Clinical Characteristics and Outcome of Severe Melioidosis Requiring Intensive Care

The Epidemiology of Melioidosis and Its Association with Diabetes Mellitus: A Systematic Review and Meta-Analysis

Melioidosis is an under-recognized fatal disease in humans, caused by the Gram-negative bacterium Burkholderia pseudomallei. Globally, more than 35,000 human melioidosis cases have been reported since 1911. Soil acts as the natural reservoir of B. pseudomallei. Humans may become infected by this pathogen through direct contact with contaminated soil and/or water. Melioidosis commonly occurs in patients with diabetes mellitus, who increase the occurrence of melioidosis in a population. We carried out a systematic review and meta-analysis to investigate to what extent diabetes mellitus affects the patient in getting melioidosis. We selected 39 articles for meta-analysis. This extensive review also provided the latest updates on the global distribution, clinical manifestation, preexisting underlying diseases, and risk factors of melioidosis. Diabetes mellitus was identified as the predominant predisposing factor for melioidosis in humans. The overall proportion of melioidosis cases having diabetes was 45.68% (95% CI: 44.8-46.57, p < 0.001). Patients with diabetes mellitus were three times more likely to develop melioidosis than patients with no diabetes (RR 3.40, 95% CI: 2.92-3.87, p < 0.001). The other potential risk factors included old age, exposure to soil and water, preexisting underlying diseases (chronic kidney disease, lung disease, heart disease, and thalassemia), and agricultural activities. Evidence-based clinical practice guidelines for melioidosis in patients with diabetes mellitus may be developed and shared with healthcare professionals of melioidosis endemic countries to reduce morbidity.

Risk Factors for Mortality in Melioidosis: A Single-Centre, 10-Year Retrospective Cohort Study

Melioidosis is a tropical infectious disease with diverse clinical presentations. We aimed to investigate the characteristics and mortality risk factors of patients diagnosed with melioidosis in the past 10 years. This was a retrospective cohort study conducted at a quaternary care centre in South India. Clinical, demographic, and biochemical data in patients diagnosed with melioidosis with cultures were collected between January 2011 and December 2020 from medical records. Logistic regression analysis was performed to screen mortality risk factors of melioidosis in addition to descriptive statistics and chi-square analysis. Seventy-three melioidosis patients' records were analysed, and the most common comorbidity was type 2 diabetes mellitus (n = 53, 72.6%). The patients showed diverse presentations: pulmonary involvement, 30 (41.1%); splenomegaly, 29 (39.7%); abscesses and cutaneous involvement, 18 (24.7%); lymph node, 10 (13.7%); arthritis and osteomyelitis, 9 (12.3%); and genitourinary infection, 4 (5.4%). The mortality was noted to be 15 (20.5%). Logistic regression analysis indicated that chronic kidney disease (OR = 14.0), CRP >100 IU/L (OR = 6.964), and S. albumin <3 gm/dl (OR = 8.0) were risk factors associated with mortality and can guide in risk stratification. Hypoalbuminemia is a novel mortality risk factor, detected in this study, and requires further investigation to validate its utility as a prognostic marker and reveal possible therapeutic benefits in clinical correction.

The Trend of Direct Medical Cost of Meliodiosis Patients in Kedah: A Retrospective Study from 2014 to 2017

Purpose

This study was conducted to determine the direct medical cost of treating melioidosis patients. The calculation was made according to the variables extracted from medical records.

Materials and Methods

Data collection was performed retrospectively on a total of 293 cases from Hospital Sultanah Bahiyah, Kedah, Malaysia. The data consisted of personal information, treatment history, and investigation findings, including blood results, USG abdomen results, and CT scan results. The site of culture and sensitivity were also obtained. The total direct medical cost was based on the antibiotics/treatments received by the patients, diagnostic test and investigations performed. The trend analysis used to see the pattern of costs from 2014 to 2017. All the costs were compared based on patients’ status and duration of stay at the hospital using the independent t-test.

Results

The overall mean of direct medical cost for melioidosis amounted to US $233.61 (RM931.33). Overall, the finding confirms a huge reduction (44.7%) of direct medical cost from 2014 to 2017 (P = 0.001). From 2015 to 2016, there was a 19.1% reduction of direct medical cost (P>0.95), followed by a 38.8% reduction in costs from 2016 to 2017 (P = 0.019). In the case of the duration of stay, the mean of total direct medical cost among patients with ≥14 duration of stay was higher compared to those with <14 duration of stay (p < 0.001). There was no significant mean difference of direct medical cost between patients who were cured and died.

Conclusion

Despite the higher mortality of melioidosis cases compared to other infectious diseases, there is a limitation in the amount of published data on the management cost of melioidosis. The importance of cost in managing this disease should be underlined to perform a fully prepared management toward the disease.

A Burkholderia pseudomallei Infection Imported from Eritrea to Israel

Although it has been predicted that melioidosis is probably endemic in the Horn of Africa, no confirmed cases have ever been detected in the region. We have recently isolated Burkholderia pseudomallei from an Eritrean patient in Israel. The isolate was assigned a novel multilocus sequence type (ST-1479). The observation has important epidemiological implications in an era of massive human migration.

A 42-year-old farmer from Bangladesh with respiratory failure, septic arthritis, and multiple cavitating consolidations

A 42-year-old man was directly admitted to the ICU with respiratory failure and hypotension. Two weeks prior and just after returning from Bangladesh, he presented to a polyclinic with fever, right knee pain, and generalized aches, for which he received oral antibiotics. He was a farmer, had diabetes, never smoked, and consumed alcohol occasionally.

Short report: Predictors of severe disease in melioidosis patients in Kuala Lumpur, Malaysia

The predictors of severe disease or death were determined for 85 melioidosis patients in Kuala Lumpur, Malaysia. Most of the patients were male, > 40 years old, and diabetic. Severe disease or death occurred in 28 (32.9%) cases. Lower lymphocyte counts and positive blood cultures were significant independent predictors of severe disease, but age, presentations with pneumonia, inappropriate empirical antibiotics, or flagellin types of the infecting isolates were not. Knowledge of local predictors of severe disease is useful for clinical management.

Combining vaccination and postexposure CpG therapy provides optimal protection against lethal sepsis in a biodefense model of human melioidosis

The Gram-negative bacterium Burkholderia pseudomallei is the causative agent of melioidosis, a major cause of lethal sepsis and morbidity in endemic areas of Southeast Asia and a potential bioterrorism threat. We have used susceptible BALB/c mice to evaluate the potential of targeting vaccination and generic immunotherapy to the lung for optimal protection against respiratory challenge. Intranasal vaccination with live attenuated B. pseudomallei increased survival and induced interferon-γ-secreting T cells in the lung. Intranasal delivery of CpG oligodeoxynucleotides also provided significant protection; however, combining preexposure vaccination with CpG treatment at the time of infection or up to 18 hours after infection, provided significantly greater protection than either treatment alone. This combination prolonged survival, decreased bacterial loads by >1000-fold, and delayed the onset of sepsis. This novel approach may be applicable to other potential biodefense agents for which existing countermeasures are not fully effective.

Pulmonary melioidosis in Cambodia: a prospective study

BACKGROUND

Melioidosis is a disease caused by Burkholderia pseudomallei and considered endemic in South-East Asia but remains poorly documented in Cambodia. We report the first series of hospitalized pulmonary melioidosis cases identified in Cambodia describing clinical characteristics and outcomes.

METHODS

We characterized cases of acute lower respiratory infections (ALRI) that were identified through surveillance in two provincial hospitals. Severity was defined by systolic blood pressure, cardiac frequency, respiratory rate, oxygen saturation and body temperature. B. pseudomallei was detected in sputum or blood cultures and confirmed by API20NE gallery. We followed up these cases between 6 months and 2 years after hospital discharge to assess the cost-of-illness and long-term outcome.

RESULTS

During April 2007 - January 2010, 39 ALRI cases had melioidosis, of which three aged ≤2 years; the median age was 46 years and 56.4% were males. A close contact with soil and water was identified in 30 patients (76.9%). Pneumonia was the main radiological feature (82.3%). Eleven patients were severe cases. Twenty-four (61.5%) patients died including 13 who died within 61 days after discharge. Of the deceased, 23 did not receive any antibiotics effective against B. pseudomallei. Effective drugs that were available did not include ceftazidime. Mean total illness-related costs was of US$65 (range $25-$5000). Almost two-thirds (61.5%) incurred debt and 28.2% sold land or other belongings to pay illness-related costs.

CONCLUSIONS

The observed high fatality rate is likely explained by the lack or limited access to efficient antibiotics and under-recognition of the disease among clinicians, which led to inappropriate therapy.

Melioidosis and the vacuum-assisted closure device: a rare cause of a discharging neck wound, and a new approach to management

OBJECTIVE

We report a case of melioidosis presenting as a discharging neck abscess, and we describe the use of a vacuum-assisted closure device in its management.

METHOD

We report the case of a 44-year-old, Afro-Caribbean woman with melioidosis. We also present the results of a literature search using the search terms 'melioidosis', 'Burkholderia pseudomallei' and 'vacuum-assisted closure device'.

RESULTS

Microbiological analysis identified the causative organism as being the bacterium Burkholderia pseudomallei, and its antimicrobial sensitivities to imipenem and ciprofloxacin. A vacuum-assisted closure device was used to manage the patient's melioidosis of the neck; we believe this is the first report of such treatment.

CONCLUSIONS

Melioidosis is rare in the UK and western world; however, exposure can occur during travel to endemic areas. We therefore draw attention to this infection as part of the differential diagnosis of a neck abscess. We propose the use of vacuum-assisted closure devices as useful adjuncts to the management of discharging neck wounds.