BackgroundMelioidosis is a disease caused by Burkholderia pseudomallei and considered endemic in South-East Asia but remains poorly documented in Cambodia. We report the first series of hospitalized pulmonary melioidosis cases identified in Cambodia describing clinical characteristics and outcomes.MethodsWe characterized cases of acute lower respiratory infections (ALRI) that were identified through surveillance in two provincial hospitals. Severity was defined by systolic blood pressure, cardiac frequency, respiratory rate, oxygen saturation and body temperature. B. pseudomallei was detected in sputum or blood cultures and confirmed by API20NE gallery. We followed up these cases between 6 months and 2 years after hospital discharge to assess the cost-of-illness and long-term outcome.ResultsDuring April 2007 - January 2010, 39 ALRI cases had melioidosis, of which three aged ≤2 years; the median age was 46 years and 56.4% were males. A close contact with soil and water was identified in 30 patients (76.9%). Pneumonia was the main radiological feature (82.3%). Eleven patients were severe cases. Twenty-four (61.5%) patients died including 13 who died within 61 days after discharge. Of the deceased, 23 did not receive any antibiotics effective against B. pseudomallei. Effective drugs that were available did not include ceftazidime. Mean total illness-related costs was of US$65 (range $25-$5000). Almost two-thirds (61.5%) incurred debt and 28.2% sold land or other belongings to pay illness-related costs.ConclusionsThe observed high fatality rate is likely explained by the lack or limited access to efficient antibiotics and under-recognition of the disease among clinicians, which led to inappropriate therapy.

Contracting non-governmental organizations (NGOs) has been shown to increase health service delivery output considerably over relatively short time frames in low-income countries, especially when applying performance-related pay as a stimulus. A key concern is how to manage the transition back to government-operated systems while maintaining health service delivery output levels. In this paper we describe and analyse the transition from NGO-managed to government-managed health services over a 3-year period in a health district in Cambodia with a focus on the level of health service delivery. Data are derived from four sources, including cross-sectional surveys and health management and financial information systems. The transition was achieved by focusing on all the building blocks of the health care system and ensuring an acceptable financial remuneration for the staff members of contracted health facilities. The latter was attained through performance subsidies derived from financial commitment by the central government, and revenue from user fees. Performance management had a crucial role in the gradual handover of responsibilities. Not all responsibilities were handed back to government over the case study period-notably the development of performance indicators and targets and the performance monitoring.

Melioidosis has never been officially reported from Cambodia. Here we report two cases, a 58-year-old male (case 1) and a 49-year-old female (case 2) who presented with respiratory illnesses featuring multiple lung abscesses. The sputum culture of both patients, taken in the framework of a laboratory-based study on aetiologies of (sub-)acute respiratory infections among hospitalized patients in southern Cambodia, grew Burkholderia pseudomallei. The most striking aspect of these case stories was the extent of the delays in diagnosis. Presenting with a 1-month history of respiratory symptoms, case 1 was first suspected of tuberculosis (TB) infection, and then misdiagnosed as 'metastatic lung cancer' in Phnom Penh, Cambodia. Case 2 suffered from pulmonary infections for >10 years, during which time she was treated for TB four times. Neither patient ever produced acid-fast-bacilli (AFB)-positive sputum. Following our laboratory confirmation, the patients were traced for re-admission. Under the 'classical' trimethoprim sulphamethoxazole, chloramphenicol and doxycycline treatment, their clinical status improved considerably within 2 weeks. The two study cases illustrate issues relating to the misdiagnosis of melioidosis in Cambodia; an unfamiliarity of clinicians with the disease, which is associated with a high prevalence of TB. Therefore, a heightened awareness of melioidosis among clinicians would have a substantial impact on public health as the non-septicaemic form of the disease is potentially treatable with antibiotics that are available in Cambodian public hospitals.

Melioidosis is a disease caused by the soil-dwelling Gram-negative bacterium Burkholderia pseudomallei. It is endemic in SouthEast Asia but remains poorly documented in Cambodia where laboratory facilities are scarce. We report here a cohort of culture-confirmed cases of pulmonary melioidosis identified in two provincial hospitals in Cambodia, describing clinical and epidemiological characteristics. Patients with melioidosis were identified through a laboratory based surveillance of acute lower respiratory infections (<14 days of illness) in two provincial hospitals from April 2007 to January 2010. B. pseudomallei was detected in sputum or blood through 42 cultures and confirmed by API 20 NE gallery. We collected clinical, microbiological and radiological data and visited patients several weeks after hospital discharge to document long-term outcome. Melioidosis was found in 39 patients. The median age was 46 years including three patients ≤2 years and 56.4% were males. A close contact with soil and water was identified in 30 patients (76.9%). Pneumonia was the main radiological feature (82.3%), but pleurisy was also described in 6 patients. Eleven patients were severe. A positive blood culture was significantly associated with severe cases (90.9% vs. 50.0%; p<0.05) and with higher fatality (87.5% vs. 20%; p<0.01). A total of 24 (61.5%) patients died within 3 days, 23 without receiving any active drug against B. pseudomallei. One year after discharge, 11 patients were still alive and considered as cured. Melioidosis is an emerging public health issue in Cambodia that requires nationwide access to laboratory facilities and timely appropriate treatment.