute of Medical Education and Research, Chandigarh and the wound discharge was collected for routine smear and culture isolation studies. Swabs were also taken from different parts of the laparoscope. Gram stain, Ziehl-Neelsen (Z-N), and stains to detect fungi were performed. Swabs and fluid were cultured on to blood agar (Hi-Media Lab, India), McConkey agar (Hi-Media) and Lowenstein Jensen (LJ) (Ili-Media) medium and Sabouraud’s dextrose (Hi-Media) agar for aerobic and anaerobic bacteria, mycobacteria and fungi respectively. Z-N stain revealed acid fast bacilli (AFB) in all the patients and other stains did not show any microorganisms. The magenta coloured colonies were seen on McConkey agar after 24-48 h whereas small white colonies grew on LJ media after 3-5 days of inoculation. In two patients, AFB smears were positive but culture did not grow any organism. The definite identification of the organism as M. fortuitum was based upon growth on McConkey agar and nonphotochromogenic colonies, positive nitrate reduction, iron uptake, aryl sulphatase, tolerance to 5 per cent NaCl and 68 deg C catalase Environmental cultures including culture of tap water, a variety of fluids and materials at the three surgical units did not yield any mycobacteria and swabs from different parts of laparoscope were sterile on smear examination and culture. At that time, all the patients were started on a course of amikacin and ciprofloxacin therapy and during that period, susceptibility of these isolates was done using ‘E’test method (AB BIODISK, Solna, Sweden) according to E test technical guide 3. All the strains were sensitive to amikacin (MIC 0.38 (mu)g/I), cefoxitin (MIC 0.02 (mu)g/1), rifampicin (MIC 0.125 (mu)g/1), ciprofloxacin (MIC 0.023 (mu)g/1), ethambutol (MIC 0.06 (mu)g/l), isoniazid (MIC 0.06 (mu)g/l), streptomycin (MIC 0.09 (mu)g/l) and kanamycin (MIC 0.03 (mu)g/1) and all the strains were resistant to ethionamide (MIC>16 (mu)g/1). All the patients responded to amikacin and ciprofloxacillin. On follow up of these patients (i.e., 3 months after initiation of treatment), the wound had completely healed and patients had no signs or symptoms of active infection. Studies by Yew et al4,5 have also supported the efficacy of quinolones (ofloxacin) with or without amikacin in the treatment of M. fortuitum wound infections. In the present study, the sterilization of equipment was carried out in a chamber using formalin vapours for a minimum of 24 h. However, on recognition of the outbreak, the batch of 2 per cent xylocaine was changed and subsequently no cases of M. fortuitum surgical infection in these health centres have been reported. By the time of our investigation the suspected batch of 2 per cent xylocaine was not available and hence could not be cultured in our laboratory.
In conclusion, this study shows that M.fortuitum is a clinically important nosocomial pathogen in the setting of surgical wound infection and emphasizes the potentially disastrous consequences of infection with these organisms. High degree of suspicion, specific identification and susceptibility testing will allow the timely institution of appropriate antimicrobial therapy.
References
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Sunil Sethi, Meera Sharma, Pallab Ray, Malkit Singh & Anil Gupta*
Department of Medical Microbiology, Postgraduate Institute of Medicine Education & Research Chandiagrah & *Community Health Centre, Banur, Patiala, India
Received January 16, 2001
Reprint requests: De Meera Sharma, Professor and Head, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chadigarh 160012, India
Copyright Indian Council of Medical Research Mar 2001
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