Management of Infections with Mycobacterium Other Than Tuberculosis (MOTT) as a Complication of Surgical Procedures.

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Bikash Naskar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-33185/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND: Atypical mycobacteria (MOTT) have emerged as significant human pathogens, causing post-surgical wound infections.The aim of this study is to assess the causative organisms of such infection and their treatment response. METHODS: After matching the criteria, 28 cases, were taken for this prospective, single center, observational study.The diagnosis was confirmed by bacterial culture. RESULTS: Among 28 patients, 16 were females (median age of 45.5 year) . Patients had undergone laparoscopic cholecystectomy ( n=13 ), laparoscopic appendicectomy ( n=3), laparoscopic hernioplasty ( n=2 ), open appendicectomy ( n=2 ), open mesh hernioplasty ( n= 7 ), exploratory laparotomy (n=1 ). No major comorbidities or immunosuppression was identified. All patients were initially treated with repeated incision and drainage and started conventional antibiotics until culture and sensitivity report was available.All except one patient had culture confirmed MOTT infection. Combination antibiotics (clarithromycin, linezolid and ofloxacin ) given for initial 3 months. 12 well responded within 3 months. 9 required additional few months to get complete cure. 4 patients cured after 6 months of treatment and 3 patients did not come for follow up. CONCLUSIONS: Delayed onset chronic wound infection by Atypical mycobacteria is preventable.These organisms are not responsive to conventional antitubercular drugs but to specific drug regimens. General Surgery Chronic postoperative wound atypical mycobacteria Mycobacterium Other Than Tuberculosis Figures Figure 1 Figure 2 Introduction Postoperative infections caused by saprophytic Mycobacterium are not uncommon, and their prevalence is increasing. The clinical presentation includes cellulitis, abscess formation, draining sinuses, and postoperative wound infection. Patients often do not have fever, chills, or other manifestations that are characteristic of a systemic infection, which makes clinical diagnosis difficult. Mycobacteria are ubiquitous and have been found in both tap water and soil as well as skin surfaces on man and animals. [1] There are controversies regarding the pathways of infection. It is believed that contaminated surgical instruments, reusable surgical instruments in particular, such as the Laparoscopic instruments might be the possible sources of infection. Mycobacteria usually cannot be thoroughly killed with the usual disinfectants, and surgical equipment must be autoclaved. If surgical instruments are contaminated with Mycobacteria and cannot be autoclaved, special sterilization methods should be used. Although autoclaving surgical instruments is the best method for preventing Mycobacterial contamination of wounds, reusable instruments such as cannulas, tubings, and fibreoptic cables that can be damaged by autoclaving should be immersed completely in 2% activated gluteraldehyde for minimum 10 minutes to destroy vegetative organisms or minimum 10 hours it will destroy all forms of microbes and or ortho-pthalaldehyde solution for minimum 5 minutes(for high level disinfection) or sterilized with ethelene oxide gas (36 to 48 hours). In addition, mucus or residue from cells on surgical instruments may lead to a significant decrease in disinfecting activity, which means that decontaminating baths must be renewed according to their frequency of use. Rinsing instruments in sterilized distilled water or with 70% alcohol after disinfection and before use is an excellent method of preventing instrument colonization. Because most MOTT (Mycobacterium Other Than Tuberculosis) infections are iatrogenic, adequate sterilization of surgical instruments are needed. It is known that effective treatment of MOTT infection includes surgical treatment concurrent with combination antibiotic therapy. [2] An antibiotic combination based on susceptibility of individual isolates must be administered for a sufficiently long period of time to ensure complete wound healing and no recurrence. Conventional anti-tubercular drugs have been reported to be ineffective. It has been shown that atypical Mycobacteria, particularly M. chelonae and M.fortuitum, both of which belong to the group of rapidly growing Mycobacterium, widely colonize soil and water. This Mycobacterial complex primarily presents itself as localized cutaneous infection 3–4 weeks after surgery. There is, however, very little evidence of disseminated disease following infection with this complex except in immunocompromised hosts. [3] These bacteria have an affinity for the dermis and the subcutaneous area. Protective factors within the peritoneum destroy the Mycobacterium and prevent infection within the peritoneal cavity. In theory, these microorganisms can be isolated through culture of affected tissue but takes a longer time to grow and is difficult to culture. [4] Infections with atypical Mycobacterium have been primarily reported after laparoscopic procedures [3,4] . A recent study has shown that atypical Mycobacterium such as M. chelonae and M. smegmatis are showing increased resistance to these chemicals due to defects in porin expression in the bacterial cell walls. [5] . Porins are cell wall proteins found in Mycobacteria and have been known to create channels that allow the passage of small hydrophilic molecules, such as antibiotic drugs, through the highly hydrophobic Mycobacterial cell wall. [6] Mutations leading to defects in porin expression prevent the delivery of antibiotics such as β-lactams, fluoroquinolones and chloramphenicol into the Mycobacterial cell thus conferring drug resistance. [7] Surgical wound infection by atypical Mycobacteria may be of following types - 1. Portsite infection: Wound discharge, nodule and erythema around the port site are the most common presentation of non-mycobacterial infection.There are five clinical stages of atypical mycobacterial port site infection (PSI). [8] First stage: A tender nodule appears in the vicinity of the port site, and its usual timing of appearance is around four weeks following the surgery. Second stage: Increase in the size of the nodule, and increased tenderness of the site along with other signs of inflammation with eventual formation of a discharging sinus. Third stage: Reduced pain sensation following discharge of the purulent material and necrosis of the skin surrounding the port site. Fourth stage: Chronic sinus discharging white or serous fluid. Fifth stage: Hyper-pigmentation of the skin surrounding the sinus and appearance of multiple nodules at different places. 2. Wound infection following mesh hernioplasty: Usual presentation is chronic discharging sinus. Discharge is usually serous in nature. The objective of this study is to assess the causative organisms of such infection and to study their treatment response. Methods This is an institution based (single center) prospective, observational study. Ethical approval for the study was obtained from the Institutional Ethics Committee, NRSMCH, Bankura, West Bengal, India. The study population comprised of 28 cases of surgical wound infection (who undergone surgery from January 2017 to June 2018 in general surgery department of N. R.S medical college) presenting with signs of persistent inflammation at the incision site and no pyogenic organism was recovered.The cases did not respond to usual antibiotics and dressing for more than 4 weeks. They had granulomas in tissue obtained from the surgical wound or surrounding structures or a positive acid-fast staining but negative culture for Mycobacteria. The subjects satisfied the inclusion and exclusion criteria mentioned below. The primary data for this study were the investigation reports of the subjects. INCLUSION CRITERIA: Patients with postoperative wound infections with signs of inflammation of the skin and abscesses or drainage at the wound site in addition to not responding to abscess drainage and antibiotics used for pyogenic infections.Andorganisms isolated from an aseptically obtained culture of fluid or tissue from the incision. EXCLUSION CRITERIA: Exclusion criterion was all acute postoperative wound infections of less than 3 weeks from the time of surgery. STUDY TECHNIQUE Based on detailed history, thorough clinical examination provisional diagnosis was made. Patients were then subjected to investigations such as routine investigations: Haemoglobin, Total Leukocyte Count, Differential Count, Blood urea, Creatinine, fasting blood glucose, LFT, viral markers and special investigations: Gram staining, AFB staining, AFB culture of the secretions from the wound site.Antibiotic treatment and surgical treatment were then oferred according to study protocol.Each case was observed regarding outcome of management.They were followed up in the OPD (General surgery) to assess completeness of wound healing. MANAGEMENT DETAILS: Combination antibiotic therapy plus surgical treatment were applied to all the patients. But neither the standard regimen nor the exact dosage of antibiotics has been firmly established. 1. ANTIBIOTIC THERAPY: An antibiotic combination based on susceptibility of individual isolates was administered for a period of time to ensure complete wound healing and no recurrence. Conventional antitubercular drugs have been reported to be ineffective. The choice of antibiotics depends on in-vitrosusceptibility patterns. Some antimicrobial agents, including quinolones, amikacin have been found to be effective against M. fortuitum 2.SURGICAL MANAGEMENT: a) Port site infection: Surgical excision of skin at port site under local anesthesia. b) Mesh infection: removal of mesh ˃ debridement of wound ˃ wound to be kept open ˃ waiting for healthy granulation tissue to appear > secondary suturing of the wound. The statistical analysis was carried out using available standard statistical software. Odds ratio with 95% confidence interval (CI) and multivariate analysis has used establish the interrelationships between pre-operative and intra operative findings. All statistical tests has two tailed and P value <0.05 has taken as significant. Results Total twenty eight patient with post-operative delayed wound infection with MOTT were identified. All of the 28 patients met inclusion criteria were selected in the study after after obtaining written consent.The following observations were made during the course of the study according to age .[Table 1]. Median value of age distribution was 45.5 years. Table 1: Distribution of patients according to age distribution AGE (YEAR) NO. OF PATIENTS 18 - 30 4 31 – 40 6 41 – 50 9 51 - 60 7 61 - 70 2 TOTAL 28 The majority of patients were female ( 16 females and 12 males) with median age of 45.5 year (range 18 –70). [TABLE 2]. Table 2 : Distribution of study population according to sex SEX NO MALE 12 FEMALE 16 TOTAL 28 Those patients had undergone different surgeries like laparoscopic cholecystectomy ( n = 13), laparoscopic appendicectomy ( n = 3), laparoscopic hernioplasty ( n = 2), open appendicectomy ( n = 2), open mesh hernioplasty ( n = 7), exploratory laparotomy (n = 1). No major disease comorbidities or causes of immunosuppression (e.g., HIV infection) were identified except three patients were diabetic and two were hypertensive. [TABLE 3] Table 3: Distribution of study subjects according to types of previous surgical procedures SURGERY NO LAPAROSCOPIC CHOLECYSTECTOMY 13 LAPAROSCOPIC APPENDICECTOMY 3 LAPAROSCOPIC MESH HERNIOPLASTY 2 OPEN MESH INGUINAL HERNIOPLASTY 7 OPEN APPENDICECTOMY 2 EXPLORATORY LAPAROTOMY 1 All the patients were initially treated with repeated incision and drainage and were started with conventional antibiotics like amoxicillin/ clavulanic acid or second or third generation cephalosporin until culture and sensitivity report available. [ FIGURE 1] showswound of astudy subject,who underwent exploratory laparotomy followed by splenectomy in a case of blunt trauma abdomen. Wound infection occurred after 2 months following operation. And [Figure 2] shows the wound of same patient after 3 months of continued combination antibiotic treatment and repeated debridement. Skin findings varied widely, including sinus tracts, non-healing ulcers, subcutaneous abscesses or firm nodules of varying size and erythema or chronic discharge from prior surgical wound. All patients had cultured- confirmed MOTT except one who was only AFB positive by ZN stain. Species identified were Mycobacterium fortuitum and M chelonae. After getting the culture and sensitivity reports, combination antibiotics (clarithromycin, linezolid and ofloxacin) given for initial 3 months. 12 out of 28 patients well responded with 3 months of treatment. 9 patients required additional few months to get complete cure. Four patients cured after 6 months of treatment and three patients did not come for follow up. Antibiotics were continued for additional three months after patient got cure to prevent relapse of infection. [TABLE 4]. A comparative analysis of present study with other studies is given in [Table 5] Table 4: Distribution of study population according to clinical outcome OUTCOME NO. CURED 21 CURED AFTER 6 MONTHS OF TREATMENT 4 LOST FOLLOW UP 3 Table 5: Comparative analysis of present study with other studies. Author Size of study population Clinical Features Bacteriological Features Management Jury B. Kaltia et al [18] 25 Delayed onset post-operative wound infection (3 weeks after surgery), appearance of erythema and oedema followed by breakdown of wound and suppuration / discharging sinuses, absence of symptoms / illness and lack of response to antibiotics used for pyogenic infections. swab from 20 out of 25 patients revealed growth of rapidly growing Mycobacterium spp. ( M. fortuitum- chelonae complex). Remaining 5 culture negative cases received prior treatment with one or the other fluoroquinolones which are known drugs for treatment of mycobacterial infection Only 7 patients who turned up in the OPD could be followed up and all of them were cured when treated with fluoroquinolones along with clarithromycin and amikacin for 2 to 3 months along with vigorous surgical debridement. Julio et al [19] 1,who underwent laparoscopic inguinal herniorrhaphy The local findings were erythema, local warmth, painful nodules and minimal purulent discharge from deep fistulous tract. No improvement was observed even after 10 days of treatment and local dressings with 10% povidone iodine. Microscopic examination of biopsy material showed acid fast bacilli in Ziehl Neelsen stained smear. Culture results were positive for mycobacteria. Polymerase chain reaction (PCR) restriction enzyme analysis of the hsp 65 gene, rpoB partial gene sequencing identified the strain as Mycobacterium massiliense . This patient underwent mesh removal with debridement of extensive granulomatous inflammatory tissue in pre-peritoneal pelvic area. The antibiotic scheme consisted of clarithromycin, amikacin, and minocycline for 3 months and thereafter clarithromycin, minocycline and moxifloxacin. Antibiotics were maintained for additional 3 months. Patient had a full recovery following this course of treatment Mahvash Haider et al [20] A 40 years old immunocompetent female underwent laparoscopic cholecystectomy Three weeks later she developed port site granuloma with persistent seropurulent discharge. Empirical oral antibiotics were started but provided no relief. After 3 months the wound was explored and tissues were sent for histopathological examination and smear microscopy along with culture-sensitivity. Mycobacterium abscessus was identified. Amikacin and Clarithromycin was started for a period of one month. Then clarithromycin alone was continued. Discharging sinuses improved and healed completely by the end of six months of clarithromycin therapy Kavitha Kannaiyan et al [21] 19 patients (13 female and 6 male patients, aged 18 to 60 years) who underwent laparoscopic cholecystectomy, hernioplasty, diagnostic laparoscopy, reduction mammoplasty Abscess and chronic non healing wound infection. Mycobacterium fortuitum and M chelonae were predominantly found. All patients underwent surgical procedure to drain existing abscesses, removal of immature nodule, removal of mesh and wound debridement. Linezolid and clindamycin were started for all patients. Of 19 patients 11 patients received clarithromycin for 3 months, 5 patients for 5 months, 2 patients on and off for 24 months and 1 patient was lost follow up. 16 patients were completely cured and 2 patients were not cured in this study JS Rajkumar et al [22] 38 years old lady who underwent laparoscopic ovarian cystectomy Few weeks later, the patient developed multiple discharging sinuses and abscesses. Non mycobacterium tuberculosis rapid grower Patient underwent eight successive surgical explorations for multiple skin and soft tissue sinuses along with medicinal treatment of NTM (amikacin, clarithromycin and ofloxacin). Treatment was continued for a period of six months. Abdominoplasty and meshplasty was done 2 months after complete control of infection Present study 28 patients. patients had undergone different surgeries like laparoscopic cholecystectomy ( n=13 ), laparoscopic appendicectomy ( n=3), laparoscopic hernioplasty ( n=2 ), open appendicectomy ( n=2 ), open mesh hernioplasty ( n= 7 ), exploratory laparotomy Skin findings varied widely, including sinus tracts, non-healing ulcers, subcutaneous abscesses or firm nodules of varying size and erythema or chronic discharge from prior surgical wound. All the patients were initially treated with repeated incision and drainage and were started with conventional antibiotics like amoxicillin/ clavulanic acid or second or third generation cephalosporin until culture and sensitivity report available. All patients had cultured confirmed MOTT except 1 who was only AFB positive by ZN stain. Species identified were Mycobacterium fortuitum and M chelonae. After getting the culture and sensitivity reports, combination antibiotics (clarithromycin, linezolid and ofloxacin ) given for initial 3 months. 12 out of 28 patients well responded with 3 months of treatment. 9 patients required additional few months to get complete cure. 4 patients cured after 6 months of treatment and 3 patients did not come for follow up. Antibiotics were continued for additional 3 months after patient got cure to prevent relapse of infection. Discussion An antibiotic combination is better than single-drug therapy in case of postoperative infection by atypical Mycobacteria. [9] Recent studies have demonstrated that clarithromycin, cefoxitin, and imipenem were also effective against these microorganisms [10,11,12] . Based on reported NTM [MOTT] sensitivities, amikacin with ciprofloxacin or amikacin with cefoxitin [10] should be administered to the patient while waiting for microbial sensitivity results, if there is a strong suspicion of atypical mycobacterial infection [10,13]. According to results of a study from Brown-Elliott and Wallace, the M. fortuitum group is less drug resistant than M. abscessus and M. chelonae. [13] Thus, treatment of infections caused by the M. fortuitum group has been much easier and generally more effective than treatment of M. abscessus and M. chelonae infections.Postoperative wound infections caused by MOTT generally appear few weeks to some months following the procedure. [14] In some case series the incubation period ranged from 20 to 66 days. On the contrary infections due to other pyogenic bacteria have a shorter incubation period as compared to MOTT which have a longer incubation period ranging from several days to several months. [3] The absence of clinical response after the administration of antimicrobial agents against commonly invading bacteria (e.g., Staphylococci, Streptococci) and the sterility of routine cultures of samples taken from the infected sites were clues for MOTT infection. Time between the onset of symptoms and the microbiological diagnosis also took long time. Therefore, a high index of suspicion is imperative to make the diagnosis. A study by Joon Young Song et al. stated that since the symptoms are relatively mild and indolent, the clinical diagnosis of atypical mycobacterium is often delayed and took more than two months from initial manifestation. [15] Also, in the revised literature, most publications conclude that clinical diagnosis of mycobacterial skin and soft tissue infections is not easy to perform and that the diagnosis is often delayed. Delays of more than one year have been reported. A high degree of clinical suspicion and appropriate microbiological techniques are necessary to avoid delays in diagnosis. [10] Clinically the infections caused by MOTT in post-operative wound infections are almost similar to pyogenic abscesses with induration, micro-abscesses, and discharge from sinuses and erythema. Systemic manifestations like fever and chills are rare. [2] The clinical features in our study were also similar with erythematous nodules, indurations, micro-abscesses and discharging sinuses. [9] All our patients presented with only local manifestations that started with painful nodules which gradually increased in size, which then would fistulize and open on the skin draining pus while none of them had any systemic manifestations. The source of infection in our case series is not clear. As per latest article by Maurer et al., , a number of sources could have been the possible source of infections which included contaminated gentian violet, rinsing solutions, antiseptic solutions, injectable medications, unsterile surgical instruments or poor wound care. [11] However in case of hernioplasty patients in our study as the organisms were also isolated from mesh, the source could be either the mesh or the transient presence of the mycobacteria in the surgical environment. [12] In other patients who had undergone caesarean section it is theoretically possible as per other study that nontuberculous mycobacteria might have gained access to the surgical wound from the public water system at the time of showering or it is equally possible that these organisms are present on the skin and are not eliminated by skin preparation preoperatively, thus gaining access through the skin incision. [16] Mechanical cleaning of blood and charred tissue that accumulates in the joints of the instruments may be not done properly after surgery. Thus, these contaminated instruments used during the surgical procedures might have left microorganisms implanted on the subcutaneous tissue which germinates and after an incubation period of 3–4 weeks giving rise to clinical symptoms. [17] Successful treatment of MOTT requires both surgical treatment and combination of antibiotics. [18] This Combination of antibiotics as determined by susceptibility should be prescribed for an adequately long time so that the wound heals and also to ensure that no recurrence occurs. It has been reported that conventional anti-tubercular drugs are ineffective in treating these cases. Antibiotics should be given based on their susceptibility report and also combination of antibiotics is preferable over single regimen. [19] M.fortuitum responds to antibiotics like amikacin, quinolones, doxycycline and sulphamethaxole. Latest studies reveal that clarithromycin, cefoxitin and imipenem were useful for treating MOTT. [20,21,22] Almost all the patients in our study were cured with a combined approach of drainage and clarithromycin based combination therapy. In hernioplasty patients mesh was removed. In one female patient who developed incisional hernia as a complication of this infection, underwent hernia repair and excision of abscess cavity. It has been recommended that in order to prevent recurrence, antibiotic treatment should be given for a minimum of at least three months, or to be continued for at least 3 to 6 weeks after the wound get healed. Recent research work has also recommended that antibiotic treatment should be given for 6 to 12 months though the optimal length of treatment has not been yet established. [16, 17] So, it is important to re-emphasize upon the surgeons about the importance of following strict sterilization protocols including cleaning laparoscope instruments as per the manufacturer’s instructions. Proper sterilization of medical equipments, proper skin cleansing preoperatively are essential prerequisite to prevent these infections. Clinicians should be aware to include MOTT in the differential diagnosis of surgical site infections in order to make early diagnosis and prompt treatment. The limitations of this study were as follows: the exact source of infection could not be made out for further prevention of infection involving future surgical procedures and also molecular characterization was not done. Since PCR is costly for most patients, identification is still done commonly by conventional methods in most of the laboratories in countries like India. To conclude, delayed onset chronic wound infection by Atypical mycobacteria is preventable.These organisms are not responsive to conventional antitubercular drugs but to specific drug regimens. Declarations FUNDING: No funding source/grant was available. No external fund was available. All investigations and treatment were done free of cost in the government teaching hospital named NRSMCH,WB,India. Conflict of interest: The authors declare that they have no competing interests. Ethical approval: Obtained from the Institutional Ethics Committee, NRSMCH, Bankura, West Bengal, India. Approval letter (Memo No.NMC/958 dt 23.02.17) is available for review by the editor of the journal. Written consents from individual patients were also obtained. References Dailloux M, Laurain C, Weber M, Hartemann PH. Water and nontuberculous mycobacteria. Water Res 1999;33: 2219–2228. Wallace RJ Jr(1), Brown BA, Silcox VA, Tsukamura M, Nash DR, Steele LC, et al. 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Delayed post operative wound infection due to non-tuberculous Mycobacterium.Indian J Med Res 122, December 2005, pp 535–539. Julio C. U. Coelho,Christiano M. P. Claus, João Carlos Michelotto,Fabiana Marques Fernandes, Christian Lopez Valle,Leonardo Dudeque Andriguetto, et.al. Complication of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection. Surg Endosc (2010) 24: 2708–2712. Mehvas Haider, Priyanka Banerjee, Tavleen Jaggi, Jasmin Hussain. Post-operative sinus formation due to Mycobacterium Abscessus. Indian J Tuberc 2013; 60: 177–179. Kavitha Kannaiyan, Latha Ragunathan, Sulochana Sakthivel, A. R. Sasidar.Surgical site infection due to rapidly growing Mycobacteria. Journal of clinical and Diagnostic Research.2015 Mar, vol–9(3): DC05-DC08. Js Rajkumar, A. Vinoth, S. Akbar, A.Rajkumar,H Tadimari,A Jayakrishna Reddy, et al.Non tuberculous Mycobacterium as a causative factor in port site wound infection. Surg Med Open Acc J. 1(3).SMOAJ.000511.2018 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-33185","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633213,"identity":"df196a4d-4f2f-491f-a7c6-cbf804a27f7e","order_by":1,"name":"Bikash Naskar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYJACZgaDBAYGCYYEhg9AHhs7CVoeMM4AaWEmSgsDSAvjA2YeKBcvMG/vMWAuKEiTl5/dnCZt82ubPB8zA+OHjzm4tcicOWPAPMMgx3DDnWNp0rl9tw3bmBmYJWduw61FQiLHgJnHoIJxg0QOUEvPbUagFjZmXiK02M+fkf9N2rLntj2xWnISG24kpEkz/LidSFgLz7GCwzMM0pI33EhItuxtuJ3cxszYjN8v7M0bHxf8SbadPyMh8caPP7dt57c3H/zwEY8WBgYOgwNwNmMbmGzApx4I2B8gcf4QUDwKRsEoGAUjEgAAus5MZoMpxssAAAAASUVORK5CYII=","orcid":"","institution":"BSMCH,WB,India","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bikash","middleName":"","lastName":"Naskar","suffix":""}],"badges":[],"createdAt":"2020-06-03 02:31:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-33185/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-33185/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1263444,"identity":"d411d825-9e4c-4860-a608-9faada79baf1","added_by":"auto","created_at":"2020-06-05 15:04:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139980,"visible":true,"origin":"","legend":"Wound of a study subject,who underwent exploratory laparotomy followed by splenectomy in a case of blunt trauma abdomen.","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-33185/v1/fig1.png"},{"id":1263445,"identity":"70ec185f-6d6e-4ef6-9f9e-120036e2e64b","added_by":"auto","created_at":"2020-06-05 15:04:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":261706,"visible":true,"origin":"","legend":"The wound of same patient after 3 months of continued combination antibiotic treatment and repeated debridement.","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-33185/v1/fig2.png"},{"id":13536178,"identity":"37100156-d091-441b-a421-f69729c78731","added_by":"auto","created_at":"2021-09-17 01:31:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":909513,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-33185/v1/485ffcf8-64b2-4a97-81f2-03b815669db5.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eManagement of Infections with Mycobacterium Other Than Tuberculosis (MOTT) as a Complication of Surgical Procedures.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative infections caused by saprophytic Mycobacterium are not uncommon, and their prevalence is increasing. The clinical presentation includes cellulitis, abscess formation, draining sinuses, and postoperative wound infection. Patients often do not have fever, chills, or other manifestations that are characteristic of a systemic infection, which makes clinical diagnosis difficult. Mycobacteria are ubiquitous and have been found in both tap water and soil as well as skin surfaces on man and animals.\u003csup\u003e[1]\u003c/sup\u003e There are controversies regarding the pathways of infection. It is believed that contaminated surgical instruments, reusable surgical instruments in particular, such as the Laparoscopic instruments might be the possible sources of infection. Mycobacteria usually cannot be thoroughly killed with the usual disinfectants, and surgical equipment must be autoclaved. If surgical instruments are contaminated with Mycobacteria and cannot be autoclaved, special sterilization methods should be used. Although autoclaving surgical instruments is the best method for preventing Mycobacterial contamination of wounds, reusable instruments such as cannulas, tubings, and fibreoptic cables that can be damaged by autoclaving should be immersed completely in 2% activated gluteraldehyde for minimum 10 minutes to destroy vegetative organisms or minimum 10 hours it will destroy all forms of microbes and or ortho-pthalaldehyde solution for minimum 5 minutes(for high level disinfection) or sterilized with ethelene oxide gas (36 to 48 hours). In addition, mucus or residue from cells on surgical instruments may lead to a significant decrease in disinfecting activity, which means that decontaminating baths must be renewed according to their frequency of use. Rinsing instruments in sterilized distilled water or with 70% alcohol after disinfection and before use is an excellent method of preventing instrument colonization. Because most MOTT (Mycobacterium Other Than Tuberculosis) infections are iatrogenic, adequate sterilization of surgical instruments are needed. It is known that effective treatment of MOTT infection includes surgical treatment concurrent with combination antibiotic therapy. \u003csup\u003e[2]\u003c/sup\u003e An antibiotic combination based on susceptibility of individual isolates must be administered for a sufficiently long period of time to ensure complete wound healing and no recurrence. Conventional anti-tubercular drugs have been reported to be ineffective.\u003c/p\u003e\n\n\u003cp\u003eIt has been shown that atypical \u003cem\u003eMycobacteria,\u003c/em\u003e particularly \u003cem\u003eM. chelonae\u003c/em\u003e and \u003cem\u003eM.fortuitum,\u003c/em\u003e both of which belong to the group of rapidly growing \u003cem\u003eMycobacterium,\u003c/em\u003e widely colonize soil and water. This \u003cem\u003eMycobacterial \u003c/em\u003ecomplex primarily presents itself as localized cutaneous infection 3–4 weeks after surgery. There is, however, very little evidence of disseminated disease following infection with this complex except in immunocompromised hosts. \u003csup\u003e[3]\u003c/sup\u003e These bacteria have an affinity for the dermis and the subcutaneous area. Protective factors within the peritoneum destroy the \u003cem\u003eMycobacterium\u003c/em\u003e and prevent infection within the peritoneal cavity. In theory, these microorganisms can be isolated through culture of affected tissue but takes a longer time to grow and is difficult to culture. \u003csup\u003e[4]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eInfections with atypical \u003cem\u003eMycobacterium\u003c/em\u003e have been primarily reported after laparoscopic procedures \u003csup\u003e[3,4]\u003c/sup\u003e. A recent study has shown that atypical \u003cem\u003eMycobacterium\u003c/em\u003e such as \u003cem\u003eM. chelonae\u003c/em\u003e and \u003cem\u003eM. smegmatis\u003c/em\u003e are showing increased resistance to these chemicals due to defects in porin expression in the bacterial cell walls. \u003csup\u003e[5]\u003c/sup\u003e. Porins are cell wall proteins found in \u003cem\u003eMycobacteria\u003c/em\u003e and have been known to create channels that allow the passage of small hydrophilic molecules, such as antibiotic drugs, through the highly hydrophobic \u003cem\u003eMycobacterial\u003c/em\u003e cell wall. \u003csup\u003e[6]\u003c/sup\u003e Mutations leading to defects in porin expression prevent the delivery of antibiotics such as β-lactams, fluoroquinolones and chloramphenicol into the \u003cem\u003eMycobacterial \u003c/em\u003ecell thus conferring drug resistance. \u003csup\u003e[7]\u003c/sup\u003e\u003c/p\u003e\n\n\u003cp\u003eSurgical wound infection by atypical Mycobacteria may be of following types -\u003c/p\u003e\n\n\u003cp\u003e1. Portsite infection: Wound discharge, nodule and erythema around the port site are the most common presentation of non-mycobacterial infection.There are five clinical stages of atypical mycobacterial port site infection (PSI). \u003csup\u003e[8]\u003c/sup\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eFirst stage:\u003c/em\u003e A tender nodule appears in the vicinity of the port site, and its usual timing of appearance is around four weeks following the surgery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecond stage:\u003c/em\u003e Increase in the size of the nodule, and increased tenderness of the site along with other signs of inflammation with eventual formation of a discharging sinus.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThird stage:\u003c/em\u003e Reduced pain sensation following discharge of the purulent material and necrosis of the skin surrounding the port site.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFourth stage:\u003c/em\u003e Chronic sinus discharging white or serous fluid.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFifth stage:\u003c/em\u003e Hyper-pigmentation of the skin surrounding the sinus and appearance of multiple nodules at different places.\u003c/p\u003e\n\u003cp\u003e2. Wound infection following mesh hernioplasty: Usual presentation is chronic discharging sinus. Discharge is usually serous in nature.\u003c/p\u003e\n\u003cp\u003eThe objective of this study is to assess the causative organisms of such infection and to study their treatment response.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is an institution based (single center) prospective, observational study.\u003cem\u003eEthical approval\u003c/em\u003e for the study was obtained from the Institutional Ethics Committee, NRSMCH, Bankura, West Bengal, India. The study population comprised of 28 cases of surgical wound infection (who undergone surgery from January 2017 to June 2018 in general surgery department of N. R.S medical college) presenting with signs of persistent inflammation at the incision site and no pyogenic organism was recovered.The cases did not respond to usual antibiotics and dressing for more than 4 weeks. They had granulomas in tissue obtained from the surgical wound or surrounding structures or a positive acid-fast staining but negative culture for \u003cem\u003eMycobacteria.\u003c/em\u003eThe subjects satisfied the inclusion and exclusion criteria mentioned below. The primary data for this study were the investigation reports of the subjects.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eINCLUSION CRITERIA:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatients with postoperative wound infections with signs of inflammation of the skin and abscesses or drainage at the wound site in addition to not responding to abscess drainage and antibiotics used for pyogenic infections.Andorganisms isolated from an aseptically obtained culture of fluid or tissue from the incision.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEXCLUSION CRITERIA:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExclusion criterion was all acute postoperative wound infections of less than 3 weeks from the time of surgery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSTUDY TECHNIQUE\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on detailed history, thorough clinical examination provisional diagnosis was made. Patients were then subjected to investigations such as routine investigations: Haemoglobin, Total Leukocyte Count, Differential Count, Blood urea, Creatinine, fasting blood glucose, LFT, viral markers and special investigations: Gram staining, AFB staining, AFB culture of the secretions from the wound site.Antibiotic treatment and surgical treatment were then oferred according to study protocol.Each case was observed regarding outcome of management.They were followed up in the OPD (General surgery) to assess completeness of wound healing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMANAGEMENT DETAILS:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCombination antibiotic therapy plus surgical treatment were applied to all the patients. But neither the standard regimen nor the exact dosage of antibiotics has been firmly established.\u003c/p\u003e\u003cp\u003e1. ANTIBIOTIC THERAPY:\u003c/p\u003e\n\n\u003cp\u003eAn antibiotic combination based on susceptibility of individual isolates was administered for a period of time to ensure complete wound healing and no recurrence. Conventional antitubercular drugs have been reported to be ineffective. The choice of antibiotics depends on in-vitrosusceptibility patterns. Some antimicrobial agents, including quinolones, amikacin have been found to be effective against \u003cem\u003eM. fortuitum\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.SURGICAL MANAGEMENT:\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003ea) Port site infection: Surgical excision of skin at port site under local anesthesia.\u003c/p\u003e\n\u003cp\u003eb) Mesh infection: removal of mesh ˃ debridement of wound ˃ wound to be kept open ˃ waiting for healthy granulation tissue to appear \u0026gt; secondary suturing of the wound. \u003c/p\u003e\n\u003cp\u003eThe statistical analysis was carried out using available standard statistical software. Odds ratio with 95% confidence interval (CI) and multivariate analysis has used establish the interrelationships between pre-operative and intra operative findings. All statistical tests has two tailed and P value \u0026lt;0.05 has taken as significant.\u003c/p\u003e\n"},{"header":"Results","content":"\u003cp\u003eTotal twenty eight patient with post-operative delayed wound infection with MOTT were identified. All of the 28 patients met inclusion criteria were selected in the study after after obtaining written consent.The following observations were made during the course of the study according to age\u003cem\u003e.[Table 1].\u003c/em\u003e Median value of age distribution was 45.5 years.\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 289.5pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 0.5in;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003eTable 1: Distribution of patients according to age distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;AGE (YEAR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003eNO. OF PATIENTS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 18 - 30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 31 \u0026ndash; 40 \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 41 \u0026ndash; 50\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 23.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 51 - 60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 61 - 70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;TOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 24.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cbr\u003e\n\u003cp\u003eThe majority of patients were female ( 16 females and 12 males) with median age of 45.5 year (range 18 –70). \u003cem\u003e[TABLE 2].\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"margin-left:.75in;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 342.8pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 42.2pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003eTable 2 : Distribution of study population according to sex\u0026nbsp;\u003c/p\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 171.4pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;SEX\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;NO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 171.4pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; MALE\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 12\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 171.4pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;FEMALE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 36.9pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 16\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 171.4pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 35.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;TOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 35.55pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cbr\u003e\n\u003cp\u003eThose patients had undergone different surgeries like laparoscopic cholecystectomy ( n = 13), laparoscopic appendicectomy ( n = 3), laparoscopic hernioplasty ( n = 2), open appendicectomy ( n = 2), open mesh hernioplasty ( n = 7), exploratory laparotomy (n = 1). No major disease comorbidities or causes of immunosuppression (e.g., HIV infection) were identified except three patients were diabetic and two were hypertensive.\u003cem\u003e[TABLE 3]\u003c/em\u003e \u003c/p\u003e\n\u003cdiv align=\"center\" style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\n \u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 429.75pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eTable 3: Distribution of study subjects according to types of previous surgical procedures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; SURGERY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;NO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eLAPAROSCOPIC CHOLECYSTECTOMY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eLAPAROSCOPIC APPENDICECTOMY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eLAPAROSCOPIC MESH HERNIOPLASTY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eOPEN MESH INGUINAL HERNIOPLASTY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eOPEN APPENDICECTOMY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 31.8pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312.45pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003eEXPLORATORY LAPAROTOMY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.3pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 32.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp style='margin:0in;margin-bottom:8.0pt;font-size:15px;font-family:\"Times New Roman\",serif;text-align:justify;line-height:115%;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eAll the patients were initially treated with repeated incision and drainage and were started with conventional antibiotics like amoxicillin/ clavulanic acid or second or third generation cephalosporin until culture and sensitivity report available.\u003cem\u003e[ FIGURE 1]\u003c/em\u003eshowswound of astudy subject,who underwent exploratory laparotomy followed by splenectomy in a case of blunt trauma abdomen. Wound infection occurred after 2 months following operation.\u003c/p\u003e\n\u003cp\u003eAnd \u003cem\u003e[Figure 2] \u003c/em\u003eshows the wound of same patient after 3 months of continued combination antibiotic treatment and repeated debridement.\u003c/p\u003e\n\u003cp\u003eSkin findings varied widely, including sinus tracts, non-healing ulcers, subcutaneous abscesses or firm nodules of varying size and erythema or chronic discharge from prior surgical wound.\u003c/p\u003e\n\u003cp\u003eAll patients had cultured- confirmed MOTT except one who was only AFB positive by ZN stain. Species identified were \u003cem\u003eMycobacterium fortuitum\u003c/em\u003e and \u003cem\u003eM chelonae.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter getting the culture and sensitivity reports, combination antibiotics (clarithromycin, linezolid and ofloxacin) given for initial 3 months. 12 out of 28 patients well responded with 3 months of treatment. 9 patients required additional few months to get complete cure. Four patients cured after 6 months of treatment and three patients did not come for follow up. Antibiotics were continued for additional three months after patient got cure to prevent relapse of infection.\u003cem\u003e[TABLE 4].\u003c/em\u003e A comparative analysis of present study with other studies is given in \u003cem\u003e[Table 5]\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 377.2pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003ch3 style='margin-top:3.75pt;margin-right:84.4pt;margin-bottom:.0001pt;margin-left:51.0pt;font-size:19px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:16px;\"\u003eTable 4:\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:16px;font-weight:normal;\"\u003eDistribution of study population according to\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:16px;font-weight:normal;\"\u003eclinical outcome\u003c/span\u003e\u003c/h3\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 188.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;OUTCOME\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 188.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;NO.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 188.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CURED\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 188.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 188.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;CURED AFTER 6 MONTHS OF TREATMENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 188.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 41pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 188.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 39.75pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; LOST FOLLOW UP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 188.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 39.75pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:.0001pt;font-size:15px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3 style='margin-top:3.75pt;margin-right:84.4pt;margin-bottom:.0001pt;margin-left:0in;font-size:19px;font-family:\"Times New Roman\",serif;text-align:justify;line-height:115%;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/h3\u003e\n\u003ctable style=\"float: left;width: 5.7e+2pt;border-collapse:collapse;border:none;margin-left:6.75pt;margin-right:6.75pt;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 573.3pt;border: 1pt solid black;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eTable 5:\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eComparative analysis of present study \u0026nbsp; \u0026nbsp; with other studies.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAuthor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eSize of study population\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eClinical Features\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eBacteriological Features\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 13.6pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eManagement\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 55.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eJury B. Kaltia \u003cem\u003eet\u0026nbsp;\u003c/em\u003eal [18]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 55.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e25\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 55.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eDelayed onset post-operative wound infection (3 weeks after surgery), appearance of erythema and oedema followed by breakdown of wound and suppuration / discharging sinuses, absence of symptoms / illness and lack of response to antibiotics used for pyogenic infections.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 55.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eswab from 20 out of 25 patients revealed growth of rapidly growing \u003cem\u003eMycobacterium\u003c/em\u003e spp. (\u003cem\u003eM. fortuitum- chelonae\u003c/em\u003e complex). Remaining 5 culture negative cases received prior treatment with one or the other fluoroquinolones which are known drugs for treatment of mycobacterial infection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 55.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eOnly 7 patients who turned up in the OPD could be followed up and all of them were cured when treated with fluoroquinolones along with clarithromycin and amikacin for 2 to 3 months along with vigorous surgical debridement.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 54.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eJulio \u003cem\u003eet al\u003c/em\u003e[19]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 54.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e1,who underwent laparoscopic inguinal herniorrhaphy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 54.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eThe local findings were erythema, local warmth, painful nodules and minimal purulent discharge from deep fistulous tract. No improvement was observed even after 10 days of treatment and local dressings with 10% povidone iodine.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 54.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eMicroscopic examination of biopsy material showed acid fast bacilli in Ziehl Neelsen stained smear. Culture results were positive for mycobacteria. Polymerase chain reaction (PCR) restriction enzyme analysis of the \u003cem\u003ehsp\u003c/em\u003e65 gene, rpoB partial gene sequencing identified the strain as \u003cem\u003eMycobacterium massiliense\u003c/em\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 54.85pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eThis patient underwent mesh removal with debridement of extensive granulomatous inflammatory tissue in pre-peritoneal pelvic area. The antibiotic scheme consisted of clarithromycin, amikacin, and minocycline for 3 months and thereafter clarithromycin, minocycline and moxifloxacin. Antibiotics were maintained for additional 3 months. Patient had a full recovery following this course of treatment\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eMahvash Haider \u003cem\u003eet al\u003c/em\u003e[20]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eA 40 years old immunocompetent female underwent laparoscopic cholecystectomy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eThree weeks later she developed port site granuloma with persistent seropurulent discharge. Empirical oral antibiotics were started but provided no relief.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAfter 3 months the wound was explored and tissues were sent for histopathological examination and smear microscopy along with culture-sensitivity. \u003cem\u003eMycobacterium abscessus\u003c/em\u003e was identified.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAmikacin and Clarithromycin was started for a period of one month. Then clarithromycin alone was continued. Discharging sinuses improved and healed completely by the end of six months of clarithromycin therapy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 49.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eKavitha Kannaiyan \u003cem\u003eet al\u003c/em\u003e[21]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 49.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e19 patients (13 female and 6 male patients, aged 18 to 60 years) who underwent laparoscopic cholecystectomy, hernioplasty, diagnostic laparoscopy, reduction mammoplasty\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 49.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAbscess and chronic non healing wound infection.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 49.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cem\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eMycobacterium fortuitum\u003c/span\u003e\u003c/em\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e\u0026nbsp;and \u003cem\u003eM chelonae\u003c/em\u003e were predominantly found.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 49.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAll patients underwent surgical procedure to drain existing abscesses, removal of immature nodule, removal of mesh and wound debridement. Linezolid and clindamycin were started for all patients. Of 19 patients 11 patients received clarithromycin for 3 months, 5 patients for 5 months, 2 patients on and off for 24 months and 1 patient was lost follow up. 16 patients were completely cured and 2 patients were not cured in this study\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eJS Rajkumar \u003cem\u003eet al\u003c/em\u003e[22]\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e38 years old lady who underwent laparoscopic ovarian cystectomy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eFew weeks later, the patient developed multiple discharging sinuses and abscesses.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cem\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eNon mycobacterium tuberculosis rapid grower\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 37.3pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003ePatient underwent eight successive surgical explorations for multiple skin and soft tissue sinuses along with medicinal treatment of NTM (amikacin, clarithromycin and ofloxacin). Treatment was continued for a period of six months. Abdominoplasty and meshplasty was done 2 months after complete control of infection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.45pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 94.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003ePresent study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.1pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 94.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e28 patients.\u003c/span\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003epatients had undergone \u0026nbsp;different surgeries like laparoscopic cholecystectomy ( n=13 ), laparoscopic appendicectomy ( n=3), laparoscopic hernioplasty ( n=2 ), open appendicectomy ( n=2 ), open mesh hernioplasty ( n= 7 ), exploratory laparotomy\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133.25pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 94.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eSkin findings varied widely, including sinus tracts, non-healing ulcers, subcutaneous abscesses or firm nodules of varying size and erythema or chronic discharge from prior surgical wound. All the patients were initially treated with repeated incision and drainage and were started with conventional antibiotics like amoxicillin/ clavulanic acid or second or third generation cephalosporin until culture and sensitivity report available.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.8in;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 94.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAll patients had cultured confirmed MOTT except 1 who was only AFB positive by ZN stain. Species identified were \u003cem\u003eMycobacterium fortuitum\u003c/em\u003e and \u003cem\u003eM chelonae.\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cem\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 171.9pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;padding: 0in 5.4pt;height: 94.5pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003eAfter getting the culture and sensitivity reports, combination antibiotics (clarithromycin, linezolid and ofloxacin ) given for initial 3 months. 12 out of 28 patients well responded with 3 months of treatment. 9 patients required additional few months to get complete cure. 4 patients cured after 6 months of treatment and 3 patients did not come for follow up. \u0026nbsp;Antibiotics were continued for additional 3 months after patient got cure to prevent relapse of infection.\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;margin-bottom:10.0pt;font-size:15px;font-family:\"Times New Roman\",serif;line-height:115%;'\u003e\u003cspan style=\"font-size:11px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3 style='margin-top:3.75pt;margin-right:84.4pt;margin-bottom:.0001pt;margin-left:51.0pt;font-size:19px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:16px;font-weight:normal;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/h3\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eAn antibiotic combination is better than single-drug therapy in case of postoperative infection by atypical Mycobacteria. \u003csup\u003e[9]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eRecent studies have demonstrated that clarithromycin, cefoxitin, and imipenem were also effective against these microorganisms \u003csup\u003e[10,11,12]\u003c/sup\u003e. Based on reported NTM [MOTT] sensitivities, amikacin with ciprofloxacin or amikacin with cefoxitin \u003csup\u003e[10]\u003c/sup\u003e should be administered to the patient while waiting for microbial sensitivity results, if there is a strong suspicion of atypical mycobacterial infection \u003csup\u003e[10,13].\u003c/sup\u003e According to results of a study from Brown-Elliott and Wallace, the \u003cem\u003eM. fortuitum\u003c/em\u003e group is less drug resistant than \u003cem\u003eM. abscessus\u003c/em\u003e and \u003cem\u003eM. chelonae.\u003c/em\u003e\u003csup\u003e[13]\u003c/sup\u003e Thus, treatment of infections caused by the \u003cem\u003eM. fortuitum\u003c/em\u003e group has been much easier and generally more effective than treatment of \u003cem\u003eM. abscessus\u003c/em\u003e and \u003cem\u003eM. chelonae\u003c/em\u003e infections.Postoperative wound infections caused by MOTT generally appear few weeks to some months following the procedure. \u003csup\u003e[14]\u003c/sup\u003e In some case series the incubation period ranged from 20 to 66 days. On the contrary infections due to other pyogenic bacteria have a shorter incubation period as compared to MOTT which have a longer incubation period ranging from several days to several months. \u003csup\u003e[3]\u003c/sup\u003eThe absence of clinical response after the administration of antimicrobial agents against commonly invading bacteria (e.g., Staphylococci, Streptococci) and the sterility of routine cultures of samples taken from the infected sites were clues for MOTT infection.\u003c/p\u003e\n\u003cp\u003eTime between the onset of symptoms and the microbiological diagnosis also took long time. Therefore, a high index of suspicion is imperative to make the diagnosis. A study by Joon Young Song \u003cem\u003eet al.\u003c/em\u003e stated that since the symptoms are relatively mild and indolent, the clinical diagnosis of atypical mycobacterium is often delayed and took more than two months from initial manifestation. \u003csup\u003e[15]\u003c/sup\u003e Also, in the revised literature, most publications conclude that clinical diagnosis of mycobacterial skin and soft tissue infections is not easy to perform and that the diagnosis is often delayed. Delays of more than one year have been reported. A high degree of clinical suspicion and appropriate microbiological techniques are necessary to avoid delays in diagnosis. \u003csup\u003e[10]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eClinically the infections caused by MOTT in post-operative wound infections are almost similar to pyogenic abscesses with induration, micro-abscesses, and discharge from sinuses and erythema. Systemic manifestations like fever and chills are rare. \u003csup\u003e[2]\u003c/sup\u003e The clinical features in our study were also similar with erythematous nodules, indurations, micro-abscesses and discharging sinuses. \u003csup\u003e[9]\u003c/sup\u003e All our patients presented with only local manifestations that started with painful nodules which gradually increased in size, which then would fistulize and open on the skin draining pus while none of them had any systemic manifestations.\u003c/p\u003e\n\u003cp\u003eThe source of infection in our case series is not clear. As per latest article by Maurer \u003cem\u003eet al.,\u003c/em\u003e, a number of sources could have been the possible source of infections which included contaminated gentian violet, rinsing solutions, antiseptic solutions, injectable medications, unsterile surgical instruments or poor wound care. \u003csup\u003e[11]\u003c/sup\u003eHowever in case of hernioplasty patients in our study as the organisms were also isolated from mesh, the source could be either the mesh or the transient presence of the mycobacteria in the surgical environment. \u003csup\u003e[12]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn other patients who had undergone caesarean section it is theoretically possible as per other study that nontuberculous mycobacteria might have gained access to the surgical wound from the public water system at the time of showering or it is equally possible that these organisms are present on the skin and are not eliminated by skin preparation preoperatively, thus gaining access through the skin incision. \u003csup\u003e[16]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMechanical cleaning of blood and charred tissue that accumulates in the joints of the instruments may be not done properly after surgery. Thus, these contaminated instruments used during the surgical procedures might have left microorganisms implanted on the subcutaneous tissue which germinates and after an incubation period of 3–4 weeks giving rise to clinical symptoms. \u003csup\u003e[17]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSuccessful treatment of MOTT requires both surgical treatment and combination of antibiotics. \u003csup\u003e[18]\u003c/sup\u003eThis Combination of antibiotics as determined by susceptibility should be prescribed for an adequately long time so that the wound heals and also to ensure that no recurrence occurs. It has been reported that conventional anti-tubercular drugs are ineffective in treating these cases. Antibiotics should be given based on their susceptibility report and also combination of antibiotics is preferable over single regimen. \u003csup\u003e[19]\u003c/sup\u003e \u003cem\u003eM.fortuitum\u003c/em\u003e responds to antibiotics like amikacin, quinolones, doxycycline and sulphamethaxole. Latest studies reveal that clarithromycin, cefoxitin and imipenem were useful for treating MOTT. \u003csup\u003e[20,21,22]\u003c/sup\u003e Almost all the patients in our study were cured with a combined approach of drainage and clarithromycin based combination therapy. In hernioplasty patients mesh was removed. In one female patient who developed incisional hernia as a complication of this infection, underwent hernia repair and excision of abscess cavity.\u003c/p\u003e\n\u003cp\u003eIt has been recommended that in order to prevent recurrence, antibiotic treatment should be given for a minimum of at least three months, or to be continued for at least 3 to 6 weeks after the wound get healed. Recent research work has also recommended that antibiotic treatment should be given for 6 to 12 months though the optimal length of treatment has not been yet established. \u003csup\u003e[16, 17]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSo, it is important to re-emphasize upon the surgeons about the importance of following strict sterilization protocols including cleaning laparoscope instruments as per the manufacturer’s instructions. Proper sterilization of medical equipments, proper skin cleansing preoperatively are essential prerequisite to prevent these infections. Clinicians should be aware to include MOTT in the differential diagnosis of surgical site infections in order to make early diagnosis and prompt treatment.\u003c/p\u003e\n\u003cp\u003eThe limitations of this study were as follows: the exact source of infection could not be made out for further prevention of infection involving future surgical procedures and also molecular characterization was not done. Since PCR is costly for most patients, identification is still done commonly by conventional methods in most of the laboratories in countries like India.\u003c/p\u003e\n\u003cp\u003eTo conclude, delayed onset chronic wound infection by Atypical \u003cem\u003emycobacteria\u003c/em\u003e is preventable.These organisms are not responsive to conventional antitubercular drugs but to specific drug regimens.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFUNDING: No funding source/grant was available. No external fund was available. All investigations and treatment were done free of cost in the government teaching hospital named NRSMCH,WB,India.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eConflict of interest:\u003c/em\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eEthical approval:\u003c/em\u003e Obtained from the Institutional Ethics Committee, NRSMCH, Bankura, West Bengal, India. Approval letter (Memo No.NMC/958 dt 23.02.17) is available for review by the editor of the journal. Written consents from individual patients were also obtained.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003eDailloux M, Laurain C, Weber M, Hartemann PH. Water and nontuberculous mycobacteria. Water Res 1999;33: 2219–2228.\u003c/li\u003e\u003cli\u003eWallace RJ Jr(1), Brown BA, Silcox VA, Tsukamura M, Nash DR, Steele LC, et al. Clinical disease, drug susceptibility, and biochemical patterns of the unnamed third biovariant complex of Mycobacterium fortuitum. J Infect Dis 1991;163:598–603.\u003c/li\u003e\u003cli\u003eWallace RJ Jr, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in vitro susceptibilities. J Infect Dis. 1985;152:500–14.\u003c/li\u003e\u003cli\u003eSong JY, Sohn JW, Jeong HW, Cheong HJ, Kim WJ, Kim MJ. An outbreak of post-acupuncture cutaneous infection due to Mycobacterium abscessus. BMC Infect Dis. 2006;6:6.\u003c/li\u003e\u003cli\u003eGuevara-Patiño A, Sandoval de Mora M, Farreras A, Rivera-Olivero I, Fermin D, de Waard JH. Soft tissue infection due to Mycobacterium fortuitum following acupuncture: a case report and review of the literature. J Infect Dev Ctries. 2010;4(8):521–25.\u003c/li\u003e\u003cli\u003eAl Soub H, Al-Maslamani E, Al-Maslamani M. mycobacterium fortuitum abdominal wall abscesses following liposuction. Indian J Plast Surg. 2008;41(1):58–61.\u003c/li\u003e\u003cli\u003eShah AK, Gambhir RPS, Hazra N, Katoch R. Non tuberculous mycobacteria in surgical wounds- a rising cause of concern? Indian J Surg. 2010;72:206–10.\u003c/li\u003e\u003cli\u003eMaurer FP, Castelberg C, von Braun A, Wolfensberger A, Bloemberg GV, Böttger EC, et al. Postsurgical wound infections due to rapidly growing mycobacteria in Swiss medical tourists following cosmetic surgery in Latin America between 2012 and 2014. Euro Surveill. 2014;19(37):1–4\u003c/li\u003e\u003cli\u003eMuthusami JC, Vyas FL, Mukundan U, Jesudason MR, Govil S, Jesudason SR. Mycobacterium fortuitum: an iatrogenic cause of soft tissue infection in surgery. ANZ J Surg 2004;74: 662–666.\u003c/li\u003e\u003cli\u003eMurillo J, Torres M, Bofill L, Ríos-Fabra A, Irausquin E, Istúriz R, et al. Skin and wound infection by rapidly growing mycobacteria: an unexpected complication of liposuction and liposculpture. The Venezuelan Collaborative Infectious and Tropical Diseases Study Group. Arch Dermatol 2000;136:1347–1352.\u003c/li\u003e\u003cli\u003eSungkanuparph S, Sathapatayavongs B, Pracharktam R. Infections with rapidly growing mycobacteria: report of 20 cases. Int J Infect Dis 2003;7:198–205.\u003c/li\u003e\u003cli\u003eGalea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with structural fat grafting. J Plast Reconstr Aesthet Surg 2009;62: e15–e16.\u003c/li\u003e\u003cli\u003eBrown-Elliott BA, Wallace RJ Jr. Clinical and taxonomic status of pathogenic nonpigmented or late-pigmenting rapidly growing mycobacteria.Clin Microbiol Rev 2002;15: 716–746.\u003c/li\u003e\u003cli\u003eMacadam SA, Mehling BM, Fanning A, Dufton JA. Nontuberculous Mycobacterial Breast Implant Infections. Plast Reconstr Surg. 2007;119(1):337–44.\u003c/li\u003e\u003cli\u003eChaudhuri S, Sarkar D, Mukerji R. Diagnosis and management of atypical myco-bacterial infection after laparoscopic surgery. Indian J Surg. 2010;72(6):438–42.\u003c/li\u003e\u003cli\u003eJarzembowski JA, Young MB. Nontuberculous mycobacterial infections. Arch Pathol Lab Med. 2008;132:1333–41.\u003c/li\u003e\u003cli\u003eKim HR, Kim DW. Soft tissue infection with Mycobacterium abscessus on the chin of a healthy child: a case report. J Korean Soc Plast Reconstr Surg. 2010;37:289–92.\u003c/li\u003e\u003cli\u003eJuri B. Kaltia, H. Rahman, K. C. Baruah. Delayed post operative wound infection due to non-tuberculous Mycobacterium.Indian J Med Res 122, December 2005, pp 535–539.\u003c/li\u003e\u003cli\u003eJulio C. U. Coelho,Christiano M. P. Claus, João Carlos Michelotto,Fabiana Marques Fernandes, Christian Lopez Valle,Leonardo Dudeque Andriguetto, et.al. Complication of laparoscopic inguinal herniorrhaphy including one case of atypical mycobacterial infection. Surg Endosc (2010) 24: 2708–2712.\u003c/li\u003e\u003cli\u003eMehvas Haider, Priyanka Banerjee, Tavleen Jaggi, Jasmin Hussain. Post-operative sinus formation due to Mycobacterium Abscessus. Indian J Tuberc 2013; 60: 177–179.\u003c/li\u003e\u003cli\u003eKavitha Kannaiyan, Latha Ragunathan, Sulochana Sakthivel, A. R. Sasidar.Surgical site infection due to rapidly growing Mycobacteria. Journal of clinical and Diagnostic Research.2015 Mar, vol–9(3): DC05-DC08.\u003c/li\u003e\u003cli\u003eJs Rajkumar, A. Vinoth, S. Akbar, A.Rajkumar,H Tadimari,A Jayakrishna Reddy, et al.Non tuberculous Mycobacterium as a causative factor in port site wound infection. Surg Med Open Acc J. 1(3).SMOAJ.000511.2018\u003c/li\u003e\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic postoperative wound, atypical mycobacteria, Mycobacterium Other Than Tuberculosis","lastPublishedDoi":"10.21203/rs.3.rs-33185/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-33185/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAtypical \u003cem\u003emycobacteria \u003c/em\u003e(MOTT) have emerged as significant human pathogens, causing post-surgical wound infections.The aim of this study is to assess the causative organisms of such infection and their treatment response.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMETHODS:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAfter matching the criteria, 28 cases, were taken for this prospective, single center, observational study.The diagnosis was confirmed by bacterial culture.\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRESULTS:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAmong 28 patients, 16 were females (median age of 45.5 year)\u003cstrong\u003e. \u003c/strong\u003ePatients had undergone laparoscopic cholecystectomy ( n=13 ), laparoscopic appendicectomy ( n=3), laparoscopic hernioplasty ( n=2 ), open appendicectomy ( n=2 ), open mesh hernioplasty ( n= 7 ), exploratory laparotomy (n=1 ). No major\u0026nbsp;comorbidities or immunosuppression was identified. All patients were initially treated with repeated incision and drainage and started conventional antibiotics until culture and sensitivity report was available.All except one patient had culture confirmed MOTT infection. Combination antibiotics (clarithromycin, linezolid and ofloxacin ) given for initial 3 months. 12 well responded within 3 months. 9 required additional few months to get complete cure. 4 patients cured after 6 months of treatment and 3 patients did not come for follow up.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCONCLUSIONS:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eDelayed onset chronic wound infection by Atypical \u003cem\u003emycobacteria\u003c/em\u003e is preventable.These organisms are not responsive to conventional antitubercular drugs but to specific drug regimens.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Management of Infections with Mycobacterium Other Than Tuberculosis (MOTT) as a Complication of Surgical Procedures.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-05 15:04:27","doi":"10.21203/rs.3.rs-33185/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5a432484-d251-4fe4-accd-5e3c4e510c26","owner":[],"postedDate":"June 5th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":112267,"name":"General Surgery"}],"tags":[],"updatedAt":"2020-06-05T15:04:27+00:00","versionOfRecord":[],"versionCreatedAt":"2020-06-05 15:04:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-33185","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-33185","identity":"rs-33185","version":["v1"]},"buildId":"wLkW0s4AflPzk-lpfg-fK","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}