Buruli ulcer treatment: Rate of surgical intervention differs highly between treatment centers in West Africa

Abstract

BackgroundAntibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic.MethodsA retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders.ResultsA total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5–124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly.ConclusionThe decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU

Telacebec (Q203)-containing intermittent oral regimens sterilized mice infected with Mycobacterium ulcerans after only 16 doses

“…Although nearly all Buruli ulcer lesions can be successfully treated by a two-month antibiotic combination regimen administered daily [ 21 , 22 ], new shorter and/or intermittent regimens would greatly simplify the treatment procedure in the field. Indeed, intermittent treatment would allow for organizing direct supervision of therapy and for combining drug administration and change of dressings in remote places where BU is prevalent.…”

Pharmacologic management ofMycobacterium ulceransinfection

“…In summary, we believe that wound management [168,169] would be an important area of future research to improve outcomes for patients with Buruli ulcer. The role of debridement surgery, extent of removal of the necrotic slough, or timing or type of skin grafting has also been little studied [160], there is a striking variability in surgical practice that is not explained by differences in patient populations, or clinical presentations of wounds, but rather by individual doctors caring for these patients [170]. As resection surgery does not generally bring a clear benefit to patients, this practice should best be discouraged, especially in poor-resourced settings where surgery is much more of a concern than in affluent settings where specialist care is widely availablebut even there, the benefit of resection surgery is probably over-rated.…”

Buruli ulcer in Africa: Geographical distribution, ecology, risk factors, diagnosis, and indigenous plant treatment options – A comprehensive review

“…Buruli ulcer (BU) is a necrotizing cutaneous disease caused by Mycobacterium ulcerans, an acid-fast mycobacterium [ [1] , [2] , [3] ]. While the precise mechanism of transmission is not well understood and is likely to be varied, the causative agent appears to spread from aquatic habitats to people via penetrating the skin or indirect transmission mediated by a biting insect vector [ 4 ].…”

“…Because there is no effective vaccine to prevent BU, early case discovery, and thorough patient treatment are the main priorities in current disease control strategies [ 18 ]. Treatment options available for BU include surgery debridement and antibiotics, such as the combination of rifampicin/streptomycin, and rifampicin/clarithromycin alone or in conjunction with surgery to speed up the healing of wounds and avoid deformities [ 3 , 19 , 20 ]. Although the use of antibiotic medication has significantly improved BU management and produced superior results, streptomycin injections are associated with significant nephrotoxicity and ototoxicity [ 21 ].…”