Southern Regional Meeting 2017, New Orleans, LA, February 11-13 ...
From Botched Buttocks To Botulism
Claire Panosian Dunavan, MD, is an infectious diseases expert.
Long ago, when I was a medical rookie on rounds and pre-op antibiotics were not yet routine, I saw a patient with an infected face-lift. Once beyond earshot, our attending mused about possible slip-ups in her surgical asepsis. I listened, of course, but also couldn't help thinking: "What a shame. She was looking for beauty. Instead she got this?"
Thankfully, the patient soon improved. Her gram stain showed grape-like clusters of cocci, then antibiotics were dripped in her veins, and her angry incisions faded and healed.
Fast forward several decades, and what a difference. Today, no seasoned plastic surgeon would omit prophylactic armor against Staph aureus, the world's most common post-op invader. But for patients seeking beauty at a bargain, a global market in aesthetic procedures sometimes delivers far worse harm.
Take, for example, disfiguring, hard-to-treat infections due to atypical mycobacteria. Or look at the recent outbreak of botulism in at least 60 medical customers in Turkey, several of whom, after receiving intra-gastric injections of botulinum neurotoxin meant to shrink their stomachs, landed in ICUs, struggling to breathe.
Whatever you may think about bodily obsession or dubious ways to lose weight, simply saying caveat emptor or "let the buyer beware" (translation: do your homework) is not enough to protect modern consumers.
The Appetite for Altered Bodies
Not surprisingly, the global quest for beauty translates to a big business predicted to grow by nearly 10% per year through 2030.
Current numbers back this up. The latest annual statistics from the International Society of Aesthetic Plastic Surgery (ISAPS) reveal about a 19% jump in both surgical and non-surgical procedures in 2021. What were the most desired cosmetic revamps?
In 2021, liposuction surpassed breast augmentation as the most common operation, followed by eyelid surgery, rhinoplasty, and tummy tucks, while a 4-year trend confirmed the rapidly growing popularity of buttock lifts and buttock augmentation. The top five non-surgical procedures were injections of botulinum neurotoxin and hyaluronic acid (often used as a facial filler), hair removal, skin tightening, and fat reduction.
Now, let me offer a snapshot of foreign medical tourism sites from the ISAPS report. Turkey, Colombia, Mexico, and Thailand led the list in 2021, but there's a caveat. Although ISAPS's 5,600 members reside in 117 countries, their official roster includes only "the world's most respected aesthetic and reconstructive surgeons."
In other words, it is anyone's guess who else is attracting medical tourists and performing cosmetic procedures -- and in what settings.
Notably, cosmetic procedures performed abroad aren't alone in posing risks to unwary patients. In 2021, U.S. Plastic surgeons performed roughly 60,000 Brazilian butt lifts (BBLs) despite growing evidence that they are sometimes complicated by life-threatening fat emboli. As Harvard University's Samuel Lin, MD, stated in a recent interview: "The mortality rate of BBL is estimated to be as high in one in 3,000... Greater than [for] any other [form of] cosmetic surgery. Any patient considering a BBL should be informed of the risk of death from this procedure."
Alarming Techniques and Infections
One challenge for many U.S. Doctors is grasping just how many sub rosa procedures occur in our own backyards. I'm no exception. I still remember my amazement when, in 2008, 8 women in New Jersey developed ugly, burrowing infections after unlicensed providers injected their buttocks with substances ranging from silicone to so-called "bio-gels." Eventually, Nocardia proved the common culprit. The patients required multiple antibiotics and debridements and suffered significant scarring.
More often over the last 2 decades, clusters of infections due to rapid-growing mycobacteria -- specifically M. Chelonae, M. Fortuitum, and M. Abscessus -- have plagued patients undergoing overseas breast augmentation, abdominoplasty, liposuction, and buttock lifts, especially in the Dominican Republic. Likely contributing factors? Because rapid-growing mycobacteria form biofilms and resist disinfectants, contaminated tap water and inadequate sterilization of surgical instruments are probably to blame.
Another recent article aggregated data on 214 American residents who were mainly female, middle-age, and Hispanic. These patients underwent aesthetic operations in 13 foreign countries, then returned to the U.S. With serious infections and other complications. Along with prolonged medical treatment, roughly half of the cohort required costly re-hospitalizations and/or follow-up surgery.
Even more dire consequences including necrotizing fasciitis, gas gangrene, and sepsis can follow liposuction, which typically involves infiltrating multiple liters of (potentially contaminated) wetting solution. In a 5-year review from Germany, 2,300 questionnaires completed by intensive care specialists, pathologists, and forensic medicine experts uncovered 72 such events and 23 liposuction-associated deaths.
Finally, Finnish researchers have shown that dangerous, multi-drug resistant bacteria are far more likely to accompany people returning from an overseas hospital stay in a tropical as opposed to a temperate locale.
Educating Consumers
As much as we strive to reduce them, a certain percentage of patients will always experience surgical-site infections. But people seeking low-cost, cosmetic operations in overseas settings are especially vulnerable. Not only do such tourists fly blind because they rarely speak with a doctor before scheduling their trips and promotional websites minimize risks, but also, in many cases they are placing faith in a system with virtually no health-quality data.
Let's be honest: Who among us with medical knowledge would want a family member to buy an all-inclusive "vacation package" that includes surgery?
An excellent briefing paper on cosmetic medical tourism is available from the American Society of Plastic Surgeons. In addition, perhaps the time has come to talk about surgical asepsis and present contemporary case-studies in school health classes, public libraries, and other community settings. If so, how about adding some medically-graphic photos?
I can only speak for myself, but if I were weighing the pros and cons of flying to a far-off land to enhance my looks, one glance at a post-op body part ravaged by cellulitis, sinus tracts, and scars would make me think twice.
Claire Panosian Dunavan, MD, is a professor of medicine and infectious diseases at the David Geffen School of Medicine at UCLA and a past-president of the American Society of Tropical Medicine and Hygiene. You can read more of her writing in the "Of Parasites and Plagues" column.
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Skin Infection
A skin infection is a condition in which germs (bacteria, viruses, or fungi) infect your skin and sometimes the deep tissues underneath it. In some cases, it's caused by a parasite invading your skin. You can get a skin infection any time your skin is broken, whether from a cut, tattoo, piercing, puncture, sting, or bite.
Some infections happen at the skin's surface, but they can start deeper in the wound. You can treat minor skin infections at home, but you might have to go to the doctor or emergency room for a more serious one.
If you think your skin may be infected, watch for these signs:
It can be hard to tell the difference between an infection and eczema, especially in children. People with eczema often get skin infections because the breaks in their skin let germs in. If an eczema treatment doesn't work, or if the rash gets worse, it could be an infection.
When to see a doctor
Call a doctor or go to the hospital right away if you think you might have a skin infection and:
Pink or red skin and swelling around a wound are normal, especially if you have stitches. Some amount of pain is normal, but it should start to go away after the second day.
If you see pus, fluid, or crust, call your doctor within 24 hours. Call if the pain gets worse after 48 hours.
Bacteria, a fungus, or a virus can cause skin infections. Common types include:
Boils. This is the most common type of skin infection. It's usually caused by staph bacteria. It's a pocket of pus that forms over a hair follicle or oil gland. Your skin gets red and swollen. If it breaks open, pus likely will drain out.
Impetigo. This contagious rash usually shows up as blisters with a honey-colored crust. Staph or strep bacteria are usually to blame.
Cellulitis. This bacterial infection grows in the deepest layers of your skin. It causes redness, swelling, and sores on the surface and can be painful.
Ringworm. It has nothing to do with worms. Its name comes from the circular shape of the rash it causes. The spots also have a border that's slightly raised and darker in color. This fungal infection can appear anywhere on your body. Athlete's foot and jock itch are types of ringworm.
MRSA. This bacterial infection can be dangerous because it resists some antibiotics. That means antibiotics used to treat staph infections don't work like they should. The rash usually shows up as painful red bumps that look like pimples or spider bites. It may be warm to the touch, and you might have a fever. This skin infection often shows up in schools, military barracks, nursing homes, and other places where people live in close quarters.
Eczema It's a group of conditions that includes atopic dermatitis, contact dermatitis, seborrheic dermatitis, and others that inflame and dry out the skin. You might notice a red rash, serious itchiness, or thickened or scaly skin. Eczemacan weaken the skin's protective barrier and allow bacteria and other germs that live on the skin to go deeper, which can lead to more infection from bacteria like staph and viruses like herpes.
To diagnose a skin infection, your doctor will start off by looking at the affected area and any bumps or sores. They may also ask you about your symptoms. Since skin infections can result from many different types of germs, you may need lab tests to get a proper diagnosis. The doctor will collect samples of pus, fluids, or skin scrapings and send them to a lab for more testing. This will help them give you the right treatment.
If you have an infection, your doctor may prescribe medicine. What they give you depends on the type of infection:
Any break in the skin can lead to a tetanus infection if your tetanus shot isn't up to date. Check with your doctor to see if you need a booster shot. You should get a tetanus booster every 10 years.
Proper handwashing is important. Use soap and warm water to scrub your hands for 20 seconds, then rinse and dry with a clean towel or paper towel. Use hand sanitizer if soap and water aren't nearby.
If you're an athlete or go to the gym often, use a clean towel as a barrier between your skin and shared surfaces like exercise machines or locker room benches. If the gym has sanitizer or cleaner and paper towels to clean gym equipment before and after you're on it, use them. Shower and wash your clothes and towel after every workout.
If you have a minor cut or break in your skin, keep it clean. Wash it with warm water and soap. You also can use an antibiotic ointment like bacitracin or even plain vaseline, and cover it with a clean bandage.
If you have a major skin wound, especially one with stitches, check with your doctor for proper care instructions.
Can MRSA Infect Your Eye?
MRSA infections can cause problems throughout your body. This antibiotic-resistant type of staph is also a common cause of eye infections.
Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is notorious for eluding the effects of common antibiotic treatments. A so-called superbug, MRSA infections can affect various parts of the body or even enter the bloodstream. It commonly occurs after hospitalizations and surgery.
When MRSA is the cause of an eye infection, it usually appears as conjunctivitis or pink eye. A MRSA infection in the eye doesn't usually cause permanent damage to your vision.
This article will cover what you need to know about MRSA infections of the eye, what to expect if you develop one of these infections, and how they can be treated.
MRSA bacteria can cause infections in many areas of the body.
When it comes to eye infections, MRSA accounts for 39% to 46% of all eye infections. Most MRSA eye infections present as bacterial conjunctivitis. But the conjunctiva isn't the only part of the eye that can become infected with MRSA.
As a whole, MRSA can affect the following areas in the eye:
MRSA in the eye can cause increased tear production, soreness, redness, and even blurred vision. The exact symptoms you develop depend on the specific area of the eye infected.
MRSA infections of the eye typically cause the following infections and their related complications:
Infections with MRSA in the inner areas of the eye typically cause the most severe symptoms and can even cause permanent vision loss or blindness in rare cases.
MRSA is spread through direct contact with a surface or individual with the bacteria.
Staphylococcus aureus is a pretty common type of bacteria overall. But not all bacteria in this family are resistant to antibiotics. In some cases, you may already be colonized with S. Aureus and only develop an infection if the bacteria takes over in different areas of the body.
Studies have estimated that about 35% of the general public and up to 66% of healthcare workers are colonized with S. Aureus.
Once S. Aureus is in your body, your immune system may be able to fight it off or control the spread.
Many people are colonized with this bacteria, meaning there is a certain about in their body, but it's controlled to the point where it's not causing a problem. When the bacteria overtakes your natural defenses, it can create an acute infection and even spread to other areas of your body.
If a MRSA infection enters your bloodstream, it can cause a massive infection called septicemia that can create problems throughout your entire body and even lead to death.
MRSA is a contagious bacteria and can be spread through contact with a person or surface with the bacteria.
Skin-to-skin spread is common. This includes transmission to your eye if you've touched anything contaminated with MRSA and then touch your eye.
MRSA doesn't usually cause blindness.
However, when the infection affects the inner structures of your eye (like the vitreous humor), vision changes or even blindness can occur. Severe MRSA infections of the eye that can lead to vision changes typically develop in people who:
S. Aureus infections can usually be treated with antibiotics.
However, MRSA infections are resistant to many forms of antimicrobial medications. How well MRSA infections of the eye can be treated with antibiotics depends on the individual infection and the antibiotic used.
Below are some estimates of how resistant MRSA infections of the eye are to particular antibiotics:
Research indicates that vancomycin and chloramphenicol are the most effective antibiotics to use when treating an MRSA infection of the eye.
MRSA is a common bacterial infection that is resistant to treatment with many types of antibiotics. These infections can develop anywhere in the body, and are a leading cause of bacterial eye infections like pink eye, blepharitis, and keratitis.
Vision changes and blindness are rare complications of an MRSA infection of the eye but can happen when the infection affects the inner parts of the eye instead of the more superficial areas like the conjunctiva or eyelid.
If you have an eye infection, redness, inflammation, or pain that is not getting better with time or antibiotic treatment, be sure to make an appointment to see your eye doctor or another healthcare professional. MRSA infections that enter your bloodstream can lead to severe infections affecting your entire body.
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