J Card Surg.2013 Nov;28(6):687-692

Sternal wound infection caused by Mycobacterium chelonae

Shinya Unai, MD1, Joseph Miessau, MS1, Pawel Karbowski, MS1, Gurjyot Bajwa, MD1, Nicholas C. Cavarocchi, MD1, Hitoshi Hirose, MD1.

1. From Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, PA.

Short running Title: Mediastinitis caused by Mycobacterium chelonae

Corresponding author:

Hitoshi Hirose, MD.

Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University

1025 Walnut Street Room 605, Philadelphia, PA 19107, USA.

Tel: 215-955-5654; Fax: 215-955-6010; E-mail: genex@nifty.com

 

Abstract

Introduction: Sternal wound infection caused by Mycobacterium chelonae, a member of the rapidly growing nontuberculous mycobacteria (NTM), is rare and may present without signs and symptoms of systemic infection.

Methods: We present a patient who had a M. chelonae infection of the sternum following cardiac surgery and conducted a review of the literature from 1976 to 2013.

Results: Seventy cases of NTM sternal wound infection after cardiac surgery were identified, including six outbreaks and ten sporadic cases including the present case.  The age range of the patients was between 6 and 78 years.  The average time from the surgery was 49 ± 58 days which was longer than the usual bacterial mediastinitis.  The patient may present without fever, elevated white cell counts, or watery odorless drainage.  The overall mortality rate was 29%.

Conclusion: NTM sternal wound infection is rare but may be fatal if not properly treated.  The toxic signs are often subtle and it will take longer to isolate compared to typical bacterial mediastinitis.  Early recognition, the use of appropriate antibiotics based on susceptibility tests, and aggressive surgical debridement are required for full recovery.

Key words: cardiac surgery, mediastinitis, mycobacterium, surgical site infection, acid fast bacilli

 

Summary

Our case illustrates the unique clinical presentation and the treatment for sternal wound infection caused by M. Chelonae, one of the species of rapidly growing nontuberculosis mycobacterium (NTM), and would alert clinicians that NTM may be a cause of culture negative sternal wound infection.  NTM is ubiquitous in the environment and has been isolated from water used in the operating room.1-3

A total of 70 cases of NTM sternal wound infection after cardiac surgery were reported (Table).  The patients were not necessarily immune-compromised and almost all patients had an uneventful postoperative course.  The interesting features of NTM sternal wound infection compared to typical bacterial mediastinitis is that the onset is delayed, patients do not appear to be septic4, high fever with elevated white blood cell count is rare.5  Sternal drainage is odorless and watery rather than purulent.6  The initial wound cultures are usually negative, or it may grow normal flora of the skin.  It may take up to 7 days to culture.2  The delay of the isolation may cause delay in treatment, since the drug sensitivity is different from typical pathogen of sternal wound infection.3

NTMs are usually resistant to the first-line antituberculous drugs.7  Clarithromycin is currently the drug of choice for M. chelonae, because of the excellent tissue penetration, susceptibility and few side effects.5  Combination therapy is recommended to minimize the development of drug resistance.5, 8  Recently, linezolid, tigecycline, telithromycin, gatifloxacin are reported to be effective.9, 10  At least 4 to 6 months of antibiotic treatment based on susceptibility test is recommended.9

For sternal infection caused by M. chelonae, one of the injectable agents such as tobramycin is recommended in combination with clarithromycin for at least the first 2 weeks.11  Tobramycin is preferred to amikacin because of its greater in-vitro activity.11

Surgical debridement in conjunction with appropriate antibiotic therapy is mandatory for complete recovery.  All wires should be removed.  If the combination of surgical debridement and appropriate antibiotics fails to eliminate the infection, more aggressive approach such as sternectomy combined with a pectoralis flap or omental flap will be required.

Reference

1.         Nagao M, Sonobe M, Bando T, Saito T, Shirano M, Matsushima A, Fujihara N, Takakura S, Iinuma Y, Ichiyama S. Surgical site infection due to Mycobacterium peregrinum: a case report and literature review. Int J Infect Dis 2009;13:209-211.

2.         Syed AU, Hussain R, Bhat AN, al Rasheed M, al Qethami H, al Faraidi Y, al Fagih MR. Mediastinitis due to Mycobacterium fortuitum infection following Fontan operation in a child. Scand Cardiovasc J 1997;31:311-313.

3.         Narasimhan SL, Austin TW. Prosthetic valve endocarditis due to Mycobacterium fortuitum. Can Med Assoc J 1978;119:154-155.

4.         Robicsek F, Daugherty HK, Cook JW, Selle JG, Masters TN, O’Bar PR, Fernandez CR, Mauney CU, Calhoun DM. Mycobacterium fortuitum epidemics after open-heart surgery. J Thorac Cardiovasc Surg 1978;75:91-96.

5.         Samuels LE, Sharma S, Morris RJ, Solomon MP, Granick MS, Wood CA, Brockman SK. Mycobacterium fortuitum infection of the sternum. Review of the literature and case illustration. Arch Surg 1996;131:1344-1346.

6.         Hoffman PC, Fraser DW, Robicsek F, O’Bar PR, Mauney CU. Two outbreaks of sternal wound infection due to organisms of the Mycobacterium fortuitum complex. J Infect Dis 1981;143:533-542.

7.         Esteban J, Ortiz-Perez A. Current treatment of atypical mycobacteriosis. Expert Opin Pharmacother 2009;10:2787-2799.

8.         Mushatt DM, Witzig RS. Successful treatment of Mycobacterium abscessus infections with multidrug regimens containing clarithromycin. Clin Infect Dis 1995;20:1441-1442.

9.         Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, Holland SM, Horsburgh R, Huitt G, Iademarco MF, Iseman M, Olivier K, Ruoss S, von Reyn CF, Wallace RJ, Jr., Winthrop K. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367-416.

10.       Fernandez-Roblas R, Martin-de-Hijas NZ, Fernandez-Martinez AI, Garcia-Almeida D, Gadea I, Esteban J. In vitro activities of tigecycline and 10 other antimicrobials against nonpigmented rapidly growing mycobacteria. Antimicrob Agents Chemother 2008;52:4184-4186.

11.       Brown-Elliott BA, Wallace RJ, Jr. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria. Clin Microbiol Rev 2002;15:716-746.

 

Table :  Characteristics of the sternal infection caused by rapidly growing non-tuberculosis mycobacteria.

Reference

Year

No. of cases

Age range

Organism

Duration after surgery (days)

Fever

Quality of drainage

WBC

Long-term antibiotics

Outcome

Robicsek

1976

19

42-66

M. chelonei subspecies abscessus

6-40 days

low grade

no odor, more watery than purulent

6.9-29.6

erythromycin and rifampin

5 deaths

Hoffman

1976

5

30-70

M. fortuitum

6-44 days

NA

thick, whitish, cheesy, brown, or purulent

7.0-18.5

rifampin, ethambutol, and isoniazid (4)

ethionamide ethambutol, and isoniazid (1)

all healed

Jauregui

1977

1

55

M. chelonei subspecies abscessus

61 days

Yes

yellowish, white

9.4

erythromycin and vancomycin

death

Szabo

1977

6

NA

M. chelonei subspecies abscessus

11-45 days

fever (5)

no fever (1)

serous, containing yellowish fragment,   odorless

normal

NA

3 deaths

Narasimhan

1978

1

57

M. fortuitum

35 days

Yes

NA

4.8

ethinamide, isoniazid, and rifampin

1 death

Preheim (reference Brown-Elliott 2002)

1981

5

NA

M. fortuitum

NA

NA

NA

NA

NA

1 death

Kuritsky

1981

4

49-76

M. chelonei subspecies abscessus,                      M. fortuitum biovariant   fortuitum

21-92 days

fever (2),

no fever (2)

NA

NA

amikacin and cefoxitin (2)

amikacin, cefoxitin and doxycycline (1)

1 death,    3 healed

Sethi

1982

1

61

M. fortuitum

30 days

Low grade

serous, odorless

4.4

doxycycline, sulphamethoxazole, and   ethionamide

1 healed

Kuhn

1983

1

56

M. fortuitum

28 days

low grade

brown purulent

ciprofloxacin, erythromycin, and amikacin

1 death

Yew

1987

1989

21

28-70

M. fortuitum biovariant fortuitum (7)

M. fortuitum biovariant peregrinum (12)

M. fortuitum third biovariant complex (2)

0-2 months

NA

NA

NA

NA

NA

Chow

1988

1

45

M. fortuitum

11months

NA

NA

NA

oxacillin

1 death

Samuels

1996

1

49

M. fortuitum

35 days

low grade

watery

NA

ciprofloxacin, sulfamethoxazole, and   clarithromycin

1 healed

Syed

1997

1

6

M. fortuitum

19 days

Yes

yellowish, odorless, thick pus

amikacin, sulfamethoxazole and   trimethoprim

1 healed

Idigoras

2003

1

78

M. porcinum

6 months

NA

pus

NA

ciprofloxacin

1 healed

Sarma

2010

1

75

M. abscessus

1 month

No

serosanguinous

10.4

azithromycin, amikacin, and ciprofloxacin

1 healed

Unai

2013

1

60

M. chelonae

3 months

No

serosanguinous

7.6

tigecycline, and clarithromycin

1 healed

 

NA: not available; WBC: white blood cell count (B/L);

 

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