|Year : 2016 | Volume
| Issue : 3 | Page : 353-354
The antibiotics of choice for the treatment of melioidosis in Indian set up
T Shaw1, C Tellapragada2, VK Eshwara1, HV Bhat3, C Mukhopadhyay1
1 Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
2 Directorate of Research, Manipal University, Manipal, Karnataka, India
3 Department of Community Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Submission||12-Nov-2015|
|Date of Acceptance||30-Jun-2016|
|Date of Web Publication||12-Aug-2016|
Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Therapeutic options for the treatment of melioidosis caused by Burkholderia pseudomallei are limited due to the inherent resistance conferred by this pathogen to various groups of antibiotics. Witnessing an increase in the number of microbiological culture-confirmed cases of melioidosis at our settings in the past few years, we undertook this study to estimate the minimum inhibitory concentrations of clinical isolates of B. pseudomallei against the four commonly employed antimicrobial agents in the patient management at our settings, namely, ceftazidime, meropenem, trimethoprim-sulfamethoxazole and doxycycline. All isolates were susceptible to the antibiotics tested, except for one isolate which showed resistance to doxycycline (minimum inhibitory concentration [MIC]: 32 μg/ml). MIC50 and 90 for all the four antibiotics were estimated. From this study, we conclude that the clinical isolates of B. pseudomallei from the southern part of India are well susceptible to the commonly employed antimicrobial agents for therapy.
Keywords: Burkholderia pseudomallei, melioidosis, minimum inhibitory concentration
|How to cite this article:|
Shaw T, Tellapragada C, Eshwara V K, Bhat H V, Mukhopadhyay C. The antibiotics of choice for the treatment of melioidosis in Indian set up. Indian J Med Microbiol 2016;34:353-4
|How to cite this URL:|
Shaw T, Tellapragada C, Eshwara V K, Bhat H V, Mukhopadhyay C. The antibiotics of choice for the treatment of melioidosis in Indian set up. Indian J Med Microbiol [serial online] 2016 [cited 2020 Feb 21];34:353-4. Available from: http://www.ijmm.org/text.asp?2016/34/3/353/188340
Burkholderia pseudomallei, the causative agent of melioidosis is associated with high mortality and morbidity. With increasing awareness regarding the disease, there has been increase in case detection rates from various parts of India. , Protean clinical manifestations caused by this organism are one of the greatest impediments in early diagnosis of the disease. Despite instant appropriate treatment, the fatality rate in patients is high. B. pseudomallei is intrinsically resistant to a wide range of antibiotics including β lactam antibiotics, aminoglycosides and macrolides. The therapy used against the bacteria includes an intensive phase of treatment with ceftazidime or meropenem for 10-14 days followed by eradication phase of treatment with trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline for 3 months. Such a sustained course of treatment is required to avoid reactivation from latent foci. There have been recent reports on resistance to the aforesaid antibiotics from countries such as Thailand and Singapore. , The dearth of reports regarding the antibiotic susceptibility patterns of B. pseudomallei isolates from India is evident in the published literature. In this context, we undertook this study to examine the minimum inhibitory concentrations (MICs) for four commonly administered antibiotics in the therapeutic management of melioidosis from a tertiary care teaching hospital in South India.
A total of 69 B. pseudomallei clinical isolates obtained from 33 (47.8%) patients with bacteraemic form and 36 (52.1%) with nonbacteraemic form of the disease were included in the study. Identification of all isolates before testing was performed using a species-specific polymerase chain reaction for B. pseudomallei.  MIC estimation for ceftazidime, meropenem, TMP-SMX, and doxycycline was performed using E-strips (bioMιrieux, Marcy'elToile, France) as per the manufacturer's instructions. MIC interpretation for all the four antibiotics was done in accordance with CLSI guidelines (M45-A2). MIC 50 and MIC 90 for all the four antibiotics were calculated using the WHONET software (version 5.6, World Health Organization, Francis St. Boston USA).
All isolates were susceptible to the tested antibiotics except one isolate showing resistance (MIC: 32 μg/ml) for doxycycline. The range of antibiotic concentrations and MIC 50 and 90 values for the tested antibiotics is tabulated in [Table 1]. Higher MIC 50 and 90 values were observed for ceftazidime (MIC 50 1.5 μg/ml; MIC 90 3 μg/ml) among the isolates tested. There are various resistance mechanisms affecting these antibiotics, including enzymatic activation target deletion and efflux from cell. , Ceftazidime is the antibiotic of choice in the intensive phase of the treatment, especially in the resource-poor settings. Primary resistance to ceftazidime is not common, and there is only one report of 170 isolates from Northern Australia.  The creeping resistance of ceftazidime in our setting is alarming, therefore, which may signify the excessive and indiscriminate use of the antibiotic, even at the community level. However, it still remains the antibiotic of choice in most occasions, due to unaffordability of the patients for carbapenems. On the other hand, TMP-SMX is still the drug of choice in the prolonged eradication phase. Although the primary resistance rate is much lower (3-10%),  except in Thailand,  we still have lower MIC rage for the antibiotic. It might be due to the discontinuation of the use of the antibiotic for a long period while encountered very high resistance. Acquired resistance to doxycycline is not very unfamiliar, especially when used as monotherapy.  Since the use of doxycycline alone as monotherapy or along with TMP-SMX does not give any advantage, it may still be reserved as the second choice for the eradication phase. Although resistance to precise antibiotics is not observed, considering the paucity of available treatment such instance might undermine the ability to successful treatment. Thus, we foresee a need for constant monitoring of the creeping antimicrobial resistance in view of the limited therapeutic options available and increasing resistance been reported from elsewhere.
|Table 1: Minimum inhibitory concentrations of the Burkholderia pseudomallei isolates tested |
Click here to view
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Mukhopadhyay C, Chawla K, Krishna S, Nagalakshmi N, Rao SP, Bairy I. Emergence of Burkholderia pseudomallei
and pandrug-resistant non-fermenters from Southern Karnataka, India. Trans R Soc Trop Med Hyg 2008;102 Suppl 1:S12-7.
Vidyalakshmi K, Lipika S, Vishal S, Damodar S, Chakrapani M. Emerging clinico-epidemiological trends in melioidosis: Analysis of 95 cases from western coastal India. Int J Infect Dis 2012;16:e491-7.
Kung CT, Lee CH, Li CJ, Lu HI, Ko SF, Liu JW. Development of ceftazidime resistance in Burkhoderia pseudomallei
in a patient experiencing melioidosis with mediastinal lymphadenitis. Ann Acad Med Singapore 2010;39:945-3.
Wuthiekanun V, Amornchai P, Saiprom N, Chantratita N, Chierakul W, Koh GC, et al.
Survey of antimicrobial resistance in clinical Burkholderia pseudomallei
isolates over two decades in Northeast Thailand. Antimicrob Agents Chemother 2011;55:5388-91.
Winstanley C, Hart CA. Presence of type III secretion genes in Burkholderia pseudomallei
correlates with Ara (-) phenotypes. J Clin Microbiol 2000;38:883-5.
Khosravi Y, Vellasamy KM, Mariappan V, Ng SL, Vadivelu J. Antimicrobial susceptibility and genetic characterisation of Burkholderia pseudomallei
isolated from Malaysian patients. Scientific World Journal 2014;2014:132971.
Podnecky NL, Wuthiekanun V, Peacock SJ, Schweizer HP. The BpeEF-OprC efflux pump is responsible for widespread trimethoprim resistance in clinical and environmental Burkholderia pseudomallei
isolates. Antimicrob Agents Chemother 2013;57:4381-6.
Jenney AW, Lum G, Fisher DA, Currie BJ. Antibiotic susceptibility of Burkholderia pseudomallei
from tropical Northern Australia and implications for therapy of melioidosis. Int J Antimicrob Agents 2001;17:109-13.
Piliouras P, Ulett GC, Ashhurst-Smith C, Hirst RG, Warner J, Norton R. Presented at the Australian Society of Antimicrobials. Annual Scientific Meeting, Sydney, Australia; 13-16 April, 2000.
Lumbiganon P, Tattawasatra U, Chetchotisakd P, Wongratanacheewin S, Thinkhamrop B. Comparison between the antimicrobial susceptibility of Burkholderia pseudomallei
to trimethoprim-sulfamethoxazole by standard disk diffusion method and by minimal inhibitory concentration determination. J Med Assoc Thai 2000;83:856-60.