Today, “think before you ink” has a far different meaning. It’s an exhortation to ponder the implications, and the safety, of getting a tattoo.

A report in this week’s Journal of the American Medical Association describes an outbreak of tattoo-related infections in four states: New York, Washington, Iowa, and Colorado. All involved Mycobacterium bacteria. Infection with these fast-growing bugs can cause problems ranging from a mild rash around the tattoo site to severe abscesses that require surgery and several months of antibiotic therapy.

“Tattoo-related infections aren’t common, but they do happen,” says Dr. Daihung Do, an instructor in dermatology at Harvard Medical School and director of cosmetic and laser surgery at Beth Israel Deaconess Medical Center. “They can take various forms—I once saw a patient who developed warts as a result of a tattoo.”

Once the emblem of sailors and biker gangs, tattoos have moved into the mainstream. Depending on the survey, 20% to 40% of adult Americans have one or more tattoos. In addition plenty of teens and twenty-somethings, I’ve seen them on new moms and dads and grandmothers. They are becoming accepted in the workplace.