Treatment of Burkholderia cepacia Infections
Trimethoprim-sulfamethoxazole (TMP-SMX) is the first-line treatment of choice for Burkholderia cepacia complex infections when the organism is susceptible, with ceftazidime, meropenem, or ceftazidime-avibactam as preferred alternatives based on susceptibility testing. 1
Antimicrobial Selection Algorithm
First-Line Therapy
- TMP-SMX should be initiated as empiric therapy for B. cepacia complex infections pending susceptibility results, as it demonstrates the highest susceptibility rate (83%) among tested agents 2
- This recommendation is supported by both the American College of Physicians and Infectious Diseases Society of America 1
Alternative Agents for Severe Infections or TMP-SMX Resistance
When TMP-SMX cannot be used due to resistance, allergy, or intolerance, the following agents should be selected based on susceptibility testing:
- Ceftazidime-avibactam demonstrates 78% susceptibility and represents a newer, highly effective option 2
- Ceftazidime alone shows 53% susceptibility and has clinical cure rates of 68-100% in cohort studies 3
- Meropenem demonstrates 27% susceptibility but achieved cure in 71% of case reports and 67% of cohort study patients 3
- Minocycline inhibits 38% of strains and may be considered as an alternative 4
Combination Therapy Considerations
- Combination therapy is typically recommended for severe infections rather than monotherapy, though synergy is rarely demonstrated in vitro (only 1-15% of strains show synergy with various combinations) 1, 4
- The most commonly reported successful combination in case reports is ceftazidime-based regimens (73.7% cure rate when used) 3
- Aztreonam plus ceftazidime-avibactam does not provide additional synergistic benefit for B. cepacia, as these organisms lack class B metallo-β-lactamases 2
Critical Clinical Pitfalls
Resistance Patterns
- B. cepacia is intrinsically resistant to carbapenems due to ubiquitous metallo-β-lactamase, though paradoxically meropenem shows clinical efficacy in some cases 5
- The organism carries multiple resistance genes including blapenA (98%) and blaampC (86%), contributing to multidrug resistance 2
- Susceptibility patterns differ significantly between CF and non-CF patients due to repeated antibiotic exposure in CF populations 6
Eradication Attempts
- Early eradication therapy for new B. cepacia infection has limited success, with only 29% clearance rate in patients receiving specific eradication therapy 7
- Some patients (37% in one series) clear infection spontaneously without specific eradication therapy 7
- Despite modest efficacy, eradication attempts are commonly practiced in UK adult CF centers (12/17 centers surveyed) 7
Special Populations and Settings
Cystic Fibrosis Patients
- Inhaled antibiotics should be administered twice daily using breath-enhanced open vent nebulizers at flow rates of 6 L/min 1
- Separate nebulizer equipment must be used for patients colonized with B. cepacia versus Pseudomonas aeruginosa to prevent cross-contamination 1
- Chronic B. cenocepacia infection is considered a contraindication to lung transplantation in many centers 7
Infection Control
- Contact precautions with gown and gloves are required for all patient encounters 1
- Cohorting of B. cepacia-infected patients in designated areas is recommended 1
- B. cepacia status must be communicated when transferring patients to other facilities 1
- Environmental screening of surfaces in contact with colonized patients should be performed 1
Treatment Duration and Monitoring
- The American Thoracic Society guidelines note that B. cepacia tends to colonize the respiratory tract rather than cause invasive disease, which should inform treatment duration decisions 5
- Susceptibility testing is mandatory given the high variability in resistance patterns and the poor correlation between in vitro synergy and clinical outcomes 4, 6
- For catheter-related bloodstream infections with B. cepacia, catheter removal reduces treatment failure rates and improves survival 5