Strep infection linked to death after liposuction at ‘spa’

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.

Four confirmed and nine suspected cases of invasive group A Streptococcus infection, including one fatality, developed after liposuction at a chain of "medical spas" in Maryland and Pennsylvania, according to a report published online May 26 in JAMA Internal Medicine.

In addition to the previously healthy woman who died, the three other patients with confirmed infections were hospitalized for up to 77 days for necrotizing fasciitis, as well as streptococcal toxic shock syndrome. Each patient required two to six surgical debridements. "Our findings underscore the importance of improved oversight of the increasingly complex surgical procedures that are performed at outpatient facilities that are not subject to state or federal regulation," said Amanda L. Beaudoin, Ph.D., of the epidemic intelligence service, Centers for Disease Control and Prevention, and her associates.

Melissa Brower/CDC

A public health investigation revealed that 13 infections developed among a possible 55 men and women (mean age, 39 years) interviewed who underwent liposuction during a 2-month period at two facilities that also offered Botox (onabotulinumtoxinA) injections, laser hair removal, and tattoo removal. One physician, who was not board certified in plastic surgery, performed all the procedures in which invasive group A Streptococcus infection developed. This physician and his surgical assistant were later found to be carrying the same strain of the erythromycin-, clindamycin-, and tetracycline-resistant organism when throat and anal cultures were obtained, said Dr. Beaudoin, who is also with the Pennsylvania Department of Health, Harrisburg, and her colleagues.

During the outbreak period, the physician reported that he had self-treated cellulitis of his hands with cephalexin, and the assistant reported having had a sore throat. Both said that they had used surgical masks and gowns during the procedures, but not during surgical marking, preoperative preparation, or postoperative care. However, multiple patients reported that the surgical team didn’t wear masks or gowns during the procedure, and one said that the surgical team consumed food in the procedure room.

A limited site assessment of the involved facilities revealed visibly dirty equipment; no designation of "clean" and "dirty" areas for disinfection and sterilization of equipment; surgical scrub materials left open to the air; no records of the use and maintenance of autoclaves or of performance checks on them; inadequately labeled, multiple-dose, and expired vials of medication; nonsterile surgical dressings stored in high-traffic areas; no written policies regarding infection prevention; and no records of employee training in infection prevention, the investigators said (JAMA Intern. Med. 2014 May 26 [doi:10.1001/jamainternmed.2014.1875]).

When patients ask about cosmetic procedures, physicians should emphasize that they choose a surgeon fully trained in cosmetic surgery who operates out of an accredited surgical center or hospital. All physicians should be alert to the possibility of infection after their patients undergo cosmetic surgery, "including suspicion of necrotizing fasciitis as a possible postoperative complication," Dr. Beaudoin and her associates said.

The investigators reported no financial conflicts of interest.