Treatment of melioidosis
Treatment consists of an initial phase of intravenous (with or without oral) therapy, followed by oral eradication therapy.
For initial therapy of non-neurological melioidosis, use:
1 ceftazidime 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For ceftazidime dosage adjustment in adults with kidney impairment, seek expert advice. The duration of therapy is at least 14 days (duration depends on site of infection—see Duration of therapy for melioidosis) melioidosis, treatment ceftazidime ceftazidime ceftazidime
OR
patients without septic shock and not requiring intensive care support: 1 g (child: 25 mg/kg up to 1 g) 8-hourly1
patients with septic shock or requiring intensive care support: 2 g (child: 40 mg/kg up to 2 g) administered as a loading dose over 30 minutes. After 4 hours, administer 2 g (child: 40 mg/kg up to 2 g) 8-hourly, as consecutive 8-hour infusions23.
For initial therapy of neurological melioidosis, use:
patients without septic shock and not requiring intensive care support: 2 g (child: 40 mg/kg up to 2 g) 8-hourly; administer the dose over 3 hours
patients with septic shock or requiring intensive care support: 2 g (child: 40 mg/kg up to 2 g) administered as a loading dose over 30 minutes. After 4 hours, administer 2 g (child: 40 mg/kg up to 2 g) 8-hourly, as consecutive 8-hour infusions24.
For patients with neurological infection, osteomyelitis, septic arthritis, genitourinary infection (including prostatic abscess), or skin and soft tissue infection, add to the initial therapy regimens above:
trimethoprim+sulfamethoxazole (adult more than 60 kg: 320+1600 mg; adult 40 to 60 kg: 240+1200 mg; child 1 month or older: 6+30 mg/kg up to 240+1200 mg) orally, 12-hourly (duration depends on site of infection—see Duration of therapy for melioidosis). For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole dosage adjustment melioidosis, treatment trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole
PLUS
folic acid 5 mg (child: 0.1 mg/kg up to 5 mg) orally, daily (duration depends on site of infection—see Duration of therapy for melioidosis). melioidosis folic acid folic acid folic acid
Consider granulocyte colony-stimulating factor (G-CSF) for critically ill patients with melioidosis.
When the patient is stable and if treatment will be continued at home with ambulatory antimicrobial therapy, ceftazidime or meropenem given by intermittent dosing can be switched to ceftazidime given by continuous infusion, if a suitable preparation is available.
Once the course of initial therapy is completed, follow with oral eradication therapy:
trimethoprim+sulfamethoxazole (adult more than 60 kg: 320+1600 mg; adult 40 to 60 kg: 240+1200 mg; child 1 month or older: 6+30 mg/kg up to 240+1200 mg) orally, 12-hourly for a further 3 to 6 months (duration depends on site of infection—see Duration of therapy for melioidosis) trimethoprim + sulfamethoxazole . For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole dosage adjustment
PLUS
folic acid 5 mg (child: 0.1 mg/kg up to 5 mg) orally, daily for a further 3 to 6 months (duration depends on site of infection—see Duration of therapy for melioidosis). folic acid
If trimethoprim+sulfamethoxazole is contraindicated or not tolerated and drug desensitisation is not possible, alternative options for oral therapy include doxycycline or high-dose amoxicillin+clavulanate—seek expert advice.
|
Clinical focus |
Initial phase of therapy—minimum duration [NB1] |
Eradication therapy—duration |
|---|---|---|
|
Skin infection |
2 weeks |
3 months |
|
Bacteraemia with no focus |
2 weeks |
3 months |
|
Pneumonia |
2 to 4 weeks |
3 months |
|
Prostatic abscess, septic arthritis and organ or deep-seated tissue collection |
4 weeks [NB2] |
3 months |
|
Osteomyelitis |
6 weeks |
6 months |
|
Neurological and vascular infections |
8 weeks |
6 months |
|
Note:
NB1: The duration of the initial phase of therapy may need to be extended if improvement is slow or if blood culture results remain positive at 7 days. NB2: The duration of the initial phase of therapy depends on the date and results of culture of the most recent sample following drainage of collection (eg prostatic abscess or joint washout). If the culture grows B. pseudomallei, or if the sample is not sent for culture, the clock is reset to day 1. If the culture is negative, the clock is usually not reset. Adapted from Pitman MC, Luck T, Marshall CS, Anstey NM, Ward L, Currie BJ. Intravenous therapy duration and outcomes in melioidosis: a new treatment paradigm. PLoS Negl Trop Dis 2015;9(3):e0003586. doi:10.1371/journal.pntd.0003586. © 2015 Pitman et al. https://creativecommons.org/licenses/by/4.0/ | ||