Correspondence

Septicemic Melioidosis

Subaalaxmi MVS

Assistant Professor, Department of Medicine, Nizams institute of medical sciences, Hyderabad, Andhra Pradesh.

Sir,

I read the article entitled “Septicemic melioidosis” published in the August 2009 issue of JAPI with great interest. Burkholderia pseudomallei is overlooked by the microbiologists and clinicians in many cases due to the lack of awareness. The authors have isolated B. pseudomallei in the blood culture and managed the initial part effectively. The authors have treated the patient with initial 2 weeks of intravenous Meropenem but with an advice to take trimethoprim-sulphamethoxazole (320/1600mg orally) for only 14 days. The treatment of melioidosis is divided in to two stages: 2 weeks of intensive phase with intravenous antibiotics with ceftazidime or carbapenem followed by maintenance therapy with oral trimethoprim-sulphamethoxazole for at least 12 weeks to eradicate the organism and prevent relapse.1 Even with 20 weeks of treatment, 10% of patients relapse.2 Krishnan et al described a case of melioidosis who demonstrated improvement and resolution of his splenic abscesses with use of Piperacillin/Tazobactam in the initial intensive phase. Furthermore, despite therapy initially with Piperacillin and Tazobactam, the patient did not have an adverse outcome leading one to speculate that Piperacillin/Tazobactam may have some therapeutic efficacy in Burkholderia sepsis.3 I would like to reiterate that the treatment of Melioidosis is for prolonged period not 2 weeks of co-trimoxazole during maintenance phase.

References

1. Reuben Ramphal. Infections due to pseudomonas species and Related Organisms In: Kasper, Braunwald, Fauci, Hauser, Longo, Jameson, editors. Harrison’s principles of internal medicine.17th ed. Mc Graw-Hill 2005; 949-955.
2. White NZ. Melioidosis Lancet 2003; 361:1715-22.
3. P Krishnan, Sushmitha Fernandes, Jayanthi Savio, Cecil Reuben Ross, Rekha Pradeep, Ratnamala Choudhary et al. Melioidosis. JAPI 2008; 56:636-9.

Reply from Author

Sir,

Dr. Subaalaxmi MVS has raised a very pertinent point regarding the maintenance therapy which we have not detailed in this case report. However, I would like to explain our approach regarding the management of this patient during the phase of maintenance therapy.

The recommendations for the duration of oral maintenance therapy for invasive meliodosis is between 12-20 weeks in various published literature. The patient’s indigent economic condition prompted early discharge after completion of the intensive intravenous phase. The patient was asked to come for follow up after two weeks of taking trimethoprim/sulphamthoxazole (320/1600mg orally) for planning the dose and duration of his oral maintenance therapy (trimethoprim/sulphamthoxazole alone or combination of trimethoprim/sulphamthoxazole and doxycycline depending on his condition) and to switch him back on oral hypoglycaemics. He was given written directions to that effect. Unfortunately the patient was lost to follow up.

Ujjwayini Ray (Khan)
Consultant Microbiologist, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata 700 054 Received: 18.09.2009; Accepted: 17.09.2009