CBRNE - Glanders and Melioidosis Treatment & Management

Updated: Aug 16, 2015
  • Author: Paul P Rega, MD, FACEP; Chief Editor: Duane C Caneva, MD, MSc  more...
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Treatment

Prehospital Care

Use standard precautions (ie, use of disposable surgical masks, face shields, and gowns when appropriate) to prevent human-to-human transmission of glanders and melioidosis.

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Emergency Department Care

See the list below:

  • Implement barrier protection with secretion precautions. While person-to-person transmission is unlikely, isolation rooms for these patients are advisable. Patients should be masked to prevent droplet dissemination.
  • Obtain radiography, and collect blood, urine, sputum, and skin lesion fluid.
  • Initiate rapid administration of supportive care and intravenous antibiotic therapy for severe disease.
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Consultations

Glanders and melioidosis are reportable diseases; notify local health authorities of suspected cases. The occurrence of glanders in the absence of animal attack, occupational exposure, and/or in an epidemic is presumptive evidence of a biological warfare attack. Consultation with an infectious disease specialist, the Centers for Disease Control and Prevention, and the Federal Bureau of Investigation may be warranted.

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Medical Care

Limited information exists about antibiotic therapy for glanders and melioidosis in humans because clinical studies examining antibiotic effectiveness in vivo are rare. For localized disease, a 60-  to 150-day course of oral amoxicillin/clavulanate, doxycycline, or trimethoprim/sulfamethoxazole (TMP-SMX) may be used.

For local disease with mild toxicity, combine two of the three regimens for 30 days, then switch to monotherapy with amoxicillin/clavulanate or TMP-SMX for 60-150 days.

For extrapulmonary suppurative disease, prolong treatment for 6-12 months. Drain abscesses surgically. For severe and/or septicemic disease, initiate parenteral therapy for 2 weeks followed by oral therapy for 6 months (ceftazidime combined with TMP/SMX 8 mg TMP/kg/d and 40 mg SMX/kg/d divided qid). Add streptomycin when initiating treatment if plague cannot be excluded.

Alternative choices in severe cases of melioidosis include imipenem-cilastatin or meropenem with or without trimethoprim/sulfamethoxazole. Administration of these drugs may continue for up to 4 weeks, depending on clinical response. Then, a 20-week course of doxycycline and TMP/SMX, which is said to minimize the likelihood of relapse better than amoxicillin/clavulanate, is administered.

The prevention of relapse in melioidosis is critical since it has been reported to occur in 23% of cases. Hence, the rationale behind the prolonged therapy. Other antibiotics with activity against Burkholderia pseudomallei include ceftriaxone, ticarcillin-sulbactam, and aztreonam.

Currently, no proven preexposure or postexposure prophylaxis is available. Postexposure prophylaxis with TMP/SMX may be attempted. No vaccine is available for human glanders or melioidosis.

For acute human melioidosis, the most commonly recommended treatment regimen consists of ceftazidime or a carbapenem followed by TMP/SMX. For moderate to severe melioidosis, a treatment protocol from the Royal Darwin Hospital in Australia consists of the following:

  • Ceftazidime 2 g IV q6h (50 mg/kg up to 1 g in children) or
  • Meropenem 1 g IV q8h (25 mg/kg up to 1 g in children) plus
  • Cotrimoxazole 320/1600 mg PO/IV BID (8/40 mg/kg up to 320/1600 mg in children).

This regimen is given for at least 14 days, but may have to be continued for longer. Once the acute episode is resolved, then the eradication period would commence. [15]

For systemic glanders, initial therapy should consist of imipenem, ceftazidime, or meropenem plus either ciprofloxacin or doxycycline. Intravenous therapy may last as long as 2-3 weeks followed by a switch to oral antibiotics (ciprofloxacin, doxycycline, TMP/SMX, or amoxicillin/clavulanate) for up to 150 days in order to prevent reactivation;  most authors advise a total of 24 weeks. [16]

Investigational therapy

BAL 30072, an investigational intravenously administered monosulfactam antibiotic, shows excellent activity against B pseudomallei. [17] Antibiotics represent only one aspect of research into therapy for glanders and melioidosis, however, since these disease entities have demonstrated resistance to the more traditional antimicrobial regimens. Another promising avenue of therapy is inhalational immunotherapy with cationic liposome DNA complexes (CLDC). These complexes are potent activators of innate immunity within the pulmonary system, which makes this modality an attractive approach to inhalational exposure to these bacteria. [18]

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