Mycobacterium abscessus
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: M. abcessus, non tuberculous mycobacterium, NTM, rapidly growing mycobacterium, RGM
Overview
Mycobacterium abscessus is a rapidly growing mycobacterium (RGM) that is a common water contaminant. Mycobacterium abscessus is a bacterium distantly related to the ones that cause tuberculosis and leprosy. It is part of a group known as rapidly growing mycobacteria and is found in water, soil, and dust. It has been known to contaminate medications and products, including medical devices. M. abscessus can cause a variety of infections. Healthcare-associated infections due to this bacterium are usually of the skin and the soft tissues under the skin. It is also a cause of serious lung infections in persons with various chronic lung diseases, such as cystic fibrosis, post-traumatic wound infections, and disseminated cutaneous diseases, mostly in patients with suppressed immune systems.
Historical Perspective
Mycobacterium abscessus was first isolated in 1953 from gluteal abscesses in a 62-year-old patient who had injured her knee as a child and had a disseminated infection 48 years later.[1] It was until 1992 that Mycobacterium abscessus is considered a separate organism from Mycobacterium chelonae.
The species M. bolletii, named after the late microbiologist and taxonomist Claude Bollet, was described in 2006. In current taxonomy, M. bolletii and M. massiliense (named for Massilia, the ancient Greek and Roman name for Marseille, where the organism was isolated) have been incorporated into M. abscessus subsp. bolletii. [2]
Classification
Pathophysiology
Pathogen
Mycobacterium abscessus is a bacterium distantly related to the ones that cause tuberculosis and leprosy. It is part of a group known as rapidly growing mycobacteria and is found in water, soil, and dust. It has been known to contaminate medications and products, including medical devices.
Mycobacterium abscessus is relatively resistant to chlorine and standard desinfectant.[5]
Transmission
Infection with M. abscessus is usually caused by injections of substances contaminated with the bacterium or through invasive medical procedures employing contaminated equipment or material. Infection can also occur after accidental injury where the wound is contaminated by soil. There is very little risk of transmission from person to person.
Microscopy
- Gram-positive, nonmotile and acid-fast rods (1.0-2.5µm x 0.5µm).
Colony characteristics
- Colonies on Löwenstein-Jensen media may occur as smooth as well as rough, white or greyish and nonphotochromogenic.
Physiology
- Growth at 28°C and 37°C after 7 days but not at 43°C.
- On MacConkey agar at 28°C and even 37°C.
- Tolerance to 5% NaCl and 500mg/l hydroxylamine (Ogawa egg medium) and 0.2% picrate (Sauton agar medium).
- Positive degradation of p-aminosalicylate.
- Production of arylsulfatase but not of nitrate reductase and Tween 80 hydrolase.
- Negative iron uptake test. No utilisation of fructose, glucose, oxalate and citrate as sole carbon sources.
Differential characteristics
- M. abscessus and M. chelonae can be distinguished from M. fortuitum or M. peregrinum by their failure to reduce nitrate and to take up iron.
- Tolerance to 5% NaCl in Löwenstein-Jensen media tolerance to 0.2% picrate in Sauton agar and non-utilisation of citrate as a sole carbon source are characteristics that distinguish M. abscessus from M. chelonae.
- M. abscessus and M. chelonae sequevar I share an identical sequence in the 54-510 region of 16S rRNA, However, both species can be differentiated by their hsp65 or ITS sequences
Strains
ATCC 19977 = CCUG 20993 = CIP 104536 = DSM 44196 = JCM 13569 = NCTC 13031
Genetics
A draft genome sequence of M. abscessus subsp. bolletii BDT was completed in 2012.[6] More than 25 different strains of this subspecies, including pathogenic isolates, have had their genomes sequenced.[7]
Resistance to Antibiotics
Intrinsic Factors
- The permeability barrier of the envelope of the myobacterium[8]
- Low affinity of the antibiotics to their target[8]
- Drug export systems[8]
- Neutralization of the antibiotics by cytoplasmic enzymes[8]
Acquired Factors
- Mutation of the genes that code the antibiotic targets[8]
Risk Factors
Mycobacterium abscessus infecttion has been reported in the following cases:
Skin and Soft Tissue Infection
- Open wounds
- Penetrating injury
- Surgical tourism[9]
- Laparoscopic surgery[9]
- Cosmetic surgery[10]
- Intramuscular injections[11][12][13][14]
- Inappropriate skin disinfection
- Inappropriate sterilization of the equipment[15]
- Contaminated solutions
- Contaminated municipal or water supply[5]
- Acupuncture (contaminated solution used to clean the physical therapy device)[16]
- Dialysis[17][18]
- Bronchoscopy[5]
- Inadequate desinfection of the bronchoscope
- Contaminated local anesthesia solution
- Contaminated tap water
- Contaminated antimicrobial solution
- Wading and public pool exposure (hand-and-foot disease)[19][20]
Bronchopulmonary Infection
- Chronic lung disease (for example, cystic fibrosis)[21][22]
- Bronchiectasis[23]
- Previously untreated mycobacterial infection
- Co-existent mycobacterium avium complex infection
- Chronic vomiting[23]
- Lipoid pneumonia[23]
- Alpha antitrypsin deficiency[23]
- AIDS/HIV (not a common infection in this population)[24]
Disseminated Infection
Natural History, Complications and Prognosis
Infection with Mycobacterium abscessus can lead to:
- Skin and soft tissue infection
- Open wound infection
- Sternal wound infection[27]
- Bronchopulmonary infection[8]
- Disseminated infection in non AIDS immunocompromised patients[8]
- Other rare infections
- Vertebral osteomyelitis[28]
- Abdominal infection[29]
- Lymphadenitis[23]
Mycobacterium abscessus is reported in many health-care associated infections. A history of Mycobacterium abscessus infection is a contraindication for lung transplantation.[8]
Mycobacterium abscessus is the most common non tuberculosis mycobacterial infection in cystic fibrosis.[21] Chronic infection with Mycobacterium abscessus is associated with a decline in lung function among patients with cystic fibrosis.[30] The most commonly reported symptom is cough. Constitutional symptoms increase as the disease progresses. The only effective long-term therapy for Mycobacterium abscessus was reported to be surgical resection of the localized disease.[31] Death may occur in these patients (mortality in ~14% of patients) due to respiratory failure secondary to the progressive lung disease.[31]
Diagnosis
History
The patient should be asked about any recent history of procedures, such as surgery or injections.
Symptoms
Symptoms of Skin and Soft Tissue Infection
Symptoms of Pulmonary Infection
- Cough[31]
Constitutional Symptoms
Physical Examination
Skin
- Skin infected with M. abscessus is usually red, warm, tender to the touch, swollen, and/or painful.
- Infected areas can also develop boils or pus-filled vesicles.
Laboratory Studies
To reach a definitive diagnosis, the organism has to be cultured from the infection site or, in severe cases, from a blood culture. The diagnosis is made by growing this bacterium in the laboratory from a sample of the pus or biopsy of the infected area.
Chest X-Ray
Patients with pulmonary Mycobacterium abscessus infection might have the following on chest X-ray:[31][23]
- Upper lobe infiltrates
- Bilateral involvement of the lungs
- Mulilobal involvement
- Opacities (patchy, reticulonodular, ot mixed interstitial-alveolar)
- Cavitation
HCRT
- Bronchiectasis[23]
- Small nodules[23]
Diagnostic Criteria for Pulmonary Mycobacterium Abscessus
The diagnosis of pulmoanry mycobacterium abscessus infection requires the presence of clinical and microbiological criteria.[23]
Clinical Diagnostic Criteria
- Pulmonary symptoms, OR
- Cavitation or nodular opacities on chest X-ray, OR
- Multifocal bronchiectasis with multiple small nodules on HRCT scan
AND
- Other diagnoses, such as tuberculosis, are ruled out[23]
Microbiological Diagnostic Criteria
- Positive culture from ≥2 different expectorated sputum samples
OR
- Positive culture from ≥1 bronchial wash or bronchial lavage
OR
- Histopathologic features of mycobacterial infection in transbronchial or lung biopsy AND positive culture for mycobacterium abscessus
OR
- Histopathologic features of mycobacterial infection in transbronchial or lung biopsy AND positive culture of ≥1 expectorated sputum or bronchial wash samples[23]
Treatment
Skin and Soft Tissue Infections
- Draining collections of pus
- Surgical debridement[23]
- Administration of combination of antibiotics for a prolonged period of time: macrolide based regimen[23]
- Infection with this bacterium usually does not improve with the usual antibiotics used to treat skin infections. Testing the bacteria against different antibiotics is helpful in guiding doctors to the most appropriate treatment for each patient.
Pulmonary Infection
- Administration of combination of antibiotics for a prolonged period of time: clarithromycin 1,000 mg/day based regimen[23]
- A combination of antibiotics is indicated for the treatment of pulmonary infection with mycobacterium abscessus; however, there is no evidence on the optimal multidrug regimen.
- Surgical resection of the localized disease[23]
- Surgical resection and multidrug antibiotic therapy is associated with a higher chance of a successful treatment.
Primary Prevention
- There should not be exposure to tap water or tap water ice of any of the following:[23]
- Surgical wounds
- Intravenous catheters
- Injection sites
- Avoid chloride based disinfectant
- Avoid multidose vials
- Endoscope
- Automated endoscopic washing machines
- Manual Cleaning
- Tap water or tap water ice should not be used in the operating rooms, particularly in cardiac surgeries or mammoplasty.[23]
- Tap water or tap water ice should not be used in the outpatient plastic surgery procedures, such as mammoplasty and liposuction.[23]
- Anyone who touches or cares for the infected site should wash their hands carefully with soap and water.
- Patients should follow all instructions given by their healthcare provider following any surgery or medical procedure.
- Subjects should avoid receiving procedures or injections by unlicensed persons.
References
- ↑ MOORE M, FRERICHS JB (1953). "An unusual acid-fast infection of the knee with subcutaneous, abscess-like lesions of the gluteal region; report of a case with a study of the organism, Mycobacterium abscessus, n. sp". J Invest Dermatol. 20 (2): 133–69. PMID 13035193.
- ↑ Etymologia: Mycobacterium abscessus subsp. bolletii. Emerg Infect Dis [Internet]. 2014 Mar [February 20, 2014]. http://dx.doi.org/10.3201/eid2003.ET2003
- ↑ Adékambi T, Reynaud-Gaubert M, Greub G, Gevaudan MJ, La Scola B, Raoult D; et al. (2004). "Amoebal coculture of "Mycobacterium massiliense" sp. nov. from the sputum of a patient with hemoptoic pneumonia". J Clin Microbiol. 42 (12): 5493–501. doi:10.1128/JCM.42.12.5493-5501.2004. PMC 535245. PMID 15583272.
- ↑ Adékambi T, Berger P, Raoult D, Drancourt M (2006). "rpoB gene sequence-based characterization of emerging non-tuberculous mycobacteria with descriptions of Mycobacterium bolletii sp. nov., Mycobacterium phocaicum sp. nov. and Mycobacterium aubagnense sp. nov". Int J Syst Evol Microbiol. 56 (Pt 1): 133–43. doi:10.1099/ijs.0.63969-0. PMID 16403878.
- ↑ 5.0 5.1 5.2 Wallace RJ, Brown BA, Griffith DE (1998). "Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria". Annu Rev Microbiol. 52: 453–90. doi:10.1146/annurev.micro.52.1.453. PMID 9891805.
- ↑ Choi, G.-E.; Cho, Y.-J.; Koh, W.-J.; Chun, J.; Cho, S.-N.; Shin, S. J. (24 April 2012). "Draft Genome Sequence of Mycobacterium abscessus subsp. bolletii BDT". Journal of Bacteriology. 194 (10): 2756–2757. doi:10.1128/JB.00354-12.
- ↑ Davidson, Rebecca M. (December 2013). "Phylogenomics of Brazilian epidemic isolates of Mycobacterium abscessus subsp. bolletii reveals relationships of global outbreak strains". Infection, Genetics and Evolution. 20: 292–297. doi:10.1016/j.meegid.2013.09.012. Unknown parameter
|coauthors=ignored (help) - ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Nessar R, Cambau E, Reyrat JM, Murray A, Gicquel B (2012). "Mycobacterium abscessus: a new antibiotic nightmare". J Antimicrob Chemother. 67 (4): 810–8. doi:10.1093/jac/dkr578. PMID 22290346.
- ↑ 9.0 9.1 Viana-Niero C, Lima KV, Lopes ML, Rabello MC, Marsola LR, Brilhante VC; et al. (2008). "Molecular characterization of Mycobacterium massiliense and Mycobacterium bolletii in isolates collected from outbreaks of infections after laparoscopic surgeries and cosmetic procedures". J Clin Microbiol. 46 (3): 850–5. doi:10.1128/JCM.02052-07. PMC 2268380. PMID 18174307.
- ↑ Safranek TJ, Jarvis WR, Carson LA, Cusick LB, Bland LA, Swenson JM; et al. (1987). "Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution". N Engl J Med. 317 (4): 197–201. doi:10.1056/NEJM198707233170403. PMID 3600710.
- ↑ Kim HY, Yun YJ, Park CG, Lee DH, Cho YK, Park BJ; et al. (2007). "Outbreak of Mycobacterium massiliense infection associated with intramuscular injections". J Clin Microbiol. 45 (9): 3127–30. doi:10.1128/JCM.00608-07. PMC 2045247. PMID 17626174.
- ↑ Borghans JG, Stanford JL (1973). "Mycobacterium chelonei in abscesses after injection of diphtheria-pertussis-tetanus-polio vaccine". Am Rev Respir Dis. 107 (1): 1–8. PMID 4683319.
- ↑ Inman PM, Beck A, Brown AE, Stanford JL (1969). "Outbreak of injection abscesses due to Mycobacterium abscessus". Arch Dermatol. 100 (2): 141–7. PMID 5797954.
- ↑ Villanueva A, Calderon RV, Vargas BA, Ruiz F, Aguero S, Zhang Y; et al. (1997). "Report on an outbreak of postinjection abscesses due to Mycobacterium abscessus, including management with surgery and clarithromycin therapy and comparison of strains by random amplified polymorphic DNA polymerase chain reaction". Clin Infect Dis. 24 (6): 1147–53. PMID 9195073.
- ↑ Wenger JD, Spika JS, Smithwick RW, Pryor V, Dodson DW, Carden GA; et al. (1990). "Outbreak of Mycobacterium chelonae infection associated with use of jet injectors". JAMA. 264 (3): 373–6. PMID 2362334.
- ↑ Koh SJ, Song T, Kang YA, Choi JW, Chang KJ, Chu CS; et al. (2010). "An outbreak of skin and soft tissue infection caused by Mycobacterium abscessus following acupuncture". Clin Microbiol Infect. 16 (7): 895–901. doi:10.1111/j.1469-0691.2009.03026.x. PMID 19694761.
- ↑ Bolan G, Reingold AL, Carson LA, Silcox VA, Woodley CL, Hayes PS; et al. (1985). "Infections with Mycobacterium chelonei in patients receiving dialysis and using processed hemodialyzers". J Infect Dis. 152 (5): 1013–9. PMID 4045242.
- ↑ Lowry PW, Beck-Sague CM, Bland LA, Aguero SM, Arduino MJ, Minuth AN; et al. (1990). "Mycobacterium chelonae infection among patients receiving high-flux dialysis in a hemodialysis clinic in California". J Infect Dis. 161 (1): 85–90. PMID 2295862.
- ↑ Dytoc MT, Honish L, Shandro C, Ting PT, Chui L, Fiorillo L; et al. (2005). "Clinical, microbiological, and epidemiological findings of an outbreak of Mycobacterium abscessus hand-and-foot disease". Diagn Microbiol Infect Dis. 53 (1): 39–45. doi:10.1016/j.diagmicrobio.2005.03.010. PMID 16054324.
- ↑ Sinagra JL, Kanitz EE, Cerocchi C, Cota C, Fantetti O, Prignano G; et al. (2014). "Mycobacterium abscessus hand-and-foot disease in children: rare or emerging disease?". Pediatr Dermatol. 31 (3): 292–7. doi:10.1111/pde.12333. PMID 24758202.
- ↑ 21.0 21.1 Sermet-Gaudelus I, Le Bourgeois M, Pierre-Audigier C, Offredo C, Guillemot D, Halley S; et al. (2003). "Mycobacterium abscessus and children with cystic fibrosis". Emerg Infect Dis. 9 (12): 1587–91. doi:10.3201/eid0912.020774. PMC 3034322. PMID 14720400.
- ↑ Radhakrishnan DK, Yau Y, Corey M, Richardson S, Chedore P, Jamieson F; et al. (2009). "Non-tuberculous mycobacteria in children with cystic fibrosis: isolation, prevalence, and predictors". Pediatr Pulmonol. 44 (11): 1100–6. doi:10.1002/ppul.21106. PMID 19830845.
- ↑ 23.00 23.01 23.02 23.03 23.04 23.05 23.06 23.07 23.08 23.09 23.10 23.11 23.12 23.13 23.14 23.15 23.16 23.17 Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F; et al. (2007). "An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases". Am J Respir Crit Care Med. 175 (4): 367–416. doi:10.1164/rccm.200604-571ST. PMID 17277290.
- ↑ Benwill J, Babineaux M, Sarria JC (2010). "Pulmonary Mycobacterium abscessus in an AIDS patient". Am J Med Sci. 339 (5): 495–6. doi:10.1097/MAJ.0b013e3181d96ad7. PMID 20375687.
- ↑ Babalık A, Kuyucu T, Ordu EN, Ernam D, Partal M, Köksalan K (2012). "Non-tuberculous mycobacteria infection: 75 cases". Tuberk Toraks. 60 (1): 20–31. PMID 22554363.
- ↑ Lambertucci JR, Borges AH, Voieta I (2011). "Disseminated Mycobacterium abscessus infection in an AIDS patient". Rev Soc Bras Med Trop. 44 (2): 265. PMID 21552751.
- ↑ Hoffman PC, Fraser DW, Robicsek F, O'Bar PR, Mauney CU (1981). "Two outbreaks of sternal wound infection due to organisms of the Mycobacterium fortuitum complex". J Infect Dis. 143 (4): 533–42. PMID 7240799.
- ↑ Garcia DC, Sandoval-Sus J, Razzaq K, Young L (2013). "Vertebral osteomyelitis caused by Mycobacterium abscessus". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-009597. PMID 23925676.
- ↑ Ding LW, Lai CC, Lee LN, Hsueh PR (2006). "Abdominal nontuberculous mycobacterial infection in a university hospital in Taiwan from 1997 to 2003". J Formos Med Assoc. 105 (5): 370–6. doi:10.1016/S0929-6646(09)60132-7. PMID 16638646.
- ↑ Esther CR, Esserman DA, Gilligan P, Kerr A, Noone PG (2010). "Chronic Mycobacterium abscessus infection and lung function decline in cystic fibrosis". J Cyst Fibros. 9 (2): 117–23. doi:10.1016/j.jcf.2009.12.001. PMC 3837580. PMID 20071249.
- ↑ 31.0 31.1 31.2 31.3 Griffith DE, Girard WM, Wallace RJ (1993). "Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients". Am Rev Respir Dis. 147 (5): 1271–8. doi:10.1164/ajrccm/147.5.1271. PMID 8484642.