Antibiotic Prophylaxis for Melioidosis in Patients Receiving Hemodialysis in the Tropics? One Size Does Not Fit All

Abstract

Melioidosis has a high case fatality rate and is more common in patients with chronic kidney disease. Some authors recommended trimethoprim/sulfamethoxazole (TMP/SMX) prophylaxis for all hemodialysis (HD) patients during the wet season in melioidosis-endemic regions. Historical data were reviewed to determine if TMP/SMX prophylaxis was warranted in the HD population of Far North Queensland, Australia. Between 1997 and 2017, there were 242 culture-confirmed cases of melioidosis in the region, three (1.2%) occurred in HD patients; all survived without intensive care support. During the study period, there were 843 HD patients in the region with 3,024 cumulative patient years of risk. Even assuming 100% efficacy, it would have been necessary to prescribe TMP/SMX for 1,008 patient years to prevent one case of melioidosis. Given the significant additional cost and potentially life-threatening side effects of TMP/SMX therapy, clinicians should review the local epidemiology of melioidosis before the implementation of universal TMP/SMX prophylaxis in their HD population.

Efficacy of Co-Trimoxazole against Experimental Melioidosis Acquired by Different Routes of Infection

“…A clinical trial showed that co-trimoxazole on its own was equally as effective as co-trimoxazole and doxycycline during the eradication phase ( 5 ). Oral co-trimoxazole has also been recommended as a prophylactic agent ( 3 ) and was subsequently recommended prophylactically in hemodialysis patients ( 6 ); however, the practicalities of adopting this approach universally have been challenged ( 7 ). Murine studies have shown co-trimoxazole to be efficacious for prophylaxis for inhalational melioidosis ( 8 , 9 ).…”

Volume 43 Number 3

“…Tinea is a pruritic, scaly skin condition transmitted from human to human. Alternatively, it can also be acquired from the environment 1 or household pets, 34 and in northern Australia is caused by Microsporum spp. and Trichophyton spp.…”

“…There are data to support chemoprophylaxis in selected populations, but the relatively low incidence in even high-risk populations and the potential life-threatening side-effects of TMP-SMZ means that this is likely to have a very limited role in combating the disease. 33,34 Vaccines are under development, although none have yet undergone human trials. 35 Public health strategies to reduce the incidence of predisposing risk factors -or at least optimise their management -might reduce the burden of melioidosis as well as other complications from these comorbidities.…”

“…Acquisition of nasopharyngeal NTHi and non-vaccine serotypes 22 was associated with OM onset within weeks of birth in all PCV schedule groups. 18,34 Follow up to 3 years of age showed that OM persists causing chronic disabling hearing loss throughout early years for an average of 80% children. 35 This brings us back to the Hearing for Learning Initiative.…”

Melioidosis–a disease of socioeconomic disadvantage

“…Public health strategies that focus on human behaviour and aim to prevent exposure to B. pseudomallei are challenging to implement [40,41]. Chemoprophylaxis would not be cost-effective locally and is associated with significant side effects [42]. More comprehensive primary healthcare, with a focus on addressing the comorbidities that…”