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Gassiep I, Chatfield MD, Permana B, Burnard D, Bauer MJ, Cuddihy T, Forde BM, Mayer-Coverdale J, Norton RE, Harris PNA. The Genomic Epidemiology of Clinical Burkholderia pseudomallei Isolates in North Queensland, Australia. Pathogens 2024; 13:584. [PMID: 39057811 PMCID: PMC11279585 DOI: 10.3390/pathogens13070584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/26/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Background:Burkholderia pseudomallei, the causative agent of melioidosis, is highly genetically recombinant, resulting in significant genomic diversity. Multiple virulence factors have been associated with specific disease presentations. To date, there are limited data relating to genomic diversity and virulence factors associated with melioidosis cases in North Queensland, Australia. Aim: To describe the genetic diversity of B. pseudomallei and identify virulence factors associated with clinical risk factors and patient outcomes. Methods: Whole genome sequencing of clinical isolates was performed and analysed with clinical data obtained from a retrospective melioidosis cohort study. Results: Fifty-nine distinct sequence types (STs) were identified from the 128 clinical isolates. Six STs comprised 64/128 (50%) isolates. Novel STs accounted for 38/59 (64%) STs, with ST TSV-13 as the most prevalent (n = 7), and were less likely to possess an LPS A genotype or YLF gene cluster (p < 0.001). These isolates were most likely to be found outside the inner city (aOR: 4.0, 95% CI: 1.7-9.0, p = 0.001). ST TSV-13 was associated with increased mortality (aOR: 6.1, 95% CI: 1.2-30.9, p = 0.03). Patients with a history of alcohol excess were less likely to be infected by fhaB3 (aOR 0.2, 95% CI: 0.1-0.7, p = 0.01) or YLF (aOR: 0.4, 95% CI: 0.2-0.9, p = 0.04) positive isolates. Conclusions: There are a significant number of novel sequence types in Townsville, Australia. An emerging novel ST appears to have an association with geographic location and mortality. Ongoing investigation is required to further understand the impact of this ST on the Townsville region.
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Affiliation(s)
- Ian Gassiep
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
- Department of Infectious Diseases, Mater Hospital Brisbane, Brisbane, QLD 4101, Australia
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Brisbane, QLD 4029, Australia
| | - Mark D. Chatfield
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
| | - Budi Permana
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
| | - Delaney Burnard
- Queensland Cyber Infrastructure Foundation, Brisbane, QLD 4067, Australia;
| | - Michelle J. Bauer
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
| | - Thom Cuddihy
- Institute for Molecular Bioscience (IMB), The University of Queensland, Brisbane, QLD 4067, Australia;
| | - Brian M. Forde
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
- Institute for Molecular Bioscience (IMB), The University of Queensland, Brisbane, QLD 4067, Australia;
| | - Johanna Mayer-Coverdale
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
- Sullivan Nicolaides Pathology, Brisbane, QLD 4006, Australia
- Herston Infectious Diseases Institute, Royal Brisbane and Woman’s Hospital, Herston, Brisbane, QLD 4029, Australia
| | - Robert E. Norton
- Pathology Queensland, Townsville University Hospital, Townsville, QLD 4814, Australia;
- Faculty of Medicine, The University of Queensland, Brisbane, QLD 4006, Australia
| | - Patrick N. A. Harris
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women’s Hospital Campus, Herston, Brisbane, QLD 4029, Australia; (M.D.C.); (B.P.); (M.J.B.); (B.M.F.); (J.M.-C.); (P.N.A.H.)
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Brisbane, QLD 4029, Australia
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Seng R, Chomkatekaew C, Tandhavanant S, Saiprom N, Phunpang R, Thaipadungpanit J, Batty EM, Day NPJ, Chantratita W, West TE, Thomson NR, Parkhill J, Chewapreecha C, Chantratita N. Genetic diversity, determinants, and dissemination of Burkholderia pseudomallei lineages implicated in melioidosis in Northeast Thailand. Nat Commun 2024; 15:5699. [PMID: 38972886 PMCID: PMC11228029 DOI: 10.1038/s41467-024-50067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/28/2024] [Indexed: 07/09/2024] Open
Abstract
Melioidosis is an often-fatal neglected tropical disease caused by an environmental bacterium Burkholderia pseudomallei. However, our understanding of the disease-causing bacterial lineages, their dissemination, and adaptive mechanisms remains limited. To address this, we conduct a comprehensive genomic analysis of 1,391 B. pseudomallei isolates collected from nine hospitals in northeast Thailand between 2015 and 2018, and contemporaneous isolates from neighbouring countries, representing the most densely sampled collection to date. Our study identifies three dominant lineages, each with unique gene sets potentially enhancing bacterial fitness in the environment. We find that recombination drives lineage-specific gene flow. Transcriptome analyses of representative clinical isolates from each dominant lineage reveal increased expression of lineage-specific genes under environmental conditions in two out of three lineages. This underscores the potential importance of environmental persistence for these dominant lineages. The study also highlights the influence of environmental factors such as terrain slope, altitude, and river direction on the geographical dispersal of B. pseudomallei. Collectively, our findings suggest that environmental persistence may play a role in facilitating the spread of B. pseudomallei, and as a prerequisite for exposure and infection, thereby providing useful insights for informing melioidosis prevention and control strategies.
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Affiliation(s)
- Rathanin Seng
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chalita Chomkatekaew
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Sarunporn Tandhavanant
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Natnaree Saiprom
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rungnapa Phunpang
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Janjira Thaipadungpanit
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth M Batty
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Wasun Chantratita
- Center for Medical Genomics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T Eoin West
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nicholas R Thomson
- Parasites and Microbes Wellcome Sanger Institute, Cambridge, UK
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Julian Parkhill
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Claire Chewapreecha
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Parasites and Microbes Wellcome Sanger Institute, Cambridge, UK.
- Previous Affiliations: Bioinformatics and Systems Biology Program, School of Bioresource and Technology, King Mongkut University of Technology Thonburi, Bangkok, Thailand.
| | - Narisara Chantratita
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Dadwal P, Bonner B, Fraser D, Loveridge J, Withey G, Puri A, Smith S, Hanson J. Bone and joint infections due to melioidosis; diagnostic and management strategies to optimise outcomes. PLoS Negl Trop Dis 2024; 18:e0012317. [PMID: 39018296 PMCID: PMC11253972 DOI: 10.1371/journal.pntd.0012317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/24/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Melioidosis, a life-threatening infection caused by the gram negative bacterium Burkholderia pseudomallei, can involve almost any organ. Bone and joint infections (BJI) are a recognised, but incompletely defined, manifestation of melioidosis that are associated with significant morbidity and mortality in resource-limited settings. METHODOLOGY/PRINCIPAL FINDINGS We identified all individuals with BJI due to B. pseudomallei managed at Cairns Hospital in tropical Australia between January 1998 and June 2023. The patients' demographics, their clinical findings and their treatment were correlated with their subsequent course. Of 477 culture-confirmed cases of melioidosis managed at the hospital during the study period, 39 (8%) had confirmed BJI; predisposing risk factors for melioidosis were present in 37/39 (95%). However, in multivariable analysis only diabetes mellitus was independently associated with the presence of BJI (odds ratio (95% confidence interval): 4.04 (1.81-9.00), p = 0.001). BJI was frequently only one component of multi-organ involvement: 29/39 (74%) had infection involving other organs and bacteraemia was present in 31/39 (79%). Of the 39 individuals with BJI, 14 (36%) had osteomyelitis, 8 (20%) had septic arthritis and 17 (44%) had both osteomyelitis and septic arthritis; in 32/39 (83%) the lower limb was involved. Surgery was performed in 30/39 (77%). Readmission after the initial hospitalisation was necessary in 11/39 (28%), 5/39 (13%) had disease recrudescence and 3/39 (8%) had relapse; 4/39 (10%) developed pathological fractures. ICU admission was necessary in 11/39 (28%) but all 11 of these patients survived. Only 1/39 (3%) died, 138 days after admission, due to his significant underlying comorbidity. CONCLUSIONS The case-fatality rate from melioidosis BJI in Australia's well-resourced health system is very low. However, recrudescence, relapse and orthopaedic complications are relatively common and emphasise the importance of collaborative multidisciplinary care that includes early surgical review, aggressive source control, prolonged antibiotic therapy, and thorough, extended follow-up.
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Affiliation(s)
- Parvati Dadwal
- Department of Orthopaedic Surgery, Cairns Hospital, Cairns, Queensland, Australia
- James Cook University, Cairns, Queensland, Australia
| | - Brady Bonner
- Department of Orthopaedic Surgery, Logan Hospital, Brisbane, Queensland, Australia
| | - David Fraser
- Department of Orthopaedics, Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jeremy Loveridge
- James Cook University, Cairns, Queensland, Australia
- Far North Queensland Hand Surgery, Cairns, Queensland, Australia
| | - Grant Withey
- Department of Radiology, Cairns Hospital, Cairns, Queensland, Australia
| | - Arvind Puri
- Department of Orthopaedic Surgery, Cairns Hospital, Cairns, Queensland, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland Australia
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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Prinsloo C, Smith S, Law M, Hanson J. The Epidemiological, Clinical, and Microbiological Features of Patients with Burkholderia pseudomallei Bacteraemia-Implications for Clinical Management. Trop Med Infect Dis 2023; 8:481. [PMID: 37999600 PMCID: PMC10675116 DOI: 10.3390/tropicalmed8110481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
Patients with melioidosis are commonly bacteraemic. However, the epidemiological characteristics, the microbiological findings, and the clinical associations of Burkholderia pseudomallei bacteraemia are incompletely defined. All cases of culture-confirmed melioidosis at Cairns Hospital in tropical Australia between January 1998 and June 2023 were reviewed. The presence of bacteraemia was determined and correlated with patient characteristics and outcomes; 332/477 (70%) individuals in the cohort were bacteraemic. In multivariable analysis, immunosuppression (odds ratio (OR) (95% confidence interval (CI)): (2.76 (1.21-6.27), p = 0.02), a wet season presentation (2.27 (1.44-3.59), p < 0.0001) and male sex (1.69 (1.08-2.63), p = 0.02), increased the likelihood of bacteraemia. Patients with a skin or soft tissue infection (0.32 (0.19-0.57), p < 0.0001) or without predisposing factors for melioidosis (0.53 (0.30-0.93), p = 0.03) were less likely to be bacteraemic. Bacteraemia was associated with intensive care unit admission (OR (95%CI): 4.27 (2.35-7.76), p < 0.0001), and death (2.12 (1.04-4.33), p = 0.04). The median (interquartile range) time to blood culture positivity was 31 (26-39) hours. Patients with positive blood cultures within 24 h were more likely to die than patients whose blood culture flagged positive after this time (OR (95%CI): 11.05 (3.96-30.83), p < 0.0001). Bacteraemia portends a worse outcome in patients with melioidosis. Its presence or absence might be used to help predict outcomes in cases of melioidosis and to inform optimal clinical management.
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Affiliation(s)
- Carmen Prinsloo
- College of Medicine and Dentistry, James Cook University, Cairns Hospital, Cairns, QLD 4870, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia
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Melioidosis and Burkholderia pseudomallei : progress in epidemiology, diagnosis, treatment and vaccination. Curr Opin Infect Dis 2022; 35:517-523. [PMID: 35942848 DOI: 10.1097/qco.0000000000000869] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Melioidosis and its causative bacterium Burkholderia pseudomallei are being found in unexpected locations and bacterial genotyping is providing new insights into global spread and where and how individuals are being infected. This review summarizes recent studies covering the epidemiology, diagnosis, treatment, and prevention of melioidosis. RECENT FINDINGS Whole-genome sequencing of B. pseudomallei from patients and environmental sampling is informing the phylogeography of B. pseudomallei at regional, continental, and global levels, while also defining the epidemiology for individual cases. The situation in Africa remains the most unresolved, while the evolving story of B. pseudomallei in the Americas may establish that B. pseudomallei is endemic in parts of southern USA. Guidelines for diagnosis and treatment of melioidosis are well established, and published mortality has decreased from 50% or higher to 10% or lower in some countries but access to laboratory and therapeutic resources are not available or are extremely limited in many melioidosis-endemic regions. SUMMARY The enormous clinical diversity of melioidosis and the complexities of laboratory diagnosis and of treatment make it a sentinel disease for highlighting the continuing global disparities in access to and provision of healthcare.
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Gassiep I, Bauer MJ, Page M, Harris PNA, Norton R. Comparative evaluation of Panther Fusion and real-time PCR for detection of Burkholderia pseudomallei in spiked human blood. Access Microbiol 2022; 4:000333. [PMID: 35693467 PMCID: PMC9175970 DOI: 10.1099/acmi.0.000333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction. Melioidosis is an infection that most commonly presents with bacteraemia. Culture-based laboratory methods can result in a significant delay to organism identification. Molecular diagnostic techniques have a high sensitivity and rapid time to diagnosis. A decreased time to diagnosis is likely to improve patient outcomes. Aim. To compare the Panther Fusion automated molecular instrument to an in-house method for the detection of Burkholderia pseudomallei directly from spiked human whole-blood samples. Results. The in-house method detected 11/12 (92 %) samples with a B. pseudomallei concentration of 2.5–4.5×102 c.f.u. ml−1. The Panther was less reliable, detecting only 8/14 (75 %) samples with a similar bacterial concentration. The Panther was able to detect 12/12 (100 %) spiked blood culture-positive samples. Conclusion. The direct detection of B. pseudomallei from patient blood on presentation to a healthcare facility will significantly decrease time to diagnosis. We describe an in-house real-time PCR method with the lowest reported limit of detection to date. Due to lower sensitivity, the Panther Fusion would be best used as a diagnostic method directly from a positive blood culture.
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Affiliation(s)
- Ian Gassiep
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Infectious Diseases, Mater Hospital Brisbane, South Brisbane, Queensland, Australia
- University of Queensland Centre for Clinical Research, Royal Brisbane and Woman’s Hospital, Herston, Queensland, Australia
| | - Michelle J. Bauer
- University of Queensland Centre for Clinical Research, Royal Brisbane and Woman’s Hospital, Herston, Queensland, Australia
| | - Melissa Page
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Patrick N. A. Harris
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- University of Queensland Centre for Clinical Research, Royal Brisbane and Woman’s Hospital, Herston, Queensland, Australia
| | - Robert Norton
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Pathology Queensland, Townsville University Hospital, Townsville, Queensland, Australia
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Chowdhury S, Barai L, Afroze SR, Ghosh PK, Afroz F, Rahman H, Ghosh S, Hossain MB, Rahman MZ, Das P, Rahim MA. The Epidemiology of Melioidosis and Its Association with Diabetes Mellitus: A Systematic Review and Meta-Analysis. Pathogens 2022; 11:pathogens11020149. [PMID: 35215093 PMCID: PMC8878808 DOI: 10.3390/pathogens11020149] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 12/21/2022] Open
Abstract
Melioidosis is an under-recognized fatal disease in humans, caused by the Gram-negative bacterium Burkholderia pseudomallei. Globally, more than 35,000 human melioidosis cases have been reported since 1911. Soil acts as the natural reservoir of B. pseudomallei. Humans may become infected by this pathogen through direct contact with contaminated soil and/or water. Melioidosis commonly occurs in patients with diabetes mellitus, who increase the occurrence of melioidosis in a population. We carried out a systematic review and meta-analysis to investigate to what extent diabetes mellitus affects the patient in getting melioidosis. We selected 39 articles for meta-analysis. This extensive review also provided the latest updates on the global distribution, clinical manifestation, preexisting underlying diseases, and risk factors of melioidosis. Diabetes mellitus was identified as the predominant predisposing factor for melioidosis in humans. The overall proportion of melioidosis cases having diabetes was 45.68% (95% CI: 44.8-46.57, p < 0.001). Patients with diabetes mellitus were three times more likely to develop melioidosis than patients with no diabetes (RR 3.40, 95% CI: 2.92-3.87, p < 0.001). The other potential risk factors included old age, exposure to soil and water, preexisting underlying diseases (chronic kidney disease, lung disease, heart disease, and thalassemia), and agricultural activities. Evidence-based clinical practice guidelines for melioidosis in patients with diabetes mellitus may be developed and shared with healthcare professionals of melioidosis endemic countries to reduce morbidity.
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Affiliation(s)
- Sukanta Chowdhury
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (P.K.G.); (H.R.); (S.G.); (M.Z.R.)
- Correspondence:
| | - Lovely Barai
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka 1000, Bangladesh; (L.B.); (S.R.A.); (F.A.); (M.A.R.)
| | - Samira Rahat Afroze
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka 1000, Bangladesh; (L.B.); (S.R.A.); (F.A.); (M.A.R.)
| | - Probir Kumar Ghosh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (P.K.G.); (H.R.); (S.G.); (M.Z.R.)
| | - Farhana Afroz
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka 1000, Bangladesh; (L.B.); (S.R.A.); (F.A.); (M.A.R.)
| | - Habibur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (P.K.G.); (H.R.); (S.G.); (M.Z.R.)
| | - Sumon Ghosh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (P.K.G.); (H.R.); (S.G.); (M.Z.R.)
| | - Muhammad Belal Hossain
- Department of Ecology & Evolutionary Biology, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Mohammed Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (P.K.G.); (H.R.); (S.G.); (M.Z.R.)
| | - Pritimoy Das
- School of Health, Federation University Australia, Ballarat, VIC 3353, Australia;
| | - Muhammad Abdur Rahim
- Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka 1000, Bangladesh; (L.B.); (S.R.A.); (F.A.); (M.A.R.)
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