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Poor infection control likely led to infections in medspas, study says

An outbreak of group A Streptococcus infections at weight loss clinics in Maryland and Delaware in 2012 was probably caused by poor infection control practices on the part of the staff, according to a new study.

All of the patients — including a 59-year-old Lochearn woman who died — had undergone liposuction, in which doctors suction excess fat out of the body using special surgical equipment.


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

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


Morgan was not involved in the analysis but wrote an accompanying commentary in JAMA Internal Medicine about the lack of patient protections in outpatient cosmetic surgery. He said in an interview that the major risks from liposuction are infection or accidental overdose of lidocaine.

The study mirrors finding of a state report completed in September.

The outbreak also led to legislation passed last year in the Maryland General Assembly that gives health regulators more oversight of such facilities, which are less scrutinized because patients pay out of their pockets rather than billing private or government insurers.

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

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

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

The strep bacteria can cause mild infections or a sore throat, but invasive infections can also cause pneumonia or toxic shock syndrome, which can be fatal. The patients in all four confirmed cases were hospitalized for an average of 19 days.

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


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

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

The Maryland facility was closed by health officials and has not reopened. Monarch could not be reached for comment. A phone number on its website no longer works.

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Breast augmentation and liposuction are the most common cosmetic surgeries in the United States, the study authors wrote, with 300,000 liposuction procedures performed by board-certified specialists in 2012. Non-specialists can perform lipo, without anesthesia and in outpatient facilities like these medical spas, they noted.

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

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


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

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

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

Baltimore Sun reporter Meredith Cohn and Reuters contributed to this article.