Skip directly to local search Skip directly to A to Z list Skip directly to navigation Skip directly to site content Skip directly to page options
CDC Home

Volume 14, Number 1—January 2008

Letter

Case Cluster of Necrotizing Fasciitis and Cellulitis Associated with Vein Sclerotherapy

Suggested citation for this article

To the Editor: Varicose vein sclerotherapy is a commonly performed cosmetic surgical procedure in which a sclerosing agent is injected into small varicose veins of the leg by using small gauge needles. It is regarded as a minor, safe procedure, usually performed in an office clinic (1). We describe a cluster of infections with group A Streptococcus spp. associated with throat carriage in a cosmetic surgeon.

In early December 2006, 3 patients were seen over a 10-day period at Geelong Hospital with infections following varicose vein sclerotherapy. All patients had undergone varicose vein sclerotherapy with polidocanol (Laurath-9; Aethoxysklerol, BSN Medical, Mount Waverley, Victoria, Australia) at a clinic of a single cosmetic surgeon. The index patient (patient A) had toxic shock syndrome and necrotizing fasciitis of the treated legs. The 2 other patients (patients C and D) had multifocal cellulitis directly correlating to the injection sites. The time between sclerotherapy and disease onset was 1–2 days.

A case-patient was defined as a patient who had undergone sclerotherapy at the clinic and subsequently had infection directly related to the site of sclerosant injection. Events were dated from the day on which the index patient had her surgical procedure. We reviewed clinic notes and infection control procedures in conjunction with the Department of Human Services of the State Government of Victoria, Australia. Specimens, where available, were collected for culture from patients by the treating clinicians. A throat swab was taken from the cosmetic surgeon. Specimens were transported and cultured by using standard methods.

Figure

Thumbnail of Days of procedures for infected and noninfected patients and their first manifestations of infection. □, uninfected; ■, infected; △, patients A and B seen with infection; Ο, patient C seen with infection; and ↑, patient D seen with infection.

Figure. Days of procedures for infected and noninfected patients and their first manifestations of infection. □, uninfected; ■, infected; △, patients A and B seen with infection; Ο, patient C seen with...

During the outbreak period, 44 patients had vein sclerotherapy with 3% polidocanol at the cosmetic surgeon’s clinic. In addition to the 3 patients identified on admission to hospital, a fourth patient (patient B) sought treatment from her general practitioner for medical care for a postprocedure infection. All patients had procedures on day 1 or day 7 (Figure); patients A and B were seen consecutively on day 1, and 2 patients were treated between patients C and D on day 7.

Patient A required surgical debridement, intravenous antimicrobial drugs, intensive care, and hyperbaric oxygen therapy. Intraoperative specimens taken from her during debridement cultured group A Streptococcus spp. Patients B, C, and D had cellulitis, but no specimens suitable for microbiologic diagnosis of cellulitis were taken for culture. Patient B was treated with oral antimicrobial agents as an outpatient. Patient C was admitted to hospital for intravenous antimicrobial therapy, and patient D showed no improvement on oral antimicrobial therapy as an outpatient and was subsequently admitted to hospital for intravenous antimicrobial agents.

Group A Streptococcus spp. was isolated from a throat swab taken on day 16 from the cosmetic surgeon. He reported no upper respiratory tract infection symptoms before the outbreak. He also reported that antiseptic skin preparation was not routinely used during the procedures; nor were gloves used. However, alcohol hand rubs were used between patients. The surgeon had not changed his infection control procedures recently and had not been aware of any infective complications previously. Environmental surface swabs taken on day 14 from 3 different areas (procedural trolley, surgical spotlight, and examination couch) in the clinic during the assessment yielded no pathogenic organisms. The infection control assessment team noted overall cleaning, disinfection, and hand hygiene to be inadequate.

Decolonization of the surgeon was performed by using rifampin 600 mg daily and amoxicillin 500 mg every 6 hours for 10 days, during which time the surgeon suspended surgical procedures. Recommendations were made regarding infection prevention practices; these were undertaken by the surgeon.

Although soft tissue infection following sclerotherapy may be underreported, large case series have not noted this complication in the past (2,3); this finding suggests that any soft tissue infection following sclerotherapy should be investigated. These cases highlight the need for vigilance when considering infection control for minor procedures that take place outside of the support of hospital-based infection control services.

Soft tissue infections as complications following varicose vein sclerotherapy appear to be rare (13). The Australian Aethoxysklerol study reported no cellulitis in 16,804 legs injected with the sclerosing agent, and superficial thrombophlebitis occurred at a rate of 0.08% at 2-year review (2). Likewise, a multicenter registry with 22 European phlebology clinics reported no cellulitis or necrotizing fasciitis in 12,173 sessions (3).

Similarly, surgical site infections with Group A Streptococcus spp. are uncommon. A multicenter survey of 72 centers worldwide reported all β-hemolytic Streptococcus spp. (including group A and group G) accounted for <5% of infections (4), while surveillance in the 1990s by Centers for Disease Control and Prevention reported <1% of all surgical wound infections was caused by group A Streptococcus spp. (5). A Canadian study reported invasive group A Streptococcus infections following surgery in 1.1 cases per 100,000 admissions (6). Outbreaks have been infrequently described (5,710), and sources of colonization range from throat to anus and vagina.

Hiu-Tat Chan*, Jillian Low†, Lorraine Wilson†, Owen C Harris*, Allen C Cheng†, and Eugene Athan†Comments to Author 
Author affiliations: *St. John of God Pathology, Geelong, Victoria, Australia; †Barwon Health, Geelong, Victoria, Australia;

Acknowledgment

We thank Rosemary Lester and Michelle Cullen for their input.

References

  1. Puissegur Lupo ML. Sclerotherapy: review of results and complications in 200 patients.J Dermatol Surg Oncol. 1989;15:2149.PubMed
  2. Conrad P, Malouf GM, Stacey MC. The Australian polidocanol (aethoxysklerol) study: results at 2 years.Dermatol Surg. 1995;21:3346. DOIPubMed
  3. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions.Dermatol Surg. 2005;31:1238.PubMed
  4. Koontz FP. Trends in post-operative infections by Gram-positive bacteria.Int J Antimicrob Agents. 2001;16(Suppl 1):357. DOIPubMed
  5. Mastro TD, Farley TA, Elliott JA, Facklam RR, Perks JR, Hadler JL, An outbreak of surgical-wound infections due to group A Streptococcus carried on the scalp.N Engl J Med. 1990;323:96872.PubMed
  6. Daneman N, McGeer A, Low DE, Tyrrell G, Simor AE, McArthur M, Hospital-acquired invasive group A streptococcal infections in Ontario, Canada, 1992–2000.Clin Infect Dis. 2005;41:33442. DOIPubMed
  7. Kolmos HJ, Svendsen RN, Nielsen SV. The surgical team as a source of postoperative wound infections caused by Streptococcus pyogenes.J Hosp Infect. 1997;35:20714. DOIPubMed
  8. Viglionese A, Nottebart VF, Bodman HA, Platt R. Recurrent group A streptococcal carriage in a health care worker associated with widely separated nosocomial outbreaks.Am J Med. 1991;91: S329 S33. DOIPubMed
  9. Paul SM, Genese C, Spitalny K. Postoperative group A beta-hemolytic Streptococcus outbreak with the pathogen traced to a member of a healthcare worker's household.Infect Control Hosp Epidemiol. 1990;11:6436.PubMed
  10. Schaffner W, Lefkowitz LBJr, Goodman JS, Koenig MG. Hospital outbreak of infections with group A streptococci traced to an asymptomatic anal carrier.N Engl J Med. 1969;280:12245.PubMed

Figure

Suggested citation for this article: Chan H-T, Low J, Wilson L, Harris OC, Cheng AC, Athan E. Case cluster of necrotizing fasciitis and cellulitis associated with vein sclerotherapy [letter]. Emerg Infect Dis [serial on the Internet]. 2008 Jan [date cited]. Available from http://wwwnc.cdc.gov/eid/article/14/1/07-0250.htm

DOI: 10.3201/eid1401.070250

Related Links

Top of Page

Table of Contents – Volume 14, Number 1—January 2008

Comments to the Authors

Please use the form below to submit correspondence to the authors or contact them at the following address:

Eugene Athan, Barwon Health, PO Box 281 Geelong 3220, Victoria, Australia;





characters(s) remaining.

Comment submitted successfully, thank you for your feedback.

Comments to the EID Editors

Please contact the EID Editors via our Contact Form.

 

Past Issues

Select a Past Issue:

Art in Science - Selections from Emerging Infectious Diseases
Now available for order



CDC 24/7 – Saving Lives, Protecting People, Saving Money. Learn More About How CDC Works For You…

USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO