Micobacterias atípicas asociadas a la acupuntura : revisión integral

Objetivo: evaluar la evidencia existente sobre las principales fuentes o mecanismos de transmisión de la infección por micobacterias atípicas asociadas con la acupuntura, y las especies causantes de infecciones. Método: investigación que llevó a cabo en Diciembre de 2011 con descriptores indexados en las bases de datos LILACS, MEDLINE, EMBASE, OvidSP y la Biblioteca Cochrane, sin restricciones en cuanto a la fecha de publicación, tipo de estudio o de idioma. Resultados: de las 16 publicaciones, sólo una identificó la fuente de contaminación: la solución de glutaraldehído diluido utilizada para limpiar el equipo. Tres publicaciones establecieron como fuentes probables: las toallas, compresas calientes o el agua hervida, y la reutilización de las agujas reprocesadas. Cuatro publicaciones indicaron como fuentes posibles: las agujas contaminadas, la reutilización de agujas personales, la piel del paciente colonizada por micobacterias y la reutilización de agujas en sitios diferentes en el mismo paciente. Ocho de los estudios no mencionaron nada acerca de las fuentes. Conclusión: Entre los 295 casos, M. abscessus fue el agente patológico en más del 96% de los mismos. Se deben llevar a cabo medidas bien establecidas de control recomendadas por organismos reguladores, como el de enfermería, para la prevención de la infección, y adaptarlas a la medicina complementaria y alternativa.


Introduction
Acupuncture has been practiced for thousands of years in the East and has also increased considerably in the West (1) .This practice has been used to treat digestive (2) , psychosomatic, menstrual, allergy, alcohol and drugs rehabilitation problems (3) .It is considered a complementary health therapy (CHT) that makes use of an invasive intervention and for this reason some concern is necessary in relation to skin antisepsis.The future of acupuncture in the West largely depends on the safety and efficacy of the treatment.The acupuncturist is responsible for the non-contamination of procedures and for preventing outbreaks when practicing the technique.
In this regard, this study highlights the infections caused by nontuberculous mycobacteria, also denominated atypical mycobacteria (4) , which are implicated as possible infectious agents in acupuncture procedures.
Bacteria of the genus Mycobacterium are aerobic, immotile, non-encapsulated bacilli, which do not sporulate and contain a high lipid content, mainly in the cells wall, making permeability difficult for dye solutions, water or microbicidal agents (5) .There are approximately 50 species of mycobacterium that have been identified as causing disease in humans, however the incidence of specific diseases caused by atypical mycobacteria has increased with the advent of the HIV/AIDS and the use of immunosuppressive therapies (6) .
These infections can be included under the category of infections related to healthcare (IRHC) and nurses should consider this issue and discuss security measures for invasive procedures.In Brazil, nurses are also required to perform CHTs, including acupuncture, under specific regulating legislation, which also establishes the complementary therapies as an specialty and/or professional qualifications of nursing, after a specialization course with a workload of 360 hours has been completed (7) .
The Brazilian Nursing Ethics Code, in article 17 (8) , states that it is the nurse's ethical and moral obligation to only assume a responsibility when being capable of performing it safely for oneself and for the client, aiming for the maximum benefits and minimum risk.The nurse also has an important role regarding infection control, as established by the professional law practice (9) and the national legislation, which requires the presence of at least one nurse on the Infection Control Commission of hospitals (10) .
The integrative review consists in an exhaustive systematic search of the scientific literature aiming to produce an overview of complex concepts, theories or relevant health problems from existing studies (11) .It is a research methodology recommended by Evidence-Based Practice (EBP), which indicates that the best scientific evidence produced by studies should be applied during the decision making process, linking the clinical practice to quality care (12) .Thus, this study proposes an integrative review of literature to assess the association of atypical mycobacterial infections with acupuncture.
A review of this subject was considered due to the relevance CHT has assumed worldwide, especially acupuncture, as well as due to a warning about the occurrence of IRHC by mycobacteria, allowing acupuncturists to improve the practice with less risk to clients and to contribute to reduce costs to the health system.Importantly, the damage related to the selfesteem, as well as the psychological and physical impacts on the patient, such as pain and suffering caused by the treatment of mycobacterial infection are immeasurable to individuals.This study aimed to evaluate evidence in the scientific literature on the major sources or mechanisms of infections transmission caused by atypical mycobacteria associated with the acupuncture procedure and to determine the main species causing infections.

Methods
The method used was an integrative review of literature and the following methodologies were defined: establishment of the research question and objectives, literature studies search, sample selection, analysis of the included studies, discussion of the results, presentation of the results and finally, the summarization of knowledge through an integrative review (12) .1), which were analyzed in full.As shown in Table 1, two publications (6,13) were excluded due to the exclusion criteria.To perform the data collection a validated instrument (14) was used that was adapted to allow the production of a summary table of the publications included (Figure 1).

Results
The 16 publications included in this review were from international journals of the medical area and the earliest was published in 2001.Among the studies included in this review, six (37.5%) were published in area of dermatology (P3; P4; P6; P8; P9; P13), five (31,2%) in journals of infection (P7; P11; P12; P14; P15), two in general medical journals (P1; P5), two in clinical microbiology periodicals (P2; P10) and one in the orthopedics area (P16).The majority of the studies, about 50.0%, were from South Korea (8 publications), followed by China and Spain, with two publications in each country.Portugal, Canada, Venezuela and Brazil presented one publication per country.
As can be seen in Figure 1, the predominant study design was the case report.Although there are ten publications of this type, P1 and P2 refer to the same case of atypical mycobacterial infection.The second most frequent type of study was reports of outbreaks, which were presented in three publications, although P6 and P7 refer to the same outbreak caused by Mycobacterium abscessus that occurred in a clinic.There was only one case-control study (P13) and one observational study (P10 and P11 refer to the same patients).
The evidence levels of the publications are presented according to study design (15) .There were three studies that have evidence level 4 (Figure 1): a case-control design (P12) and two publications that refer to the same observational study (P10 and P11).Three of the 29 cases analyzed were due to acupuncture procedures, however, there was no mention of the infection source.
Article P14 did not identify the outbreak source, though the authors refer to contaminated needles used in the acupuncture procedure as a possible source.In a literature review the authors found seven articles, corresponding to P1, P2, P3, P6, P7, P8 and P12 of this integrative review.The authors mention that, although they do not have any proof, they believe that the widespread use of quaternary ammonium disinfectant for the "sterilization" of instruments is a possible risk factor for infections caused by mycobacteria.
The patient described in P15 reported that antisepsis of the skin was not carried out prior to the procedure and that the needles were reused several times in different places in the body, which led the authors to establish possible routes of M. haemophilum which caused the infection.
Article P16 reported a case of M. abscessus after the patient receive three consecutive days of acupuncture on the bilateral knees.This woman presented no evidence of other diseases.

Discussion
Acupuncture is considered a safe procedure in general (25) .However, in the last decade, reports of infection transmission have increased considerably, including those of atypical mycobacteria (6) .Only 16 The infections were caused by six species of atypical mycobacteria, three of them, species M. abscessus, M. chelonae and M. fortuitum, are classified as rapid growth (4) .These microorganisms were responsible for about 98.6% of the infections included in this review and are commonly found in treated water, soil and the environment (5) , which demonstrates a direct relationship with the identified, probable or possible infection sources, in the studies described.
Of the 16 publications included in this integrative review only one (6.2%)identified the definite source of the outbreak: M. abscessus (P12).Three publications (P6; P7; P8) established the probable sources and two of them reported the same outbreak (P6 and P7).In another three articles the possible sources of mycobacteria were described (P3; P4; P14).The eight remaining publications (P1; P2; P5; P9; P10; P11; P13; P16), corresponding to 50.0% of the studies, did not mention anything about the sources that may have caused the cases of atypical mycobacterial infections associated with acupuncture procedures.This indicates that there are failings in the investigation process of outbreaks or in the clinical conduct of the treatment, not only in clinics where alternative or complementary therapies are practiced but also in conventional medical services that screen and treat patients who develop infection.
In addition these potential sources are associated with failures during the process of disinfecting instruments, inadequate preparation of disinfectants, not performing antisepsis of the skin and/or hand hygiene.
A routine that should be strengthened for practitioners of acupuncture is the importance of using Rev. Latino-Am.Enfermagem 2013 Jan.-Feb.;21(1):450-8.
disposable needles.This procedure is recommended by the Food and Drug Administration (FDA) (30) .Although this practice is being recommended, even in a guideline (31) developed precisely for infection control in acupuncture, the reuse of needles after sterilization is still allowed.
The guideline (31) mentions the need for and types of sterilization, nevertheless does not specify which one should be indicated nor how to apply the methods.The use of personal needles is also not indicated, as the material does not undergo to any type of reprocessing that ensures sterility.Also, there is no control of the storage once the patient is responsible for the needles.
This indicates the need for a revision (3) (32) .Moreover, low-level disinfection has no action on Mycobacterium tuberculosis (32) and, probably, on other bacilli from the same genus.Therefore the use of sterile needles for acupuncture is more appropriate.
Proposals such as hand hygiene with alcoholic chlorhexidine or povidone-iodine (PVPI) are unnecessary.
Acupuncture can be compared with recommendations for intravascular insertion catheters described by the Centers for Disease Control and Prevention of the U.S.A.
i.e., simple hand hygiene with soap and water or alcohol gel hand sanitizer before performing the procedure (Category 1A), aseptic technique ensuring the sterility of the material (Category 1A) and skin antisepsis with alcohol solution (Category 1A) (33) .The indication of Category 1A means that all these procedures are strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiologic studies (33) .Thus, antisepsis should be appropriately performed with an alcohol solution and the time required for antiseptic agent action taken into account, as is recommended by Category 1A (33) .Especially considering that one of the studies included in this review found that some species of atypical mycobacteria can survive for up to 45 seconds in contact with alcohol (3) .These safety measures associated with the use of sterile disposable needles are sufficient for the puncture to be performed safely by a professional, preventing mycobacterial infection outbreaks related to this procedure.
Thus, the importance is emphasized of guidance for students that are doing alternative and complementary therapy courses and for acupuncture practitioners in their workplaces.Regarding nurses, it is expected that the experience of infection control practice in hospitals can contribute to a safe acupuncture practice.The presence of an infection control specialist nurses has been universally seen as an essential measure for infection control programs to be effective (34) , which can also be applied to establishments that practice complementary medicine.
It is emphasized that the studies included in

Conclusion
There are several cases and outbreaks reported in in an intervention study to compare the association of clarithromycin + amikacin with that of moxifloxacin + clarithromycin.The second combination presented a significantly shorter duration of treatment than the first solution.The cause of the outbreak was not mentioned.In another outbreak report, article P12 described a case-control study.It identified as risk factors the duration of acupuncture treatment, the number of needles inserted, the use of interferential therapy or low-frequency equipment and the application of hot water packs.A retrospective study (P13) investigated the clinical and microbiological characteristics of several skin infections caused by atypical mycobacteria which were treated at a hospital between 1995 and 2008.
were found in the scientific literature related to the proposed theme, even without setting limits on publication date, type of study or language.This raises two questions: a) Is there underreporting of cases of mycobacterial infections in Eastern and Western countries?b) Do cases of atypical mycobacterial infection go underreported in the literature due to the fact that methods for microorganism identification became more accurate after the year 2000?Although this review was mainly composed of studies with low levels of evidence, it is important to emphasize that cases and even outbreaks (P6; P7; P8) of atypical mycobacterial infections are happening.Females were predominant in the development of mycobacterial infections perhaps because they constitute the majority of acupuncture patients.
this review (P1 -P16) isolated and identified the Mycobacterium microorganism from different sources, however, no molecular research was carried out in order to confirm the clonal origin.This type of investigation can be explored in the case of new outbreaks, confirming the clonal origin of the bacteria and contributing to the advancement of knowledge of this subject.It is important to emphasize the role of the nurse as educator in infection prevention and control and their possible role as technical managers in the IRHC control program and clinics which perform CHTs, as well as in institutions which work with complementary medicine.Therefore, the nursing professional acupuncturist, with a solid training in infection control, can take part in the prevention and control of IRHC in complementary health practices.Furthermore, it is important to study not only the most effective and appropriate antibiotic therapy for the treatment of mycobacteria, but also to investigate the probable infection sources when cases of mycobacteria associated with acupuncture are detected.
the literature about infection by atypical mycobacteria associated with acupuncture procedures, especially those of rapid growth, however, the majority of publications did not refer to the infection source.Only one study identified a diluted glutaraldehyde solution prepared several months before the use that was applied to clean the equipment as the definite infection source.Six publications suggest probable or possible Gnatta JR, Kurebayashi LFS, Silva MJP.sources, such as objects or utensils and contaminated needles, reuse of personal needles, reuse of needles on various sites in the same patient and also the reuse of needles, which were disinfected in glutaraldehyde diluted incorrectly in tap water, on different patients.M. abscessus was the microorganism responsible for the majority of infections.Well-established control and infection prevention practices, which are recommended by regulators, should be implemented and adapted by nurses for complementary and alternative medicine.

Table 1 -
Selection of publications from databases and references of other publications according to the criteria established for inclusion of studies in this integrative review.Brazil, 2011