Burkholderia pseudomallei: Difference between revisions

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Burkholderia pseudomallei
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== Microbiology ==
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==Background==
   
  +
*Also called '''melioidosis''' or '''Whitmore's disease'''
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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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== Epidemiology ==
 +
===Microbiology===
   
  +
*Oxidase [[Oxidase::positive]], indole [[Indole::negative]] [[Stain::Gram-negative]] [[Shape::bacillus]] with "'''safety pin'''" appearance (i.e. bipolar staining)
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* Humans and animals
  
  +
*[[Hemolysis::Non-hemolytic]]
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* Important cause of death in SE Asia and northern Australia
  
  +
*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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** Up to 80% seroprevalence in Thailand, mostly asymptomatic
  
  +
*Inherently resistant to [[Polymixin|polymixins]]
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** Sporadic cases elsewhere
  
−
* May have latent disease with reactivation much later
  
−
* Acquired by percutaneous inoculation, inhalation (esp. lab workers), and ingestion
  
−
* Risk factors for clinical disease
  
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** Diabetes
  
−
** Heavy alcohol use
  
−
** Chronic lung disease
  
−
** Chronic kidney disease
  
−
** Treatment with glucocorticoids
  
−
** Cancer
  
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** Thalassemia
  
   
  +
===Epidemiology===
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== Clinical Presentation ==
  
   
  +
*Humans and animals
−
* Incubation period 9 days (range 1 to 21 days)
  
  +
*Important cause of death in south-east Asia and northern Australia
−
* Presentations can vary from asymptomatic, skin ulcers, abscesses, latent infection, chronic pneumonia (similar to TB), or fulminant shock
  
  +
**Up to 80% seroprevalence in Thailand, mostly asymptomatic
−
** Pneumonia (50%)
  
  +
**More cases during the rainy season
−
** GU infection (15%)
  
  +
**Sporadic cases elsewhere, including the Middle East, Africa, and the Americas
−
** Skin (15%)
  
  +
*May have latent disease with reactivation much later
−
** Primary bacteremia (10%)
  
  +
*Acquired by percutaneous inoculation, inhalation (esp. lab workers), and ingestion
−
** Septic arthritis/OM (3-5%)
  
  +
*Risk factors for clinical disease
−
** Neuro (3-5%)
  
  +
**Diabetes
−
* About 20% of clinical cases with develop septic shock
  
  +
**Heavy alcohol use
  +
**Chronic lung disease
  +
**Chronic kidney disease
  +
**Treatment with glucocorticoids
  +
**Cancer
  +
**Thalassemia
   
  +
==Clinical Manifestations==
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== Diagnosis ==
  
   
  +
*Incubation period [[Usual incubation period::9 days]] (range [[Incubation period range::1 to 21 days]])
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* Culture
  
  +
*Presentations can vary from asymptomatic, skin ulcers, abscesses, latent infection, chronic pneumonia (similar to TB), or fulminant shock[[CiteRef::diemert2010th]][[CiteRef::meumann2011cl]]
−
** Blood, throat, and urine cultures from all patients with suspected melioidosis
  
  +
**[[Pneumonia]] (50%)
−
** Grows on blood agar, MacConkey, etc. (i.e. ''not'' a fastidious organism)
  
  +
**Genitourinary infection (15%)
−
** Can use selective colistin or polymyxin B
  
  +
**Skin infection (15%), with ulcers, nodules, or abscesses
−
** On sheep blood agar, grows as small, smooth, cream-coloured colony with metallic sheen
  
  +
**Primary bacteremia (10%)
−
** May develop a dry and '''wrinkled''' appearance after 1 to 2 days of incubation</ul>
  
  +
**Septic arthritis/OM (3-5%)
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* MALDI-ToF is ''not'' reliable for identifying it
  
  +
**Neuro (3-5%)
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* Other methods
  
  +
**Disseminated infections can involve liver, spleen, lung, and prostate
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** PCR
  
  +
*About 50% of clinical cases have [[Causes::bacteremia]], and 20% of cases will develop [[Causes::septic shock]]
−
** Immunofluorescence and latex agglutination
  
  +
*Can occasionally lay latent and reactivate decades after exposure
−
** Serology (acute/convalescent)
  
   
  +
===Prognosis and Complications===
−
== Management ==
  
   
  +
*50% mortality even with high-quality care
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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
  
−
* TMP-SMX
  
   
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== Biosafety ==
 +
==Diagnosis==
   
  +
*Culture
−
* Lab workers can have aerosol exposure
  
  +
**Blood, throat, and urine cultures should be taken from ''all'' patients with suspected melioidosis
−
* May need prophylaxis in high-risk patients
  
  +
**Grows on blood agar, MacConkey, etc. (i.e. ''not'' a fastidious organism)
−
** Septra or doxy or amox/clav</ul>
  
  +
**Can use selective colistin or polymyxin B, since it is inherently resistant
−
* Monitor with serology at baseline, weeks 1 2 4 and 6 post-exposure
  
  +
**On sheep blood agar, grows as small, smooth, cream-coloured colony with metallic sheen
−
** Needs to be sent to CDC via NML</ul>
  
  +
**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: [[Is treated by::ceftazidime]], [[Is treated by::imipenem]], or [[Is treated by::meropenem]] for 10-14 days
  +
**Eradication: [[Is treated by::TMP-SMX]] for 3+ months
  +
*Others: [[Is treated by::amoxicillin-clavulanic acid]]
  +
  +
==Prevention==
  +
  +
===Laboratory Safety===
  +
  +
*[[Biosafety risk groups|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 use disorder|alcohol abuse]], chronic [[Corticosteroids|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
 
{{DISPLAYTITLE:''Burkholderia pseudomallei''}}
  
{{DISPLAYTITLE:''Burkholderia pseudomallei''}}
 
[[Category:Gram-negative bacilli]]
  
[[Category:Gram-negative bacilli]]

Latest revision as of 09:36, 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

Prevention

Laboratory Safety

References

  1. ^  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.

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