Content uploaded by Stefan O Brockmann
Author content
All content in this area was uploaded by Stefan O Brockmann on Nov 14, 2016
Content may be subject to copyright.
MEDICINE
ORIGINAL ARTICLE
The Risk of Bacterial Infection
After Tattooing
A Systematic Review of the Literature
Ralf Dieckmann, Ides Boone, Stefan O. Brockmann, Jens A. Hammerl, Annette Kolb-Mäurer,
Matthias Goebeler, Andreas Luch, Sascha Al Dahouk
SUMMARY
Background: Tattooing is a globally growing trend. Overall prevalence among
adults in industrialized countries is around 10–20%. Given the high and
increasing numbers of tattooed people worldwide, medical and public health
implications emerging from tattooing trends require greater attention not only
by the public, but also by medical professionals and health policy makers.
Methods: We performed a systematic review of the literature on tattoo-
associated bacterial infections and bacterial contamination of tattoo inks.
Furthermore, we surveyed tattoo inks sampled during an international tattoo
convention in Germany to study their microbial status.
Results: Our systematic review identified 67 cases published between 1984
and 2015, mainly documenting serious bacterial infectious complications after
intradermal deposition of tattoo inks. Both local skin infections (e.g. abscesses,
necrotizing fasciitis) and systemic infections (e.g. endocarditis, septic shock)
were reported. Published bacteriological surveys showed that opened as well
as unopened tattoo ink bottles frequently contained clinically relevant levels of
bacteria indicating that the manufactured tattoo product itself may be a source
of infection. In our bacteriological survey, two of 39 colorants were contami-
nated with aerobic mesophilic bacteria.
Conclusions: Inappropriate hygiene measures in tattoo parlors and non-medical
wound care are major risk factors for tattoo-related infections. In addition,
facultative pathogenic bacterial species can be isolated from tattoo inks in use,
which may pose a serious health risk.
►Cite this as
Dieckmann R, Boone I, Brockmann SO, Hammerl JA,
Kolb-Mäurer A, Goebeler M, Luch A, Al Dahouk S: The risk of bacterial
infection after tattooing—a systematic review of the literature.
Dtsch Arztebl Int 2016; 113: 665–71. DOI: 10.3238/arztebl.2016.0665
B
ody modifications including tattoos are a
globally growing trend. According to recent sur-
veys the overall prevalence of tattoos among adults in
industrialized countries is around 10–20% (1). Since
there are currently no public health reporting require-
ments for infectious complications associated with
tattooing, the actual incidence and prevalence of infec-
tions following tattooing remain largely unknown in
many countries, which is why scientifically sound risk
quantification is not possible.
In compliance with the International Classification
of Procedures in Medicine (ICPM) tattooing represents
a surgical procedure with its own Operations and
Procedures (OPS) code number (5–890.0; see OPS
version 2015). However, tattooing is almost never
performed by medical doctors and can therefore not be
epidemiologically monitored by use of medical data-
bases.
A specific diagnosis code for diseases following
non-medically indicated cosmetic surgery was intro-
duced in Germany in 2008. However, this comprises
diverse procedures such as a range of aesthetic
operations, along with tattoos and piercings. Since
there is currently no ICD (International Classification
of Diseases) code that would explicitly and specifically
associate infectious diseases with the procedure of
tattooing, it proved impossible to derive a reliable
estimate of infection rates from data collected by Ger-
man health insurance companies. Based on published
surveys, between 0.5% and 6% of the people with a tat-
too experienced infectious complications after being
tattooed (2–6).
Considering the increasing numbers of tattooed
people, tattooing may thus represent a significant
public health risk (7, 8). Therefore, physicians should
be aware of atypical clinical presentations of tattoo-
related infections that may lead to rare but severe
adverse outcomes. Tattooing results in traumatization
of the skin that may facilitate microbial pathogens to
pass the epidermal barrier causing local skin infections.
In most cases such mild-to-moderate superficial skin
infections remain unreported since they are self-
limiting or easily treated with proper aftercare, local
disinfection measures and/or antibiotic therapy. How-
ever, as tattoo needles punch through the epidermis,
German Federal Institute for Risk Assessment (BfR), Department of Biological Safety, Berlin:
Dr. rer. nat. Dieckmann, P h. D. Boon e, Dr. rer. nat. H ammerl, Prof . Dr. med., M.Sc. Al Dahouk
Regional Public Health Office, Department for Infection Control, Reutlingen: Stefan Brockmann
University Hospital Würzburg, Department of Dermatology, Venereology and Allergology, Würzburg: Prof. Dr.
med. Dr. rer. nat. Kolb -Mäurer, Prof. Dr. med. G oebeler
German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin:
Prof. Dr. med. Dr. rer. nat. Dr. med. habil. Luch
RWTH Aachen University Hospital, Clinic for Gastroenterology, Metabolic Disorders and Internal Intensive
Medicine (Medical Clinic III), Aachen: Prof. Dr. med., M.Sc. Al Dahouk
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
665
MEDICINE
thereby coming into contact with blood and lymph
vessels in the dermal layer, bacteria may cause
systemic infections by entering the blood stream. The
severity of infection depends on the virulence of the
pathogen, the immune status of the person being
tattooed and underlying diseases.
To assess hazards and disease outcomes related to
bacterial infections as a consequence of tattooing, a
systematic review of the literature and bacteriological
investigation of inks was performed.
Methods
Literature survey
We conducted an electronic literature search in
MEDLINE (PubMed), Scopus, Web of Science,
BIOSIS Previews, EMBASE and Google Scholar for
eligible studies addressing
●
bacterial infections, not related to mycobacteria,
associated with a recent tattoo, and
●
tattoo inks contaminated with bacteria other than
mycobacteria.
A flow chart of the selection process is presented in
the Figure (see eBox 1 for a detailed description of the
methodology).
Microbiological analysis
A total of 39 samples of tattoo inks originating from
opened vials that were randomly collected by local
health inspectors during the 10
th
International Tattoo
Convention in Reutlingen, Germany, were analyzed.
Enumeration and detection of aerobic mesophilic bac-
teria (i.e., aerobic bacteria that grow best at moderate
temperatures) were performed in accordance with vali-
dated guidelines for the microbiological analysis of
cosmetic products (EN ISO 21149:2009), as was the
detection of specified and non-specified microorgan-
isms including Escherichia (E.) coli, Pseudomonas (P. )
aeruginosa, and Staphylococcus (S.) aureus (EN ISO
18415:2011). Isolates from contaminated samples were
sub-cultured for further identification by Matrix-
Assisted Laser Desorption/Ionization Time-of-Flight
Mass Spectrometry (MALDI-ToF MS) and 16S rRNA
gene sequencing.
Results
Tattoo-related infections
Our initial literature search yielded 1379 records, of
which 1345 were excluded, mainly because they de-
scribed non-infectious cases, non-bacterial infections,
non-clinical studies or were summary reports of already
considered cases (Figure). Two systematic reviews of
tattoo-associated skin infections caused by non-
tuberculous mycobacteria (NTM) were published quite
recently (9, 10). Since our survey revealed only four
additional reports describing six new cases (e1–e4),
mycobacterial infections were excluded from our data
analysis and interpretation because of a lack of novelty.
We identified 67 cases of non-mycobacterial
FIGURE
Records excluded (n = 1252)
Main reasons:
Mycobacterium spp. detection only;
non-bacterial; non-infectious cases;
non-clinical studies
Records excluded (n = 93)
Main reasons:
Review article containing previously published cases;
Mycobacterium spp. detection only;
no pathogen detected
Included studies on tattoo-associated
bacterial infections
n = 27
(Table 1)
Included studies on bacterial
contamination of tattoo links
n = 7
(Table 2)
Records identified through electronic
database searches (de-duplicated)
n = 1361
Additional records through other sources
(manual search of reference lists,
Google scholar) n = 18
(mycobacterial infections and contaminants were not considered)
Full-text papers reviewed for
eligibility n = 127
Titles and abstracts
reviewed n = 1379
Literature search: Clinical studies as well as case reports on bacterial infections following tattooing and microbiological studies on the
bacterial contamination of tattoo ink were included.
666
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
MEDICINE
infections reported in 27 publications published
between 1984 and 2015 (11–37), mainly documenting
serious bacterial infectious complications after intra-
dermal deposition of tattoo inks (Table 1, eTable).
Since the CDC case series (16) presented only aggre-
gated data, those 34 cases were omitted from the statis-
tical analysis and discussed separately. Most patients
were male (75%). The mean age was 28 years (range:
0–48 years). Most cases were reported from the United
States (n=12), Europe (n=11) and New Zealand (n=5).
The number of reports increased over time and 9 out of
11 cases from Europe and 10 out of 13 cases from
North America were published between 2011 and 2015,
which might indicate an increased awareness. S. aureus
was reported as an etiological agent in 81% of the
cases. Long-term antibiotic therapy with a mean
duration of six weeks (range 1–15 weeks) was the treat-
ment of choice in 21 reports, which provided this type
of information. Two patients died due to complications
related to their infections (11, 15).
Bacteriological contamination of tattoo inks
Since only seven reports on contaminated tattoo inks
have been published so far (Tab l e 2 ) we officially
collected 39 tattoo inks in use during an international
tattoo convention in Germany, 2014, and determined
their microbial status to specify the risk of infection
associated with the subepidermal application of ink
deposits. A total of 19 inks (49%) were claimed to be
sterile/sterilized on the label. Fifteen (38%) contained
benzisothiazolinone as a preservative, three addition-
ally contained methylisothiazolinone and phenoxy -
ethanol. Twenty-three products used alcohol as a
solvent, in most cases isopropyl alcohol. Among the 39
colorants investigated, two (5%) were contaminated
with aerobic mesophilic bacteria (~10
7
bacteria per
gram of ink). Both products were free of preservatives.
In one sample various Pseudomonas species (P. p s e u -
doalcaligenes, P. stutzeri, P. fluorescens group) and
Delftia spp. (D. lacustris/tsuruhatensis group) were
detected. The other sample was contaminated with P.
aeruginosa, Stenotrophomonas maltophilia, Agrobac-
terium tumefaciens/Rhizobium sp. and bacteria belong-
ing to the Staphylococcus warneri/pasteuri group. The
bacterial genera identified were largely in line with
those described in the literature (Table 2).
Discussion
Infectious complications from tattoos include superfi-
cial infections such as impetigo, deep bacterial skin
infections presenting as erysipelas or cellulitis and
systemic infections which may lead, in very rare
cases, to life-threatening complications due to endoc-
arditis, septic shock, and multi-organ failure (38).
Acute pyogenic skin infections or bacteremia usually
occur within a few days after placement of the tattoo
and predominantly involve methicillin-resistant S.
aureus (MRSA) or methicillin-sensitive S. aureus
(MSSA), Streptococcus spp., and Pseudomonas
aeruginosa.
TABLE 1
Local skin infections, systemic complications and etiological agents extracted
from reported cases of tattoo-related, non-mycobacterial infections*
*see the eTable for more detailed information;
MSSA, methicillin-sensitive S. aureus; MRSA, methicillin-resistant S. aureus
Local skin infections
(reference)
– abscesses
(12, 16, 22, 25, 27, 30, 33, 34)
– cutaneous diphtheria (23, 24)
– erythema (18, 20, 35–37)
– necrotizing fasciitis or tissue necrosis
(12, 15, 21, 22)
– pustules or papules (13, 16, 35, 36)
– staphylococcal scalded skin syndrome
(37)
– cellulitis (12, 15, 16, 17, 21–24, 26)
Systemic complications
(reference)
– abdominal compartment syndrome (15)
– bacteremia (16)
– endocarditis (14, 18, 19, 28, 32)
– iliopsoas abscess (31)
– necrotizing pneumonia (33)
– toxic shock syndrome (35)
– septicemia (11, 12, 27, 29, 32)
– septic shock and multiple organ failure
(15, 21)
– spinal epidural abscess (13)
– tropical pyomyositis (26)
– xanthogranulomatous pyelonephritis
(20)
Bacteria isolated from wound swab or
abscess drainage (reference)
– Corynebacterium diphtheriae (23, 24)
– Pseudomonas aeruginosa (36)
– Serratia marcescens (34)
– Staphylococcus aureus (23, 24, 29, 37)
MSSA (22, 30)
MRSA (17, 22, 25)
– Streptococcus pyogenes (22)
Bacteria isolated from blood, tissue,
wound swab and/or abscess drainage
(reference)
– Bacteroides fragilis (12)
– Corynebacterium spp. (15)
– Haemophilus influenzae (29)
– Klebsiella oxytoca (12, 15)
– Moraxella lacunata (19)
–
Pseudomonas aeruginosa (11, 12, 15, 21)
– Staphylococcus aureus (14, 15, 21, 26)
MSSA (12, 13, 27, 28, 32, 35)
MRSA (16, 20, 31, 33)
– Staphylococcus lugdunensis (18)
– Streptococcus pyogenes (12, 15, 21)
– Streptococcus spp. (group A) (27)
– Streptococcus spp. (group C) (21)
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
667
MEDICINE
Nontuberculous mycobacterial (NTM) skin infections
In recent years, a considerable number of reports
describing cases of nontuberculous mycobacterial in-
fections following tattooings have been published (9,
10). Conaglen et al. identified a total of 25 reports de-
scribing 71 confirmed and 71 probable tattoo-related
infections with NTM such as M. chelonae, M. haemo-
philum, and M. abscessus (10). NTM infections
typically occurred in healthy individuals within weeks
to months after tattooing and manifested as localized
cutaneous infections presenting as papules, pustules
and nodules at the site of the tattoo. Often, lesions were
restricted to a single colored part of the tattoo. The most
frequently postulated route of transmission was the di-
lution of tattoo ink with non-sterile water. With several
months of antibiotic treatment (either clarithromycin
alone or in combination with quinolones) outcomes of
these long-lasting infections tended to be good.
Other bacterial infectious complications
Seven cases followed traditional Samoan tattooing in
previously healthy, young men from New Zealand,
Australia and the USA (12, 15, 21, 23, 24, 27). Typi-
cally, patients initially developed erysipelas, multiple
subcutaneous abscesses and necrotizing soft tissue
infections localized in the tattooed skin area which led
to severe polymicrobial septicemia, septic shock and
life-threatening organ failure. In one of these cases,
cutaneous diphtheria caused by a toxigenic strain of
Corynebacterium diphtheriae (var. gravis) has been
reported (23, 24). However, it could well be that S.
aureus was the primary pathogen in this case.
One patient died of acute heart failure as a conse-
quence of septic shock following a ritual Samoan
tattooing (15). In this case, the used ink and a natural
yellow pigment (turmeric) showed high contamination
with Gram-positive bacteria. Most patients recovered
but required prolonged hospitalization with intravenous
antibiotic treatment. Inadequate cleaning and steril -
ization of tattoo equipment as well as inappropriate
infection control measures and the more invasive pro-
cedures were supposed to be the main risk factors of
traditional tattooing.
The Centers for Disease Control and Prevention
(CDC) have documented a series of 34 cases of MRSA
infections among recipients of tattoos from 13 un-
licensed tattooists in the USA in 2004–2005 (16). The
majority of patients were white males without underly-
ing diseases or risk factors. Most infections were mild
to moderate (erysipelas, bacterial pustules, and ab-
scesses) and wound healing could be improved with
surgical drainage and/or oral antibiotics. Four patients
developed bacteremia and required hospitalization for
intravenous vancomycin treatment. Suboptimal infec-
tion control procedures of unlicensed tattooists were
identified as the major risk factor.
Similar outcomes and risk factors for three cases of
tattoo-associated S. aureus infections were described in
a recent report (22). In at least one of the cases ink con-
tamination may have caused the infection, since the
distribution of the infectious lesions was linked to a
single color. Two outbreaks of community-associated
MRSA (CA-MRSA) and Panton-Valentine Leukocidin
(PVL)-positive MSSA skin and soft tissue infections at
a correctional facility in the USA and in a prison in
France have been attributed to unhygienic tattooing
conditions (17, 30).
Rare complications of tattoo-related infections
caused by S. aureus are the toxic shock syndrome
(TSS) caused by toxigenic strains of S. aureus (35) and
the staphylococcal scalded skin syndrome (SSSS) (37).
Five cases of presumably tattoo-related infective
endocarditis were found in the literature. Prior heart
disease was noticed as a risk factor in four of them.
Etiologic agents were human commensals such as S.
aureus (14, 28), S. lugdunensis (18), and Moraxella
lacunata (19). Typically, symptoms started within a
week after tattoo placement with recurring episodes of
high fever and dyspnea.
Tattoos are generally accepted to be an initial en-
trance door for bacteria into the human body, but the
clinical pictures of possible tattoo-related infectious
diseases can be more heterogeneous and the etiologic
agents more diverse than actually expected (Table 1,
eTable).
Contamination of tattoo inks as a potential source of infection
Although most licensed tattoo parlors have imple-
mented hygiene measures, bacterial infections
emerge. Inappropriate infection control is often
blamed to be responsible for tattoo-related infections.
Pathogens may originate from surfaces in the tattoo
studio environment and from inadequately sterilized
instruments or other equipment, or from the commen-
sal or transient skin flora of the tattooed person and
the tattooist alike. Tattoo wounds may also become
infected during the healing process due to inadequate
wound care or personal hygiene. In addition, the ap-
plied colorant itself might have gotten extrinsically
contaminated during usage or intrinsically during
production. Published bacteriological surveys
(e5–e11) show that opened (used) as well as uno-
pened (unused) tattoo ink bottles frequently contain
considerable numbers of bacteria indicating that the
manufactured tattoo product itself may be a risk fac-
tor in tattoo-related infections (Table 2). Contami-
nation rates beyond 10% are not unusual for tattoo
inks. In general, lower bacterial counts of bacilli or
other spore-forming bacteria are found in unopened
ink containers (102–103 colony forming units per
gram ink [cfu/g]), whereas high bacterial loads are
common for opened bottles (103–109 cfu/g). From
opened bottles, Gram-negative aerobic bacteria such
as P. aeruginosa were isolated in high numbers (e6).
These ubiquitous germs (?) are able to colonize vir-
tually all environments including soil, tap and marine
waters, as well as the human skin. Yet Gram-positive
bacteria such as Staphylococcus spp. that are part of
the commensal flora of the human skin can also be
found in opened as well as unopened bottles (e8).
668
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
MEDICINE
Conclusions
With respect to the considerable popularity of tattoos and
yet insufficient regulation of hygiene measures in both the
production of tattoo inks and the process of tattooing, in-
fection risks associated to this kind of body art should be
recognized as a potential public health concern (2, 3, 8,
38). Since consumers may not be aware of infection risks
from tattooing and tattoo artists complying with hygiene
guidelines cannot easily be identified, statutory rules are
urgently needed for consumer protection. Physicians
should be aware of the tattoo-related complications, edu-
cate patients about potential health risks and provide ad-
vice to those with predisposing conditions regarding the
need of preventive measures such as specific follow-up
care. If indicated patients shall be asked to refrain from tat-
toos which may help to prevent sequelae.
Acknowledgments
This study has been financially supported by intramural grants of the German
Federal Institute for Risk Assessment (BfR).
Conflict of interest statement
Prof. Al Dahouk has written a medical expertise report regarding this paper's
subject matter.
All other authors declare that no conflict of interest exists.
Manuscript received on 2 December 2015, revised version accepted on
8 June 2016
Most of the bacterial contaminants were not highly
virulent though, but instead opportunistic pathogens
(e5–e11).
Many of the bacterial genera that have been as-
sociated with tattoo-related infections are in accord-
ance with those found in bacteriological surveys of
opened tattoo ink bottles (see Tables 1 and 2, eT-
able). Bottling of ink solutions from stock bottles to
smaller non- sterile cups recurrently contaminated
during the placement of a tattoo represents only one
but certainly a highly likely source of contamination,
in particular, when the top of the stock bottle re-
peatedly gets into contact with the cup. Another
common source is the mixing of colors and dilution
of inks by the tattoo artist under non-sterile condi-
tions or with non-sterile diluents (e.g., tap water or
“distilled”, but not germ-free water). As a conse-
quence, bacteria may readily reach infective doses
(>10
3
to 10
8
cfu/g, see Tab l e 2 ) in tattoo products, es-
pecially when they are inadequately preserved (e6,
e8, e10). Hence, tattoo inks may be underrated as a
potential source of bacterial infection and harmon-
ized legal requirements for tattooing services as well
as mandatory quality measures are needed not only
for tattoo parlors but also for producers of tattoo inks
(see eBox 2 on regulatory aspects).
TABLE 2
Bacterial contamination of tattoo inks
cfu
,
colon
y
formin
g
unit
Reference
Reus and
van Buuren (2001)
(e5)
Charnock (2004)
(e6)
Droß and
Mildau (2007) (e7)
Baumgartner and
Gautsch (2011)
(e8)
Kluger et al. (2011)
(e9)
Høgsberg et al.
(2013) (e10)
Bonadonna et al.
(2014) (e11)
Total numb er
of tested inks
(opened/
unopened)
63 (32/31)
12 (10/2)
245
(mainly opened)
145 (106/39)
16 (16/0)
64 (6/58)
34 (27/7)
Number (percentage)
of contaminated
samples
Total
11 (18)
7 (58)
26 (11)
41 (28)
0 (0)
7 (11)
29 (85)
Opened,
Unopened
8 (25),
3 (10)
6 (60),
1 (50)
27 (26),
14 (36)
–
1 (17),
6 (10)
23 (85),
6 (86)
Bacterial load [cfu/g]
(samples)
10
4
–10
5
(1), > 10
5
(7)
10
2
–10
4
(3)
10
2
–10
3
(2), 10
6
–10
9
(4)
10
2
–10
3
(1)
10
2
–10
7
(26)
< 10
1
(5), 10
1
–10
3
(18),
10
3
–10
8
(4)
< 10
1
(7), 10
1
–10
3
(7)
–
10
2
(1)
10
2
–10
3
(6)
< 10
1
(11), 10
1
–10
3
(12)
< 10
1
(4), < 10
2
(2)
Organisms identified
Pseudomonas aeruginosa, P. putida, P. fluorescens
Gram-positive, aerobic rods, Citrobacter freundii,
Achromobacter xylosoxidans, A. denitrificans,
Corynebacterium sp., Brevundimonas diminuta, P. aeruginosa,
Stenotrophomonas maltophilia, Leuconostoc spp.,
Methylobacterium mesophilicum
Pseudomonas spp., Citrobacter spp., aerobic spore-forming
bacteria, Ralstonia pickettii, coliform bacteria
Enterococcus spp., Micrococcus spp., Staphylococcus spp.,
Brevundimonas vesicularis, P. fluorescens, S. maltophilia,
Bacillus spp., Geobacillus spp., Paenibacillus spp.,
Virgibacillus pantothenticus, Brevibacillus laterosporus
–
Streptococcus spp., Acinetobacter sp., Bacillus sp., Staphylo-
coccus sp., Aeromonas sobria, Acidovorax, Pseudomonas sp.,
Dietzia maris, Blastomonas sp., Enterococcus faecium
Bacillus spp., Staphylococcus spp., Enterobacter intermedius,
Cronobacter sakazakii, Sphingomonas paucimobilis
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
669
MEDICINE
REFERENCES
1. Kluger N: Epidemiology of tattoos in industrialized countries.
Curr Probl Dermatol 2015; 48: 6–20.
2. Laux P, Tralau T, Tentschert J, et al.: A medical-toxicological view of
tattooing. Lancet 2016; 387: 395–402.
3. Klügl I, Hiller KA, Landthaler M, Bäumler W: Incidence of health
problems associated with tattooed skin: a nation-wide survey in
German-speaking countries. Dermatology 2010; 221: 43–50.
4. Kazandjieva J, Tsankov N: Tattoos: dermatological complications.
Clin Dermatol 2007; 25: 375–82.
5. Kluger N: Self-reported tattoo reactions in a cohort of 448 French
tattooists. Int J Dermatol 2015; 55: 764–8.
6. Liszewski W, Kream E, Helland S, Cavigli A, Lavin BC, Murina A: The
demographics and rates of tattoo complications, regret, and unsafe
tattooing practices: a cross-sectional study. Dermatol Surg 2015;
41: 1283–9.
7. Schmidt A: Hygiene standards for tattooists. Curr Probl Dermatol
2015; 48: 223–7.
8.
Wenzel SM, Rittmann I, Landthaler M, Bäumler W: Adverse reactions
after tattooing: review of the literature and comparison to results of
a survey. Dermatology 2013; 226: 138–47.
9.
Mudedla S, Avendano EE, Raman G: Non-tuberculous mycobacterium
skin infections after tattooing in healthy individuals: a systematic
review of case reports. Dermatol Online J 2015; 21(6).
10. Conaglen PD, Laurenson IF, Sergeant A, Thorn SN, Rayner A,
Stevenson J: Systematic review of tattoo-associated skin infection
with rapidly growing mycobacteria and public health investigation of
a cluster in Scotland, 2010. Eurosurveillance 2013; 18.
11. Mathur DR, Sahoo A: Pseudomonas septicemia following tribal tatoo
marks. Trop Geogr Med 1984; 36: 301–2.
12. Korman TM, Grayson ML, Turnidge JD: Polymicrobial septicaemia
with Pseudomonas aeruginosa and Streptococcus pyogenes following
traditional tattooing. J Infect 1997; 35: 203.
13. Chowfin A, Potti A, Paul A, Carson P: Spinal epidural abscess after
tattooing. Clin Infect Dis 1999; 29: 225–6.
14. Satchithananda DK, Walsh J, Schofield PM: Bacterial endocarditis
following repeated tattooing. Heart 2001; 85: 11–2.
15. Porter CJW, Simcock JW, MacKinnon CA: Necrotising fasciitis and
cellulitis after traditional Samoan tattooing: case reports. J Infect
2005; 50: 149–52.
16.
Centers for Disease Control and Prevention (CDC): Methicillin-resistant
Staphylococcus aureus skin infections among tattoo recipients—
Ohio, Kentucky, and Vermont, 2004–2005. Morb Mortal Wkly Rep
2006; 55: 677–9.
17. Stemper ME, Brady JM, Qutaishat SS, et al.: Shift in Staphylococcus
aureus clone linked to an infected tattoo. Emerg Infect Dis 2006;
12: 1444–6.
18. Tse D, Khan S, Clarke S: Bacterial endocarditis complicating body
art. Int J Cardiol 2009; 133: e28–e9.
19. Callejo RM, Nacinovich F, Prieto MA, et al.: Moraxella lacunata in-
fective endocarditis after tattooing as confirmed by 16S rRNA gene
sequencing from heart valve tissue. Clin Microbiol Newsl 2010; 32:
6–7.
20. Chalmers D, Marietti S, Kim C: Xanthogranulomatous pyelonephritis
in an adolescent. Urology 2010; 76: 1472–4.
21. McLean M, D’Souza A: Life-threatening cellulitis after traditional
Samoan tattooing. Aust N Z J Public Health 2011; 35: 27–9.
22. Coulson A: Illegal tattoos complicated by Staphylococcus infections:
a North Carolina wound care and medical center experience.
Wounds 2012; 24: 323–6.
23. Sears A, McLean M, Hingston D, Eddie B, Short P, Jones M: Cases
of cutaneous diphtheria in New Zealand: implications for surveillance
and management. N Z Med J 2012; 125: 64–71.
24. McGouran DC, Ng SK, Jones MR, Hingston D: A case of cutaneous
diphtheria in New Zealand. N Z Med J 2012; 125: 93–5.
25. Wollina U: Severe adverse events related to tattooing: a retro -
spective analysis of 11 years. Indian J Dermatol 2012; 57:
439–43.
26. Báez Sarría F, Rodríguez Collar TL, Santos VF: Tropical pyomyositis
as a complication of a tattoo. Rev Cubana Med Mil 2013; 42:
417–22.
27.
Elegino-Steffens DU, Layman C, Bacomo F, Hsue G: A case of severe
septicemia following traditional Samoan tattooing. Hawaii J Med
Public Health 2013; 72: 5–9.
28. Akkus NI, Mina GS, Fereidoon S, Rajpal S: Tattooing complicated by
multivalvular bacterial endocarditis. Herz 2014; 39: 349–51.
29. Kaldas V, Katta P, Trifinova I, Marino C, Sitnitskaya Y, Khanna S: Rare
tattoo complication: Haemophilus influenzae sepsis in a teenager.
Consultant 2014; 54: 289–91.
30. Bourigault C, Corvec S, Brulet V, et al.: Outbreak of skin infections
due to panton-valentine leukocidin-positive methicillin-susceptible
Staphylococcus aureus in a French prison in 2010–2011. PLoS
Curr 2014; 6.
31. Gulati S, Jain A, Sattari M: Tattooing: a potential novel risk factor for
iliopsoas abscess. World J Clin Cases 2014; 2: 459–62.
32. Orton CM, Norrington K, Alam H, Alonso-Gonzalez R, Gatzoulis M:
The danger of wearing your heart on your sleeve. Int J Cardiol
2014; 175: e6–7.
33.
Rabbani S, Sharma TR: MRSA necrotizing pneumonia and peripheral
septic thrombophlebitis. Consultant 2014; 54.
34. Diranzo García, J, Villodre Jiménez J, Zarzuela Sánchez V, Castillo
Ruiperez L, Bru Pomer A: Skin abscess due to Serratia marcescens
in an immunocompetent patient after receiving a tattoo. Case Rep
Infect Dis 2015; 2015: 626917.
35.
Jeong KY, Kim KS, Suh GJ, Kwon WY: Toxic shock syndrome following
tattooing. Korean J Crit Care Med 2015; 30: 184–90.
36. Maloberti A, Betelli M, Perego MR, Foresti S, Scarabelli G, Grassi G:
A case of Pseudomonas aeruginosa commercial tattoo infection.
G Ital Dermatol Venereol 2015; (Epub ahead of print).
37. Mikkelsen CS, Holmgren HR, Arvesen KB, Jarjis RD, Gunnarsson
GL: Severe scratcher-reaction: an unknown health hazard? Derma-
tology Reports 2015; 7: 9–11.
KEY MESSAGES
●
In recent years, skin infections associated with tattoos
are more frequently recognized as public health con-
cern.
●
Serious bacterial infectious complications following
tattooing have occasionally been documented in the
literature.
●
Inappropriate hygiene measures and pre-existing condi-
tions are among the major risk factors, and tattoo inks
are likely being underrated as a potential source of
bacterial infection.
●
Mandatory quality measures for tattoo ink producers,
tattoo parlors, and the tattoo artists are urgently recom-
mended to protect consumers’ health.
●
Physicians should adequately inform their patients
about potential hazards and clinical complications after
tattooing.
670
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
MEDICINE
38. Serup J, Hutton Carlsen K, Sepehri M: Tattoo complaints and
complications: diagnosis and clinical spectrum. Curr Probl Dermatol:
S. Karger AG 2015; 48–60.
Corresponding author
Prof. Dr. med. Sascha Al Dahouk
Bundesinstitut für Risikobewertung (BfR)
Diedersdorfer Weg 1
12277 Berlin, Germany
Sascha.Al-Dahouk@bfr.bund.de
@
Supplementary material
eReferences:
www.aerzteblatt-international.de/ref4016
eBoxes and eTable:
www.aerzteblatt-international.de/16m0665
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
671
MEDICINE
I
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
eREFERENCES
e1. Frew JW, Nguyen RT: Tattoo-associated mycobacterial infections:
an emerging public health issue. Med J Aust 2015; 203: 223.
e2. Philips RC, Hunter-Ellul LA, Martin JE, Wilkerson MG: Mycobac-
terium fortuitum infection arising in a new tattoo. Dermatol Online
J 2014; 20:10.
e3. Sousa PP, Cruz RC, Schettini AP, Westphal DC: Mycobacterium
abscessus skin infection after tattooing—case report. An Bras
Dermatol 2015; 90: 741–3.
e4. Danford B, Weingartner J, Patel G: Rapidly growing mycobacterial
infection following tattoo. J Am Acad Dermatol 2015; 72: AB129.
e5. Reus H, van Buuren R: Kleurstoffen voor tatoeage en permanente
make-up. Legislation report no ND COS 012. Inspectorate for
Health Protection North, Ministry of Health 2001; 1–36.
e6. Charnock C: Colourants used for tattooing contaminated with
bacteria. Tatoveringsløsninger forurenset av bakterier 2004; 124:
933–5.
e7. Droß A, Mildau G: Mikrobiologischer Status von Mitteln zum
Tätowieren. Berichte zur Lebensmittelsicherheit 200, Bundesweiter
Überwachungsplan 2007. Bundesamt für Verbraucherschutz und
Lebensmittelsicherheit 2007: 2.
e8. Baumgartner A, Gautsch S: Hygienic-microbiological quality of
tattoo- and permanent make-up colours. J Verbrauch Lebensm
2011; 6: 319–25.
e9. Kluger N, Terru D, Godreuil S: Bacteriological and fungal survey
of commercial tattoo inks used in daily practice in a tattoo parlour.
J Eur Acad Dermatol Venereol 2011; 25: 1230–1.
e10. Høgsberg T, Saunte DM, Frimodt-Møller N, Serup J: Microbial
status and product labelling of 58 original tattoo inks. J Eur Acad
Dermatol Venereol 2013; 27: 73–80.
e11. Bonadonna L, Briancesco R, Coccia AM, et al.: Valutazione
delle caratteristiche microbiologiche di inchiostri per tatuaggi in
confezioni integre e dopo l’apertura. Microbiologica Medica 2014;
29: 6.
e12. Council of Europe: Resolution ResAP(2003)2 on tattoos and
permanent make-up. Strasbourg, France, Council of Europe 2003.
e13. Council of Europe: Resolution ResAP(2008)1 on requirements
and criteria for the safety of tattoos and permanent make-up
(superseding resolution ResAP(2003)2 on tattoos and permanent
make-up). Strasbourg, France, Council of Europe 2008.
e14. CEN: European committee for standardization CEN/TC 435—
Project committee tattooing services: Safe practice and hygiene
requirements. https://standards.cen.eu/ (last accessed 15 August
2016).
e15. Liberati A, Altman DG, Tetzlaff J, et al.: The PRISMA statement
for reporting systematic reviews and meta-analyses of studies that
evaluate health care interventions: explanation and elaboration.
Ital J Public Health 2009; 6: 354–91.
e16. Vandenbroucke JP: In defense of case reports and case series.
Ann Intern Med 2001; 134: 330–4.
Supplementary material to:
The Risk of Bacterial Infection After Tattooing
A Systematic Review of the Literature
by Ralf Dieckmann, Ides Boone, Stefan O. Brockmann, Jens A. Hammerl, Annette Kolb-Mäurer,
Matthias Goebeler, Andreas Luch, and Sascha Al Dahouk
Dtsch Arztebl Int 2016; 113: 665–71. DOI: 10.3238/arztebl.2016.0665
MEDICINE
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
II
eBOX 1
Literature survey
An electronic literature search was performed in MEDLINE (PubMed), Scopus, Web of Science, BIOSIS Previews, EMBASE and Google Scholar for
eligible studies addressing
– bacterial infections associated with a recent tattoo, and
– tattoo inks contaminated with bacteria other than mycobacteria.
Mycobacterial infections were excluded from the search. Search terms used were “tattoo*” combined with “bacteria”, “bacterial” or “microbial”.
Searches were performed on all records available up to February 11, 2016 without language restrictions taking into account the PRISMA
guidelines (e15). No review protocol was used. In addition, we hand-searched bibliography lists of selected full papers for potentially missed articles
and added them to our database. Duplicate records were discarded. Titles and abstracts of all records in our database were screened to ensure the
selection criteria have been met. Records on mycobacteria, non-bacterial infections, non-infectious cases associated with tattoos or non-clinical
studies were excluded.
Two scientists independently screened and evaluated the references. Data was extracted on patient demographics, incubation period, clinical
diagnoses and outcomes, bacterial pathogens identified, and likely cause of infection or transmission route. Relevant data were used to carry out
basic statistical analyses.
The quality of the records was not assessed because most of the identified studies were case reports. Generally, case reports and case series
provide weak evidence of causality, but contain useful information regarding, e.g., rare manifestations or unexpected risks, and therefore allow to
generate hypotheses (e16). Consequently, our study should be considered as exploratory.
Our review might be somewhat biased as severe hospitalized cases were predominantly described in the literature, most cases were reported
from a few geographic regions (primarily North America and Europe), and methicillin-resistant Staphylococcus (S.) aureus (MRSA) cases were mostly
reported in publications from the United States. Although no language restriction was used, cases from the so-called gray literature or published in
non-English language might have been missed.
MEDICINE
III
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
eBOX 2
Regulatory aspects
Because there are currently no harmonized legal requirements for tattooing services, qualification standards of tattoo artists regarding hygiene,
infection control and prevention greatly vary (2). Generally tattoo inks are regarded as cosmetic products and the colorants and ingredients do not
require explicit governmental approval prior to deposition into the skin (2).
The composition of tattoo inks is highly variable and often unknown. Since manufacturers usually refuse to disclose the individual ingredients of
their ink formulas, these may contain numerous hazardous compounds including inorganic metal salts and additives originating from plants or
animals, the latter of which may be sources of bacterial contamination. Still, companies producing and distributing tattoo inks have the legal
responsibility to ensure the safety of their products, but legislative bodies do not provide specifications for product sterility requirements and do not
set specific standards for sterilization measures, sterility testing or preservation.
Some manufacturers claim their inks to be “sterilized” on the label, but they are not obliged to report their sterility testing results to the legal
authorities.
In 2003 and 2008, two resolutions have been published by the Council of Europe regarding the safety of tattooing, which recommended sterility of
products used for tattooing and permanent make-up (PMU) (e12, e13). However, they are not legally binding to European member states and even
differ in their recommendations about preservation and container usage.
While ResAP(2003)2 suggests that tattoo and PMU products may only be permitted if they are sterile and supplied in single-use containers which
maintain sterility until application in the absence of chemical preservatives, ResAP(2008)1 states that such preservatives (e.g., isothiazolinones or
formaldehyde) should be used to ensure preservation of the product after opening. Further, according to the newer resolution multi-use containers
could be used if their design ensures that the contents will not be contaminated during the lifetime of the bottle.
In 2014, the German Institute for Standardization (Deutsches Institut für Normung, DIN) proposed a new project to the European CEN Technical
Board to compile European standards establishing requirements related to tattooing. The proposal was accepted as CEN/TC 435 “Tattooing services”
comprising hygienic performance of tattooing, including knowledge and skills, infection control, vaccination, suitable facilities as well as requirements
for cleaning, disinfection and sterilization, management of waste, necessary documentation and aftercare information (e14). However, microbiological
quality criteria of tattoo inks are not covered, as this may be a potential future mandate on tattoo products in the framework of the General Product
Safety Directive (2001/95/EC).
MEDICINE
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
IV
eTABLE
Reported cases of tattoo-related, non-mycobacterial infections.
Manifestations at
primary infection site
(tattoo)
Local skin infections
Skin and soft
tissue infection
Abscess
Abscess, tissue
necrosis
Multiple abscesses,
cellulitis
Cutaneous diphtheria,
cellulitis
Abscess
Abscesses
Abscess
Erythema, pustules
Secondary infection
complications,
(concomitant
pre-existing
conditions
supporting bacterial
infections)
(drug detoxification)
Number of cases*,
patient’s country of
origin
1, United States of
America
3, United States of
America
1, New Zealand
1, Germany
4, France
1, Spain
1, Italy
Age (years),
sex (m/f)
45, m
18, f
22, f
37, m
Adult, m
31, m
29–43, m
32, m
31, f
Organisms
identified (Source)
MRSA
(WS)
MRSA
(WS, abscess
drainage)
MRSA
(WS, abscess
drainage)
MSSA, S. pyogenes
(WS, abscess
drainage)
Toxigenic
Corynebacterium
diphtheriae var.
gravis,
S. aureus (WS)
MRSA
(WS, abscess
drainage)
MSSA (WS)
S. marcescens
(WS, abscess
drainage)
P. aeruginosa
(WS)
Incubation
period (days)
NA
NA
NA
7
within days
NA
<21
30
2
Likely cause
of infection,
transmission
route
Improper sanitary
conditions: sharing
needles and tattoo
paraphernalia at a
correctional facility
Unhygienic
conditions
NA
Potential ink
contamination
Traditional Samoan
tattooing
NA
Tattooing or body
shaving with
mechanical razors
NA
Possible use of
non-sterile tattooing
technique or
contamination of the ink
Outcome
NA
Fully recovered after
8 weeks
Fully recovered after
6 weeks
Hospitalization,
fully recovered after
4 weeks
Hospitalization,
fully recovered within
1 week
NA
NA
Hospitalization,
fully recovered after
15 weeks
Recovery after
2 weeks
Reference
Stemper et al.
(2006) (17)
Coulson
(2012) (22)
Sears et al.
(2012) (23),
McGouran et al.
(2012) (24)
Wollina
(2012) (25)
Bourigault et al.
(2014) (30)
Diranzo-Garcia et al.
(2015) (34)
Maloberti et al.
(2015) (36)
MEDICINE
V
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
Manifestations at
primary infection site
(tattoo)
Erythema
Systemic complications
Purulent wound
infection
Cellulitis and
fasciitis, subcutaneous
abscess
Pustular lesions
Cellulitis
Necrotizing
fasciitis
Cellulitis, pustules,
abscesses
Local skin infection
Erythema
Secondary infection
complications,
(concomitant
pre-existing
conditions
supporting bacterial
infections)
Lyell's syndrome
(staphylococcal
scalded skin syndrome;
SSSS)
Septicemia
Polymicrobial
septicemia
Acute spinal epidural
abscess with lower limb
weakness
Endocarditis
(bicuspid aortic valve)
Septic shock
Septic shock,
abdominal
compartment
syndrome,
acute heart failure
Bacteremia
(4/34 cases)
(no underlying diseases
except for one patient
with hepatitis C)
Endocarditis
(bicuspid aortic valve)
Xanthogranulomatous
pyelonephritis
Number of cases*,
patient’s country of
origin
1, Denmark
1, Nigeria
1, Australia
1, United States of
America
1, United Kingdom
2, New Zealand
34, United States of
America
1, United Kingdom
1, United States of
America
Age (years),
sex (m/f)
48, m
Newborn, NA
25, m
25, f
28, m
45, m
29, m
15–42, 73% m
44, m
16, m
Organisms
identified (Source)
S. aureus
(WS)
P. aeruginosa
(BC, WS, pus)
P. aeruginosa,
S. pyogenes (BC, WS),
K. oxytoca,
MSSA (WS),
Bacteroides fragilis
(abscess drainage)
MSSA
(WS, abscess
drainage)
S. aureus
(BC, explanted aortic
valve)
S. aureus,
S. pyogenes,
P. aeruginosa (WS)
S. pyogenes,
S. aureus (WS),
Corynebacterium spp.,
K. oxytoca
(soft tissue
debridement)
MRSA
(WS)
S. lugdunensis
(BC)
MRSA
(renal tissue)
Incubation
period (days)
NA
1
7
7
7
2
2
4–22
NA
<21
Likely cause
of infection,
transmission
route
Home kit tattoo ink
imported via the
internet, probable
phototoxic reaction to
the ink followed by a
break in the skin barrier
due to itching resulting
in bacterial infection
Tribal tattooing under
unhygienic conditions
Traditional Samoan
tattooing under
unhygienic conditions
NA
NA
Traditional Samoan
tattooing under
unhygienic conditions
Traditional Samoan
tattooing, use of
non-sterile equipment,
highly contaminated ink
and yellow pigment
(aerobic spore-forming
bacilli)
Use of non-sterile
equipment and
suboptimal
infection-control
practices (unlicensed
tattooists)
NA
Unsterile
tattooing
Outcome
Hospitalization,
recovery after 1 week
(followed by a 6 months
treatment against
allergic contact
dermatitis reaction)
Hospitalization,
death
Hospitalization,
fully recovered after
9 weeks
Hospitalization,
fully recovered after
8 weeks
Hospitalization,
fully recovered after
16 weeks
Hospitalization,
fully recovered after
4 weeks
Hospitalization,
death
Hospitalization
(4/34 cases)
Hospitalization,
full recovery
Hospitalization,
fully recovered after
4 weeks
Reference
Mikkelsen et al.
(2015) (37)
Mathur and Sahoo
(1984) (11)
Korman et al.
(1997) (12)
Chowfin et al.
(1999) (13)
Satchithananda et al.
(2001) (14)
Porter et al.
(2005) (15)
CDC
(2006) (16)
Tse et al.
(2009) (18)
Chalmers et al.
(2010) (20)
MEDICINE
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
VI
Manifestations at
primary infection site
(tattoo)
Extensive cellulitis
Severe cellulitis,
necrotizing fasciitis
Deep skin infection,
multiple abscesses
Superficial skin
infection
Abscess
Secondary infection
complications,
(concomitant
pre-existing
conditions
supporting bacterial
infections)
Endocarditis
Septic shock leading to
acute renal failure
Septic shock leading to
multi-organ failure
Sepsis
Tropical pyomyositis
Iliopsoas abscess
Iliopsoas abscess
(intravenous drug
abuse, hepatitis C)
Endocarditis
(myxoid degeneration
of the mitral valve),
septic emboli (knee,
brain, lung)
Peripheral septic
thrombophlebitis;
necrotizing pneumonia
(intravenous drug
abuse in medical
history)
Number of cases*,
patient’s country of
origin
1, Argentina
2, New Zealand
1, United States of
America
1, Cuba
2, United States of
America
1, United States of
America
1, United States of
America
Age (years),
sex (m/f)
34, f
23, m
25, m
46, m
19, f
Adult, m
48, f
23, m
28, m
Organisms
identified (Source)
Moraxella lacunata
(BC)
S. aureus and group C
streptococci (WS)
S. pyogenes,
P. aeruginosa (WS)
Group A streptococci
and MSSA (BC)
S. aureus
(WS)
MRSA
MRSA
(BC)
MSSA
(BC)
MRSA
(WS, abscess drainage,
BC, sputum)
Incubation
period (days)
4
3
2
<5
15
NA
NA
1–2
7
Likely cause
of infection,
transmission
route
NA
Traditional Samoan
tattooing under
unhygienic conditions
Traditional Samoan
tattooing under
unhygienic conditions
Traditional Samoan
tattooing
Non-professional
tattooing under
unhygienic conditions
Sharing the same ink
and equipment with his
wife
Non-professional
home-made tattoo
under unhygienic
conditions or potential
ink contamination
NA
NA
Outcome
Hospitalization,
fully recovered after
8 weeks
Hospitalization,
full recovery after
6 weeks but ongoing
wound management
required
Hospitalization,
full recovery after
6 weeks but ongoing
wound management
required
Hospitalization,
fully recovered after
6 weeks
Complete recovery
after 4 weeks
Hospitalization
Hospitalization,
fully recovered
Hospitalization,
fully recovered after
6 weeks
Hospitalization,
fully recovered after
6 weeks
Reference
Callejo et al.
(2010) (19)
McLean and D’Souza
(2011) (21)
Elegino-Steffens et al.
(2013) (27)
Báez Sarría et al.
(2013) (26)
Gulati et al.
(2014) (31)
Akkus et al.
(2014) (28)
Rabbani and Sharma
(2014) (33)
MEDICINE
VII
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2016; 113: 665–71
|
Supplementary material
*Confirmed by pathogen detection
A
bbreviations: f, female; m, male; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive Staphylococcus aureus; NA, data not available; WS, wound swab; BC, blood culture.
K., Klebsiella; P., Pseudomonas; S., Staphylococcus in S. aureus and S. lugdunensis; S., Serratia in S. marcescens; S., Streptococcus in S. pyogenes
Manifestations at
primary infection site
(tattoo)
Erythematous rash and
multiple papules
Secondary infection
complications,
(concomitant
pre-existing
conditions
supporting bacterial
infections)
Sepsis, septic emboli
(muscle and joints)
Sepsis, endocarditis,
pulmonary emboli
(open valvotomy
for congenital aortic
stenosis at the age of
18 months followed by
Ross procedure)
Toxic shock
syndrome
Number of cases*,
patient’s country of
origin
1, United States of
America
1, United Kingdom
1, South Korea
Age (years),
sex (m/f)
18, m
20, m
26, m
Organisms
identified (Source)
Haemophilus
influenzae (BC)
MSSA (BC, excised
pulmonary homograft
tissue)
MSSA
(WS)
Incubation
period (days)
14
28
3
Likely cause
of infection,
transmission
route
NA
Tattooing under
unhygienic conditions
NA
Outcome
Hospitalization,
fully recovered after
2 weeks
Hospitalization,
recovered after
8 weeks
Hospitalization,
fully recovered after
2–3 weeks
Reference
Kaldas et al.
(2014) (29)
Orton et al.
(2014) (32)
Jeong et al.
(2015) (35)
