Our study identified 30 patients who were seen by our department due to complications from cosmetic tourism during the 15-month study time frame. Of these patients, 93.3% were female (n = 28), 6.6% were male (n = 2), and the mean age was 40.54 years (SD 10.8). The geographic distribution of original procedures is illustrated in Fig. 1, with Turkey being the most common destination (n = 20), followed by Lithuania (n = 8), while Germany and Kuwait each accounted for a single patient. Twelve patients (40%) had multiple procedures combined into a single surgery.

Distribution of countries where cosmetic procedures performed

Abdominoplasty was the most common operation encountered (n = 16) followed by breast augmentation (n = 10), with breast reduction (n = 4), mastopexy (n = 3), liposuction (n = 3), skin excision (n = 3), buttock augmentation (n = 2), face lift (n = 2), neck lift (n = 2), and hair transplantation (n = 1) also referred (Fig. 2). Fourteen patients underwent a single procedure, 3 patients underwent 2 procedures, and 5 patients underwent 3 procedures.

Types of cosmetic procedure performed

The infectious complications encountered (Table 2) were classified according to the Centers for Disease Control and Prevention (CDC) guidelines on Surgical Site Infection (SSI) [18]. All infections in our population constituted superficial incisional SSIs, occurring within 30 days of the index procedure, and involved the skin and subcutaneous tissue. Wound dehiscence secondary to infection was the most common presentation (n = 22) followed by seroma (n = 6); skin necrosis (n = 2) and infected hematoma (n = 1) accounting for the remainder of cases.

A likely microbial etiology was demonstrated in 18 of the 30 patients included in this study. Of our 30 patients, 80% (n = 24) had tissue, pus, fluid, or wound swabs sent for microbial culture with 40 specimens being recorded in total. Considerable variation in both quality and timing of samples was noted with some being obtained on admission, others during inpatient stay and several in the course of surgical intervention. Admission screening was conducted for CPE in 70% and MRSA in 60% of cases with no positive screens detected. Discounting common commensal flora these specimens had a 75% positivity rate (n = 30) accounting for 16 distinct bacterial species. The most prevalent species isolated was Staphylococcus aureus (n = 5). While relatively common nosocomial pathogens such as Enterococcus faecalis (n = 2) were identified, so too were more unusual pathogens such as Morganella morganii (n = 2), Enterobacter cloacae (n = 3), and Pseudomonas putida (n = 1). Gram-negative species accounted for the majority of those identified (61%) and over half (n = 16) of the total isolates. The most common gram-negative bacteria encountered were Enterobacter cloacae (n = 3), Klebsiella oxytoca (n = 2), Morganella morganii (n = 2), and Escherichia coli (n = 2). Geographically, no significant difference between country of procedure and positive culture rate, type of species identified, or antimicrobial resistance in organisms was identified.

The most frequently prescribed antibiotics to treat this cohort of patients were piperacillin-tazobactam (168 total doses), co-amoxiclav (128 doses), flucloxacillin (50 doses), and clindamycin (46 doses). Of the 16 species isolated, a number of isolates displayed resistance to the most frequently prescribed empirical antibiotics such as co-amoxiclav (n = 4) and piperacillin-tazobactam (n = 6). In 2 cases, antibiotic treatment was changed based on culture results and antimicrobial resistance to an empirically prescribed antibiotic. Notably, four isolates identified met the criteria for multidrug resistant organisms (MDRO), which are defined as being non-susceptible to ≥ 1 agent in ≥ 3 antimicrobial categories, including a Vancomycin Resistant Enterococcus (VRE) and an Extended Spectrum Beta Lactamase (ESBL) producing isolate. Tables 1 and 2 detail the resistance patterns of the gram-positive and gram-negative isolates respectively.

Source control was required in 65% (n = 15) of patients admitted, with 10 patients requiring operative treatment and 7 interventional radiological procedures required.

A total of 76% (n = 23) of the patients required hospital admission with a mean length of stay of 6.65 days (range 1–20 days). Of the patients requiring admission, 78% (n = 18) required parenteral antibiotic treatment comprising a total of 181 days of therapy.