the nontuberculous mycobacteria ( ntm ) represent an emerging and increasingly recognized etiology of skin and soft tissue infections associated with injections and minor surgical procedures in the united states . because these organisms require laboratory techniques other than the standard gram stain with aerobic and anaerobic culture and sensitivity for identification , and tend not to respond to courses of typical antibacterial agents effective against streptococci and staphylococci , delay in diagnosis and appropriate antimicrobial management may occur . the purpose of this review is to highlight the typical mycobacteria that are causative of infections associated with more common cosmetic procedures , and to describe methods of identification and best treatment practices . the ntm group of organisms consists of more than 125 species , defined as mycobacteria species other than m. tuberculosis and m. leprae . tap water is the primary reservoir for human transmission , but ntm are also found in soil , animals , vegetable matter , and birds ( mandell et al . , 2009 ) . there have been no documented cases of human - to - human or animal - to - human transmission . an abnormal immune system , involving , for example , a decline in cd4  + t cell count or macrophage dysfunction , is prone to ntm infection . similar to other intracellular pathogens , ntm are phagocytized and killed by normal functioning macrophages in response to ifn -  production , up - regulated by interleukin-12 ( il-12 ) . as such , deficiencies or abnormalities in this positive feedback loop , acquired or genetic , increase the risk of ntm infections ( griffith et al . , 2007 ) . tumor necrosis factor  ( tnf ) plays a critical role in control of infection by intracellular organisms , as evidenced by well - documented risk of reactivation tuberculosis in patients receiving tnf inhibitor therapy ( keane , 2004 ) . ifn -  and il-12 control mycobacteria through the up - regulation tnf  , made predominantly by monocytes / macrophages . an increased risk of ntm infections is therefore theoretically plausible during tnf inhibitor therapy , and most experts recommend treating and controlling known ntm infections in this setting . the most common clinical manifestations of ntm infection in the united states include pulmonary disease , lymphatic disease , skin and soft tissue infections , and disseminated disease . mycobacterium avium complex ( mac ) , m. fortuitum , and m. kansasii are the most common isolates in the us , with reports of all three most common in the southeastern united states ( griffith et al . , 2007 ) . the incidence of ntm infections related to cosmetic procedures is on the rise and increasingly becoming a public health concern . ntm have been recently implicated in skin and soft tissue infections following pedicure , mesotherapy , laser resurfacing , breast augmentation , tattoos , implants and fillers , body piercings , liposuction , mohs micrographic surgery , punch biopsies , and injections . mycobacteria are aerobic , non - motile , acid - fast bacilli , in that they have the ability to retain dyes after washing of alcohol decolorization . ntm are classified into ( 1 ) rapid growing mycobacteria ( rgm ) with subsets of pigmented and nonpigmented organisms , which form mature colonies on culture in less than 7 days ; ( 2 ) slow - growing mycobacteria with subsets of nonchromogens ( do not produce pigment ) , scotochromogens ( produce pigment in the absence of light ) and photochromogens ( produce yellow pigment with light exposure ) , which form mature colonies on culture in more than 7 days ( table  1 ) . we will focus primarily on the organisms that most commonly cause skin and soft tissue infections in the united states : m. abscessus , m. fortuitum and m. chelonae . in terms of specimen collection for laboratory evaluation , potential sources of contamination , such as tap water , aseptic collection of as much fluid as possible by needle aspiration or surgical procedures is recommended . swabs are not recommended for sample collection because they often result in limited culture material , decreasing chances for recovery of ntm . in many cases , the ntm , especially the rgm , may be more sensitive to the afb decolorization procedure and may not stain at all with fluorochrome stains , so negative smears do not necessarily mean that ntm , especially rgm , are not present in a clinical sample ( griffith et al . histopathology of tissue specimens obtained from skin biopsy may yield additional helpful information , as certain morphological characteristics , such as granulomatous changes , lymphohistiocytic infiltrate , as well as special stains for afb may indicate mycobacterial infection . however , culture would still be necessary to identify a specific organism and determine specific antimicrobial susceptibility ( see below ) ( drage et al . , 2010 ) . the optimal temperature for most cultures for ntm is between 28 and 37c with rare exception ( m. haemophilum , m. ulcerans ) . all skin , joint fluid , and bone specimens should be cultured at 28 to 30c and at 35 to 37c ( tortoli , 2003 ) . there has been a significant surge in popularity of cosmetic procedures in recent years . according to the american society for aesthetic plastic surgery ( http://www.surgery.org/ ) , in 2011 alone , approximately 9 million non - surgical and surgical cosmetic procedures , most commonly botulinum toxin and liposuction ( 2.6 million and 325,332 procedures , respectively ) were performed . the reported increased incidence of cutaneous ntm infections over the last few decades is likely to be associated with higher demand for and more frequent performance of cosmetic procedures  ( wentworth et al . , 2013 ) . rgm , in particular m. chelonae , m. fortuitum and m. abscessus have been commonly reported as causative of skin and soft tissue infections ( sstis ) related to non - surgical cosmetic procedures including tattoos , permanent eyebrow makeup , dermal fillers , laser resurfacing and mesotherapy . infections related to surgical cosmetic procedures such as liposuction , breast augmentation , mohs surgery , and facelifts have also been reported , as well as pedicure and foot bath related infections . permanent tattoos are created by intradermal injection of imperishable ink , which is dispersed throughout the epidermis and upper dermis . the manipulation of the skin barrier and the presence of pigment activate the immune system to phagocytize the pigment , producing the image . the number of adults with one or more tattoos in the us has increased from 14% in 2008 to 21% in 2012 ( leblanc et al . , 2012 ) . multiple reports across western europe , australia , and the us of ntm have surfaced as causes of tattoo - associated skin and soft tissue infections ( atkins and gottlieb , 2014 ) , which has prompted numerous investigations by the food and drug administration ( fda ) . one of the first such reports , published online in 2009 , documents an outbreak of m. chelonae in 6 patients who had received tattoos at a single establishment ; diagnosis of ntm was delayed in all 6 cases , and no clear source was identified ( inks , soaps , water were culture negative ) ( drage et al . , 2010 ) . in january 2012 , 19 individuals were reported in rochester , new york , who presented with persistent red papules on the gray areas of tattoos within 3 weeks of acquiring the tattoo ( kennedy et al . , 2012 ) . there were 14 confirmed cases of m. chelonae tattoo associated infections in monroe county new york and 1 confirmed case of m. abscessus tattoo associated infection reported in colorado ( centers for disease control and prevention , 2012 ) . the fda investigated many of these reported cases and discovered that the inks contained mycobacteria , contaminated during manufacturing of black or grey inks or when the inks were diluted with tap water . the fact that tattoo artists and establishments in many communities are not subject to mandatory health inspections and that the ink and tattoo equipment do not require fda approval , may contribute to the increase in the incidence of tattoo related sstis . the cdc now recommends that all tattoo inks to be manufactured or diluted with sterile water only . twelve cases of m. haemophilum - associated skin lesions of the eyebrows and ipsilateral cervical lymphadenopathy associated with permanent eyebrow makeup procedure were reported in switzerland in 2009 ( giulieri et al . , 2011 ) . in addition , m. haemophilum was confirmed as the causative organism in 2 patients who presented with nodular lesions of the eyebrows where permanent makeup had been applied ( wollina , 2011 ) . injection of dermal fillers such as silicone , collagen , and hyaluronic acid into the face has become increasingly popular to decrease the appearance of wrinkles . the first 3 cases of m. chelonae skin and soft tissue infections associated with dermal injections were confirmed in oregon in 2008 . the clinic 's water supply was identified as the source of the isolates ( rodriguez et al . , 2013 ) . one case report describes the development of multiple erythematous papules and pustules diffusely over the face , neck , and chest 2 weeks after undergoing laser resurfacing . the patient developed painful pustular lesions on her neck 9 days after the procedure , and m. chelonae was identified ( culton et al . , 2013 ) . mesotherapy is a technique that involves injection of plant extracts , homeopathic agents , pharmaceuticals , vitamins , and other bioactive substances into the dermis and subcutaneous tissue for the purposes of weight loss and cellulite reduction . ntm infections associated with mesotherapy have been linked to contaminated material being injected by non - physicians ( sanudo et al . , 2007 ) . eleven cases of m. chelonae - related erythematous , tender , subcutaneous draining nodules at the injection site were reported in 20062007 ( regnier et al . , 2009 ) . five cases of m. chelonae were reported in colombia during 20042005 , in which patients presented with localized skin lesions to the area of mesotherapy ( sanudo et al . , 2007 ) . in 2001 , 3 cases were reported because they developed painful nodules after receiving mesotherapy caused by m. fortuitum in spain ( nagore et al . , 2001 ) . m. abscessus has also been implicated in skin infections after mesotherapy in 17 otherwise healthy subjects in 2009 in spain ( galmes - truyols et al . , 2011 ) and 3 patients in thailand in 2011 ( wongkitisophon et al . , 2011 ) . in 2005 , virginia department of health and the cdc investigated and outbreak of skin lesions unresponsive to antimicrobial therapy patients who receive mesotherapy by a non - licensed practitioner in the district of columbia . m. chelonae and m. haemophilum were both identified as the causative isolates ( centers for disease control and prevention , 2005 ) . thirty four cases of cutaneous abscesses within 6 months after undergoing liposuction by a single practitioner caused by m. chelonae were reported in 2002 ( meyers et al . , 2002 ) . two cases of m. fortuitum associated sstis presenting with recurrent abscesses following abdominal plastic surgery and liposuction were reported in france in 2008 ( regnier et al . , 2008 ) . additionally , more recent cases of recurrent abdominal abscesses following abdominoplasty and liposuction have been reported ( bax et al . , 2014 , kim and mascola , 2010 ) . a case of m. abscessus infection presented as multiple erythematous papules post - mohs procedure  ( fisher and gloster , 2005 ) . in 2003 , the new jersey department of health and senior services investigated 8 cases of m.chelonae ssti following facelift procedures  ( centers for disease control and prevention , 2004 ) . m. fortuitum ssti following a bilateral facelift presenting with a maxillary nodule was also reported ( angeli et al . , 2004 ) . the use of contaminated gentian violet , a marking solution , has been associated to many surgical site infections following facelifts and blepharoplasty ( murillo et al . , 2000 ) . breast augmentations are performed frequently for either cosmetic or reconstructive purposes ( vinh et al . , 2006 ) . infections following breast augmentation are rare , with a risk of 13% ( feldman et al . , 2009 , heistein et al . , 2000 ) . infections are most commonly due to normal skin flora and infrequently due to mycobacteria ( heistein et al . , 2000 ) . cases of m. fortuitum related wound infection post breast implant placement were described ( lizaso et al . , 2011 , vinh et al . , 2006 ) . two cases of m. fortuitum and 1 case of m. chelonae breast infections after bilateral reduction mammoplasty were documented ( boettcher et al . , 2010 ) . multiple pedicure - associated ntm infection , referred to as furunculosis , most commonly due to rgm , have been registered within the united states . an outbreak in north carolina during 20052008 , involving 40 cases of pedicure - associated furunculosis due to m. fortuitum , m. abscessus , m. bolletii , and m. chelonae , presenting with pustules , plaques , nodules , pustules persisting on the lower extremities ( stout et al . , 2011 ) . the outbreak was linked to mycobacteria present in the biofilm in the foot baths and water intake pipes . a common finding identified among infected individuals was recent shaving of legs prior to the pedicure . in california during 2000 , a large outbreak was identified , consisting of 110 cases of pedicure - associated furunculosis caused by m. fortuitum , associated with suboptimal cleaning practices of pedicure foot baths at a single nail salon ( stout et al . , 2011 ) . as discussed previously , species identification and antimicrobial susceptibility testing is critical in the management of patients with skin and soft tissue infections caused by ntm . degrees of susceptibility to oral agents vary by ntm species , and prolonged combination therapy is frequently indicated , particularly in cases of severe , deeper seated infections . for serious skin and soft tissue disease caused by rapid growers , including m. abscessus , chelonae , and fortuitum , a minimum of 4 months of combination therapy is likely necessary , with consideration of longer durations when bone is involved ( griffith et al . , 2007 ) . surgical debridement and removal of infected foreign material should always be pursued in conjunction with antimicrobial therapy when feasible , to maximize the chances of cure . inherently resistant to standard antituberculous agents , m. abscessus has emerged as one of the most difficult ntm to manage with antimicrobial therapy . m. abscessus may also acquire resistance to certain agents , for example , via induction of the erm gene ( erythromycin methylase ) conferring resistance to macrolides ( atkins and gottlieb , 2014 , choi et al . the macrolides are the most reliably active oral agents for the treatment of m. abscessus infections , although increasing consideration is given to oxazolidinones , such as linezolid , which may also manifest low mics . as such , combination therapy with parenteral agents is usually appropriate , specifically with amikacin , the most reliably active parenteral agent , plus one or more others ( griffith et al . , 2007 ) . . it may be reasonable to deescalate to an oral regimen after initial combination therapy for several weeks , if there is clear evidence of clinical improvement . given relatively high rates of relapse , however , this strategy must be undertaken with extreme caution ( atkins and gottlieb , 2014 , regnier et al . , 2009 , van dissel and kuijper , 2009 ) . relatively less resistant to antimicrobials than m. abscessus , m. chelonae demonstrates frequent susceptibility to clarithromycin , tobramycin , imipenem , and linezolid , and is uniformly resistant to cefoxitin . in general , among the aminoglycosides , tobramycin exhibits more in vitro activity than amikacin ( griffith et al . , 2007 ) . m. fortuitum is generally regarded as less resistant to antimicrobial agents , and therefore , easier to treat than other rapid growers . although appropriate therapeutic regimens should still be based upon in vitro susceptibility testing results , the organism is generally sensitive to a variety of agents , both oral and parenteral , including clarithromycin , cefoxitin , imipenem , amikacin , doxycycline , and trimethoprim / sulfamethoxazole ( lim et al . , 2012 ) . in vitro susceptibility to clarithromycin must be interpreted with caution , however , given the ability of the m. fortuitum to express the erm gene ( griffith et al . , 2007 ) . susceptibility data for other species of ntm , such as m. hemophilum are limited and tend to lack standardization , making interpretation of results a challenge . this reinforces the need to obtain minimum inhibitory concentrations for individual clinical isolates to best guide therapeutic choices . variability in susceptibilities to antimicrobial agents among different ntm species has generated interest in identifying appropriate salvage regimens for the treatment of these infections . tigecycline is a glycylcycline antibiotic with broad spectrum antimicrobial activity against both gram positive and gram negative organisms . structurally related to tetracyclines , it reportedly has good activity against ntm in vitro ( huang et al . , 2013 , wallace et al . , 2014 ) . tigecycline was tested for synergistic effect with clarithromycin and amikacin in isolates of rapid growers , showing in vitro synergy with clarithromycin and antagonism with amikacin ( huang et al . , 2013 ) . a clinical study of 52 patients with rapid grower ntm infections of the lung and skin / soft tissue / bone resulted in 48% overall clinical improvement with tigecycline - based salvage therapy , with significant numbers discontinuing prematurely due to adverse events ( wallace et al . , toxicities of antimicrobial agents commonly used to treat ntm infections of the skin and soft tissues are well known and summarized in table  2 . the last several years have witnessed a surge in medical tourism and interest in cosmetic and aesthetic procedures on a global scale . taken together with inconsistent infection control procedures in different practice settings , these circumstances dictate a heightened awareness and suspicion for skin and soft tissue infections caused by the ntm . the complexities and idiosyncrasies in diagnosis and treatment require communication between specialists in infectious diseases , dermatology , surgery , and lab medicine , in order to appropriately manage these infections . more stringent regulation and monitoring of procedures and products labeled as  cosmetics  going forward will help reduce baseline rates of these infections and prevent future outbreaks .
interest in surgical and non - surgical cosmetic procedures has increased significantly over the last few decades . 
 billions of dollars are spent on these procedures annually . although the associated risk is generally low , multiple cases of skin and soft tissue infections have been reported . 
 nontuberculous mycobacteria ( ntm ) , in particular m. chelonae , m. fortuitum , and m. abscessus , have been increasingly identified as causative of numerous cosmetic procedure  related infections worldwide . 
 this has therefore become a public health concern . 
 delays in diagnosis and appropriate management may occur given subtleties in diagnostic methods . 
 the purpose of this review is to highlight the ntm - related skin and soft tissue infections associated with more common cosmetic procedures , describe methods of identification , and outline best treatment practices .