Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 19, Number 3—March 2013
Letter

Mycobacterium fortuitum Endocarditis Associated with Cardiac Surgery, Serbia

On This Page
Tables
Article Metrics
9
citations of this article
EID Journal Metrics on Scopus

Cite This Article

To the Editor: Mycobacterium fortuitum is a member of the group of rapidly growing nontuberculous mycobacteria. It is a well-known causative agent of skin and soft tissue infections, postsurgical wound infections, and other health care–associated infections (1). Only sporadic cases of endocarditis caused by this bacterium have been reported (24). We describe a cardiac surgery–related outbreak of endocarditis caused by M. fortuitum in 3 children.

Over a 3-week period during 2009, eight children consecutively underwent surgery for correction of ventricular septal defect (VSD) by insertion of a bovine pericardial patch at the University Children’s Hospital in Belgrade, Serbia. None of them had previous cardiac surgery. The same patch, SJM Pericardial Patch with EnCap Technology (St. Jude Medical, St. Paul, MN, USA), was used as a source for smaller, tailored patches for all patients. Sterile scissors and forceps were used to tailor a piece of the patch needed for a corresponding VSD closure. During repeated performances of this procedure and between surgeries, the patch had been continuously stored in 2% propylene oxide (PO) provided by the manufacturer. Each tailored piece of the patch had been immersed into freshly prepared sterile saline for 6 min before defect patching. The postoperative course had been uneventful for all patients, and they were discharged 7 days after the procedure. However, 3 patients were readmitted to the hospital because of prolonged fever and increasing fatigue. Patients 1, 2, and 3 (Table) had been the fourth, sixth, and eighth patients undergoing VSD repair, respectively. Diagnosis of infective endocarditis in these patients was established by transthoracic echocardiography findings and blood cultures positive for acid-fast bacteria (Table). Acid-fast bacteria also were recovered from the patch and vegetation taken during reoperation in patient 3 (Table). The isolates were identified as M. fortuitum by the GenoType Mycobacterium CM assay (Hain Lifescience, Nehren, Germany) (5). Empiric treatment with vancomycin and ceftriaxone was switched to amikacin, ciprofloxacin, and imipenem. After 6 weeks of treatment, the patients were discharged, and all were asymptomatic 12 months later.

The cultural characteristics and susceptibility patterns of all the isolates obtained were indistinguishable. To explore their possible clonal relatedness, we genotyped 3 M. fortuitum strains isolated from blood cultures (1 isolate per patient) and 2 M. fortuitum isolates recovered from samples taken during reoperation in 1 of the patients. The enterobacterial repetitive intergenic consensus PCR was used (6), and all isolates produced identical patterns.

Nosocomially acquired M. fortuitum endocarditis has been reported but only sporadically in adults, and these cases usually were fatal (3,4,7). In contrast, we describe 3 related cases of M. fortuitum endocarditis in children who recovered. The relatedness of the cases is strongly supported by the following. First, epidemiologic links are obvious because the 3 patients underwent surgery in the same operating room, and the same patch was used in all of them. Second, M. fortuitum strains isolated from the 3 patients were phenotypically and genotypically identical.

Repeated use of the same patch in multiple surgeries strongly suggests the contaminated patch was the source of M. fortuitum infection in the 3 patients. This possibility could not be corroborated by bacteriologic examination of the patch because the remaining unusable fragments had been discarded after the surgeries (i.e., ≈3 months before the outbreak became evident). Although contamination of the patch during manufacture is possible (8), it seems more reasonable to assume that the contamination occurred intraoperatively. The common factor in nosocomially acquired M. fortuitum infections is presumed to be exposure to a liquid contaminated with this organism (1,9). The patch was not exposed to solutions other than the PO in which it had been stored and the sterile saline used during the rinsing procedure. Because only a piece of the patch tailored for a particular patient was exposed to a saline freshly prepared for each surgery, contamination of the PO by M. fortuitum presumably led to contamination of the patch. Liquid PO is used as a chemical sterilant for bioprostheses intended for single use. However, multiple use of the same patch implied repeated exposure of the PO solution to the environment and prolonged storage at 4°C between surgeries. Because PO effectiveness is markedly reduced at temperatures <16°C (10), the specific circumstances could have compromised the sterilizing capacity of the PO solution and enabled contamination by ubiquitous M. fortuitum.

We are well aware that the patch was intended for single use only and that application of the same patch in multiple patients is not a practice in industrialized countries. However, it is a practice in some resource-limited countries. The outbreak of M. fortuitum endocarditis we describe is a clear warning that such practice is associated with high risk and thus should be discontinued.

Top

Acknowledgment

The work of D.V., I.D., B.S., and I.Ć. was supported by project grant no. 175039 from the Ministry of Education and Science, Republic of Serbia.

Top

Dragana VukovićComments to Author , Vojislav Parezanović, Branislava Savić, Ivana Dakić, Suzana Laban-Nestorović, Slobodan Ilić, Ivana Ćirković, and Srdjan Stepanović

Author affiliations: Author affiliations: University of Belgrade, Belgrade, Serbia (D. Vuković, V. Parezanović, B. Savić, I. Dakić, S. Ilić, I. Ćirković, S. Stepanović); University Children's Hospital, Belgrade (V. Parezanović, S. Laban-Nestorović, S. Ilić)

Top

References

  1. Griffith  DE, Aksamit  T, Brown-Elliot  BA, Catanzaro  A, Daley  C, Gordin  F, An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. [Erratum in: Am J Respir Crit Care Med. 2007;175:744–5. ]. Am J Respir Crit Care Med. 2007;175:367416. DOIPubMed
  2. Spell  DW, Szurgot  JG, Greer  RW, Brown  JW. Native valve endocarditis due to Mycobacterium fortuitum biovar fortuitum: case report and review. Clin Infect Dis. 2000;30:6056. DOIPubMed
  3. Kunin  M, Salamon  F, Weinberger  M, Genkin  I, Sagie  A, Tur-Kaspa  R. Conservative treatment of prosthetic valve endocarditis due to Mycobacterium fortuitum. Eur J Clin Microbiol Infect Dis. 2002;21:53941. DOIPubMed
  4. Olalla  J, Pombo  M, Aguado  JM, Rodríguez  E, Palenque  E, Costa  JR, Mycobacterium fortuitum complex endocarditis-case report and literature review. Clin Microbiol Infect. 2002;8:1259. DOIPubMed
  5. Richter  E, Rüsch-Gerdes  S, Hillemann  D. Evaluation of the GenoType Mycobacterium assay for identification of mycobacterial species from cultures. J Clin Microbiol. 2006;44:176975. DOIPubMed
  6. Sampaio  JL, Chimara  E, Ferrazoli  L, da Silva Telles  MA, Del Guercio  VM, Jerico  ZV, Application of four molecular typing methods for analysis of Mycobacterium fortuitum group strains causing post-mammaplasty infections. Clin Microbiol Infect. 2006;12:1429. DOIPubMed
  7. Sharma  S, Tleyjeh  IM, Espinosa  RE, Costello  BA, Baddour  LM. Pacemaker infection due to Mycobacterium fortuitum. Scand J Infect Dis. 2005;37:667. DOIPubMed
  8. Strabelli  TMV, Siciliano  RF, Castelli  JB, Demarchi  LM, Leão  SC, Viana-Niero  C, Mycobacterium chelonae valve endocarditis resulting from contaminated biological prostheses. J Infect. 2010;60:46773. DOIPubMed
  9. Wallace  RJ Jr, Brown  BA, Griffith  DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annu Rev Microbiol. 1998;52:45390. DOIPubMed
  10. Wright  RC. The sterilizing capacity of propylene oxide and chlorhexidine diacetate solutions upon pre-injection swabs saturated with propan-2-ol. J Hyg (Lond). 1983;91:28792. DOIPubMed

Top

Table

Top

Cite This Article

DOI: 10.3201/eid1903.120763

Related Links

Top

Table of Contents – Volume 19, Number 3—March 2013

Comments

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

Dragana Vuković, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, dr Subotića 1, 11000 Belgrade, Serbia

Send To

character(s) remaining.

Comment submitted successfully, thank you for your feedback.

Top

Page created: January 30, 2013
Page updated: January 30, 2013
Page reviewed: January 30, 2013
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external