Mycobacterium ulcerans Disease: Experience with Primary Oral Medical Therapy in an Australian Cohort

Abstract

Background Mycobacterium ulcerans (MU) is responsible for disfiguring skin lesions and is endemic on the Bellarine peninsula of southeastern Australia. Antibiotics have been shown to be highly effective in sterilizing lesions and preventing disease recurrences when used alone or in combination with surgery. Our practice has evolved to using primarily oral medical therapy.MethodsFrom a prospective cohort of MU patients managed at Barwon Health, we describe those treated with primary medical therapy defined as treatment of a M. ulcerans lesion with antimicrobials either alone or in conjunction with limited surgical debridement.ResultsFrom 1/10/2010 through 31/12/11, 43 patients were treated with exclusive medical therapy, of which 5 (12%) also underwent limited surgical debridement. The median patient age was 50.2 years, and 86% had WHO category 1 and 91% ulcerative lesions. Rifampicin was combined with ciprofloxacin in 30 (70%) and clarithromycin in 12 (28%) patients. The median duration of antibiotic therapy was 56 days, with 7 (16%) receiving less than 56 days. Medication side effects requiring cessation of one or more antibiotics occurred in 7 (16%) patients. Forty-two (98%) patients healed without recurrence within 12 months, and 1 patient (2%) experienced a relapse 4 months after completion of 8 weeks of antimicrobial therapy.ConclusionOur experience demonstrates the efficacy and safety of primary oral medical management of MU infection with oral rifampicin-based regimens. Further research is required to determine the optimal and minimum durations of antibiotic therapy, and the most effective antibiotic dosages and formulations for young children.

Increasing Experience with Primary Oral Medical Therapy for Mycobacterium ulcerans Disease in an Australian Cohort

“…This rate of adverse effects is in keeping with rates previously described for rifampin, clarithromycin, and ciprofloxacin in our experience (1,5,15), which are higher than rates reported for younger populations in Africa (7). The older median age of our cohort likely contributes significantly to reduced drug tolerability in our cohort (15).…”

“…Furthermore, in 2010, a randomized controlled trial in Ghana was published that found RS8 to have an efficacy similar to that of 4 weeks of rifampin-streptomycin followed by 4 weeks of rifampin-clarithromycin (RC) (RS4RC4) (8). These successes paved the way for the use of the fully oral combinations of rifampin and fluoroquinolones (RFQ) and RC in both Australia and Benin (1,5,9). Most recently, treatment success was demonstrated in Ghana with an even shorter duration of injectable streptomycin therapy of 2 weeks (RS2) followed by oral RC for 6 weeks (4).…”

“…uruli ulcer (BU) is a necrotizing infection of subcutaneous tissue that is caused by Mycobacterium ulcerans and is responsible for disfiguring skin lesions (1). While the disease is most common in West African countries (2), it is also endemic to specific geographic regions in the state of Victoria in southeastern Australia (3).…”

“…Antibiotics have been shown to be highly effective at sterilizing lesions and preventing disease recurrences when used alone or in combination with surgery (1,(5)(6)(7)(8)(9). Mounting evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has substantially shifted the balance in favor of medical therapy over surgery, and our practice has evolved to using primarily oral medical therapy (1,5).…”

“…Mounting evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has substantially shifted the balance in favor of medical therapy over surgery, and our practice has evolved to using primarily oral medical therapy (1,5). In 2013, we described the results of medical therapy in a group of 43 patients, among whom 42 patients (98%) healed without recurrence within 12 months (1).…”