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Muhi S, Buultjens AH, Porter JL, Marshall JL, Doerflinger M, Pidot SJ, O’Brien DP, Johnson PDR, Lavender CJ, Globan M, McCarthy J, Osowicki J, Stinear TP. Mycobacterium ulcerans challenge strain selection for a Buruli ulcer controlled human infection model. PLoS Negl Trop Dis 2024; 18:e0011979. [PMID: 38701090 PMCID: PMC11095734 DOI: 10.1371/journal.pntd.0011979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/15/2024] [Accepted: 04/21/2024] [Indexed: 05/05/2024] Open
Abstract
Critical scientific questions remain regarding infection with Mycobacterium ulcerans, the organism responsible for the neglected tropical disease, Buruli ulcer (BU). A controlled human infection model has the potential to accelerate our knowledge of the immunological correlates of disease, to test prophylactic interventions and novel therapeutics. Here we present microbiological evidence supporting M. ulcerans JKD8049 as a suitable human challenge strain. This non-genetically modified Australian isolate is susceptible to clinically relevant antibiotics, can be cultured in animal-free and surfactant-free media, can be enumerated for precise dosing, and has stable viability following cryopreservation. Infectious challenge of humans with JKD8049 is anticipated to imitate natural infection, as M. ulcerans JKD8049 is genetically stable following in vitro passage and produces the key virulence factor, mycolactone. Also reported are considerations for the manufacture, storage, and administration of M. ulcerans JKD8049 for controlled human infection.
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Affiliation(s)
- Stephen Muhi
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Andrew H. Buultjens
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jessica L. Porter
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julia L. Marshall
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marcel Doerflinger
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Sacha J. Pidot
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel P. O’Brien
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Paul D. R. Johnson
- Northeast Public Health Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Caroline J. Lavender
- Victorian Infectious Disease Reference Laboratory (VIDRL), Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Maria Globan
- Victorian Infectious Disease Reference Laboratory (VIDRL), Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - James McCarthy
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, Victoria, Australia
- Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Timothy P. Stinear
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Disease Reference Laboratory (VIDRL), Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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O’Keeffe JC, Yin AH, O’Brien DP. A lesion in two: Buruli ulcer and squamous cell carcinoma coexistence. PLoS Negl Trop Dis 2024; 18:e0011911. [PMID: 38329944 PMCID: PMC10852329 DOI: 10.1371/journal.pntd.0011911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
The concurrent diagnoses of Buruli ulcer (BU) and cutaneous squamous cell carcinoma (SCC) is a phenomenon not previously described, despite the fact that both conditions are highly prevalent in Australia. This report presents an intriguing case of concurrent diagnoses, with clues alluding to more than one skin condition being present. The case involves a 73-year-old man with BU diagnosed on the scalp, an atypical location, which led to the consideration of malignancy, ultimately revealing concurrent SCC. This case highlights the importance of considering both conditions in patients with epidemiological risk factors, necessitating multiple lines of investigation for accurate diagnosis. Medical practitioners must remain vigilant and incorporate this possibility into their diagnostic algorithms for suspicious skin lesions to optimize treatment and outcomes. This is the first recorded instance of simultaneous diagnosis, underlining the need for enhanced awareness and attention to these unique cases.
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Affiliation(s)
- Jessica C. O’Keeffe
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- Barwon South West Public Health Unit, Geelong, Victoria, Australia
| | - Albert H. Yin
- Department of Anatomical Pathology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Daniel P. O’Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- Barwon South West Public Health Unit, Geelong, Victoria, Australia
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3
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Nohrenberg M, Wright A, Krause V. Non-tuberculous mycobacterial skin and soft tissue infections in the Northern Territory, Australia, 1989-2021. Int J Infect Dis 2023; 135:125-131. [PMID: 37524256 DOI: 10.1016/j.ijid.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND A previous review demonstrated that the majority of NTM infections in the Northern Territory (NT) are pulmonary in nature [1], however skin and soft tissue (SST) are likely the next most common sites of disease. The current epidemiology of NTM SST infections across the NT is not known. We aimed to establish the current and historical incidence rates, and the organisms involved. METHODS All NTM cases reported to the Centre for Disease Control in Darwin from 1989-2021 were retrospectively reviewed. RESULTS 226 NTM notifications were reviewed. 73 (32%) cases were SST infections. The incidence of SST cases increased over the study period. Female cases were more common (p=0·002). Disease occurred across a wide age range (1-85 years). Only 16% of cases occurred in Aboriginal individuals which may reflect immunological factors requiring further investigation. Many cases had no clear provocation, but localised skin trauma was the most common risk factor. The most common organism identified was M. fortuitum (41%). Diagnosis was often delayed, with a median time to diagnosis of 69 days (IQR=31-149). Most cases (60%) underwent surgical intervention with adjunctive anti-mycobacterial medical therapy. CONCLUSION NTM SST incidence rates increased over the study period. NTM SST infections are a rare but important differential diagnosis for non-healing cutaneous wounds.
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Affiliation(s)
- Michael Nohrenberg
- Public Health Unit (Centre for Disease Control & Environmental Health), Building 4, 105 Rocklands Drive, Tiwi, Northern Territory, Australia, 0810.
| | - Alyson Wright
- Public Health Unit (Centre for Disease Control & Environmental Health), Building 4, 105 Rocklands Drive, Tiwi, Northern Territory, Australia, 0810; Health Statistics and Informatics, Sector and System Leadership, NT Health, Floor 7, Manunda Place, 38 Cavenagh Street, Darwin
| | - Vicki Krause
- Public Health Unit (Centre for Disease Control & Environmental Health), Building 4, 105 Rocklands Drive, Tiwi, Northern Territory, Australia, 0810
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4
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Dominguez J, Mendes AI, Pacheco AR, Peixoto MJ, Pedrosa J, Fraga AG. Repurposing of statins for Buruli Ulcer treatment: antimicrobial activity against Mycobacterium ulcerans. Front Microbiol 2023; 14:1266261. [PMID: 37840746 PMCID: PMC10570734 DOI: 10.3389/fmicb.2023.1266261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Mycobacterium ulcerans causes Buruli Ulcer, a neglected infectious skin disease that typically progresses from an early non-ulcerative lesion to an ulcer with undermined edges. If not promptly treated, these lesions can lead to severe disfigurement and disability. The standard antibiotic regimen for Buruli Ulcer treatment has been oral rifampicin combined with intramuscular streptomycin administered daily for 8 weeks. However, there has been a recent shift toward replacing streptomycin with oral clarithromycin. Despite the advantages of this antibiotic regimen, it is limited by low compliance, associated side effects, and refractory efficacy for severe ulcerative lesions. Therefore, new drug candidates with a safer pharmacological spectrum and easier mode of administration are needed. Statins are lipid-lowering drugs broadly used for dyslipidemia treatment but have also been reported to have several pleiotropic effects, including antimicrobial activity against fungi, parasites, and bacteria. In the present study, we tested the susceptibility of M. ulcerans to several statins, namely atorvastatin, simvastatin, lovastatin and fluvastatin. Using broth microdilution assays and cultures of M. ulcerans-infected macrophages, we found that atorvastatin, simvastatin and fluvastatin had antimicrobial activity against M. ulcerans. Furthermore, when using the in vitro checkerboard assay, the combinatory additive effect of atorvastatin and fluvastatin with the standard antibiotics used for Buruli Ulcer treatment highlighted the potential of statins as adjuvant drugs. In conclusion, statins hold promise as potential treatment options for Buruli Ulcer. Further studies are necessary to validate their effectiveness and understand the mechanism of action of statins against M. ulcerans.
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Affiliation(s)
- Juan Dominguez
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ana I. Mendes
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ana R. Pacheco
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Maria J. Peixoto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Pedrosa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexandra G. Fraga
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Bartley B, O'Brien D. Buruli ulcer - A neglected tropical disease in the Barwon region of Victoria, Australia: An emerging public health threat with local and national ramifications. Emerg Med Australas 2023; 35:697-701. [PMID: 37454363 DOI: 10.1111/1742-6723.14235] [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: 01/08/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023]
Abstract
Mycobacterium ulcerans (MU) is known to be endemic in heavily touristed coastal regions of Victoria and is the cause of Buruli ulcer (BU) disease. The incidence, severity and geographic spread of MU infection/BU disease is increasing, including metropolitan Victorian suburbs. While the specifics of disease transmission and effective prevention strategies remain uncertain, severe complications can be mitigated by health systems that provide vigilant population surveillance to underpin early recognition, early specialist involvement and definitive treatment for the individual. Current theories regarding disease transmission and 'best practice' (or best guess) prevention and mitigation measures are presented herein. Opportunities to improve the health system response to this emerging public health threat are identified. It is incumbent upon all healthcare providers, including ED clinicians, to contribute by familiarising themselves with the established and emerging areas of endemicity of MU infection and the array of BU clinical presentations.
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Affiliation(s)
- Bruce Bartley
- Emergency Department, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Daniel O'Brien
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
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Muhi S, Osowicki J, O'Brien D, Johnson PDR, Pidot S, Doerflinger M, Marshall JL, Pellegrini M, McCarthy J, Stinear TP. A human model of Buruli ulcer: The case for controlled human infection and considerations for selecting a Mycobacterium ulcerans challenge strain. PLoS Negl Trop Dis 2023; 17:e0011394. [PMID: 37384606 DOI: 10.1371/journal.pntd.0011394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Critical knowledge gaps regarding infection with Mycobacterium ulcerans, the cause of Buruli ulcer (BU), have impeded development of new therapeutic approaches and vaccines for prevention of this neglected tropical disease. Here, we review the current understanding of host-pathogen interactions and correlates of immune protection to explore the case for establishing a controlled human infection model of M. ulcerans infection. We also summarise the overarching safety considerations and present a rationale for selecting a suitable challenge strain.
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Affiliation(s)
- Stephen Muhi
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Daniel O'Brien
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Barwon Health, Geelong, Victoria, Australia
| | - Paul D R Johnson
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Sacha Pidot
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marcel Doerflinger
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Julia L Marshall
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marc Pellegrini
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - James McCarthy
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Timothy P Stinear
- Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
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7
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Mahony M, Hung TY, Cox V, Sufyan W, Wallis P, Nizzero D, Francis J, Yan J. Complicated Mycobacterium ulcerans infection in a child in the Northern Territory. J Paediatr Child Health 2023; 59:392-394. [PMID: 36422163 DOI: 10.1111/jpc.16288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Michelle Mahony
- Department of Paediatrics, Division of Women, Child and Youth Health, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Te-Yu Hung
- Department of Paediatrics, Division of Women, Child and Youth Health, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Victoria Cox
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Global Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Wajiha Sufyan
- Anatomical Pathology, Territory Pathology, Darwin, Northern Territory, Australia
| | - Peter Wallis
- Department of Paediatrics, Division of Women, Child and Youth Health, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Danielle Nizzero
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Joshua Francis
- Department of Paediatrics, Division of Women, Child and Youth Health, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Global Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Jennifer Yan
- Department of Paediatrics, Division of Women, Child and Youth Health, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Global Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
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8
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Tweedale B, Collier F, Waidyatillake NT, Athan E, O'Brien DP. Mycobacterium ulcerans culture results according to duration of prior antibiotic treatment: A cohort study. PLoS One 2023; 18:e0284201. [PMID: 37093836 PMCID: PMC10124831 DOI: 10.1371/journal.pone.0284201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/24/2023] [Indexed: 04/25/2023] Open
Abstract
Mycobacterium ulcerans disease is a necrotising disease of the skin and subcutaneous tissue and is effectively treated with eight-weeks antibiotic therapy. Significant toxicities, however, are experienced under this prolonged regimen. Here, we investigated the length of antibiotic duration required to achieve negative cultures of M. ulcerans disease lesions and evaluated the influence of patient characteristics on this outcome. M. ulcerans cases from an observational cohort that underwent antibiotic treatment prior to surgery and had post-excision culture assessment at Barwon Health, Victoria, from May 25 1998 to June 30 2019, were included. Antibiotic duration before surgery was grouped as <2 weeks, ≥2-<4 weeks, ≥4-<6 weeks, ≥6-<8 weeks, ≥8-<10 weeks and ≥10-20 weeks. Cox regression analyses were performed to assess the association between variables and culture positive results. Ninety-two patients fitted the inclusion criteria. The median age was 60 years (IQR 28-74.5) and 51 (55.4%) were male. Rifampicin-based regimens were predominantly used in combination with clarithromycin (47.8%) and ciprofloxacin (46.7%), and the median duration of antibiotic treatment before surgery was 23 days (IQR, 8.0-45.5). There were no culture positive results after 19 days of antibiotic treatment and there was a significant association between antibiotic duration before surgery and a culture positive outcome (p<0.001). The World Health Organisation category of the lesion and the antibiotic regimen used had no association with the culture outcome. Antibiotics appear to be effective at achieving negative cultures of M. ulcerans disease lesions in less than the currently recommended eight-week duration.
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Affiliation(s)
- Brodie Tweedale
- Geelong Centre for Emerging Infectious Diseases (GCEID), Deakin University, Geelong, Australia
- Department of Infectious Disease, Barwon Health, Geelong, Australia
| | - Fiona Collier
- Geelong Centre for Emerging Infectious Diseases (GCEID), Deakin University, Geelong, Australia
| | - Nilakshi T Waidyatillake
- Department of Infectious Disease, Barwon Health, Geelong, Australia
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Eugene Athan
- Geelong Centre for Emerging Infectious Diseases (GCEID), Deakin University, Geelong, Australia
- Department of Infectious Disease, Barwon Health, Geelong, Australia
| | - Daniel P O'Brien
- Department of Infectious Disease, Barwon Health, Geelong, Australia
- Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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9
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O'Brien DP, Friedman ND, Cowan R, Walton A, Athan E. Six vs Eight Weeks of Antibiotics for Small Mycobacterium ulcerans Lesions in Australian Patients. Clin Infect Dis 2021; 70:1993-1997. [PMID: 31231766 DOI: 10.1093/cid/ciz532] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/19/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antibiotics are highly effective in curing Mycobacterium ulcerans lesions, but are associated with significant toxicity. In those not undergoing surgery, we compared 6 weeks with the currently recommended 8 weeks of combination antibiotic therapy for small M. ulcerans lesions. METHODS Mycobacterium ulcerans cases from an observational cohort at Barwon Health, Victoria, treated with antibiotics alone from 1 October 2010 to 31 March 2018 were included. The 6-week antibiotic group received ≥28 days and ≤42 days and the 8-week antibiotic group received ≥56 days of antibiotic therapy, respectively. Only World Health Organization category 1 lesions were included. RESULTS 207 patients were included; 53 (25.6%) in the 6-week group and 154 (74.4%) in the 8-week group. The median age of patients was 53 years (interquartile range [IQR], 33-69 years) and 100 (48.3%) were female. Lesions were ≤900 mm2 in size in 79.7% of patients and 93.2% were ulcerative. Fifty-three patients (100%) achieved treatment cure in the 6-week group compared with 153 (99.4%) in the 8-week group (P = .56). No patients died or were lost to follow-up during the study. Median time to heal was 70 days (IQR, 60-96 days) in the 6-week group and 128 days (IQR, 95-173 days) in the 8-week group (P < .001). Two (3.8%) patients in the 6-week group experienced a paradoxical reaction compared with 39 (25.3%) patients in the 8-week group (P = .001). CONCLUSIONS For selected small M. ulcerans lesions, 6 weeks may be as effective as 8 weeks of combined antibiotic therapy in curing lesions without surgery.
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Affiliation(s)
- Daniel P O'Brien
- Department of Infectious Diseases, University Hospital Geelong.,Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Australia.,Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | | | - Raquel Cowan
- Department of Infectious Diseases, University Hospital Geelong
| | - Aaron Walton
- Department of Infectious Diseases, University Hospital Geelong
| | - Eugene Athan
- Department of Infectious Diseases, University Hospital Geelong.,School of Medicine, Deakin University, Geelong, Australia
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10
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Betts JM, Tay EL, Johnson PDR, Lavender CJ, Gibney KB, O'Brien DP, Globan M, Tzimourtas N, O'Hara MA, Crouch SR. Buruli ulcer: a new case definition for Victoria. ACTA ACUST UNITED AC 2020; 44. [PMID: 33349204 DOI: 10.33321/cdi.2020.44.93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract Laboratory-confirmed infection with Mycobacterium ulcerans is currently notifiable to health departments in several jurisdictions. Accurate surveillance is imperative to understanding current and emerging areas of endemicity and to facilitate research into a neglected tropical disease with poorly-understood transmission dynamics. The state of Victoria currently reports some of the highest numbers of M. ulcerans cases in the world each year, with 340 cases notified in 2018 (an incidence of 5.5 per 100,000 population). In May 2019, a group of clinical, laboratory and public health experts met to discuss a new case definition for the surveillance of M. ulcerans disease in Victoria, incorporating clinical and epidemiological elements. The new case definition supports important public health messaging and actions for residents and visitors to popular tourist areas in Victoria.
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Affiliation(s)
- Juliana M Betts
- Victorian Government Department of Health and Human Services.,School of Public Health and Preventive Medicine, Monash University, Melbourne
| | - Ee Laine Tay
- Victorian Government Department of Health and Human Services
| | | | - Caroline J Lavender
- Mycobacterium Reference Laboratory, Victorian Infectious Diseases Reference Laboratory (VIDRL), at the Peter Doherty Institute for Infection and Immunity, Victoria, 3000, Australia
| | - Katherine B Gibney
- Victorian Government Department of Health and Human Services.,Department of Infectious Diseases, Austin Hospital, Melbourne.,The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, 3000, Australia
| | - Daniel P O'Brien
- Department of Infectious Diseases, University Hospital, Geelong.,Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne
| | - Maria Globan
- Mycobacterium Reference Laboratory, Victorian Infectious Diseases Reference Laboratory (VIDRL), at the Peter Doherty Institute for Infection and Immunity, Victoria, 3000, Australia
| | | | - Miriam A O'Hara
- Victorian Government Department of Health and Human Services
| | - Simon R Crouch
- Victorian Government Department of Health and Human Services
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11
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Risk Factors Associated with Antibiotic Treatment Failure of Buruli Ulcer. Antimicrob Agents Chemother 2020; 64:AAC.00722-20. [PMID: 32571813 DOI: 10.1128/aac.00722-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/03/2020] [Indexed: 11/20/2022] Open
Abstract
Combination antibiotic therapy is highly effective in curing Buruli ulcer (BU) caused by Mycobacterium ulcerans Treatment failures have been uncommonly reported with the recommended 56 days of antibiotics, and little is known about risk factors for treatment failure. We analyzed treatment failures among BU patients treated with ≥56 days of antibiotics from a prospective observational cohort at Barwon Health, Victoria, from 1 January 1998 to 31 December 2018. Treatment failure was defined as culture-positive recurrence within 12 months of commencing antibiotics under the following conditions: (i) following failure to heal the initial lesion or (ii) a new lesion developing at the original or at a new site. A total of 430 patients received ≥56 days of antibiotic therapy, with a median duration of 56 days (interquartile range [IQR], 56 to 80). Seven (1.6%) patients experienced treatment failure. For six adult patients experiencing treatment failure, all were male, weighed >90 kg, did not have surgery, and received combination rifampin-clarithromycin (median rifampin dose, 5.6 mg per kg of body weight per day; median clarithromycin dose, 8.1 mg/kg/day). When compared to those who did not fail treatment on univariate analysis, treatment failure was significantly associated with a weight of >90 kg (P < 0.001), male gender (P = 0.02), immune suppression (P = 0.04), and a first-line regimen of rifampin-clarithromycin compared to a regimen of rifampin-fluoroquinolone (P = 0.05). There is a low rate of treatment failure in Australian BU patients treated with rifampin-based oral combination antibiotic therapy. Our study raises the possibility that treatment failure risk may be increased in males, those with a body weight of >90 kg, those with immune suppression, and those taking rifampin-clarithromycin antibiotic regimens, but future pharmacokinetic and pharmacodynamics studies are required to determine the validity of these hypotheses.
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12
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Walker G, Friedman DN, O'Brien MP, Cooper C, McDonald A, Callan P, O'Brien DP. Paediatric Buruli ulcer in Australia. J Paediatr Child Health 2020; 56:636-641. [PMID: 31821679 DOI: 10.1111/jpc.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/03/2019] [Indexed: 11/30/2022]
Abstract
AIM This study describes an Australian cohort of paediatric Buruli ulcer (BU) patients and compares them with adult BU patients. METHODS Analysis of a prospective cohort of all BU cases managed at Barwon Health, Victoria, from 1 January 1998 to 31 May 2018 was performed. Children were defined as ≤15 years of age. RESULTS A total of 565 patients were included: 52 (9.2%) children, 289 (51.2%) adults aged 16-64 years and 224 (39.6%) adults aged ≥65 years. Among children, half were female and the median age was 8.0 years (interquartile range 4.8-12.3 years). Six (11.5%) cases were diagnosed from 2001 to 2006, 14 (26.9%) from 2007 to 2012 and 32 (61.5%) from 2013 to 2018. Compared to adults, children had a significantly higher proportion of non-ulcerative lesions (32.7%, P < 0.001) and a higher proportion of severe lesions (26.9%, P < 0.01). The median duration of symptoms prior to diagnosis was shorter for children compared with adults aged 16-64 years (42 vs. 56 days, P = 0.04). Children were significantly less likely to experience antibiotic complications (6.1%) compared with adults (20.6%, P < 0.001), but had a significantly higher rate of paradoxical reactions (38.8%) compared with adults aged 16-64 (19.2%) (P < 0.001). Paradoxical reactions in children occurred significantly earlier than in adults (median 17 vs. 56 days, P < 0.01). Cure rates were similarly high for children compared to adults treated with antibiotics alone or with antibiotics and surgery. CONCLUSIONS Paediatric BU cases in Australia are increasing and represent an important but stable proportion of Australian BU cohorts. Compared with adults, there are significant differences in clinical presentation and treatment outcomes.
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Affiliation(s)
- Georgia Walker
- Department of Paediatrics, Barwon Health, Geelong, Victoria, Australia
| | - Deborah N Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Matthew P O'Brien
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Chris Cooper
- Department of Paediatrics, Barwon Health, Geelong, Victoria, Australia
| | - Anthony McDonald
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Peter Callan
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Daniel P O'Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Manson Unit, Médecins Sans Frontières, London, United Kingdom
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Piazena H, Müller W, Pendl W, von Ah S, Cap VH, Hug PJ, Sidler X, Pluschke G, Vaupel P. Thermal field formation during wIRA-hyperthermia: temperature measurements in skin and subcutis of piglets as a basis for thermotherapy of superficial tumors and local skin infections caused by thermosensitive microbial pathogens. Int J Hyperthermia 2020; 36:938-952. [PMID: 31535588 DOI: 10.1080/02656736.2019.1655594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Purpose: The temporal and spatial formation of the temperature field and its changes during/upon water-filtered infrared-A (wIRA)-irradiation in porcine skin and subcutis were investigated in vivo in order to get a detailed physical basis for thermotherapy of superficial tumors and infections caused by thermosensitive microbial pathogens (e.g., Mycobacterium ulcerans causing Buruli ulcer). Methods: Local wIRA-hyperthermia was performed in 11 anesthetized piglets using 85.0 mW cm-2, 103.2 mW cm-2 and 126.5 mW cm-2, respectively. Invasive temperature measurements were carried out simultaneously in 1-min intervals using eight fiber-optical probes at different tissue depths between 2 and 20 mm, and by an IR thermometer at the skin surface. Results: Tissue temperature distribution depended on incident irradiance, exposure time, tissue depths and individual 'physiologies' of the animals. Temperature maxima were found at depths between 4 and 7 mm, exceeding skin surface temperatures by about 1-2 K. Tissue temperatures above 37 °C, necessary to eradicate M. ulcerans at depths <20 mm, were reached reliably. Conclusions: wIRA-hyperthermia may be considered as a novel therapeutic option for treatment of local skin infections caused by thermosensitive pathogens (e.g., in Buruli ulcer). To ensure temperatures required for heat treatment of superficial tumors deeper than 4 mm, the incident irradiance needed can be controlled either by (a) invasive temperature measurements or (b) control of skin surface temperature and considering possible temperature increases up to 1-2 K in underlying tissue.
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Affiliation(s)
- Helmut Piazena
- Medical Photobiology Group, Department of Internal Medicine, Charité-University Medicine Berlin , Berlin , Germany
| | - Werner Müller
- Physical Optics Consultant Office , Wetzlar , Germany
| | - Wolfgang Pendl
- Department of Farm Animals, Division of Swine Medicine, Vetsuisse Faculty, University of Zürich , Zürich , Switzerland
| | - Sereina von Ah
- Department of Farm Animals, Division of Swine Medicine, Vetsuisse Faculty, University of Zürich , Zürich , Switzerland
| | - Veronika H Cap
- Section of Anaesthesiology, Equine Department, Vetsuisse Faculty, University of Zürich , Zürich , Switzerland
| | - Petra J Hug
- Section of Anaesthesiology, Equine Department, Vetsuisse Faculty, University of Zürich , Zürich , Switzerland
| | - Xaver Sidler
- Department of Farm Animals, Division of Swine Medicine, Vetsuisse Faculty, University of Zürich , Zürich , Switzerland
| | - Gerd Pluschke
- Department of Medical Parasitology and Infection Biology, Molecular Immunology Unit, Swiss Tropical and Public Health Institute , Basel , Switzerland
| | - Peter Vaupel
- Department of Radiation Oncology, University Medical Center , Freiburg i. Breisgau , Germany
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14
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Wadagni AC, Steinhorst J, Barogui YT, Catraye PM, Gnimavo R, Abass KM, Amofa G, Frimpong M, Sarpong FN, van der Werf TS, Phillips R, Sopoh GE, Johnson CR, Stienstra Y. Buruli ulcer treatment: Rate of surgical intervention differs highly between treatment centers in West Africa. PLoS Negl Trop Dis 2019; 13:e0007866. [PMID: 31658295 PMCID: PMC6855495 DOI: 10.1371/journal.pntd.0007866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background Antibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. Methods A retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders. Results A total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5–124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly. Conclusion The decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU Buruli ulcer is a necrotizing and disabling skin infection, caused by Mycobacterium ulcerans. The infection, a skin-related Neglected Tropical Diseases, affects mostly people living in limited resources settings. Since the introduction of rifampicin based combination antibiotic therapy as standard care, the role of surgery as adjunct therapy to kill M. ulcerans is less defined and understood. A randomized controlled trial showed benefit from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. We present the differences in rate of surgical interventions in six different Buruli ulcer treatment centers in Ghana and Benin. We demonstrate that these differences mainly depend on the opinion of the health care workers working in the treatment centers even after adjusting for disease severity.
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Affiliation(s)
- Anita C. Wadagni
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
- * E-mail:
| | - Jonathan Steinhorst
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
| | - Yves T. Barogui
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - P. M. Catraye
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Ronald Gnimavo
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | | | | | - Michael Frimpong
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Francisca N. Sarpong
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Tjip S. van der Werf
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
| | - Richard Phillips
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Ghislain E. Sopoh
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Christian R. Johnson
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Ymkje Stienstra
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
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Abstract
Recommendations for first-line and second-line drug testing and organism group, specific methodologies, and reporting recommendations have been addressed by the Clinical and Laboratory Standards Institute (CLSI) and are important in the selection of appropriate antimicrobial treatment regimens for nontuberculous mycobacteria (NTM) disease. This review also includes recent information on new antimicrobials proposed for the treatment of NTM but not yet addressed by the CLSI and molecular (gene sequencing) methods associated with the detection of antimicrobial resistance of two major therapeutic antimicrobials, clarithromycin and amikacin.
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Delays in Patient Presentation and Diagnosis for Buruli Ulcer ( Mycobacterium ulcerans Infection) in Victoria, Australia, 2011-2017. Trop Med Infect Dis 2019; 4:tropicalmed4030100. [PMID: 31277453 PMCID: PMC6789443 DOI: 10.3390/tropicalmed4030100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 11/22/2022] Open
Abstract
Uncertainty regarding transmission pathways and control measures makes prompt presentation and diagnosis for Buruli ulcer critical. To examine presentation and diagnosis delays in Victoria, Australia, we conducted a retrospective study of 703 cases notified between 2011 and 2017, classified as residing in an endemic (Mornington Peninsula; Bellarine Peninsula; South-east Bayside and Frankston) or non-endemic area. Overall median presentation delay was 30 days (IQR 14–60 days), with no significant change over the study period (p = 0.11). There were significant differences in median presentation delay between areas of residence (p = 0.02), but no significant change over the study period within any area. Overall median diagnosis delay was 10 days (IQR 0–40 days), with no significant change over the study period (p = 0.13). There were significant differences in median diagnosis delay between areas (p < 0.001), but a significant decrease over time only on the Mornington Peninsula (p < 0.001). On multivariable analysis, being aged <15 or >65 years; having non-ulcerative disease; and residing in the Bellarine Peninsula or South-East Bayside (compared to non-endemic areas) were significantly associated with shorter presentation delay. Residing in the Bellarine or Mornington Peninsula and being notified later in the study period were significantly associated with shorter diagnosis delay. To reduce presentation and diagnosis delays, awareness of Buruli ulcer must be raised with the public and medical professionals, particularly those based outside established endemic areas.
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Loftus MJ, Kettleton-Butler N, Wade D, Whitby RM, Johnson PD. A severe case of <em>Mycobacterium ulcerans</em> (Buruli ulcer) osteomyelitis requiring a below-knee amputation. Med J Aust 2019; 208:290-291. [PMID: 29642809 DOI: 10.5694/mja17.01158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 02/08/2018] [Indexed: 11/17/2022]
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18
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O’Brien DP, Murrie A, Meggyesy P, Priestley J, Rajcoomar A, Athan E. Spontaneous healing of Mycobacterium ulcerans disease in Australian patients. PLoS Negl Trop Dis 2019; 13:e0007178. [PMID: 30779807 PMCID: PMC6396929 DOI: 10.1371/journal.pntd.0007178] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 03/01/2019] [Accepted: 01/22/2019] [Indexed: 11/23/2022] Open
Abstract
Background Mycobacterium ulcerans causes necrotising infections of skin and soft tissue mediated by the polyketide exotoxin mycolactone that causes cell apoptosis and immune suppression. It has been postulated that infection can be eradicated before the development of clinical lesions but spontaneous resolution of clinical lesions has been rarely described. Methodology/Principal findings We report a case series of five Australian patients who achieved healing of small M. ulcerans lesions without antibiotics or surgery. The median age of patients was 47 years (IQR 30–68 years) and all patients had small ulcerative lesions (median size 144mm2, IQR 121-324mm2). The median duration of symptoms prior to diagnosis was 90 days (IQR 90–100 days) and the median time to heal from diagnosis without treatment was 68 days (IQR 63–105 days). No patients recurred after a median follow-up of 16.6 months (IQR 16.6–17.9 months) from the development of symptoms and no patients suffered long-term disability from the disease. Conclusions We have shown that healing without specific treatment can occur for small ulcerated M. ulcerans lesions suggesting that in selected cases a robust immune response alone can cure lesions. Further research is required to determine what lesion and host factors are associated with spontaneous healing, and whether observation alone is an effective and safe form of management for selected small M. ulcerans lesions. Mycobacterium ulcerans causes a destructive infection of skin and soft tissue known as Buruli ulcer that when severe can lead to serious long-term deformity and disability. It is currently not well documented whether people with Mycobacterium ulcerans disease can cure themselves without treatment. In our study we describe five people with small ulcers who cured their disease without specific medical or surgical treatment. This suggests that a proportion of people can develop an immune response sufficient enough to eradicate the disease without the help of medical intervention. This is an important step, as recognition of this possibility provides important further insights into the human immune response against the disease. It also opens the possibility to further studies that may determine characteristics of the organism and hosts that favour spontaneous healing of lesions. This knowledge may in turn improve efforts to prevent and control the disease which are currently lacking.
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Affiliation(s)
- Daniel P. O’Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
| | - Adrian Murrie
- Sorrento Medical Centre, Sorrento, Victoria, Australia
| | | | | | | | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
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19
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Mycobacterium Ulcerans soft tissue defects: reconstructive challenges. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-018-1459-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chung J, Ince D, Ford BA, Wanat KA. Cutaneous Infections Due to Nontuberculosis Mycobacterium: Recognition and Management. Am J Clin Dermatol 2018; 19:867-878. [PMID: 30168084 DOI: 10.1007/s40257-018-0382-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Nontuberculous mycobacteria (NTM) are a diverse group of organisms that are ubiquitous in the environment, and the incidence of cutaneous infections due to NTM has been steadily increasing. Cutaneous infections due to NTM can be difficult to diagnose, due to their wide spectrum of clinical presentations and histopathological findings that are often nonspecific. A variety of modalities including tissue culture and polymerase chain reaction (PCR) assays may be necessary to identify the organism. Treatment can also be challenging, as it can depend on multiple factors, including the causative organism, the patient's immunological status, and the extent of disease involvement. In this review, we discuss the common presentations of cutaneous NTM infections, diagnostic tools, and treatment recommendations. A multi-disciplinary approach that involves good communication between the clinician, the histopathologist, the microbiologist, and infectious disease specialists can help lead to successful diagnosis and management.
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Affiliation(s)
- Jina Chung
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Dilek Ince
- Division of Infectious Disease, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bradley A Ford
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Karolyn A Wanat
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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21
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Bretzel G, Beissner M. PCR detection of Mycobacterium ulcerans-significance for clinical practice and epidemiology. Expert Rev Mol Diagn 2018; 18:1063-1074. [PMID: 30381977 DOI: 10.1080/14737159.2018.1543592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Buruli ulcer (BU) is a neglected disease which has been reported from mostly impoverished, remote rural areas from 35 countries worldwide. BU affects skin, subcutaneous tissue, and bones, and may cause massive tissue destruction and life-long disabilities if not diagnosed and treated early. Without laboratory confirmation diagnostic and treatment errors may occur. This review describes the application of IS2404 PCR, the preferred diagnostic test, in the area of individual patient management and clinico-epidemiological studies. Areas covered: A Medline search included publications on clinical sample collection, DNA extraction, and PCR detection formats of the past and present, potential and limitations of clinical application, as well as clinico-epidemiological studies. Expert commentary: A global network of reference laboratories basically provides the possibility for PCR confirmation of 70% of all BU cases worldwide as requested by the WHO. Keeping laboratory confirmation on a constant level requires continuous outreach activities. Among the potential measures to maintain sustainability of laboratory confirmation and outreach activities are decentralized or mobile diagnostics available at point of care, such as IS2404-based LAMP, which complement the standard IS2404-based diagnostic tools available at central level.
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Affiliation(s)
- Gisela Bretzel
- a Division of Infectious Diseases and Tropical Medicine , University Hospital, Ludwigs-Maximilians-University , Munich , Germany
| | - Marcus Beissner
- a Division of Infectious Diseases and Tropical Medicine , University Hospital, Ludwigs-Maximilians-University , Munich , Germany
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22
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Abstract
Mycobacterium ulcerans is recognised as the third most common mycobacterial infection worldwide. It causes necrotising infections of skin and soft tissue and is classified as a neglected tropical disease by the World Health Organization (WHO). However, despite extensive research, the environmental reservoir of the organism and mode of transmission of the infection to humans remain unknown. This limits the ability to design and implement public health interventions to effectively and consistently prevent the spread and reduce the incidence of this disease. In recent years, the epidemiology of the disease has changed. In most endemic regions of the world, the number of cases reported to the WHO are reducing, with a 64% reduction in cases reported worldwide in the last 9 years. Conversely, in a smaller number of countries including Australia and Nigeria, reported cases are increasing at a rapid rate, new endemic areas continue to appear, and in Australia cases are becoming more severe. The reasons for this changing epidemiology are unknown. We review the epidemiology of M. ulcerans disease worldwide, and document recent changes. We also outline and discuss the current state of knowledge on the ecology of M. ulcerans, possible transmission mechanisms to humans and what may be enabling the spread of M. ulcerans into new endemic areas.
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O'Brien DP, Callan P, Friedman ND, Athan E, Hughes A, McDonald A. Mycobacterium ulcerans disease management in Australian patients: the re-emergence of surgery as an important treatment modality. ANZ J Surg 2018; 89:653-658. [PMID: 30239097 DOI: 10.1111/ans.14829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 12/25/2022]
Abstract
With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re-emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible.
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Affiliation(s)
- Daniel P O'Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine and Infectious Diseases, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Manson Unit, Médecins Sans Frontières, London, UK
| | - Peter Callan
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Andrew Hughes
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Anthony McDonald
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
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Wynne JW, Stinear TP, Athan E, Michalski WP, O’Brien DP. Low incidence of recurrent Buruli ulcers in treated Australian patients living in an endemic region. PLoS Negl Trop Dis 2018; 12:e0006724. [PMID: 30102695 PMCID: PMC6107289 DOI: 10.1371/journal.pntd.0006724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/23/2018] [Accepted: 07/28/2018] [Indexed: 12/04/2022] Open
Abstract
We examined recurrent Buruli ulcer cases following treatment and assumed cure in a large cohort of Australian patients living in an endemic area. We report that while the recurrence rate was low (2.81 cases/year/1000 population), it remained similar to the estimated risk of primary infection within the general population of the endemic area (0.85–4.04 cases/year/1,000 population). The majority of recurrent lesions occurred in different regions of the body and were separated by a median time interval of 44 months. Clinical, treatment and epidemiological factors combined with whole genome sequencing of primary and recurrent isolates suggests that in most recurrent cases a re-infection was more likely as opposed to a relapse of the initial infection. Additionally, all cases occurring more than 12 months after commencement of treatment were likely re-infections. Our study provides important prognostic information for patients and their health care providers concerning the nature and risks associated with recurrent cases of Buruli ulcer in Australia. Mycobacterium ulcerans (M. ulcerans) causes a necrotising infection of skin and soft-tissue known as Buruli ulcer. Since the regular use of antibiotics for Buruli ulcer treatment in Australian populations was introduced at the turn of the century, treatment success rates have been very high. However there is no information from the Australian setting on the risk of recurrent disease following treatment and assumed cure, despite this being important prognostic information for patients, their families and health-care providers. Furthermore, it is also not known if recurrent disease represents late relapse of the initial treated infection or a subsequent new infection. In our study we have shown for the first time in Australian patients living in an endemic area that the incidence of recurrent Buruli ulcer following treatment and healing is low, and that this risk is similar to the estimated risk of primary infection within the general population of the endemic area. Furthermore, we have used clinical, treatment and epidemiological data supported by genomic information of M. ulcerans organisms to determine that the majority of recurrent lesions appear to result from re-infection. This suggests that for a proportion of treated patients’ acquired protective immunity against the development of recurrent M. ulcerans disease does not develop from their initial infection.
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Affiliation(s)
- James W. Wynne
- CSIRO, Australian Animal Health Laboratory, Geelong, Victoria, Australia
| | - Timothy P. Stinear
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia
- Doherty Applied Microbial Genomics, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | | | - Daniel P. O’Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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25
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Meher-Homji Z, Johnson PDR. An Overview of the Treatment of Mycobacterium ulcerans Infection (Buruli Ulcer). CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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O'Brien DP, Friedman D, Hughes A, Walton A, Athan E. Antibiotic complications during the treatment of Mycobacterium ulcerans disease in Australian patients. Intern Med J 2018; 47:1011-1019. [PMID: 28585259 DOI: 10.1111/imj.13511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/14/2017] [Accepted: 06/01/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antibiotics are the recommended first-line treatment for Mycobacterium ulcerans disease. Antibiotic toxicity is common in Australian patients, yet antibiotic complication rates and their risk factors have not been determined. AIM To determine the incidence rate and risk factors for antibiotic toxicity in Australian patients treated for M. ulcerans disease. METHODS An analysis of severe antibiotic complications was performed using data from a prospective cohort of M. ulcerans cases managed at Barwon Health from 1 January 1998 to 30 June 2016. A severe antibiotic complication was defined as an antibiotic adverse event that required its cessation. Antibiotic complication rates and their associations were assessed using a Poisson regression model. RESULTS A total of 337 patients was included; 184 (54.6%) males and median age 57 years (interquartile range (IQR) 36-73 years). Median antibiotic treatment duration was 56 days (IQR 49-76 days). Seventy-five (22.2%) patients experienced severe antibiotic complications after a median 28 days (IQR 17-45 days) at a rate of 141.53 per 100 person-years (95% confidence interval (CI) 112.86-177.47). Eleven (14.7%) patients required hospitalisation. Compared with rifampicin/clarithromycin combinations, severe complication rates were not increased for rifampicin/ciprofloxacin (rate ratio (RR) 1.49, 95% CI 0.89-2.50, P = 0.13) or rifampicin/moxifloxacin (RR 2.54, 95% CI 0.76-8.50, P = 0.13) combinations, but were significantly increased for 'other' combinations (RR 2.53, 95% CI 1.13-5.68, P = 0.03). In a multivariable analysis, severe complication rates were significantly increased with reduced estimated glomerular filtration rates (EGFR) (adjusted rate ratio (aRR) 2.65, 95% CI 1.24-5.65 for EGFR 60-89 mL/min and aRR 1.31, 95% CI 0.49-3.53 for EGFR 0-59 mL/min compared with EGFR ≥90 mL/min, P < 0.01) and female gender (aRR 2.15, 95% CI 1.38-3.30, P < 0.01). CONCLUSIONS Severe antibiotic complications during M. ulcerans treatment are high with increased rates independently associated with reduced renal function and female gender.
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Affiliation(s)
- Daniel P O'Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Manson Unit, Médecins Sans Frontières, London, UK
| | - Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Andrew Hughes
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Aaron Walton
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
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Tai AYC, Athan E, Friedman ND, Hughes A, Walton A, O'Brien DP. Increased Severity and Spread of Mycobacterium ulcerans, Southeastern Australia. Emerg Infect Dis 2018; 24. [PMID: 28980523 PMCID: PMC5749465 DOI: 10.3201/eid2401.171070] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Reported cases of Mycobacterium ulcerans disease (Buruli ulcer) have been increasing in southeastern Australia and spreading into new geographic areas. We analyzed 426 cases of M. ulcerans disease during January 1998–May 2017 in the established disease-endemic region of the Bellarine Peninsula and the emerging endemic region of the Mornington Peninsula. A total of 20.4% of cases patients had severe disease. Over time, there has been an increase in the number of cases managed per year and the proportion associated with severe disease. Risk factors associated with severe disease included age, time period (range of years of diagnosis), and location of lesions over a joint. We highlight the changing epidemiology and pathogenicity of M. ulcerans disease in Australia. Further research, including genomic studies of emergent strains with increased pathogenicity, is urgently needed to improve the understanding of this disease to facilitate implementation of effective public health measures to halt its spread.
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Buruli Ulcer, a Prototype for Ecosystem-Related Infection, Caused by Mycobacterium ulcerans. Clin Microbiol Rev 2017; 31:31/1/e00045-17. [PMID: 29237707 DOI: 10.1128/cmr.00045-17] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Buruli ulcer is a noncontagious disabling cutaneous and subcutaneous mycobacteriosis reported by 33 countries in Africa, Asia, Oceania, and South America. The causative agent, Mycobacterium ulcerans, derives from Mycobacterium marinum by genomic reduction and acquisition of a plasmid-borne, nonribosomal cytotoxin mycolactone, the major virulence factor. M. ulcerans-specific sequences have been readily detected in aquatic environments in food chains involving small mammals. Skin contamination combined with any type of puncture, including insect bites, is the most plausible route of transmission, and skin temperature of <30°C significantly correlates with the topography of lesions. After 30 years of emergence and increasing prevalence between 1970 and 2010, mainly in Africa, factors related to ongoing decreasing prevalence in the same countries remain unexplained. Rapid diagnosis, including laboratory confirmation at the point of care, is mandatory in order to reduce delays in effective treatment. Parenteral and potentially toxic streptomycin-rifampin is to be replaced by oral clarithromycin or fluoroquinolone combined with rifampin. In the absence of proven effective primary prevention, avoiding skin contamination by means of clothing can be implemented in areas of endemicity. Buruli ulcer is a prototype of ecosystem pathology, illustrating the impact of human activities on the environment as a source for emerging tropical infectious diseases.
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Kuntz M, Henneke P. Infektionen durch nichttuberkulöse Mykobakterien im Kindesalter. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ruf MT, Steffen C, Bolz M, Schmid P, Pluschke G. Infiltrating leukocytes surround early Buruli ulcer lesions, but are unable to reach the mycolactone producing mycobacteria. Virulence 2017; 8:1918-1926. [PMID: 28873327 PMCID: PMC5810495 DOI: 10.1080/21505594.2017.1370530] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Marie-Thérèse Ruf
- a Swiss Tropical and Public Health Institute , Basel , Switzerland.,b University of Basel , Basel , Switzerland
| | - Christina Steffen
- c Department of Surgery , Cairns Hospital , Cairns , QLD , Australia
| | - Miriam Bolz
- a Swiss Tropical and Public Health Institute , Basel , Switzerland.,b University of Basel , Basel , Switzerland
| | - Peter Schmid
- a Swiss Tropical and Public Health Institute , Basel , Switzerland.,b University of Basel , Basel , Switzerland
| | - Gerd Pluschke
- a Swiss Tropical and Public Health Institute , Basel , Switzerland.,b University of Basel , Basel , Switzerland
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Steffen CM, Freeborn H. Mycobacterium ulcerans in the Daintree 2009-2015 and the mini-epidemic of 2011. ANZ J Surg 2016; 88:E289-E293. [PMID: 27804194 DOI: 10.1111/ans.13817] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/01/2016] [Accepted: 09/22/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mycobacterium ulcerans infection (Buruli ulcer) is the third most common mycobacterial disease in humans, with presentations ranging from self-limiting skin nodules and ulcers to aggressive infiltrative infections with extensive oedema, fat and skin necrosis. The two foci in Australia are in Victoria and Far North Queensland. We present the 2009-2015 case series for the Queensland focus with special reference to the 2011 spike of 64 cases. METHODS This case series is based on a combination of prospectively and retrospectively collected data on 95 confirmed cases of M. ulcerans between 2009 and 2015 from the endemic area, consisting of 88 Category 1 lesions (single lesion less than 5 cm), three Category 2 (5-15 cm plaques) and four Category 3 (one multiple lesions, three oedematous infection). RESULTS Eighty-nine patients underwent surgery. Thirty-two patients received antibiotics. Management details for three patients were unavailable. Recurrent disease was identified in six patients (6%). CONCLUSION Mycobacterium ulcerans infection (Buruli ulcer) is an endemic but uncommon infection in Far North Queensland with usually fewer than 10 cases per year. Small ulcers predominate. Most were excised and antibiotic treatment was frequently adjuvant rather than therapeutic. The 64 cases in 2011 was unexpected, not duplicated subsequently, and may relate to local climatic variations. Local awareness of the disease facilitated early presentation and diagnosis in most cases, enabling timely treatment while lesions were small and easily managed.
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Affiliation(s)
- Christina M Steffen
- Department of Surgery, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - Helen Freeborn
- Department of Surgery, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
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Albrecht B, Staiger PK, Best D, Hall K, Nielsen S, Lubman DI, Miller P. Benzodiazepine use of community-based violent offenders: a preliminary investigation. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.1080/14659891.2016.1195893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Increasing Experience with Primary Oral Medical Therapy for Mycobacterium ulcerans Disease in an Australian Cohort. Antimicrob Agents Chemother 2016; 60:2692-5. [PMID: 26883709 DOI: 10.1128/aac.02853-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/20/2022] Open
Abstract
Buruli ulcer (BU) is a necrotizing infection of subcutaneous tissue that is caused by Mycobacterium ulcerans and is responsible for disfiguring skin lesions. The disease is endemic to specific geographic regions in the state of Victoria in southeastern Australia. Growing evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has evolved our practice to the use of primarily oral medical therapy. An observational cohort study was performed on all confirmed M. ulcerans cases treated with primary rifampin-based medical therapy at Barwon Health between October 2010 and December 2014 and receiving 12 months of follow-up. One hundred thirty-two patients were managed with primary medical therapy. The median age of patients was 49 years, and nearly 10% had diabetes mellitus. Lesions were ulcerative in 83.3% of patients and at WHO stage 1 in 78.8% of patients. The median duration of therapy was 56 days, with 22 patients (16.7%) completing fewer than 56 days of antimicrobial treatment. Antibiotic-associated complications requiring cessation of one or more antibiotics occurred in 21 (15.9%) patients. Limited surgical debridement was performed on 30 of these medically managed patients (22.7%). Cure was achieved, with healing within 12 months, in 131 of 132 patients (99.2%), and cosmetic outcomes were excellent. Primary rifampin-based oral medical therapy for M. ulcerans disease, combined with either clarithromycin or a fluoroquinolone, has an excellent rate of cure and an acceptable toxicity profile in Australian patients. We advocate for further research to determine the optimal and safest minimum duration of medical therapy for BU.
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Mycobacterium ulcerans in the Elderly: More Severe Disease and Suboptimal Outcomes. PLoS Negl Trop Dis 2015; 9:e0004253. [PMID: 26630648 PMCID: PMC4667883 DOI: 10.1371/journal.pntd.0004253] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/31/2015] [Indexed: 02/04/2023] Open
Abstract
Background The clinical presentation of M. ulcerans disease and the safety and effectiveness of treatment may differ in elderly compared with younger populations related to relative immune defficiencies, co-morbidities and drug interactions. However, elderly populations with M. ulcerans disease have not been comprehensively studied. Methodology/Principal Findings A retrospective analysis was performed on an observational cohort of all confirmed M. ulcerans cases managed at Barwon Health from 1/1/1998-31/12/2014. The cohort included 327 patients; 131(40.0%) ≥65 years and 196(60.0%) <65 years of age. Patients ≥65 years had a shorter median duration of symptoms prior to diagnosis (p<0.01), a higher proportion with diabetes (p<0.001) and immune suppression (p<0.001), and were more likely to have lesions that were multiple (OR 4.67, 95% CI 1.78–12.31, p<0.001) and WHO category 3 (OR 4.59, 95% CI 1.98–10.59, p<0.001). Antibiotic complications occurred in 69(24.3%) treatment episodes at an increased incidence in those aged ≥65 years (OR 5.29, 95% CI 2.81–9.98, p<0.001). There were 4(1.2%) deaths, with significantly more in the age-group ≥65 years (4 compared with 0 deaths, p = 0.01). The overall treatment success rate was 92.2%. For the age-group ≥65 years there was a reduced rate of treatment success overall (OR 0.34, 95% CI 0.14–0.80, p = <0.01) and when surgery was used alone (OR 0.21, 95% CI 0.06–0.76, p<0.01). Patients ≥65 years were more likely to have a paradoxical reaction (OR 2.06, 95% CI 1.17–3.62, p = 0.01). Conclusions/Significance Elderly patients comprise a significant proportion of M. ulcerans disease patients in Australian populations and present with more severe and advanced disease forms. Currently recommended treatments are associated with increased toxicity and reduced effectiveness in elderly populations. Increased efforts are required to diagnose M. ulcerans earlier in elderly populations, and research is urgently required to develop more effective and less toxic treatments for this age-group. Mycobacterium ulcerans is an infection that can affect all age-groups. It causes necrosis of skin and soft-tissue often resulting in severe outcomes and long-term disability. However, due to the majority of infections worldwide occurring in children and young adults, there is a paucity of information available in elderly patients. It is important that elderly patients are not neglected as the clinical presentation and treatment outcomes may differ significantly from younger patients related to relative immune defficiencies, co-morbidities and increased potential for drug interactions. We specifically examined patients with M. ulcerans disease aged ≥ 65 years and showed that they comprise a significant proportion of patients affected in Australian populations. They present with more severe and advanced disease forms, and suffer from increased toxicity and reduced effectiveness of the currently recommended treatments. Therefore, our study demonstrates that increased efforts are required to diagnose M. ulcerans disease earlier in elderly populations, and that research is urgently required to develop more effective and less toxic treatments for this age-group.
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Pescitelli L, Galeone M, Tripo L, Prignano F. Cutaneous Non-Tuberculous Mycobacterial Infections: Clinical Clues and Treatment Options. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0064-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Clinical Epidemiology of Buruli Ulcer from Benin (2005-2013): Effect of Time-Delay to Diagnosis on Clinical Forms and Severe Phenotypes. PLoS Negl Trop Dis 2015; 9:e0004005. [PMID: 26355838 PMCID: PMC4565642 DOI: 10.1371/journal.pntd.0004005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/23/2015] [Indexed: 01/05/2023] Open
Abstract
Buruli Ulcer (BU) is a neglected infectious disease caused by Mycobacterium ulcerans that is responsible for severe necrotizing cutaneous lesions that may be associated with bone involvement. Clinical presentations of BU lesions are classically classified as papules, nodules, plaques and edematous infiltration, ulcer or osteomyelitis. Within these different clinical forms, lesions can be further classified as severe forms based on focality (multiple lesions), lesions' size (>15 cm diameter) or WHO Category (WHO Category 3 lesions). There are studies reporting an association between delay in seeking medical care and the development of ulcerative forms of BU or osteomyelitis, but the effect of time-delay on the emergence of lesions classified as severe has not been addressed. To address both issues, and in a cohort of laboratory-confirmed BU cases, 476 patients from a medical center in Allada, Benin, were studied. In this laboratory-confirmed cohort, we validated previous observations, demonstrating that time-delay is statistically related to the clinical form of BU. Indeed, for non-ulcerated forms (nodule, edema, and plaque) the median time-delay was 32.5 days (IQR 30.0-67.5), while for ulcerated forms it was 60 days (IQR 20.0-120.0) (p = 0.009), and for bone lesions, 365 days (IQR 228.0-548.0). On the other hand, we show here that time-delay is not associated with the more severe phenotypes of BU, such as multi-focal lesions (median 90 days; IQR 56-217.5; p = 0.09), larger lesions (diameter >15 cm) (median 60 days; IQR 30-120; p = 0.92) or category 3 WHO classification (median 60 days; IQR 30-150; p = 0.20), when compared with unifocal (median 60 days; IQR 30-90), small lesions (diameter ≤15 cm) (median 60 days; IQR 30-90), or WHO category 1+2 lesions (median 60 days; IQR 30-90), respectively. Our results demonstrate that after an initial period of progression towards ulceration or bone involvement, BU lesions become stable regarding size and focal/multi-focal progression. Therefore, in future studies on BU epidemiology, severe clinical forms should be systematically considered as distinct phenotypes of the same disease and thus subjected to specific risk factor investigation.
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Yotsu RR, Murase C, Sugawara M, Suzuki K, Nakanaga K, Ishii N, Asiedu K. Revisiting Buruli ulcer. J Dermatol 2015; 42:1033-41. [PMID: 26332541 DOI: 10.1111/1346-8138.13049] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 06/23/2015] [Indexed: 11/27/2022]
Abstract
Buruli ulcer (BU), or Mycobacterium ulcerans infection, is a new emerging infectious disease which has been reported in over 33 countries worldwide. It has been noted not only in tropical areas, such as West Africa where it is most endemic, but also in moderate non-tropical climate areas, including Australia and Japan. Clinical presentation starts with a papule, nodule, plaque or edematous form which eventually leads to extensive skin ulceration. It can affect all age groups, but especially children aged between 5 and 15 years in West Africa. Multiple-antibiotic treatment has proven effective, and with surgical intervention at times of severity, it is curable. However, if diagnosis and treatment is delayed, those affected may be left with life-long disabilities. The disease is not yet fully understood, including its route of transmission and pathogenesis. However, due to recent research, several important features of the disease are now being elucidated. Notably, there may be undiagnosed cases in other parts of the world where BU has not yet been reported. Japan exemplifies the finding that awareness among dermatologists plays a key role in BU case detection. So, what about in other countries where a case of BU has never been diagnosed and there is no awareness of the disease among the population or, more importantly, among health professionals? This article will revisit BU, reviewing clinical features as well as the most recent epidemiological and scientific findings of the disease, to raise awareness of BU among dermatologists worldwide.
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Affiliation(s)
- Rie R Yotsu
- Department of Dermatology, National Suruga Sanatorium, Shizuoka, Japan.,Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chiaki Murase
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Koichi Suzuki
- Department of Clinical Laboratory Science, Faculty of Medical Technology, Teikyo University, Tokyo, Japan.,Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazue Nakanaga
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Norihisa Ishii
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kingsley Asiedu
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Abstract
Buruli ulcer (BU) is caused by Mycobacterium ulcerans and can manifest as a simple nodule or as aggressive skin ulcers leading to debilitating osteoarthritis or limb deformity. The disease is more prevalent in those living in remote rural areas, especially in children younger than 15 years. The exact mode of transmission is possibly through traumatic skin lesions contaminated by M ulcerans. IS2404 polymerase chain reaction from ulcer swabs or biopsies is a rapid method for confirmation of BU. In coendemic countries, HIV infection complicates the progression of BU, leading to rapidly spreading osteomyelitis. Treatment is principally medical, with antitubercular drugs, and surgery is utilized for complicated disease. Because of ineffective vaccination, primary prevention is the best option for control of the disease.
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Kirwan A, Quinn B, Winter R, Kinner SA, Dietze P, Stoové M. Correlates of property crime in a cohort of recently released prisoners with a history of injecting drug use. Harm Reduct J 2015; 12:23. [PMID: 26238245 PMCID: PMC4523012 DOI: 10.1186/s12954-015-0057-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/13/2015] [Indexed: 12/02/2022] Open
Abstract
Background Injecting drug use (IDU) is a strong predictor of recidivism and re-incarceration in ex-prisoners. Although the links between drug use and crime are well documented, studies examining post-release criminal activity and re-incarceration risk among ex-prisoners with a history of IDU are limited. We aimed to explore factors associated with property crime among people with a history of IDU recently released from prison. Method Individuals with a history of IDU released from prison within the past month were recruited via targeted and snowball sampling methods from street drug markets and services for people who inject drugs (PWID) into a 6-month cohort study. A multivariate logistic regression analysis of baseline data identified adjusted associations with self-reported property crime soon after release. Results Interviews were conducted a median of 23 days post-release with 141 participants. Twenty-eight percent reported property crime in this period and 85 % had injected drugs since release. Twenty-three percent reported injecting at least daily. Reporting daily injecting (adjusted odds ratio (aOR) 4.36; 95 % confidence interval (CI) = 1.45–13.07), illicit benzodiazepine use (aOR = 2.59; 95 % CI = 1.02–5.67), being arrested (aOR = 6.12; 95 % CI = 1.83–20.45) and contact with mental health services (aOR = 4.27; 95 % CI = 1.45–12.60) since release were associated with property crime. Conclusion Criminal activity soon after release was common in this sample of PWID, underscoring the need for improved pre-release, transitional and post-release drug use dependence and prevention programmes. Addressing co-occurring mental disorder and poly-pharmaceutical misuse among those with a history of IDU in prison, and during the transition to the community, may reduce property crime in this group.
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Affiliation(s)
- Amy Kirwan
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia.
| | - Brendan Quinn
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Rebecca Winter
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Stuart A Kinner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. .,Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, Melbourne, Victoria, 3010, Australia. .,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - Paul Dietze
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Mark Stoové
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, 3004, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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O'Brien DP, Huffam S. Pre-emptive steroids for a severe oedematous Buruli ulcer lesion: a case report. J Med Case Rep 2015; 9:98. [PMID: 25927351 PMCID: PMC4428109 DOI: 10.1186/s13256-015-0584-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/21/2015] [Indexed: 01/23/2023] Open
Abstract
Introduction Severe oedematous forms of Buruli ulcer (BU) often result in extensive tissue destruction, even with the institution of appropriate antibiotic treatment, leading to reconstructive surgery and long-term disability. We report a case of a patient with severe oedematous BU, which describes for the first time the pre-emptive use of prednisolone therapy commenced at the time of antibiotic initiation aimed at limiting the ongoing tissue destruction and its secondary sequelae. Case presentation A 91-year-old Australian-born Caucasian woman presented with a WHO category 3 oedematous BU lesion on the anterior aspect of her right ankle that she had first noticed three weeks earlier. Treatment was commenced with an antibiotic combination of rifampicin and ciprofloxacin. At the same time, pre-emptive prednisolone was commenced (a dose of 0.5mg/kg daily). Treatment resulted in rapid and significant reduction in the size of the induration associated with the lesion, and no significant increase in the size of the skin ulceration. Antibiotics were continued for 56 days and prednisolone therapy ceased 130 days after antibiotics commenced. No surgery was required. The wound healed completely after 10 months and there was no long-term limitation of movement at the ankle joint. Conclusions Pre-emptive corticosteroid therapy may prevent further progressive tissue necrosis and the need for secondary reconstructive surgery that commonly occurs during the antibiotic treatment of severe odematous forms of BU.
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Affiliation(s)
- Daniel P O'Brien
- Department of Infectious Diseases, University Hospital, 292-392 Ryrie Street, Geelong, VIC, 3220, Australia. .,Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, Melbourne, VIC, 3052, Australia. .,Manson Unit, Médecins Sans Frontières, 67-74 Saffron Street, London, EC1N 8QX, UK.
| | - Sarah Huffam
- Department of Infectious Diseases, University Hospital, 292-392 Ryrie Street, Geelong, VIC, 3220, Australia.
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Sugawara M, Ishii N, Nakanaga K, Suzuki K, Umebayashi Y, Makigami K, Aihara M. Exploration of a standard treatment for Buruli ulcer through a comprehensive analysis of all cases diagnosed in Japan. J Dermatol 2015; 42:588-95. [PMID: 25809502 DOI: 10.1111/1346-8138.12851] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 02/07/2015] [Indexed: 11/29/2022]
Abstract
Buruli ulcer (BU) is a refractory skin ulcer caused by Mycobacterium ulcerans or M. ulcerans ssp. shinshuense, a subspecies thought to have originated in Japan or elsewhere in Asia. Although BU occurs most frequently in tropical and subtropical areas such as Africa and Australia, the occurrence in Japan has gradually increased in recent years. The World Health Organization recommends multidrug therapy consisting of a combination of oral rifampicin (RFP) and i.m. streptomycin (SM) for the treatment of BU. However, surgical interventions are often required when chemotherapy alone is ineffective. As a first step in developing a standardized regimen for BU treatment in Japan, we analyzed detailed records of treatments and prognoses in 40 of the 44 BU cases that have been diagnosed in Japan. We found that a combination of RFP (450 mg/day), levofloxacin (LVFX; 500 mg/day) and clarithromycin (CAM; at a dose of 800 mg/day instead of 400 mg/day) was superior to other chemotherapies performed in Japan. This simple treatment with oral medication increases the probability of patient adherence, and may often eliminate the need for surgery.
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Affiliation(s)
- Mariko Sugawara
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,West Yokohama Sugawara Dermatology Clinic, Yokohama, Japan
| | - Norihisa Ishii
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazue Nakanaga
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Koichi Suzuki
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshihiro Umebayashi
- Department of Dermatology and Plastic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Michiko Aihara
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Abstract
Buruli ulcer (Mycobacterium ulcerans infection) is a neglected tropical disease of skin and subcutaneous tissue that can result in long-term cosmetic and functional disability. It is a geographically restricted infection but transmission has been reported in endemic areas in more than 30 countries worldwide. The heaviest burden of disease lies in West and Sub-Saharan Africa where it affects children and adults in subsistence agricultural communities. Mycobacterium ulcerans infection is probably acquired via inoculation of the skin either directly from the environment or indirectly via insect bites. The environmental reservoir and exact route of transmission are not completely understood. It may be that the mode of acquisition varies in different parts of the world. Because of this uncertainty it has been nicknamed the 'mysterious disease'. The therapeutic approach has evolved in the past decade from aggressive surgical resection alone, to a greater focus on antibiotic therapy combined with adjunctive surgery.
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Affiliation(s)
- Gene Khai Lin Huang
- Department of Infectious Diseases, Austin Hospital, Victoria 3084, Australia
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43
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Mycobacterium ulcerans treatment--can antibiotic duration be reduced in selected patients? PLoS Negl Trop Dis 2015; 9:e0003503. [PMID: 25658304 PMCID: PMC4319776 DOI: 10.1371/journal.pntd.0003503] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 12/30/2014] [Indexed: 11/19/2022] Open
Abstract
Introduction Mycobacterium ulcerans (M. ulcerans) is a necrotizing skin infection endemic to the Bellarine Peninsula, Australia. Current treatment recommendations include 8 weeks of combination antibiotics, with adjuvant surgery if necessary. However, antibiotic toxicity often results in early treatment cessation and local experience suggests that shorter antibiotic courses may be effective with concurrent surgery. We report the outcomes of patients in the Barwon Health M. ulcerans cohort who received shorter courses of antibiotic therapy than 8 weeks. Methodology / Principal findings A retrospective analysis was performed of all M. ulcerans infections treated at Barwon Health from March 1, 1998 to July 31, 2013. Sixty-two patients, with a median age of 65 years, received < 56 days of antibiotics and 51 (82%) of these patients underwent concurrent surgical excision. Most received a two-drug regimen of rifampicin combined with either ciprofloxacin or clarithromycin for a median 29 days (IQR 21–41days). Cessation rates were 55% for adverse events and 36% based on clinician decision. The overall success rate was 95% (98% with concurrent surgery; 82% with antibiotics alone) with a 50% success rate for those who received < 14 days of antibiotics increasing to 94% if they received 14–27 days and 100% for 28–55 days (p<0.01). A 100% success rate was seen for concurrent surgery and 14–27 days of antibiotics versus 67% for concurrent surgery and < 14 days of antibiotics (p = 0.12). No previously identified risk factors for treatment failure with surgery alone were associated with reduced treatment success rates with < 56 days of antibiotics. Conclusion In selected patients, antibiotic treatment durations for M. ulcerans shorter than the current WHO recommended 8 weeks duration may be associated with successful outcomes. Buruli ulcer is a necrotizing skin and subcutaneous tissue infection caused by Mycobacterium ulcerans and is the third most common mycobacterial infection, behind tuberculosis and leprosy, world-wide. In recent years, the World Health Organisation has modified its guidelines for M. ulcerans treatment, moving from predominantly surgical to predominantly medical based management. It now recommends the combination of oral rifampicin and intramuscular streptomycin for a period of eight weeks as first-line therapy, with surgery as adjunctive therapy if necessary. The Barwon Health experience from south-eastern Australia has demonstrated that the entirely oral combination of rifampicin with either ciprofloxacin or clarithromycin for eight weeks can be an effective treatment option. However, these antibiotics are often toxic leading to early cessation, especially in the elderly. In addition, clinicians have been using a shorter duration of therapy for smaller lesions that have also been surgically managed. This study reviews our experience treating M. ulcerans with antibiotic durations of less than 8 weeks and demonstrates that successful outcomes can be achieved in selected patients, with success rates influenced by the duration of treatment and the use of surgical excision. This finding needs confirmation in further studies, but could have significant benefits in terms of reducing toxicity and improving adherence associated with Buruli ulcer antibiotic treatment.
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Dunkel B, Johns IC. Antimicrobial use in critically ill horses. J Vet Emerg Crit Care (San Antonio) 2015; 25:89-100. [PMID: 25582245 DOI: 10.1111/vec.12275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 09/15/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To discuss controversies surrounding antimicrobial use in critically ill horses. DATA SOURCES PubMed searches from 1970-present for terms including, but not limited to: "horse," "foal," "antimicrobial," "prophylaxis," "infection," "surgery," "sepsis," and "antimicrobial resistance." HUMAN DATA SYNTHESIS Increasing bacterial antimicrobial resistance has changed first-line antimicrobial choices and prompted shortening of the duration of prophylactic and therapeutic treatment. The need to decrease bacterial resistance development to critically important antimicrobials has been highlighted. VETERINARY DATA SYNTHESIS Veterinary medicine has followed a similar trend but often without a high-level evidence. Common dilemmas include diseases in which the theoretically most effective drug is a reserved antimicrobial, the inability to differentiate infectious from noninfectious disease, the duration and necessity of prophylactic antimicrobials and use of antimicrobials in primary gastrointestinal disease. These problems are illustrated using examples of purulent infections, neonatal sepsis, colic surgery, and treatment of colitis. Although enrofloxacin, cephalosporins, and doxycycline, in contrast to gentamicin, reach therapeutic concentrations within the lungs of healthy horses, the first two should not be used as first line treatment due to their reserved status. Due to the high risk of bacterial sepsis, antimicrobial treatment remains indispensable in compromised neonatal foals but shortening the length of antimicrobial treatment might be prudent. One prospective randomized study demonstrated no difference between 3 and 5 days of perioperative antimicrobial treatment in colic surgery but shorter durations were not evaluated. High-level evidence to recommend antimicrobial treatment of adult horses with undifferentiated diarrhea does not exist. CONCLUSIONS Few evidence-based recommendations can be made. Commonly used antimicrobial combinations remain the mainstay for treating purulent infections. Antimicrobial treatment for compromised foals should not extend beyond recovery. Continuation of prophylactic antimicrobials >3 days is likely unnecessary after colic surgery; shorter durations might be equally effective. Antimicrobial prophylaxis in adult horses with diarrhea is unlikely to be beneficial.
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Affiliation(s)
- Bettina Dunkel
- Department of Clinical Science and Services, The Royal Veterinary College, North Mymms, Hatfield, Hertforshire, United Kingdom, United Kingdom
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Wanda F, Nkemenang P, Ehounou G, Tchaton M, Comte E, Toutous Trellu L, Masouyé I, Christinet V, O'Brien DP. Clinical features and management of a severe paradoxical reaction associated with combined treatment of Buruli ulcer and HIV co-infection. BMC Infect Dis 2014; 14:423. [PMID: 25073531 PMCID: PMC4122778 DOI: 10.1186/1471-2334-14-423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/15/2014] [Indexed: 12/04/2022] Open
Abstract
Background In West and Central Africa Buruli ulcer (BU) and HIV co-infection is increasingly recognised and management of these two diseases combined is an emerging challenge for which there is little published information. In this case we present a severe paradoxical reaction occurring after commencing antibiotic treatment for BU combined with antiretroviral therapy for HIV, and describe its clinical features and management. This includes to our knowledge the first reported use of prednisolone in Africa to manage a severe paradoxical reaction related to BU treatment. Case presentation A 30 year old immunosuppressed HIV positive man from Cameroon developed a severe paradoxical reaction 24 days after commencing antibiotic treatment for BU and 14 days after commencing antiretroviral therapy for HIV. Oral prednisolone was successfully used to settle the reaction and prevent further tissue loss. The antiretroviral regimen was continued unchanged and the BU antibiotic treatment not prolonged beyond the recommended duration of 8 weeks. A second small local paradoxical lesion developed 8 months after starting antibiotics and settled with conservative treatment only. Complete healing of lesions occurred and there was no disease recurrence 12 months after commencement of treatment. Conclusions Clinicians should be aware that severe paradoxical reactions can occur during the treatment of BU/HIV co-infected patients. Prednisolone was effectively and safely used to settle the reaction and minimize the secondary tissue damage. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-423) contains supplementary material, which is available to authorized users.
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