1. Case of Medical Tourism

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

9. 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

10. 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.