Postcesarean section wound infection caused by Mycobacterium massiliense.
OBJECTIVE
Mycobacterium abscessus subsp. massiliense (a subspecies of the M. abscessus complex) is a rare causative agent of surgical site infection after cesarean section (C section). We tried to seek the common source of infection and unravel the optimal treatment modalities.


METHODS
From September 2009 to October 2012, four postpartum women developed C-section wound infections caused by M. massiliense. Speciation of the four isolates was identified using of hsp65, rpoB, and secA1 partial gene sequencing and the Basic Local Alignment Search Tool. The erm(41) and rrl genes were detected for the possibility of inducible macrolide resistance. Pulsed-field gel electrophoresis was used as a tool of molecular epidemiology. All patients underwent intensive intravenous and oral antimycobacterial regimens. Of these patients, three underwent debridement at least once.


RESULTS
All four isolates were identified as M. abscessus subsp. massiliense. All of the isolates harbored a truncated erm(41) gene without rrl gene mutations, which explains the susceptibility to clarithromycin and azithromycin. Three isolates were indistinguishable by DNA strain typing, and the fourth strain was clonal with the other three strains. Their infections were not improved in spite of teicoplanin treatment initially. These patients underwent antimycobacterial regimens with/without surgery and were all cured.


CONCLUSIONS
Teicoplanin treatment failure, painful cutaneous nodules, and persistent wound drainage alerted us to the possibility of nontuberculous mycobacterial skin and soft tissue infection. Accurate identification of subspecies, detection of drug resistance genes, susceptibility testing, and optimal antimycobacterial agents with/without surgical debridement are warranted for successful treatment.
Infection Control Committee, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University, Number 259, Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, Taiwan.
Ting-Shu
TS
Wu
Department of Dermatology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan.
Chih-Hsun
CH
Yang
Mycobacteria/Nocardia Laboratory, Department of Microbiology, University of Texas Health Science Center, 11937 United States Highway 271, Tyler, TX 75708-3154, USA.
Barbara A
BA
Brown-Elliott
Department of Gynecology and Obstetrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan.
An-Shine
AS
Chao
Infection Control Committee, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan.
Hsieh-Shong
HS
Leu
Department of Laboratory Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan.
Tsu-Lan
TL
Wu
Infection Control Committee, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan.
Chun-Sui
CS
Lin
Pulmonary and Critical Care Division, University of Texas Health Science Center, 11937 United States Highway 271, Tyler, TX 75708-3154, USA. Electronic address: David.Griffith@uthct.edu.
David E
DE
Griffith
Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Number 5, Fu-Hsing Street, Kwei-Shan, Taoyuan 333, Taiwan. Electronic address: chchiu@cgmh.org.tw.
Cheng-Hsun
CH
Chiu
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017963:Azithromycin / Q000627:therapeutic use; D001426:Bacterial Proteins / Q000235:genetics; D002585:Cesarean Section / Q000009:adverse effects*; D018834:Chaperonin 60 / Q000235:genetics; D015377:Cilastatin / Q000627:therapeutic use; D000077728:Cilastatin, Imipenem Drug Combination; D017291:Clarithromycin / Q000627:therapeutic use; D004338:Drug Combinations; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D006801:Humans; D015378:Imipenem / Q000627:therapeutic use; D008780:Methyltransferases / Q000235:genetics; D008826:Microbial Sensitivity Tests; D058889:Molecular Typing; D000077266:Moxifloxacin; D009164:Mycobacterium Infections / Q000188:drug therapy* / Q000382:microbiology; D009170:Nontuberculous Mycobacteria / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification*; D011247:Pregnancy; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology; D017334:Teicoplanin / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D018834:Chaperonin 60; D004338:Drug Combinations; D024841:Fluoroquinolones; C074119:heat-shock protein 65, Mycobacterium; D015377:Cilastatin; D017334:Teicoplanin; D015378:Imipenem; D017963:Azithromycin; D000077728:Cilastatin, Imipenem Drug Combination; D008780:Methyltransferases; C431709:ErmA protein, Bacteria; D017291:Clarithromycin; D000077266:Moxifloxacin
antimycobacterial agents; cesarean section; erm(41); pulsed-field gel electrophoresis; susceptibility testing