Report highlights risk of medical tourism superbug

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An investigation by the Centers for Disease Control and Prevention (CDC) linked an outbreak of extensively drug-resistant infections among American medical tourists in 2018 and 2019 to a single facility and surgeon in Mexico.

The results of the investigation, published last week in Emerging infectious diseases, revealed that 38 U.S. patients who traveled to Tijuana, Mexico for bariatric surgery from January 2018 to December 2019 returned with an infection caused by carbapenem resistance Pseudomonas aeruginosa—a virulent and opportunistic pathogen capable of causing severe disease.

Of the 38 patients, 31 were operated on by the same surgeon, 27 of whom were operated in the same establishment.

The facility, which was found to have multiple gaps in infection control by Mexican health authorities, closed in March 2019. But investigators warn that the protracted outbreak highlights the increased risk of infections for the 750 000 US residents who travel overseas for medical care each year. in Mexico and other places that have different standards and regulations for infection control.

“Our survey underscores the potential of medical tourism to introduce pathogens of great concern into the US healthcare system,” wrote the survey authors. “American patients and providers should be aware of the risk of colonization and infection with highly resistant pathogens that are not commonly encountered in the United States after medical tourism. “

A highly resistant pathogen

The CDC was first informed of the outbreak in late September 2018, when the Arizona Department of Health Services notified the agency of a patient with an abdominal wound infected with a carbapenem-resistant virus. Paeruginosa producing the Verona integron-encoded metallo-beta-lactamase enzyme (VIM-CRPA), a pathogen commonly linked to obtaining healthcare.

VIM is associated with resistance to several classes of antibiotics and is the most commonly identified carbapenemase in Paeruginosa worldwide and the United States, but the incidence of VIM-CRPSA in the United States is low. In 2017-2018, less than 200 isolates were detected in the United States.

After the initial investigation into this case determined the patient had undergone bariatric surgery in Tijuana, the CDC received reports of five additional patients with VIM-CRPA isolates who had also undergone bariatric surgery in Tijuana. Four of the patients had used the same travel agency and had undergone surgery at the same facility (facility A) with the same surgeon (surgeon 1).

In response, the CDC opened a broader investigation and appealed for Exchange of information on the epidemic for additional cases of VIM-CRPA linked to patients who had undergone bariatric surgery in Tijuana since August 2018. In December 2018, the Federal Commission for the Protection against Health Risks of Mexico inspected establishment A and found several deficiencies in infection prevention and control, including hand hygiene practices, incomplete medical records, and a lack of chemical or biological indicators to ensure sterility of medical equipment and device.

In January 2019, the CDC issued a Level 2 Travel Health Advisory advising U.S. residents not to undergo surgery at Institution A; American medical tourists, however, continued to undergo procedures there until March 2019, when it was closed.

After the initial cluster of cases, state health departments investigating potential cases of VIM-CRPA among patients who reported surgery in Tijuana began collecting information on the types of surgeries performed, names healthcare facilities, surgeons, subsequent hospitalizations in the United States and travel agencies used. by the sick. Meanwhile, the CDC and state health labs performed whole genome sequencing (WGS) and antibiotic susceptibility testing on the VIM-CRPA isolates.

From January 2018 to December 2019, the investigation identified a total of 44 cases of VIM-CRPA in 19 states. Twenty-five of the cases were confirmed, 13 were probable and 6 suspected. The majority of patients were women (34 [89.5%]), with a median age of 39 years. Sleeve gastrectomy was the most common operation, reported by 34 patients (89.5%).

After the surgery in Tijuana, 16 patients (42.1%) were then hospitalized in the United States, including four admitted to an intensive care unit (ICU). One patient died in hospital 9 days after his first surgery. No evidence of further transmission of VIM-CRPA in US hospitals has been reported.

Of the confirmed and probable case patients, 37 named 10 facilities where they underwent invasive procedures, 27 named facility A, and 31 of 35 patients named surgeon 1, including the 27 patients who underwent invasive procedures. facility A and 4 who underwent surgery at unknown facilities.

Of the 22 isolates that underwent WGS, 17 formed a distinct genetic group – suggesting exposure to a common source – and 16 of these were associated with surgeon 1. The rest were genetically distinct and appeared to be sporadic. All isolates were extremely resistant to the drugs.

No definitive source

Although the investigation did not identify a definitive source of the VIM-CRPA bacteria, the authors say that links to surgeon 1 and the infection control failures at Institution A suggest that a laparoscope contaminated so persistent used by surgeon 1 in several establishments could be the culprit.

P. aeruginosa is known to persistently colonize medical devices, including flexible endoscopes; in Brazil, surgeons transporting their own laparoscopic equipment between different hospitals were behind a multi-facility Mycobacterium spp. epidemic, “they wrote.” Alternative explanations include a persistently heavily contaminated environmental or water source in facility A or a persistently colonized healthcare worker, such as surgeon 1. “

In addition to the risks associated with medical tourism, the authors say the survey highlights additional concerns. Among them is the fact that neither CDC warnings nor reports of the outbreak deterred people from visiting Facility A before it closed.

About 30% of 160 U.S. medical tourists who used the same travel agency (Travel Agency A) and were interviewed during the survey said they were aware of the outbreak associated with Establishment A before their operation, but they still proceeded with the operation.

Another concern is that almost a third of cases of VIM-CRPA represent clinical isolates that have not been tested for carbapenemases, even though susceptibility testing indicated the isolates to be multidrug-resistant or very resistant to the drugs. They have also been identified in patients with a medical history of concern during a high profile outbreak identified only through active outreach.

“Despite the increase in carbapenemase testing for CRPA through the network of antibiotic resistance laboratories, our investigation shows that CP [carbapenemase-producing]-CRPA continues to be under-detected, “they wrote.

The authors suggest that any identification of these types of extensively drug-resistant isolates, particularly in patients who received healthcare outside the United States, should increase the suspicion of CP-CRPA.


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