Burkholderia pseudomallei: Difference between revisions
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Burkholderia pseudomallei
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==Background== |
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= ''Burkholderia pseudomallei'' (melioidosis) = |
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*Also called '''melioidosis''' or '''Whitmore's disease''' |
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= Microbiology = |
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===Microbiology=== |
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* Oxidase positive, indole-negative Gram-negative rod with "'''safety pin'''" appearance |
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* Non-hemolytic |
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*Oxidase [[Oxidase::positive]], indole [[Indole::negative]] [[Stain::Gram-negative]] [[Shape::bacillus]] with "'''safety pin'''" appearance (i.e. bipolar staining) |
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= Epidemiology = |
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*[[Hemolysis::Non-hemolytic]] |
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*Colonies start small, smooth, cream-coloured with a metallic sheen, but become dry and wrinkly after 1 to 2 days of incubation |
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*Inherently resistant to [[Polymixin|polymixins]] |
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===Epidemiology=== |
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* Humans and animals |
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* Important cause of death in SE Asia and northern Australia |
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** Up to 80% seroprevalence in Thailand, mostly asymptomatic |
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** Sporadic cases elsewhere |
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* May have latent disease with reactivation much later |
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* Acquired by percutaneous inoculation, inhalation (esp. lab workers), and ingestion |
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* Risk factors for clinical disease |
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** Diabetes |
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** Heavy alcohol use |
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** Chronic lung disease |
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** Chronic kidney disease |
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** Treatment with glucocorticoids |
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** Cancer |
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** Thalassemia |
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*Humans and animals |
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= Clinical Presentation = |
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*Important cause of death in south-east Asia and northern Australia |
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**Up to 80% seroprevalence in Thailand, mostly asymptomatic |
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**More cases during the rainy season |
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**Sporadic cases elsewhere, including the Middle East, Africa, and the Americas |
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*May have latent disease with reactivation much later |
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*Acquired by percutaneous inoculation, inhalation (esp. lab workers), and ingestion |
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*Risk factors for clinical disease |
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**Diabetes |
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**Heavy alcohol use |
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**Chronic lung disease |
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**Chronic kidney disease |
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**Treatment with glucocorticoids |
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**Cancer |
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**Thalassemia |
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==Clinical Manifestations== |
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* Incubation period 9 days (range 1 to 21 days) |
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* Presentations can vary from asymptomatic, skin ulcers, abscesses, latent infection, chronic pneumonia (similar to TB), or fulminant shock |
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** Pneumonia (50%) |
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** GU infection (15%) |
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** Skin (15%) |
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** Primary bacteremia (10%) |
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** Septic arthritis/OM (3-5%) |
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** Neuro (3-5%) |
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* About 20% of clinical cases with develop septic shock |
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*Incubation period [[Usual incubation period::9 days]] (range [[Incubation period range::1 to 21 days]]) |
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= Diagnosis = |
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*Presentations can vary from asymptomatic, skin ulcers, abscesses, latent infection, chronic pneumonia (similar to TB), or fulminant shock[[CiteRef::diemert2010th]][[CiteRef::meumann2011cl]] |
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**[[Pneumonia]] (50%) |
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**Genitourinary infection (15%) |
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**Skin infection (15%), with ulcers, nodules, or abscesses |
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**Primary bacteremia (10%) |
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**Septic arthritis/OM (3-5%) |
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**Neuro (3-5%) |
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**Disseminated infections can involve liver, spleen, lung, and prostate |
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*About 50% of clinical cases have [[Causes::bacteremia]], and 20% of cases will develop [[Causes::septic shock]] |
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*Can occasionally lay latent and reactivate decades after exposure |
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===Prognosis and Complications=== |
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* Culture |
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** Blood, throat, and urine cultures from all patients with suspected melioidosis |
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** Grows on blood agar, MacConkey, etc. (i.e. ''not'' a fastidious organism) |
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** Can use selective colistin or polymyxin B |
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** On sheep blood agar, grows as small, smooth, cream-coloured colony with metallic sheen |
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** May develop a dry and '''wrinkled''' appearance after 1 to 2 days of incubation</ul> |
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* MALDI-ToF is ''not'' reliable for identifying it |
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* Other methods |
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** PCR |
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** Immunofluorescence and latex agglutination |
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** Serology (acute/convalescent) |
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*50% mortality even with high-quality care |
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= Management = |
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==Diagnosis== |
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* Intrinsic resistance to many antibiotics, especially using efflux pumps |
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* Ceftazidime |
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* Amoxicillin-clavulanic acid |
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* TMP-SMX |
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*Culture |
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= Biosafety = |
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**Blood, throat, and urine cultures should be taken from ''all'' patients with suspected melioidosis |
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**Grows on blood agar, MacConkey, etc. (i.e. ''not'' a fastidious organism) |
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**Can use selective colistin or polymyxin B, since it is inherently resistant |
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**On sheep blood agar, grows as small, smooth, cream-coloured colony with metallic sheen |
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**May develop a dry and '''wrinkled''' appearance after 1 to 2 days of incubation |
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*MALDI-ToF may misidentify it as [[Burkholderia thailandensis]], and automated biochemical tests may misidentify it as [[Chromobacterium violaceum]] |
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*Other methods |
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**PCR |
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**Immunofluorescence and latex agglutination |
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**Serology (acute/convalescent) |
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==Management== |
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* Lab workers can have aerosol exposure |
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* May need prophylaxis in high-risk patients |
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** Septra or doxy or amox/clav</ul> |
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* Monitor with serology at baseline, weeks 1 2 4 and 6 post-exposure |
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** Needs to be sent to CDC via NML</ul> |
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*Intrinsic resistance to many antibiotics, including [[colistin]], primarily using efflux pumps |
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*Treat with induction followed by eradication therapy |
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**Induction: [[Is treated by::ceftazidime]], [[Is treated by::imipenem]], or [[Is treated by::meropenem]] for 10-14 days |
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**Eradication: [[Is treated by::TMP-SMX]] for 3+ months |
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*Others: [[Is treated by::amoxicillin-clavulanic acid]] |
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==Prevention== |
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===Laboratory Safety=== |
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*[[Biosafety risk groups|Biosafety risk group 3]] |
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*Lab workers can have aerosol exposure if aerosol-generating procedure done outside of a BSC, bite/scratch from infected lab animals, or needlestick/percutaneous exposure |
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**Those at higher risk include: not wearing proper PPE, [[diabetes]], [[chronic liver disease]], [[chronic kidney disease]], [[Alcohol use disorder|alcohol abuse]], chronic [[Corticosteroids|corticosteroid]] use, [[hematologic malignancy]], [[neutropenia]] or neutrophil dysfunction, [[chronic lung disease]], [[thalassemia]], or other [[immunosuppression]] |
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*May need prophylaxis in high-risk patients |
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**[[TMP-SMX]] or [[doxycycline]] or [[amoxicillin-clavulanic acid]] |
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**[[TMP-SMX]] DS 2 tablets (>60 kg) or SS 3 tablets (40-60 kg) or DS 1 tablet (<40 kg) PO bid |
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**[[Amoxicillin-clavulanic acid]] 20/5 mg/kg/dose PO tid |
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**Duration: 21 days |
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*Monitor with serology at baseline, weeks 1 2 4 and 6 post-exposure |
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**Needs to be sent to CDC via NML |
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{{DISPLAYTITLE:''Burkholderia pseudomallei''}} |
{{DISPLAYTITLE:''Burkholderia pseudomallei''}} |
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[[Category:Gram-negative bacilli]] |
[[Category:Gram-negative bacilli]] |
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Latest revision as of 13:36, 25 May 2021
Background
- Also called melioidosis or Whitmore's disease
Microbiology
- Oxidase positive, indole negative Gram-negative bacillus with "safety pin" appearance (i.e. bipolar staining)
- Non-hemolytic
- Colonies start small, smooth, cream-coloured with a metallic sheen, but become dry and wrinkly after 1 to 2 days of incubation
- Inherently resistant to polymixins
Epidemiology
- Humans and animals
- Important cause of death in south-east Asia and northern Australia
- Up to 80% seroprevalence in Thailand, mostly asymptomatic
- More cases during the rainy season
- Sporadic cases elsewhere, including the Middle East, Africa, and the Americas
- May have latent disease with reactivation much later
- Acquired by percutaneous inoculation, inhalation (esp. lab workers), and ingestion
- Risk factors for clinical disease
- Diabetes
- Heavy alcohol use
- Chronic lung disease
- Chronic kidney disease
- Treatment with glucocorticoids
- Cancer
- Thalassemia
Clinical Manifestations
- Incubation period 9 days (range 1 to 21 days)
- Presentations can vary from asymptomatic, skin ulcers, abscesses, latent infection, chronic pneumonia (similar to TB), or fulminant shock12
- Pneumonia (50%)
- Genitourinary infection (15%)
- Skin infection (15%), with ulcers, nodules, or abscesses
- Primary bacteremia (10%)
- Septic arthritis/OM (3-5%)
- Neuro (3-5%)
- Disseminated infections can involve liver, spleen, lung, and prostate
- About 50% of clinical cases have bacteremia, and 20% of cases will develop septic shock
- Can occasionally lay latent and reactivate decades after exposure
Prognosis and Complications
- 50% mortality even with high-quality care
Diagnosis
- Culture
- Blood, throat, and urine cultures should be taken from all patients with suspected melioidosis
- Grows on blood agar, MacConkey, etc. (i.e. not a fastidious organism)
- Can use selective colistin or polymyxin B, since it is inherently resistant
- On sheep blood agar, grows as small, smooth, cream-coloured colony with metallic sheen
- May develop a dry and wrinkled appearance after 1 to 2 days of incubation
- MALDI-ToF may misidentify it as Burkholderia thailandensis, and automated biochemical tests may misidentify it as Chromobacterium violaceum
- Other methods
- PCR
- Immunofluorescence and latex agglutination
- Serology (acute/convalescent)
Management
- Intrinsic resistance to many antibiotics, including colistin, primarily using efflux pumps
- Treat with induction followed by eradication therapy
- Induction: ceftazidime, imipenem, or meropenem for 10-14 days
- Eradication: TMP-SMX for 3+ months
- Others: amoxicillin-clavulanic acid
Prevention
Laboratory Safety
- Biosafety risk group 3
- Lab workers can have aerosol exposure if aerosol-generating procedure done outside of a BSC, bite/scratch from infected lab animals, or needlestick/percutaneous exposure
- Those at higher risk include: not wearing proper PPE, diabetes, chronic liver disease, chronic kidney disease, alcohol abuse, chronic corticosteroid use, hematologic malignancy, neutropenia or neutrophil dysfunction, chronic lung disease, thalassemia, or other immunosuppression
- May need prophylaxis in high-risk patients
- TMP-SMX or doxycycline or amoxicillin-clavulanic acid
- TMP-SMX DS 2 tablets (>60 kg) or SS 3 tablets (40-60 kg) or DS 1 tablet (<40 kg) PO bid
- Amoxicillin-clavulanic acid 20/5 mg/kg/dose PO tid
- Duration: 21 days
- Monitor with serology at baseline, weeks 1 2 4 and 6 post-exposure
- Needs to be sent to CDC via NML
References
- ^ Bart J. Currie, Linda Ward, Allen C. Cheng. David Joseph Diemert. The Epidemiology and Clinical Spectrum of Melioidosis: 540 Cases from the 20 Year Darwin Prospective Study. PLoS Neglected Tropical Diseases. 2010;4(11):e900. doi:10.1371/journal.pntd.0000900.
- ^ E. M. Meumann, A. C. Cheng, L. Ward, B. J. Currie. Clinical Features and Epidemiology of Melioidosis Pneumonia: Results From a 21-Year Study and Review of the Literature. Clinical Infectious Diseases. 2011;54(3):362-369. doi:10.1093/cid/cir808.
