Case Study: Persistent infection in surgical wounds: Atypical mycobacteria and its surgical treatment

Summary

The non-tuberculous mycobacteria (NTM) have become significant opportunistic pathogens recently, and occur in epidemic proportions in some centers. For example, atypical mycobacterial infections are a frequent problem found at the port site in laparoscopic surgery patients. The NTM, which include Mycobacterium fortuitum and M. chelonae, are classified as rapid growing mycobacteria (RGM) and are grouped as M. fortuitum-chelonae complex. Non-healing postoperative wound infections that are not responsive to the types of antibiotics that are used for pyogenic infections, and have sterile routine aerobic cultures should raise a suspicion of NTM. Clinical diagnosis can be difficult, because RGM have no characteristic clinical features. There is no defined standard of antibiotics for treating RGM infections. I’ve encountered histopathology for 41 cases over 9 months of such post-operative wound infection where ultimately surgical excisions were done to get relief from the persistent and resistant infection!

Background

Atypical mycobacteria can be found in the soil, tap water, and natural water, so they can also contaminate solutions and especially disinfectants in hospital settings. This kind of infection causes significant morbidity for patients recovering from laparoscopic and other surgeries [1]. Improper sterilization of instruments is mainly responsible for such infections, and it adds to post-operative morbidity in our country and developing countries.

There is controversy about therapy for atypical mycobacteria infection. Anti-tuberculosis drugs have a limited effect on the microorganisms, so the standard treatment uses combinations of second-line anti-tuberculosis drugs, such as macrolides (e.g., clarithromycin), quinolones (ciprofloxacin), tetracyclines (doxycycline), and aminoglycosides (amikacin). When clinical symptoms are observed, the standard treatment is 28 days of oral clarithromycin and ciprofloxacin or amikacin. Local administration of aminoglycosides can also be highly effective for treating any stubborn nodules and sinuses that remain afterward [2].

But what should we do if the wound still does not heal?

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