{
 "id": "nontuberculous-mycobacteria",
 "names": {
  "name": "Nontuberculous mycobacteria",
  "aliases": [
   "NTM",
   "rapidly growing mycobacteria",
   "Mycobacterium abscessus"
  ],
  "said": "The first culture comes back negative, because the organism grows too slowly for a standard plate."
 },
 "region": [
  "global",
  "caribbean"
 ],
 "facets": {
  "kind": "infection"
 },
 "text": {
  "what": "Environmental mycobacteria that live in water and soil, are not tuberculosis, resist most ordinary antibiotics, and infect surgical wounds where instruments, rinse water or injectables were contaminated. The CDC names the resulting outbreak in its medical travel chapter: \"surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic\".",
  "story": "The first cluster began with two Maryland residents in 2013 whose surgical sites would not respond to treatment after cosmetic procedures at one Dominican clinic. The multistate investigation that followed identified 21 case-patients in 6 states who had been operated on at one of 5 clinics, 13 of them — 62% — at the same one. Isolates from 12 of those patients, 92%, grew Mycobacterium abscessus complex.\n\nWhat the same investigation recorded about treatment is the part worth carrying. Of 9 case-patients from that clinic with data available, all required therapeutic surgical intervention, 8 were hospitalised, and 7 needed three months or more of antibacterial therapy. The report notes incomplete information on the financial burden, with some patients experiencing insurance claim denials and lost wages.\n\nIt happened again. In 2018 the CDC reported a second Dominican cluster: 52 patients reported, 38 meeting the confirmed case definition, with surgery between 4 January and 14 July 2017. Twenty-six of 32 confirmed cases with information available had been treated at one centre, Centro Internacional de Cirugía Plástica Avanzada; 14 surgeons at seven surgical centres were identified in total. Fourteen of 15 with treatment information required therapeutic surgical procedures after returning to the United States. One death was reported.\n\nA 2023 systematic review of 44 studies covering 589 patients who presented with complications after cosmetic surgery abroad found that 98% of the infectious organisms were bacterial and 81% of those were from the genus Mycobacterium.\n\n*Inference —* the organism is not exotic, and the pattern is not about a country. It is about water and instrument reprocessing in high-volume elective surgery, which is a procurement and engineering question rather than a surgical one, and which no accreditation logo on a website discloses.",
  "how": "These infections declare themselves late, over weeks rather than days, as painless or mildly painful nodules and non-healing wounds that do not respond to standard antibiotics. Diagnosis needs the laboratory to be told to look: standard cultures may be reported negative because the organism grows slowly. Treatment is multi-drug, months long, frequently intravenous, and usually requires the wound to be opened and debrided more than once.",
  "today": "As of 16 September 2026 the two Dominican investigations remain the best-documented clusters, at 21 and 38 confirmed cases respectively, and they are counts of people who presented in the United States rather than rates for any clinic or any country."
 },
 "metrics": {
  "note": "From the 2013-2014 investigation: 21 case-patients in 6 US states operated on at 5 Dominican clinics, 13 of them at one clinic; Mycobacterium abscessus complex in 12 of 13 isolates tested; of 9 patients from that clinic with data, all required therapeutic surgery, 8 were hospitalised and 7 needed three months or more of antibacterial therapy. From the 2017 cluster: 52 patients reported, 38 confirmed, 1 death, 14 of 15 with data requiring surgery after returning. Case counts, not rates.",
  "as_of": "2016",
  "source": "s:eid-dr-mycobacteria-2016",
  "url": "https://wwwnc.cdc.gov/eid/article/22/8/15-1938_article"
 },
 "kin": [
  {
   "to": "dominican-republic-ntm-outbreak",
   "as": "The investigations themselves, with their clinics and dates.",
   "rel": "event"
  },
  {
   "to": "dominican-republic",
   "as": "Where both clusters were traced to.",
   "rel": "place"
  },
  {
   "to": "santo-domingo",
   "as": "The city the named clinics operated in.",
   "rel": "place"
  },
  {
   "to": "surgical-site-infection",
   "as": "The general case this is the hardest version of.",
   "rel": "whole"
  },
  {
   "to": "antimicrobial-resistance",
   "as": "Resistant by nature rather than by acquisition, which is why the courses run months.",
   "rel": "kin"
  },
  {
   "to": "bbl",
   "as": "Among the cosmetic procedures the case-patients had travelled for.",
   "rel": "procedure"
  },
  {
   "to": "liposuction",
   "as": "Among the procedures in both Dominican clusters.",
   "rel": "procedure"
  },
  {
   "to": "abdominoplasty",
   "as": "Among the procedures in both Dominican clusters.",
   "rel": "procedure"
  },
  {
   "to": "revision-at-home",
   "as": "All of the documented cases needed further surgery after returning.",
   "rel": "kin"
  },
  {
   "to": "follow-up-gap",
   "as": "Weeks-long incubation means the first clinician to see it is always at home.",
   "rel": "kin"
  }
 ],
 "links": [
  {
   "label": "Emerging Infectious Diseases 2016 — multistate outbreak, Dominican Republic 2013-2014",
   "url": "https://wwwnc.cdc.gov/eid/article/22/8/15-1938_article"
  },
  {
   "label": "MMWR 2018 — Notes from the Field, Dominican Republic 2017",
   "url": "https://www.cdc.gov/mmwr/volumes/67/wr/mm6712a5.htm"
  }
 ],
 "sources": [
  "s:eid-dr-mycobacteria-2016",
  "s:mmwr-dr-mycobacteria-2018",
  "s:alkaelani-aesthetic-review-2023",
  "s:cdc-yellowbook-2026-medical-tourism",
  "s:cdc-yellowbook-medical-tourism"
 ],
 "provenance": {
  "default": {
   "tier": "cited",
   "source": "s:eid-dr-mycobacteria-2016"
  },
  "fields": {
   "text.story": {
    "tier": "cited",
    "note": "the closing paragraph is marked inline as this project's reading"
   },
   "text.how": {
    "tier": "tradition",
    "note": "the clinical and laboratory account is general knowledge of the organism; the case numbers are cited"
   }
  }
 },
 "confidence": "high",
 "schema": 1,
 "type": "risk",
 "updated": "2026-09-16",
 "blurb": "Environmental mycobacteria that live in water and soil, are not tuberculosis, resist most ordinary antibiotics, and infect surgical wounds where instruments, rinse water or injectables were contaminated.",
 "region_terms": [
  {
   "key": "global",
   "name": "Everywhere",
   "note": "use for a node that belongs to no one country — a standard, a word, a risk"
  },
  {
   "key": "caribbean",
   "name": "The Caribbean",
   "note": "the Dominican Republic, Cuba, Barbados, the Caymans"
  }
 ],
 "kin_out": [
  {
   "to": "dominican-republic-ntm-outbreak",
   "type": "event",
   "name": "The Dominican mycobacterial outbreaks, 2013–14 and 2017",
   "as": "The investigations themselves, with their clinics and dates.",
   "rel": "event"
  },
  {
   "to": "dominican-republic",
   "type": "destination",
   "name": "Dominican Republic",
   "as": "Where both clusters were traced to.",
   "rel": "place"
  },
  {
   "to": "santo-domingo",
   "type": "hub",
   "name": "Santo Domingo",
   "as": "The city the named clinics operated in.",
   "rel": "place"
  },
  {
   "to": "surgical-site-infection",
   "type": "risk",
   "name": "Surgical site infection",
   "as": "The general case this is the hardest version of.",
   "rel": "whole"
  },
  {
   "to": "antimicrobial-resistance",
   "type": "risk",
   "name": "Antimicrobial resistance acquired abroad",
   "as": "Resistant by nature rather than by acquisition, which is why the courses run months.",
   "rel": "kin"
  },
  {
   "to": "bbl",
   "type": "procedure",
   "name": "Gluteal fat grafting",
   "as": "Among the cosmetic procedures the case-patients had travelled for.",
   "rel": "procedure"
  },
  {
   "to": "liposuction",
   "type": "procedure",
   "name": "Liposuction",
   "as": "Among the procedures in both Dominican clusters.",
   "rel": "procedure"
  },
  {
   "to": "abdominoplasty",
   "type": "procedure",
   "name": "Abdominoplasty",
   "as": "Among the procedures in both Dominican clusters.",
   "rel": "procedure"
  },
  {
   "to": "revision-at-home",
   "type": "risk",
   "name": "Revision at home",
   "as": "All of the documented cases needed further surgery after returning.",
   "rel": "kin"
  },
  {
   "to": "follow-up-gap",
   "type": "risk",
   "name": "The follow-up gap",
   "as": "Weeks-long incubation means the first clinician to see it is always at home.",
   "rel": "kin"
  }
 ],
 "source_list": [
  {
   "id": "s:eid-dr-mycobacteria-2016",
   "kind": "paper",
   "title": "Multistate US Outbreak of Rapidly Growing Mycobacterial Infections Associated with Medical Tourism to the Dominican Republic, 2013-2014",
   "publisher": "Emerging Infectious Diseases 2016;22(8), US Centers for Disease Control and Prevention",
   "url": "https://wwwnc.cdc.gov/eid/article/22/8/15-1938_article",
   "accessed": "2026-09-16"
  },
  {
   "id": "s:mmwr-dr-mycobacteria-2018",
   "kind": "org",
   "title": "Notes from the Field: Nontuberculous Mycobacteria Infections in U.S. Medical Tourists Associated with Plastic Surgery — Dominican Republic, 2017",
   "publisher": "Morbidity and Mortality Weekly Report 2018;67(12), US Centers for Disease Control and Prevention",
   "url": "https://www.cdc.gov/mmwr/volumes/67/wr/mm6712a5.htm",
   "accessed": "2026-09-16"
  },
  {
   "id": "s:alkaelani-aesthetic-review-2023",
   "kind": "paper",
   "title": "Complications of Medical Tourism in Aesthetic Surgery: A Systematic Review",
   "publisher": "Annals of Plastic Surgery 2023;91(6):668-673 (Alkaelani MT, Koussayer B, Blount T, et al.)",
   "url": "https://pubmed.ncbi.nlm.nih.gov/37962261/",
   "accessed": "2026-09-16"
  },
  {
   "id": "s:cdc-yellowbook-2026-medical-tourism",
   "kind": "org",
   "title": "Medical Tourism — CDC Yellow Book 2026, chapter by Rhett J. Stoney and Laura Leidel, page dated 23 April 2025",
   "publisher": "US Centers for Disease Control and Prevention",
   "url": "https://www.cdc.gov/yellow-book/hcp/health-care-abroad/medical-tourism.html",
   "accessed": "2026-09-16",
   "note": "the 2026 edition of the chapter registered as s:cdc-yellowbook-medical-tourism, read in full at the URL above; the named outbreaks, the pathogen list and the ten-day flying rule are quoted from this page"
  },
  {
   "id": "s:cdc-yellowbook-medical-tourism",
   "kind": "org",
   "title": "Medical Tourism — CDC Yellow Book: Health Information for International Travel",
   "publisher": "US Centers for Disease Control and Prevention",
   "url": "https://wwwnc.cdc.gov/travel/yellowbook/2024/health-care-abroad/medical-tourism",
   "accessed": "2026-09-16",
   "note": "the standing public-health account of what travelling for treatment involves and what goes wrong"
  }
 ],
 "tiers": {
  "text.what": {
   "tier": "cited",
   "source": "s:eid-dr-mycobacteria-2016"
  },
  "text.story": {
   "tier": "cited",
   "note": "the closing paragraph is marked inline as this project's reading"
  },
  "text.how": {
   "tier": "tradition",
   "note": "the clinical and laboratory account is general knowledge of the organism; the case numbers are cited"
  },
  "text.today": {
   "tier": "cited",
   "source": "s:eid-dr-mycobacteria-2016"
  },
  "metrics": {
   "tier": "cited",
   "source": "s:eid-dr-mycobacteria-2016"
  }
 },
 "primary_image": null,
 "tag_facts": [],
 "recognition_facts": [],
 "acclaim": 0,
 "kin_in": [
  {
   "from": "dominican-republic",
   "type": "destination",
   "name": "Dominican Republic",
   "as": "The organism that made this country a case study.",
   "rel": "risk"
  },
  {
   "from": "santo-domingo",
   "type": "hub",
   "name": "Santo Domingo",
   "as": "The organism that made this city a case study, twice, four years apart.",
   "rel": "risk"
  },
  {
   "from": "antimicrobial-resistance",
   "type": "risk",
   "name": "Antimicrobial resistance acquired abroad",
   "as": "Already resistant by nature, and the reason those wounds took three months of therapy.",
   "rel": "kin"
  },
  {
   "from": "bbl-mortality",
   "type": "risk",
   "name": "Death from gluteal fat grafting",
   "as": "What the survivors of the Dominican clusters had come for.",
   "rel": "kin"
  },
  {
   "from": "surgical-site-infection",
   "type": "risk",
   "name": "Surgical site infection",
   "as": "The organism behind the best-documented cluster of these infections in cosmetic surgery patients returning from abroad.",
   "rel": "kin"
  },
  {
   "from": "dominican-republic-ntm-outbreak",
   "type": "event",
   "name": "The Dominican mycobacterial outbreaks, 2013–14 and 2017",
   "as": "The organism, and why water and solutions are where it comes from.",
   "rel": "risk"
  }
 ]
}