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Mycobacterium abscessus infection of a cochlear implant insertion site
International Journal of Pediatric Otorhinolaryngology Extra 8 (2013) 122–124
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Mycobacterium abscessus infection of a cochlear implant insertion site Jason H. Anderson a,*, Thomas G. Boyce a,b,1, Nancy L. Wengenack c,1, Colin L.W. Driscoll d,1, Philip R. Fischer a,1 a
Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN, United States c Department of Clinical Microbiology, Mayo Clinic, Rochester, MN, United States d Department of Otolaryngology, Mayo Clinic, Rochester, MN, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 April 2013 Received in revised form 3 August 2013 Accepted 6 August 2013 Available online 16 August 2013
Infectious complications of cochlear implantation are unusual but can be severe, often requiring implant removal. We report a child who underwent cochlear implant revision and developed a post-operative infection with Mycobacterium abscessus complex. The patient’s symptoms were refractory to empiric antibacterial therapy. After more than 2 weeks incubation, M. abscessus complex grew in culture. Resolution of the infection was achieved utilizing prolonged multi-drug therapy and device removal with the intra-cochlear leads remaining in place. Clinical signs of an infectious process with concomitant sterile bacterial cultures should raise concern for a potential mycobacterial infection in association with cochlear implantation. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mycobacterium Abscessus Cochlear implant
1. Introduction Infectious complications of cochlear implantation can be severe and result in necessitated implant removal. The incidence of infectious complications is low, ranging between 0% and 8.2% depending on the study and peri-operative antibiotic administration, but it continues to be one of the leading complications of nondevice related cochlear implant failures [1–3]. Infectious complications of cochlear implantation include otitis media, meningitis, and surgical site infections. These complications may result in severe morbidity and mortality leading the American Academy of Pediatrics to release a policy statement regarding the prevention and management of infectious complications associated with cochlear implantation [4]. The most common organisms resulting in cochlear implant surgical site infections include Staphylococcus aureus, Pseudomonas aeruginosa, and coagulase negative Staphylococcus. Other organisms reported at a lower incidence include group A streptococcus, group G streptococcus, Alcaligenes xylosoxidans, Candida albicans, Klebsiella pneumoniae, Escherichia coli, and diphtheroids [3,5].
* Corresponding author at: 200 First Street, Mayo Clinic, Rochester, MN 55905, United States. Tel.: +1 507 284 5233; fax: +1 507 284 9744. E-mail addresses: [email protected], [email protected] (J.H. Anderson), [email protected] (T.G. Boyce), [email protected] (N.L. Wengenack), [email protected] (Colin L.W. Driscoll), [email protected] (P.R. Fischer). 1 200 First Street, Mayo Clinic, Rochester, MN 55905, United States. 1871-4048/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pedex.2013.08.001
We present what is, to our knowledge, the first reported nontuberculous mycobacteria (NTM) infection associated with cochlear prosthesis implantation. 2. Case report A 7-month-old male with a past medical history of bilateral sensorineural hearing loss secondary to Streptococcus pneumoniae meningitis was referred to our institution for evaluation of cochlear prosthesis implantation. Simultaneous bilateral cochlear implant placement was performed at 7 months of age utilizing a Nucleus Freedom CI512 cochlear implant in both ears. The surgery was uncomplicated and the patient made appropriate developmental progress. At 23 months of age, the patient’s right internal cochlear implant failed, requiring a revision. A Nucleus Freedom Cochlear Contour CI24RE device was implanted and a new electrode array was placed without difficulty for a full insertion. Subcutaneous tissue was packed around the cochleostomy. Intraoperative testing of the device was performed followed by closure of the postauricular incision. Intraoperative cefazolin was administered during the procedure. Four weeks after placement of this device, the patient developed a fever, firm swelling over the implant, erythema surrounding the incision site, and an opaque right middle ear effusion. He was admitted for right sided mastoiditis and acute otitis media and taken for postauricular wound exploration with debridement. Multiple cultures of the postauricular tissue and mastoid were obtained for bacteria, mycobacteria, and fungi.
J.H. Anderson et al. / International Journal of Pediatric Otorhinolaryngology Extra 8 (2013) 122–124
Extensive inflammatory tissue with a gray exudate was noted around the device and in the mastoid during the debridement. A right sided myringotomy with pressure equalizing tube placement was performed, and the middle ear effusion was aspirated for culture for bacteria, mycobacteria, and fungi. The incision was closed and intravenous antimicrobial therapy consisting of vancomycin and cefepime was initiated. The mastoid aspirate acid fast smear for mycobacteria was positive. Due to concern for a potential contaminant, it was repeated and remained positive raising concern for a potential mycobacterial infection. Subsequent Mycobacterium tuberculosis complex polymerase chain reaction was negative and the mastoid tissue acid fast smear was negative. He was discharged four days later on ceftriaxone to continue for three weeks for presumptive treatment of bacterial mastoiditis. Two weeks after discharge, the peri-auricular incision dehisced, revealing serosanguineous drainage. At this time, 16 days from ascertainment, the mastoid tissue and mastoid fluid aspirate cultures were positive for M. abscessus complex on Middlebrook 7H11 agar. The right cochlear implant was removed with resection of the electrodes in the fascial recess leaving the intra-cochlear aspect in place. Susceptibilities for the organism demonstrated resistance to doxycycline, ciprofloxacin, moxifloxacin, and tobramycin with intermediate resistance to cefoxitin and linezolid. The species was susceptible to tigecycline, clarithromycin, and amikacin; therefore, his antimicrobial regimen was initiated utilizing amikacin, clarithromycin, and cefoxitin. After 3 weeks, cefoxitin was discontinued due to medication-induced neutropenia. After 10 weeks, amikacin was discontinued. Due to the presence of the erm gene within the M. abscessus complex organism which may cause inducible resistance to clarithromycin, linezolid was added. Dual therapy with linezolid and clarithromycin was continued for 25 additional weeks. Revision was performed with removal of the existing electrode and uncomplicated implantation of a Nucleus Freedom CI422 after 33 weeks of antimicrobial therapy. The electrode was analyzed and demonstrated a negative acid fast smear with no growth documented after 45 days of incubation on Middlebrook 7H11 agar. The re-implantation was a success and the patient healed with no signs of persistent infection. In total the patient received 35 weeks of antimicrobial therapy. 3. Discussion To our knowledge, this is the first reported infection of a cochlear implant with nontuberculous mycobacteria. The resistant nature of this organism leads to a requirement for prolonged and directed anti-microbial therapy with removal of the device due to the severity of the infection and biofilm development. Traditionally, even during device removal, the electrodes are left in place to act as a stent and prevent cochlear ossification in the setting of the infection [5]. Fortunately, after debridement and prolonged antimicrobial administration, the patient did not require removal of the electrodes for clearance of the NTM infection and underwent successful reimplantation. The source of the infection remains unclear but there are multiple cases in the literature of NTM associated with other implant infections, specifically involving breast augmentation [6– 9], periocular and facial surgery [10,11], pacemaker implantation [12], and total knee arthroplasty [13,14]. M. abscessus complex has also been identified as an uncommon cause of chronic otitis media [15]. The organisms can be difficult to identify leading to delays in initiation of therapy. Furthermore, prolonged treatment courses and additional surgical interventions may be required due to biofilm development. As cited by Macadam et al., the median duration of antimicrobial therapy for patients identified with NTM infections status post breast augmentation was 22 weeks [8].
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Therefore, it is of the utmost importance for the surgical specialist to have a high index of suspicion for a potential NTM infection in patients who are refractory to initial therapy with sterile bacterial cultures. In our case, the surgeon had requested mycobacterial cultures with the initial debridement. Isolation of NTM may be obtained on several different media including chocolate agar and mycobacterial specific culture media such as Lowenstein-Jensen or Middlebrook 7H11. In the above case, if the surgeon had not requested these cultures it could have delayed therapy potentially compromising future attempts at reimplantation. The Infectious Diseases Society of America and American Thoracic Society have published recommendations regarding the diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases including infections with M. abscessus complex. It is recommended that patients receive 4–6 months of therapy for serious soft tissue and bone infections [16]. The duration of therapy for an infection with nontuberculous mycobacteria in the setting of a retained foreign body that cannot be completely removed has not been defined. Based on the susceptibility pattern showing limited treatment options and the retained electrodes, the antimicrobial course was extended to 9 months with successful eradication. The consequences of relapse in this case were more dire than usual and might have precluded further attempts at cochlear implantation on the side of the infection if therapy was unsuccessful. Antimicrobial selection for treatment of M. abscessus complex infections usually consists of oral clarithromycin or azithromycin combined with parenteral antimicrobial agents including amikacin, cefoxitin, or imipenem. Amikacin and cefoxitin are utilized until clinical improvement is evident [16]. Due to the need to discontinue cefoxitin secondary to medication induced neutropenia, amikacin administration was extended to 10 weeks with levels and toxicity labs monitored closely. The patient had no toxicity from amikacin that we identified. Clarithromycin would normally be continued as monotherapy thereafter but due to acquired mutational resistance, dual therapy with linezolid was utilized for this patient. Preventive measures to limit infectious complications must be performed in conjunction with cochlear implant placement. These include vaccination with pneumococcal conjugate vaccine (PCV13) followed by pneumococcal polysaccharide vaccine (PPV-23) and tympanostomy tube placement in otitis prone individuals [4]. Currently, there are no preventive measures available to limit NTM infections. The development of NTM infection is uncommon but the otorhinolaryngologist must remain vigilant to the possibility of this infectious etiology as prompt detection and aggressive surgical and medical management are the keys to effective treatment of these unusual infections. Ethical publication The authors confirm to have read the Journal’s publication on issues involved in ethical publication and affirm this report is consistent with those guidelines. Conflict of interest statement The authors of this manuscript have no conflict of interest including any financial, personal, academic or intellectual issues. Funding source No funding was utilized in the production of this manuscript.
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J.H. Anderson et al. / International Journal of Pediatric Otorhinolaryngology Extra 8 (2013) 122–124
References [1] N.L. Cohen, R.A. Hoffman, Complications of cochlear implant surgery in adults and children, Ann. Otol. Rhinol. Laryngol. 100 (1991) 708–711. [2] K.C. Yu, J.L. Hegarty, B.J. Gantz, A.K. Lalwani, Conservative management of infections in cochlear implant recipients, Otolaryngol. – Head Neck Surg. 125 (2001) 66–70. [3] M.T. Hopfenspirger, S.C. Levine, F.L. Rimell, Infectious complications in pediatric cochlear implants, Laryngoscope 117 (2007) 1825–1829. [4] L.G. Rubin, B. Papsin, Committee on infectious D, section on O-H, neck S, Cochlear implants in children: surgical site infections and prevention and treatment of acute otitis media and meningitis, Pediatrics 126 (2010) 381–391. [5] C.D. Cunningham 3rd, W.H. Slattery 3rd, W.M. Luxford, Postoperative infection in cochlear implant patients, Otolaryngol. – Head & Neck Surg. 131 (2004) 109–114. [6] M. Brickman, A.A. Parsa, F.D. Parsa, Mycobacterium cheloneae infection after breast augmentation, Aesthet. Plastic Surg. 29 (2005) 116–118. [7] E.M. Feldman, W. Ellsworth, E. Yuksel, S. Allen, Mycobacterium abscessus infection after breast augmentation: a case of contaminated implants? J. Plast. Reconstr. Aesthet. Surg. 62 (2009) e330–e332. [8] S.A. Macadam, B.M. Mehling, A. Fanning, J.A. Dufton, K.T. Kowalewska-Grochowska, P. Lennox, et al., Nontuberculous mycobacterial breast implant infections, Plastic Reconstr. Surg. 119 (2007) 337–344.
[9] M.C. Padoveze, C.M.C.B. Fortaleza, M.P. Freire, D. Brandao de Assis, G. Madalosso, A.C.G. Pellini, et al., Outbreak of surgical infection caused by nontuberculous mycobacteria in breast implants in Brazil, J. Hosp. Infect. 67 (2007) 161–167. [10] J.A. Mauriello Jr., Atypical mycobacterial study G, Atypical mycobacterial infection of the periocular region after periocular and facial surgery, Ophthal. Plast. Reconstr. Surg. 19 (2003) 182–188. [11] D. Zuercher, T. Malet, Mycobacterium abscessus infection in a case of recurrent orbital implant exposure, Orbit 26 (2007) 337–339. [12] M. Amin, J. Gross, C. Andrews, S. Furman, Pacemaker infection with Mycobacterium avium complex, Pacing Clin. Electrophysiol. 14 (1991) 152–154. [13] M. Pring, D.G. Eckhoff, Mycobacterium chelonae infection following a total knee arthroplasty, J. Arthroplasty 11 (1996) 115–116. [14] I. Cheung, A. Wilson, Mycobacterium fortuitum infection following total knee arthroplasty: a case report and literature review, Knee 15 (2008) 61–63. [15] J.J. Linmans, R.J. Stokroos, C.F. Linssen, Mycobacterium abscessus, an uncommon cause of chronic otitis media: a case report and literature review, Archiv. Otolaryngol. – Head Neck Surg. 134 (2008) 1004–1006. [16] D.E. Griffith, T. Aksamit, B.A. Brown-Elliott, A. Catanzaro, C. Daley, F. Gordin, et al., An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases, Am. J. Respir. Crit. Care Med. 175 (2007) 367–416.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology Extra journal homepage: www.elsevier.com/locate/ijporl
Case report
Mycobacterium abscessus infection of a cochlear implant insertion site Jason H. Anderson a,*, Thomas G. Boyce a,b,1, Nancy L. Wengenack c,1, Colin L.W. Driscoll d,1, Philip R. Fischer a,1 a
Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN, United States c Department of Clinical Microbiology, Mayo Clinic, Rochester, MN, United States d Department of Otolaryngology, Mayo Clinic, Rochester, MN, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 April 2013 Received in revised form 3 August 2013 Accepted 6 August 2013 Available online 16 August 2013
Infectious complications of cochlear implantation are unusual but can be severe, often requiring implant removal. We report a child who underwent cochlear implant revision and developed a post-operative infection with Mycobacterium abscessus complex. The patient’s symptoms were refractory to empiric antibacterial therapy. After more than 2 weeks incubation, M. abscessus complex grew in culture. Resolution of the infection was achieved utilizing prolonged multi-drug therapy and device removal with the intra-cochlear leads remaining in place. Clinical signs of an infectious process with concomitant sterile bacterial cultures should raise concern for a potential mycobacterial infection in association with cochlear implantation. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mycobacterium Abscessus Cochlear implant
1. Introduction Infectious complications of cochlear implantation can be severe and result in necessitated implant removal. The incidence of infectious complications is low, ranging between 0% and 8.2% depending on the study and peri-operative antibiotic administration, but it continues to be one of the leading complications of nondevice related cochlear implant failures [1–3]. Infectious complications of cochlear implantation include otitis media, meningitis, and surgical site infections. These complications may result in severe morbidity and mortality leading the American Academy of Pediatrics to release a policy statement regarding the prevention and management of infectious complications associated with cochlear implantation [4]. The most common organisms resulting in cochlear implant surgical site infections include Staphylococcus aureus, Pseudomonas aeruginosa, and coagulase negative Staphylococcus. Other organisms reported at a lower incidence include group A streptococcus, group G streptococcus, Alcaligenes xylosoxidans, Candida albicans, Klebsiella pneumoniae, Escherichia coli, and diphtheroids [3,5].
* Corresponding author at: 200 First Street, Mayo Clinic, Rochester, MN 55905, United States. Tel.: +1 507 284 5233; fax: +1 507 284 9744. E-mail addresses: [email protected], [email protected] (J.H. Anderson), [email protected] (T.G. Boyce), [email protected] (N.L. Wengenack), [email protected] (Colin L.W. Driscoll), [email protected] (P.R. Fischer). 1 200 First Street, Mayo Clinic, Rochester, MN 55905, United States. 1871-4048/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pedex.2013.08.001
We present what is, to our knowledge, the first reported nontuberculous mycobacteria (NTM) infection associated with cochlear prosthesis implantation. 2. Case report A 7-month-old male with a past medical history of bilateral sensorineural hearing loss secondary to Streptococcus pneumoniae meningitis was referred to our institution for evaluation of cochlear prosthesis implantation. Simultaneous bilateral cochlear implant placement was performed at 7 months of age utilizing a Nucleus Freedom CI512 cochlear implant in both ears. The surgery was uncomplicated and the patient made appropriate developmental progress. At 23 months of age, the patient’s right internal cochlear implant failed, requiring a revision. A Nucleus Freedom Cochlear Contour CI24RE device was implanted and a new electrode array was placed without difficulty for a full insertion. Subcutaneous tissue was packed around the cochleostomy. Intraoperative testing of the device was performed followed by closure of the postauricular incision. Intraoperative cefazolin was administered during the procedure. Four weeks after placement of this device, the patient developed a fever, firm swelling over the implant, erythema surrounding the incision site, and an opaque right middle ear effusion. He was admitted for right sided mastoiditis and acute otitis media and taken for postauricular wound exploration with debridement. Multiple cultures of the postauricular tissue and mastoid were obtained for bacteria, mycobacteria, and fungi.
J.H. Anderson et al. / International Journal of Pediatric Otorhinolaryngology Extra 8 (2013) 122–124
Extensive inflammatory tissue with a gray exudate was noted around the device and in the mastoid during the debridement. A right sided myringotomy with pressure equalizing tube placement was performed, and the middle ear effusion was aspirated for culture for bacteria, mycobacteria, and fungi. The incision was closed and intravenous antimicrobial therapy consisting of vancomycin and cefepime was initiated. The mastoid aspirate acid fast smear for mycobacteria was positive. Due to concern for a potential contaminant, it was repeated and remained positive raising concern for a potential mycobacterial infection. Subsequent Mycobacterium tuberculosis complex polymerase chain reaction was negative and the mastoid tissue acid fast smear was negative. He was discharged four days later on ceftriaxone to continue for three weeks for presumptive treatment of bacterial mastoiditis. Two weeks after discharge, the peri-auricular incision dehisced, revealing serosanguineous drainage. At this time, 16 days from ascertainment, the mastoid tissue and mastoid fluid aspirate cultures were positive for M. abscessus complex on Middlebrook 7H11 agar. The right cochlear implant was removed with resection of the electrodes in the fascial recess leaving the intra-cochlear aspect in place. Susceptibilities for the organism demonstrated resistance to doxycycline, ciprofloxacin, moxifloxacin, and tobramycin with intermediate resistance to cefoxitin and linezolid. The species was susceptible to tigecycline, clarithromycin, and amikacin; therefore, his antimicrobial regimen was initiated utilizing amikacin, clarithromycin, and cefoxitin. After 3 weeks, cefoxitin was discontinued due to medication-induced neutropenia. After 10 weeks, amikacin was discontinued. Due to the presence of the erm gene within the M. abscessus complex organism which may cause inducible resistance to clarithromycin, linezolid was added. Dual therapy with linezolid and clarithromycin was continued for 25 additional weeks. Revision was performed with removal of the existing electrode and uncomplicated implantation of a Nucleus Freedom CI422 after 33 weeks of antimicrobial therapy. The electrode was analyzed and demonstrated a negative acid fast smear with no growth documented after 45 days of incubation on Middlebrook 7H11 agar. The re-implantation was a success and the patient healed with no signs of persistent infection. In total the patient received 35 weeks of antimicrobial therapy. 3. Discussion To our knowledge, this is the first reported infection of a cochlear implant with nontuberculous mycobacteria. The resistant nature of this organism leads to a requirement for prolonged and directed anti-microbial therapy with removal of the device due to the severity of the infection and biofilm development. Traditionally, even during device removal, the electrodes are left in place to act as a stent and prevent cochlear ossification in the setting of the infection [5]. Fortunately, after debridement and prolonged antimicrobial administration, the patient did not require removal of the electrodes for clearance of the NTM infection and underwent successful reimplantation. The source of the infection remains unclear but there are multiple cases in the literature of NTM associated with other implant infections, specifically involving breast augmentation [6– 9], periocular and facial surgery [10,11], pacemaker implantation [12], and total knee arthroplasty [13,14]. M. abscessus complex has also been identified as an uncommon cause of chronic otitis media [15]. The organisms can be difficult to identify leading to delays in initiation of therapy. Furthermore, prolonged treatment courses and additional surgical interventions may be required due to biofilm development. As cited by Macadam et al., the median duration of antimicrobial therapy for patients identified with NTM infections status post breast augmentation was 22 weeks [8].
123
Therefore, it is of the utmost importance for the surgical specialist to have a high index of suspicion for a potential NTM infection in patients who are refractory to initial therapy with sterile bacterial cultures. In our case, the surgeon had requested mycobacterial cultures with the initial debridement. Isolation of NTM may be obtained on several different media including chocolate agar and mycobacterial specific culture media such as Lowenstein-Jensen or Middlebrook 7H11. In the above case, if the surgeon had not requested these cultures it could have delayed therapy potentially compromising future attempts at reimplantation. The Infectious Diseases Society of America and American Thoracic Society have published recommendations regarding the diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases including infections with M. abscessus complex. It is recommended that patients receive 4–6 months of therapy for serious soft tissue and bone infections [16]. The duration of therapy for an infection with nontuberculous mycobacteria in the setting of a retained foreign body that cannot be completely removed has not been defined. Based on the susceptibility pattern showing limited treatment options and the retained electrodes, the antimicrobial course was extended to 9 months with successful eradication. The consequences of relapse in this case were more dire than usual and might have precluded further attempts at cochlear implantation on the side of the infection if therapy was unsuccessful. Antimicrobial selection for treatment of M. abscessus complex infections usually consists of oral clarithromycin or azithromycin combined with parenteral antimicrobial agents including amikacin, cefoxitin, or imipenem. Amikacin and cefoxitin are utilized until clinical improvement is evident [16]. Due to the need to discontinue cefoxitin secondary to medication induced neutropenia, amikacin administration was extended to 10 weeks with levels and toxicity labs monitored closely. The patient had no toxicity from amikacin that we identified. Clarithromycin would normally be continued as monotherapy thereafter but due to acquired mutational resistance, dual therapy with linezolid was utilized for this patient. Preventive measures to limit infectious complications must be performed in conjunction with cochlear implant placement. These include vaccination with pneumococcal conjugate vaccine (PCV13) followed by pneumococcal polysaccharide vaccine (PPV-23) and tympanostomy tube placement in otitis prone individuals [4]. Currently, there are no preventive measures available to limit NTM infections. The development of NTM infection is uncommon but the otorhinolaryngologist must remain vigilant to the possibility of this infectious etiology as prompt detection and aggressive surgical and medical management are the keys to effective treatment of these unusual infections. Ethical publication The authors confirm to have read the Journal’s publication on issues involved in ethical publication and affirm this report is consistent with those guidelines. Conflict of interest statement The authors of this manuscript have no conflict of interest including any financial, personal, academic or intellectual issues. Funding source No funding was utilized in the production of this manuscript.
124
J.H. Anderson et al. / International Journal of Pediatric Otorhinolaryngology Extra 8 (2013) 122–124
References [1] N.L. Cohen, R.A. Hoffman, Complications of cochlear implant surgery in adults and children, Ann. Otol. Rhinol. Laryngol. 100 (1991) 708–711. [2] K.C. Yu, J.L. Hegarty, B.J. Gantz, A.K. Lalwani, Conservative management of infections in cochlear implant recipients, Otolaryngol. – Head Neck Surg. 125 (2001) 66–70. [3] M.T. Hopfenspirger, S.C. Levine, F.L. Rimell, Infectious complications in pediatric cochlear implants, Laryngoscope 117 (2007) 1825–1829. [4] L.G. Rubin, B. Papsin, Committee on infectious D, section on O-H, neck S, Cochlear implants in children: surgical site infections and prevention and treatment of acute otitis media and meningitis, Pediatrics 126 (2010) 381–391. [5] C.D. Cunningham 3rd, W.H. Slattery 3rd, W.M. Luxford, Postoperative infection in cochlear implant patients, Otolaryngol. – Head & Neck Surg. 131 (2004) 109–114. [6] M. Brickman, A.A. Parsa, F.D. Parsa, Mycobacterium cheloneae infection after breast augmentation, Aesthet. Plastic Surg. 29 (2005) 116–118. [7] E.M. Feldman, W. Ellsworth, E. Yuksel, S. Allen, Mycobacterium abscessus infection after breast augmentation: a case of contaminated implants? J. Plast. Reconstr. Aesthet. Surg. 62 (2009) e330–e332. [8] S.A. Macadam, B.M. Mehling, A. Fanning, J.A. Dufton, K.T. Kowalewska-Grochowska, P. Lennox, et al., Nontuberculous mycobacterial breast implant infections, Plastic Reconstr. Surg. 119 (2007) 337–344.
[9] M.C. Padoveze, C.M.C.B. Fortaleza, M.P. Freire, D. Brandao de Assis, G. Madalosso, A.C.G. Pellini, et al., Outbreak of surgical infection caused by nontuberculous mycobacteria in breast implants in Brazil, J. Hosp. Infect. 67 (2007) 161–167. [10] J.A. Mauriello Jr., Atypical mycobacterial study G, Atypical mycobacterial infection of the periocular region after periocular and facial surgery, Ophthal. Plast. Reconstr. Surg. 19 (2003) 182–188. [11] D. Zuercher, T. Malet, Mycobacterium abscessus infection in a case of recurrent orbital implant exposure, Orbit 26 (2007) 337–339. [12] M. Amin, J. Gross, C. Andrews, S. Furman, Pacemaker infection with Mycobacterium avium complex, Pacing Clin. Electrophysiol. 14 (1991) 152–154. [13] M. Pring, D.G. Eckhoff, Mycobacterium chelonae infection following a total knee arthroplasty, J. Arthroplasty 11 (1996) 115–116. [14] I. Cheung, A. Wilson, Mycobacterium fortuitum infection following total knee arthroplasty: a case report and literature review, Knee 15 (2008) 61–63. [15] J.J. Linmans, R.J. Stokroos, C.F. Linssen, Mycobacterium abscessus, an uncommon cause of chronic otitis media: a case report and literature review, Archiv. Otolaryngol. – Head Neck Surg. 134 (2008) 1004–1006. [16] D.E. Griffith, T. Aksamit, B.A. Brown-Elliott, A. Catanzaro, C. Daley, F. Gordin, et al., An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases, Am. J. Respir. Crit. Care Med. 175 (2007) 367–416.