Surgical Site Infection due To Mycobacterium mageritense and Literature Review

Yoshihiko Ogawa^1*, Soichiro Ito², Ryuichi Nakano³, Kei Kasahara¹ , Masamitsu Kuwahara² , Hisakazu Yano³, and Keiichi Mikasa¹

¹Center for Infectious Diseases, Nara Medical University, Nara, Japan

²Department of Plastic Surgery, Nara Medical University, Nara, Japan

³Department of Microbiology and Infectious Diseases, Nara Medical University, Nara, Japan

*Corresponding Author:

Yoshihiko Ogawa
Center for Infectious Diseases
Nara Medical University, Nara, Japan
Tel: +81-744-22-3051
Fax: +81-744-22-4121
E-mail: hikoichi@naramed-u.ac.jp

Received date: June 07, 2016; Accepted date: June 15, 2016; Published date: June 17, 2016

Citation: Ogawa Y, Ito S, Nakano R, Kasahara K, Kuwahara M, et al. (2016) Surgical Site Infection due To Mycobacterium mageritense and Literature Review . J Infect Dis Ther 4: 283. doi:10.4172/2332-0877.1000283

Copyright: © Ogawa Y, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Surgical site infection due to Mycobacterium mageritense is reported in an 85-year-old Japanese woman. In this patient, a mesh patch was inserted to close a ventral hernia and surgical site infection occurred 7 days postoperatively. The isolate was confirmed to be Mycobacterium mageritense by analysis of the 16S rRNA and rpoB genes. The infection was successfully treated with negative pressure wound therapy and long-term antibiotics without removal of the mesh patch.

Keywords

Mycobacterium mageritense ; Surgical site infection; 16S rRNA; rpoB ; Negative pressure wound therapy

Introduction

Mycobacterium mageritense is a rapidly growing nonpigmented mycobacterium that most closely resembles the M. fortuitum third biovariant complex [1]. There have been few reports about skin or soft tissue infections, especially surgical site infection, due to M. mageritense [2-5]. Here we report the first case of successful treatment of surgical site infection due to M. mageritense without removing the implanted mesh patch.

Case Report

An 85-year-old woman was admitted to our hospital for surgery to control a symptomatic incisional hernia. In June 2006, she had undergone extended resection and transplantation of a rectus abdominis musculocutaneous flap for Paget’s disease of the vulva. However, a postoperative ventral hernia developed along with cicatricial stenosis of her anal region. In October 2006, a second operation was performed for the ventral hernia and it was found that the hernial orifice was too large to close, so it was reinforced with mesh. Subsequently, we recommended re-operation with a mesh patch, but the patient declined. After her symptoms gradually became worse and control of excretion was impaired, she eventually agreed to surgery.

In October 2015, hernia repair was performed with a mesh patch. On postoperative day 7, the abdominal wall became tense and the wound discharge changed from serous to yellowish-brown and purulent. A swab of the wound site was taken to test for microorganisms. Then the wound was opened widely and we performed irrigation and debridement, followed by negative pressure wound therapy (NPWT). An acid-fast bacillus was detected after only 2 days of culture of the wound swab on blood agar at 35°C under aerobic conditions and was identified as Mycobacterium abscessus by the DNA-DNA hybridization method (Kyokuto, Japan).

We also performed drug susceptibility testing and found resistance to clarithromycin, which suggested that other rapidly growing mycobacteria should be considered. Therefore, we performed analysis of the 16S ribosomal RNA (16S rRNA) and rpoB genes by amplifying sequences of 1,391 bp and 723 bp, respectively. According to the Eztaxon database (http://www.ezbiocloud.net/eztaxon), the isolate showed 100% concordance of its 16S rRNA sequence with that of Mycobacterium mageritense (DSM 44476^T) and 99.57% concordance with Mycobacterium peregrinum (ATCC 14467^T). According to the BLAST database (http://blast.ddbj.nig.ac.jp/blastn?lang=ja), the rpoB sequence of the isolate showed 100% agreement with that of M.mageritense (ATCC 700351). Thus, we concluded that the isolate was M. mageritense .

NPWT was continued with wound irrigation at every dressing change and intravenous antimicrobial therapy was provided with a combination of levofloxacin and imipenem/cilastatin for 6 weeks. Signs of infection improved and granulation of the wound occurred gradually, after which we switched her antimicrobial therapy to oral minocycline and levofloxacin for an additional 3 months.

Discussion`

M. mageritense was first described by Domenech et al. [1]. Similar to other rapidly growing mycobacteria like Mycobacterium fortuitum and M. abscessus , this microorganism is commonly linked to human disease. Similar with other rapidly growing mycobacteria, this organism is ubiquitous and also isolated from most municipal water supplies. In our case, infection might be established through water. There have been few reports describing skin or soft tissue infections due to M. mageritense . Table 1 summarizes the reported cases of skin and soft tissue infection [2-6].

Table 1: Past reports of skin and soft tissue infection due to Mycobacterium mageritense.

Unlike other rapidly growing mycobacteria, M. mageritense is resistant to clarithromycin [2]. In our patient, the isolate was resistant to clarithromycin but susceptible to fluoroquinolones, imipenem, and minocycline.

This case suggests that if a rapidly growing mycobacterium is isolated which shows resistance to clarithromycin, it is necessary to perform a gene assay instead of DNA-DNA hybridization. Adekambi et al. suggested that rpoB is more suitable than 16S rRNA for diagnosis of rapid growth mycobacterias [7]. And for the identification of the isolate in our case, 16S rRNA was also useful. Thus, we recommend to use rpoB gene analysis together with 16S rRNA for identifying rapid growth mycobacteria. Also, even if the strain is initially susceptible to macrolides, resistance to these drugs is easily induced by endogenous resistance genes, so it is thought that the use of macrolides for M.mageritense infection should be restricted [8]. Thus, it may be necessary to repeat drug susceptibility testing, particularly at institutions that cannot perform gene assays.

The treatment of M. mageritense infection has not been established and it varied in the cases reported to date (Table 1). Because infection was refractory, antibiotic therapy was performed for several months in the previous patients and was combined with drainage and surgical treatment.

Unlike the reported cases, our patient’s wound infection improved with repeated irrigation and NPWT plus antimicrobial therapy, and we did not remove the mesh patch taking her overall status and her request for no further surgery into consideration. When infection of a foreign body occurs, it often becomes a reservoir for bacteria and leads to treatment failure. Kannaiyan et al. reported a series of surgical site infections caused by rapidly growing mycobacteria [9], including four cases with a mesh. And the mesh was removed in all patients.

NPWT is a method of reducing edema by removal of intercellular lymph fluid, and it promotes wound healing through this mechanical effect as well as reducing the bacterial burden by suction drainage [10]. With our combined approach to treatment, it soon became impossible to isolate M. mageritense from the wound, but complete granulation required several months. In conclusion, removal of the mesh patch may have promoted more rapid healing and is recommended when the patients’ condition permits it if surgical site infection due to rapid growth mycobacteria is detected, but combination therapy with NPWT and long-term antibiotic therapy could be the alternative strategy when the patients’ condition does not permit.

References

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