CBRNE - Glanders and Melioidosis Treatment & Management

Updated: Jan 17, 2019
  • Author: Paul P Rega, MD, FACEP; Chief Editor: Duane C Caneva, MD, MSc  more...
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Treatment

Approach Considerations

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

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. Current practices to disinfect and sterilize patient-care equipment and environmental surfaces are sufficient for managing areas where glanders and melioidosis patients are evaluated, admitted, and treated. [18, 16]

Obtain radiography, and collect blood, urine, sputum, and skin lesion fluid.

Initiate rapid administration of supportive care and intravenous antibiotic therapy for severe disease. Ventilatory support may be needed for patients with severe pneumonia.  Septicemia requires agressive care including fluid resuscitation, vasopressors and management of coagulopathy. [6]

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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. All patients, regardless of severity, will need an antibiotic treatment regimen. Treatment consists of an intravenous (IV) therapy for a minimum of 10 to 14 days until there is clinical improvement. This phase of treatment may last up to 4 to 8 weeks for critical illness, severe pulmonary disease, deep abscesses, bone, joint or CNS involvement. Oral eradication therapy follows and lasts 3 to 6 months. [18, 6] {ref13222324-INVALID REFERENCE}

Intravenous therapy consists of ceftazidime administered every 6-8 hours or meropenem administered every 8 hours. [18, 6, 16]  Meropenem is advised for patients with CNS involvement. A switch to meropenem is also indicated if there are positive blood cultures after 7 days of treatment or clinical deterioration at any time with ceftazidime therapy. Fever may persist and does not indicate treatment failure. [6]  

Oral eradication therapy consists of trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline taken every 12 hours. [18, 6, 16]

 

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.

Investigational therapy

BAL 30072, an investigational intravenously administered monosulfactam antibiotic, shows excellent activity against B pseudomallei. [20] 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. [21]

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Surgical Care

Large abscesses and empyemas should be drained. Prostatic and parotid abscesses in melioidosis may require surgical intervention. Small absesses in the spleen or liver usually respond to prolonged antibiotic therapy. [6]  

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Prevention

Biosafety level 3 containment practices are required for laboratory staff when working with cases of glanders and melioidosis.

In countries where glanders is endemic in animals, identification and elimination of the disease in the animal population prevents disease in humans. [16]

In areas where melioidosis is endemic, persons who have chronic illnesses that lead to an immunocompromised state should avoid contact with soil and standing water. Wearing boots and gloves during agricultural work is advised. [18]

No vaccine is available for glanders or melioidosis. Because of the disease's resistance to multiple antibiotics (ie, beta-lactams, aminoglycosides, macrolides, polymixins) and the frequency of relapses (13-26%), the research for a viable vaccine continues and a wide range of proteins and polysaccharides have been identified which protective immunity in mice. Several live attenuated and subunit vaccine formulations have been evaluated in animal studies but development of effective vaccines against these bacteria remain in preclinical stages. [22, 23]

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