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PubMed1989

Interactions in vitro between agents used to treat melioidosis.

Combinations of antimicrobial agents are usually recommended for the treatment of melioidosis. In Thailand, the conventional treatment regimen for Pseudomonas pseudomallei infections is a combination of chloramphenicol, doxycycline and cotrimoxazole. We have consistently observed antagonism between these agents during routine disc susceptibility testing. Interactions between these antimicrobials were studied further by a chequerboard microdilution method, using five clinical isolates of P. pseudomallei. Both trimethoprim and sulphamethoxazole antagonised the bacteriostatic activity of chloramphenicol and doxycycline. The combination of trimethoprim and sulphamethoxazole was synergistic, but not bactericidal. Bacteriostatic drugs antagonised the bactericidal activity of ceftazidime, which is undergoing clinical trials in severe melioidosis. These findings may be of therapeutic relevance.

Anti-Bacterial Agents↗
PubMed2000

Serum bactericidal and inhibitory titres in the management of melioidosis.

A retrospective evaluation of the relationship between serum bactericidal and inhibitory titres and treatment outcome in 195 adult Thai patients with severe melioidosis was conducted. Drug regimens included ceftazidime (52% of patients), co-amoxiclav (24%), imipenem (11%) or the conventional four-drug combination (11%). Pre- and 1 h post-dose serum samples were collected after 48-72 h of therapy, and serum inhibitory and bactericidal titrations determined. Median post-dose titres were: bactericidal 1:8 (range 0-1:128) and inhibitory 1:16 (range 0-1:128). Overall mortality was 26% and outcome was not influenced by either inhibitory or bactericidal titres. Pre-dose titres correlated with renal function; renal function was the most important predictor of mortality. Determination of serum inhibitory or bactericidal titres is unhelpful in the management of severe melioidosis.

Adolescent↗
PubMed2000

Comparison of efficacy of ciprofloxacin and doxycycline against experimental melioidosis and glanders.

Melioidosis and glanders are caused by the closely related species Burkholderia pseudomallei and Burkholderia mallei, respectively. Whereas melioidosis is a significant cause of morbidity in south-east Asia, glanders is extremely rare. The efficacies of ciprofloxacin and doxycycline were assessed against a strain of B. pseudomallei and a strain of B. mallei which were susceptible to both antimicrobials in vitro. Porton outbred mice and Syrian hamsters were given 40 mg/kg of either doxycycline or ciprofloxacin twice daily by sc injection according to one of three regimens: dosing starting 48 h before challenge and continuing for 5 days postchallenge; 5 days' therapy starting immediately after challenge; 5 days' therapy starting 24 h after challenge. Mice were challenged ip with B. pseudomallei 4845 and hamsters were challenged ip with B. mallei 23344. Antimicrobial efficacy was determined by the shift in the median lethal dose (MLD). Ciprofloxacin prophylaxis and immediate therapy both raised the MLD of B. pseudomallei to 4 x 10(6) cfu from 19 cfu in untreated animals, but therapeutic ciprofloxacin only raised the MLD to 180 cfu. The results for doxycycline were similar. Ciprofloxacin prophylaxis raised the MLD of B. mallei 23344 to 4.6 x 10(5) cfu compared with 4 cfu in untreated controls. Immediate therapy raised the MLD to 7.0 x 10(4) cfu and therapy raised the MLD to 1.6 x 10(3) cfu. All regimens of doxycycline protected hamsters against challenges of up to 2 x 10(7) cfu. Despite using a susceptible strain of B. pseudomallei, neither antimicrobial was effective when used therapeutically. The timely administration of either antimicrobial, however, was effective in preventing symptomatic infection. Doxycycline was the superior of the two antimicrobials against experimental glanders although relapse did occur in treated animals approximately 4-5 weeks after challenge.

Animals↗
PubMed2002

Melioidosis.

Melioidosis is an important public health problem in some regions, and a potential bioweapon. Recent reports confirm that it is endemic in China, Taiwan and Laos, but the true incidence in most countries is unknown, and the ecology poorly understood. Potable water was the source of two recent outbreaks. The epidemiology and clinical manifestations of the disease in Australia are similar to those in Thailand, although prostatic abscesses and neurological manifestations are more common and parotid abscesses less so. Mycotic aneurysms are not uncommon. Patients with cystic fibrosis are at risk of pulmonary melioidosis. Comparison with the avirulent Burkholderia thailandensis has identified capsular polysaccharide as an important virulence determinant in Burkholderia pseudomallei. Diagnosis still relies on culture, and a throat swab is a worthwhile sample. Several beta-lactams, such as meropenem, reduce the mortality, and long courses of cotrimoxazole-containing regimes are needed to prevent relapse. The value of adjunctive treatments, such as granulocyte colony-stimulating factor, warrants further evaluation.

Anti-Bacterial Agents↗
PubMed1988

Neonatal melioidosis: a report of 5 cases.

Melioidosis, caused by Pseudomonas pseudomallei, occurs in tropical areas and is diagnosed mostly in adults. In Khon Kaen, a province of northeast Thailand, five cases of infantile melioidosis were managed at Srinagarind Hospital. The patient's specimens were submitted to microbiologic and serologic examination for P. pseudomallei demonstrated by indirect hemagglutination. Possible modes of transmission such as environment, perinatal exposure and venereal transmission were investigated.

Cefotaxime↗
PubMed1995

Clinical manifestations of melioidosis in children.

Fifty-five children with culture-proved melioidosis treated at Srinagarind Hospital from 1979 to 1993 were retrospectively reviewed. Twenty patients had septicemia and 35 patients had localized infection. Eleven patients (55%) in the septicemic group had underlying diseases but none in the localized infection group. In the septicemic patients the most common organ involvement was the lung (75%). Shock was present in 45% and the case fatality rate was very high (60%). In localized melioidosis suppurative parotitis was the most common manifestation (40%). Other common infections included skin and subcutaneous abscesses and lymphadenitis. There was no shock or death in this group.

Adolescent↗
PubMed1997

Toxin production by Burkholderia pseudomallei strains and correlation with severity of melioidosis.

An exotoxin lethal to cells in culture (cytolethal toxin, CLT) was identified in culture filtrates of Burkholderia pseudomallei, the causative organism of melioidosis. CLT could pass through a 10-kDa cut-off ultrafilter and its properties suggest that it is a peptide. Isolates from soil, animals and man showed differential cytolethality in vitro. The isolates were divided into low, medium and high CLT producers with soil isolates being low producers and isolates from patients with melioidosis encephalitis being high producers. CLT levels are subject to regulation, as a strain isolated from an infected goat was one of the highest producers whereas the same strain isolated from soil was a low producer. In addition to CLT, all isolates produced a protein with cell-elongating activity which was also present in culture filtrates.

Animals↗
PubMed2004

Attenuated virulence and protective efficacy of a Burkholderia pseudomallei bsa type III secretion mutant in murine models of melioidosis.

Melioidosis is a severe infectious disease of animals and humans caused by the Gram-negative intracellular pathogen Burkholderia pseudomallei. An Inv/Mxi-Spa-like type III protein secretion apparatus, encoded by the B. pseudomallei bsa locus, facilitates bacterial invasion of epithelial cells, escape from endocytic vesicles and intracellular survival. This study investigated the role of the Bsa type III secretion system in the pathogenesis of melioidosis in murine models. B. pseudomallei bipD mutants, lacking a component of the translocation apparatus, were found to be significantly attenuated following intraperitoneal or intranasal challenge of BALB/c mice. Furthermore, a bipD mutant was attenuated in C57BL/6 IL-12 p40(-/-) mice, which are highly susceptible to B. pseudomallei infection. Mutation of bipD impaired bacterial replication in the liver and spleen of BALB/c mice in the early stages of infection. B. pseudomallei mutants lacking either the type III secreted guanine nucleotide exchange factor BopE or the putative effectors BopA or BopB exhibited varying degrees of attenuation, with mutations in bopA and bopB causing a significant delay in median time to death. This indicates that bsa-encoded type III secreted proteins may act in concert to determine the outcome of B. pseudomallei infection in mice. Mice inoculated with the B. pseudomallei bipD mutant were partially protected against subsequent challenge with wild-type B. pseudomallei. However, immunization of mice with purified BipD protein was not protective.

Animals↗
PubMed1995

Imaging patterns in melioidosis.

Melioidosis is an infectious disease caused by Pseudomonas pseudomallei. It is seldom diagnosed promptly and, if untreated, can lead to an 80-100% mortality rate. Twenty-eight patients with melioidosis were identified over a 6 year period, and their imaging patterns were analysed. Respiratory infections were the commonest form of presentation, frequently shown as diffuse airspace consolidation, and accounted for the highest mortality. Visceral and musculoskeletal infections were associated with chronicity and a high relapse rate. Multifocal splenic abscesses were a common occurrence. Septic arthritis of the knee was frequently seen. The majority of patients had diabetes mellitus and chronic ill-health. An increased awareness of the disease can contribute to its early detection and appropriate treatment.

Abscess↗
PubMed1996

The radiology of melioidosis.

Melioidosis varies from subclinical infection to fulminating disease with multiple organ involvement. Although endemic in South-East Asia and northern Australia, it may be imported into temperate zones. It is the wide spectrum of manifestation that makes it 'the great imitator'. The purpose of this pictorial essay is to familiarize the radiologist with the range of radiological manifestations of this disease. Intrathoracic findings include pulmonary nodules, consolidation, necrotizing lesions, pleural effusion, pleural thickening and mediastinal abscess. Abscess in almost all organ systems can be seen in the septicaemic and suppurative infections. Both clinical and radiological findings are non-specific. A high index of suspicion is required to focus the search for bacteriological confirmation. A prompt diagnosis is essential, as melioidosis is often rapidly fatal.

Abdominal Abscess↗
PubMed1995

Enzyme-linked immunosorbent assay (ELISA) using a glycolipid antigen for the serodiagnosis of melioidosis.

The serodiagnosis of melioidosis is commonly performed with tests using protein or polysaccharide as antigen. However, due to the low sensitivity, specificity and difficulty in the preparation of the antigens, more simple, precise and reproducible diagnostic tests were required. A purified glycolipid antigen (GL) which is a specific lipid component of Burkholderia pseudomallei has been used in an ELISA. With this antigen, specific immunoglobulin G (IgG) was detected in 49 out of 50 melioidosis sera. IgG was also detected in 2 out of 185 (Japanese) and 16 out of 181 (Vietnamese) control sera. Thus, the sensitivity was 98.0%, and specificity was 98.9% and 91.1% in the Japanese and Vietnamese sera, respectively. When the ELISA and indirect haemagglutination (IHA) tests were combined, a sensitivity of 100% and specificity of 97.8% were achieved. The advantages of the glycolipid antigen are ease of preparation, stability, high sensitivity and specificity.

Antigens, Bacterial↗
PubMed1978

Melioidosis in a sulphur-crested cockatoo (Cacatua galerita).

A case of melioidosis in a sulphur-crested cockatoo (Cacatua galerita) kept as a pet in Townsville is described. This case was characterised by liver necrosis with both a heterophil and mononuclear cell inflammatory response associated with giant cells. Pseudomonas pseudomallei was isolated by blood plate culture and guinea pig inoculation. This is the first case of melioidosis reported in a native bird in Australia.

Animals↗
PubMed1986

Melioidosis in intensive piggeries in south eastern Queensland.

The epidemiology of melioidosis was investigated in 8 intensive piggery units which used water from the same river in south eastern Queensland. In 3 consecutive years cases of disease followed heavy rainfall and flooding. Although Pseudomonas pseudomallei was not isolated from water or soil samples the water supply was suspected as the source of infection. Affected pigs were detected at slaughter by the presence of abscesses most commonly in the bronchial lymph nodes (40%) and spleen (34%). One hundred and fifty nine cases were observed at slaughter from a total of 17,397 animals at risk. Infection by inhalation of water aerosols derived from nipple drinkers, hose sprays and a water misting cooler was considered to be responsible for the bronchial lymph node lesions. These outbreaks occurred outside the area in which melioidosis is generally regarded as being endemic.

Animals↗
PubMed1988

Evaluation of four serological tests for the diagnosis of caprine melioidosis.

A complement fixation (CF) test, 2 indirect haemagglutination (IHA-A; IHA-L) tests which differed in antigen preparation and technique, and a microtitre agglutination (MA) test were compared in the serodiagnosis of melioidosis in goats. One hundred and eighteen experimental serums and 3143 field serums from goats in endemic and non-endemic areas of north Queensland were used in the evaluation. Culture of samples for Pseudomonas pseudomallei from 112 goats provided substantiating evidence of infection. The IHA-A test was the most sensitive, and the CF test the most specific. We advocate the use of the IHA-A as a screening test followed by the CF test for confirmation of active melioidosis. The IHA-A test is the better indicator of past infection.

Acute Disease↗
PubMed2005

Open-label randomized trial of oral trimethoprim-sulfamethoxazole, doxycycline, and chloramphenicol compared with trimethoprim-sulfamethoxazole and doxycycline for maintenance therapy of melioidosis.

Melioidosis (infection caused by Burkholderia pseudomallei) requires a prolonged course of oral antibiotics following initial intravenous therapy to reduce the risk of relapse after cessation of treatment. The current recommendation is a four-drug regimen (trimethoprim [TMP], sulfamethoxazole [SMX], doxycycline, and chloramphenicol) and a total treatment time of 12 to 20 weeks. Drug side effects are common; the aim of this study was to compare the efficacy and tolerance of the four-drug regimen with a three-drug regimen (TMP-SMX and doxycycline). An open-label, randomized trial was conducted in northeast Thailand. A total of 180 adult Thai patients were enrolled, of which 91 were allocated to the four-drug regimen and 89 to the three-drug regimen. The trial was terminated early due to poor drug tolerance, particularly of the four-drug regimen. The culture-confirmed relapse rates at 1 year were 6.6% and 5.6% for the four- and three-drug regimens, respectively (P = 0.79). The three-drug regimen was better tolerated than the four-drug regimen; 36% of patients receiving four drugs and 19% of patients receiving three drugs required a switch in therapy due to side effects (P = 0.01). The duration of oral therapy was significantly associated with relapse; after adjustment for confounders, patients receiving less than 12 weeks of oral therapy had a 5.7-fold increase of relapse or death. A combination of TMP-SMX and doxycycline is as effective as and better tolerated than the conventional four-drug regimen for the oral treatment phase of melioidosis.

Adolescent↗
PubMed1970

Serological diagnosis of human melioidosis with indirect hemagglutination and complement fixation tests.

An indirect hemagglutination (IHA) test and a complement fixation (CF) test were evaluated from test results on sera from 212 human melioidosis patients of which 119 were culturally proved cases. Significant antibody titers (IHA titers of 1:40 or greater and CF titers of 1:4 or greater) were demonstrated with either test in all except five patients. IHA and CF titers ranged as high as 1:20,480 and 1:1,024, respectively. Antibodies were usually demonstrated by both tests 1 week after onset of disease. Transient seronegative reactions during the course of disease were seen in sera of approximately 19% of the patients with either IHA and CF but rarely with both tests. High titers in either test were obtained by the third week of disease and reached maximum levels in 4 to 5 months. Titers usually were detectable for 9 or more months. Antibodies were detected by IHA and CF tests in 80 to 100% of the sera obtained at various time intervals from 9 months to 2 or more years after disease onset. Antibody persistence occurred in patients who had a short disease course, as well as in patients with prolonged, complicated infections. The IHA test had excellent specificity when evaluated with normal human sera and diverse antimicrobial sera from hyperimmunized rabbits and human patients. The CF antigen appeared to contain common antigens with some but not all types of Pseudomonas aeruginosa. The specificity of the CF antigen could be enhanced without appreciable effect on its sensitivity by use of a titer of 1:8 in lieu of 1:4 as a criterion for a significant reaction. Either test could be used advantageously for the laboratory diagnosis of melioidosis.

Animals↗
PubMed1999

Characterization of a murine model of melioidosis: comparison of different strains of mice.

Melioidosis is an infectious disease caused by the saprophytic gram-negative rod Burkholderia pseudomallei. The aim of this study was to establish and characterize a murine model of melioidosis to provide a basis for further investigations on the pathogenesis of the disease. After intravenous infection with B. pseudomallei, C57BL/6 mice were found to be significantly more resistant than BALB/c mice. There was a marked organotropism of B. pseudomallei for the spleen and liver in both strains of mice, with the highest bacterial load in the spleen. Electron microscopic investigations of the spleen clearly demonstrated intracellular replication within membrane-bound phagosomes. Electron micrographs of the liver provided evidence that B. pseudomallei-containing phagosomes in hepatocytes fuse with lysosomes, leading to degradation of bacteria. In both strains of mice, the course of infection was highly dependent on the infective dose and the bacterial strain used, ranging from death within a few days to death after several weeks. In comparison with BALB/c mice, the bacterial counts in C57BL/6 mice were decreased 12 h after infection, which is suggestive of an innate immune mechanism against B. pseudomallei in this early phase of infection contributing to the lower susceptibility of C57BL/6 mice. BALB/c mice developed a more pronounced lymphopenia, granulocytosis, and splenomegaly at a lower infective dose compared to C57BL/6 mice. Analysis of the antibody response against B. pseudomallei 11 days after infection revealed a significantly higher immunoglobulin G2A (IgG2a)/IgG1 ratio in C57BL/6 mice than in BALB/c mice, indicating that a T helper type 1 immune response is associated with resistance to infection with B. pseudomallei.

Animals↗
PubMed2000

The CXC chemokines gamma interferon (IFN-gamma)-inducible protein 10 and monokine induced by IFN-gamma are released during severe melioidosis.

Gamma interferon (IFN-gamma)-inducible protein 10 (IP-10) and monokine induced by IFN-gamma (Mig) are related CXC chemokines which bind to the CXCR3 receptor and specifically target activated T lymphocytes and natural killer (NK) cells. The production of IP-10 and Mig by various cell types in vitro is strongly dependent on IFN-gamma. To determine whether IP-10 and Mig are released during bacterial infection in humans, we measured plasma levels of IP-10 and Mig in patients with melioidosis, a severe gram-negative infection caused by Burkholderia pseudomallei. IP-10 and Mig were markedly elevated in patients with melioidosis on admission, particularly in blood culture-positive patients, and remained elevated during the 72-h study period. Levels of IP-10 and Mig showed a positive correlation with IFN-gamma concentrations and also correlated with clinical outcome. In whole blood stimulated with heat-killed B. pseudomallei, neutralization of IFN-gamma and tumor necrosis factor alpha (TNF-alpha) partly attenuated IP-10 and Mig release, while anti-interleukin-12 (IL-12) and anti-IL-18 had a synergistic effect. Stimulation with other bacteria or endotoxin also induced strong secretion of IP-10 and Mig. These data suggest that IP-10 and Mig are part of the innate immune response to bacterial infection. IP-10 and Mig may contribute to host defense in Th1-mediated host defense during infections by attracting CXCR3(+) Th1 cells to the site of inflammation.

Adolescent↗