Case of Medical Tourism

Patient History 34 yr old previously healthy female presenting to Emergency Department (ED) with low grade fever, abdominal tenderness, redness, swelling and draining fluid Computed Tomography (CT) scan shows fluid collection and concern for abdominal wall abscess 2 months prior patient had traveled to the Dominican Republic to have elective abdominal plastic surgery Incision and drainage was performed in the ED and an aspirate of abscess material and fluid was sent to the microbiology lab for culture

Possible organisms that can cause this patient’s infection Staphylococcus aureus MRSA Streptococcus anginosus Enterococcus Enterobacteriaceae Rapidly Growing Mycobacteria Mycobacterium abscessus Mycobacterium fortuitum Anaerobes Bacteroides fragilis

Specimen Collection and Processing Aspirated abscess material and fluid sent in syringe to laboratory and planted to culture media within 1 hour from collection Aerobic and Anaerobic culture media Blood agar Chocolate agar CNA agar MacConkey agar Brucella agar PEA agar KV agar Thioglycolate broth

Microbiological Identification Aerobic culture growth at 48 hrs Blood agar – 2 pinpoint colony types Organism 1: Gram stain- Gram positive cocci in chains, identification (ID) by MALDI-Tof - Streptococcus anginosus Organism 2: Gram stain- Gram positive beaded rods, No ID by MALDI-Tof or Vitek 2 Subculture Organism 2 to Mycobacteria and Aerobic Actinomyces media 7H11 media- for culture of Mycobacteria BCYE media- for culture of Nocardia and Aerobic Actinomyces Organism 2 on Blood Agar Organism 2 Gram Stain

Mycobacteria Identification Growth on 7H11 media Small, slightly rounded cream colored colonies Acid Fast Stain positive Isolate sent to reference laboratory for ID by 16s ribosomal sequencing and antimicrobial susceptibility testing Identification: Mycobacterium abscessus Growth on 7H11 AFB Positive Stain

Mycobacteria abscesses Rapidly Growing Mycobacteria Growth < 7 days, Avg 3-5 days Acid Fast Stain: positive Colony waxy consistency and non-pigmented Traditionally used growth characteristics and biochemical testing for identification Current methods for identification are: Molecular sequencing Mass spectrophotometry (MALDI-TOF) Koneman’s , 6th Ed.; MCM, 11th Ed.

Mycobacteria abscesses Naturally found in the environment; on land in the water Contaminate water supplies, including reagents and wash solutions used in hospitals Opportunistic infections Skin and soft tissue Post-traumatic wound infection (Community Acquired) Post-surgical site wound infection (Hospital Acquired) Can be resistant to commonly prescribed antibiotics Recommend antimicrobial susceptibility testing and using results to guide therapy Koneman’s , 6th Ed.; MCM, 11th Ed.

Patient Outcome Patient was treated in the hospital for 3 days with Vancomycin and Piperacillin-tazobactam while awaiting culture results Discharged on oral doxycycline Returned to ED 1 month later with new draining wounds Infectious Disease consulted and used susceptibility data to recommend appropriate treatment 4-6 weeks of IV Tigecycline and Amikacin Followed by 6-12 months of oral Azithromycin With follow up in the Infectious Disease clinic

April Bobenchik, PhD, D(ABMM) Dr. Bobenchik is the Associate Director of Microbiology and Infectious Diseases Molecular Diagnostics at Lifespan Academic Medical Center and Assistant Professor of Pathology and Laboratory Medicine at Warren Alpert School of Medicine of Brown University. She completed a CPEP-accredited medical microbiology and public health fellowship at the David Geffen Medical School, UCLA in Los Angeles, CA, and is a diplomat of the American Board of Medical Microbiology. Dr. Bobenchik’s research interests include new diagnostic test development, quality improvement and clinical outcome studies, and detection of antimicrobial resistance.