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Deadly 2012 outbreak at "medical spa" linked to workers

By Kathryn Doyle

NEW YORK (Reuters Health) - Outbreaks of group A Streptococcus infections at weight loss clinics in Maryland and Delaware in 2012 were probably caused by poor infection control practices on the part of the staff, according to a new study.

All of the patients had undergone liposuction, in which doctors suction excess fat out of the body using special surgical equipment.

The outpatient treatment centers where they had the surgery were part of a chain of so-called medical spas, with licensed doctors or nurses, but not subject to state regulation.

“Although there were not that many patients involved compared to other outbreaks, the fact that all 13 patients were previously healthy with many having to be hospitalized or even dying makes this a very serious outbreak,” said Dr. Daniel J. Morgan of the Department of Public Health and Epidemiology at the University of Maryland School of Medicine in Baltimore.

Morgan was not involved in the analysis, but wrote an accompanying commentary in JAMA Internal Medicine about the lack of patient protections in outpatient cosmetic surgery.

“The two major risks (of outpatient liposuction) are infection, such as in this outbreak, or accidental overdose of lidocaine, which has killed patients at other medical spas,” he told Reuters Health in an email.

At the time of the outbreak, the Maryland Department of Health and Mental Hygiene had been notified of three patients hospitalized with invasive strep infection, including one death, all of whom had undergone liposuction at the Maryland outpost.

To trace the source of the outbreak, researchers from the U.S. Centers for Disease Control and Prevention and the Pennsylvania Department of Health contacted all patients who underwent liposuction at any of the chain locations between July and September of 2012. At the Maryland and Delaware sites, 66 lipo procedures had been performed.

The study team identified one additional confirmed infection, from a spa location in Delaware, and nine more suspected cases.

The strep bacteria can cause mild infections or a sore throat, but invasive infections can also cause pneumonia or toxic shock syndrome, which can be fatal.

All four confirmed cases of infection were hospitalized for an average of 19 days, including the patient who died.

The same doctor had performed the procedures on all four confirmed infected patients and had worked in Maryland and Delaware.

That doctor was found to have had a colony of the bacteria that caused the infections in his throat. He and his team reported wearing surgical gloves and masks during the procedures, but not during pre-op prep or postoperative care.

According to interviews, medical records and bacterial analysis, other employees also carried the strain of bacteria implicated in the outbreak.

The Maryland facility was closed by health officials and has not been reopened.

Breast augmentation and liposuction are the most common cosmetic surgeries in the U.S., the study authors write, with 300,000 liposuction procedures performed by board-certified specialists in 2012.

Non-specialists can also perform lipo, without anesthesia and in outpatient facilities like these medical spas, they note.

In ‘tumescent liposuction’ a cocktail of fluids and chemicals are injected under the skin before a tube is inserted to suck out the fat.

“Liposuction is a major surgical procedure and does come with some risks,” said lead author Amanda L. Beaudoin of the Pennsylvania Department of Health. ”Major complications can include fat embolism, necrosis of the skin and underlying tissues, and severe infections like those described in this publication.”

Patients should always discuss their individual situation and the risk of complications with a surgeon and their physician prior to undergoing liposuction, Beaudoin told Reuters Health by email.

Accredited outpatient surgical centers or hospitals are required to comply with infection prevention guidelines applicable to federally or state-certified ambulatory surgical centers, and are the best choice, she said.

But once you’ve checked for accreditation, there is no obvious way to tell if the facility you choose for liposuction is safe, Morgan said.

“Some facts that would imply a better functioning medical spa would be a board certified dermatologist or plastic surgeon providing services, confirmation that a physician is present during any procedures and evidence of basic infection control activities,” he said.

“There were some big red flags noted in this outbreak which should steer one away from a facility such as a dirty environment or seeing staff eating in an operating room,” he said.

The medical spa with the lowest price may be the one cutting the most corners in important areas, he said. It’s especially important to consider safety for invasive procedures like liposuction, rather than laser therapy or electrolysis, he noted.

“Although it is not a guarantee of good practice, a physician being board-certified generally implies more training,” Morgan said.

New legislation that subjects these facilities to state and federal regulation would help reduce risk to patients, but the businesses themselves should also seek out infection control training for their workers, he said.

SOURCE: http://bit.ly/1gyudS9 and http://bit.ly/1hvQpaI JAMA Internal Medicine, online May 26, 2014.

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