Nearly two dozen women who traveled from the U.S. to the Dominican Republic in search of less-expensive tummy tucks and other cosmetic procedures came home with more than they bargained for—severe surgical infections that required months of antibiotic treatment or additional surgeries, or both. The pathogen that caused their problemsMycobacterium abscessusis distantly related to both tuberculosis and leprosy and has become more and more of a problem in a growing number of medical settings around the world, according to the U.S. Centers for Disease Control and Prevention.

The cases were discovered in 2013 after an astute physician in Maryland noticed that two patients who had recently undergone surgery in the Dominican Republic had prolonged swelling, tenderness and fluid discharges at the site of their incisions that didn’t respond to standard treatment. The doctor alerted local health authorities, who called in the CDC. Further investigation uncovered 19 other infections among medical tourists from five other states (Connecticut, Massachusetts, New Jersey, New York and Pennsylvania). More than half of the women had surgery at the same clinic in the Dominican Republic.

M. abscessus is naturally found in both water and soil, along with other so-called rapidly growing mycobacteria. Generally this strain affects either the lungs or skin, usually after some kind of invasive procedure. Previous outbreaks have been traced to contaminated tattoo ink (New York), shared diagnostic equipment at a cystic fibrosis clinic (Hawaii) and contaminated water at a pediatric dental office (Georgia). The infection can also spread during floods, particularly if individuals are battered and bruised by the turbulent flow of water.  M. abcessus contaminated the wounds of a number of survivors of the 2004 Indian Ocean tsunami.

Many of the women who became infected in the more recent Dominican outbreak were subsequently admitted several times to the hospital, underwent one or more operations to remove hopelessly infected or damaged tissue and needed to take antibiotics for more than three months. The study, which was published in the August 2016 Emerging Infectious Diseases, “highlights the need for consumers to be informed of the risks of medical tourism and for clinicians and public official to be on the lookout for these infections in patients who have undergone surgery in foreign destinations,” one of the co-authors, Doug Esposito, a medical epidemiologist with the CDC’s Traveler’s Health Branch, wrote in an email.