Investigators indicate that at least three liposuction infections that occurred last year at the Monarch Medspa clinic in Timonium, Maryland were probably caused by dirty equipment, but also said that the infections could have been passed to patients by two staff members.
The infections occurred in September 2012 at the Monarch Medspa in Baltimore County, Maryland. One of the patients, Eula Witherspoon, died just days after her surgery. The death lead to an investigation, the results of which were announced this month.
Investigators found “visibly dirty equipment, no separation of clean and dirty areas for equipment sterilization, a clogged sink in the liposuction procedure room with debris and liquid leaking onto surgical supplies stored underneath” and other problems, like expired supplies on shelves and unlabeled, opened vials of lidocaine, according to the final report (PDF) issued by the Maryland Department of Health and Mental Hygiene (DHMH). The facility was shut down and has not reopened.
The 31-page report also notes that it is possible the Monarch Medspa infections occurred because at least two workers were found to be carrying the same bacteria that infected the patients. Doctors and nurses at Monarch did not always wear gloves during procedures, the state investigation found. Whether the bacteria was spread through the equipment or from staff will likely never be known, according to the state’s report.
All three confirmed victims were women and all contracted severe invasive Group-A Streptococcus infections. A fourth suspect case was not confirmed.
The ailment is usually associated with strep throat, but can cause more dangerous infections when it invades other parts of the body.
The doctor that performed the liposuction procedures and a nurse were found carrying the same strain and the doctor reported that he self-treated himself for a hand infection the month before the outbreak and did not come into work for five days at that time.
Due to Marland laws in place at the time, the facility was virtually unregulated. However, a new law resulting from the outbreak goes into effect on October 1, which gives DHMH more authority over similar medical spas.
According to the state report, there were more than 200,000 liposuction procedures performed in the U.S. in 2012. Complications occur in between 0.1% and 0.5% of all liposuction procedures, resulting in one death out of every 5,000 liposuction operations. In addition to infections, liposuction health risks can include perforation, pulmonary or arterial embolism, cardiac arrest, hemorrhage, shock, pulmonary edema, and sepsis.