What is the treatment for Meiliniosis?

Treatment of Melioidosis

Treat melioidosis with a two-phase approach: an intensive phase using intravenous meropenem or imipenem for at least 14 days, followed by an eradication phase with trimethoprim-sulfamethoxazole (TMP-SMX) for 3-6 months. 1

Intensive Phase (Initial Treatment)

Carbapenems are the preferred first-line agents for severe melioidosis, demonstrating superior clinical outcomes compared to ceftazidime. 1

• Administer meropenem or imipenem intravenously for a minimum of 14 days 1, 2
• Meropenem has shown better clinical outcomes than ceftazidime in severe disease cases 1, 3
• All clinical Burkholderia pseudomallei isolates demonstrate consistent susceptibility to carbapenems (meropenem and imipenem) but are resistant to ertapenem 1, 2

Alternative Intensive Phase Option

• Ceftazidime 100 mg/kg/day can be used if carbapenems are unavailable, though it is less effective 1, 2
• Ceftazidime remains acceptable when carbapenems cannot be obtained, but observational data favor meropenem 1

Extended Intensive Phase Duration

Extend the intensive phase beyond 14 days for the following high-risk presentations: 1, 2

• Critical illness or septic shock
• Extensive pulmonary disease
• Deep-seated abscesses or organ collections
• Osteomyelitis or septic arthritis
• Central nervous system involvement (neurologic melioidosis)

Adjunctive Therapy

• Consider adding G-CSF 300 mg IV for 10 days in patients with melioidosis-induced septic shock 1

Eradication Phase (Maintenance Treatment)

TMP-SMX is the standard treatment for the eradication phase and must be continued for 3-6 months to prevent the 13% relapse rate. 1, 2, 3

Standard Dosing (Weight-Based)

• Adults <40 kg: 160/800 mg (1 double-strength tablet) twice daily 1
• Adults 40-60 kg: 240/1200 mg (1.5 double-strength tablets) twice daily 1
• Adults >60 kg: 320/1600 mg (2 double-strength tablets) twice daily 1
• Add folic acid 0.1 mg/kg up to 5 mg daily to prevent antifolate effects without compromising antimicrobial activity 1

Evidence Supporting TMP-SMX Monotherapy

• TMP-SMX monotherapy for 20 weeks is as effective as combination therapy with TMP-SMX plus doxycycline in preventing recurrence 1, 2
• The 3-6 month duration is critical for eradicating intracellular bacteria 1

Extended Eradication Phase

Extend treatment to 4-8 weeks or longer for: 1

• Central nervous system involvement (use TMP-SMX 8/40 mg/kg IV/PO every 12 hours up to 320/1600 mg)
• Osteomyelitis or septic arthritis

Alternative Eradication Regimens

• Amoxicillin-clavulanate 20/5 mg/kg every 8 hours (maximum 1500/375 mg every 8 hours) is the preferred alternative for pregnant women, children, or patients intolerant to TMP-SMX, though it is significantly less effective than first-line therapy 1, 2
• Doxycycline can be used as an alternative if TMP-SMX is contraindicated 1, 2

Critical Resistance Patterns to Avoid

B. pseudomallei is inherently resistant to multiple antibiotics that must never be used: 1, 2, 3

• Penicillin, ampicillin
• First- and second-generation cephalosporins
• Gentamicin, streptomycin, polymyxin
• Ertapenem (despite being a carbapenem)
• Azithromycin, moxifloxacin
• Ceftriaxone and cefotaxime (associated with higher mortality rates compared to ceftazidime) 1

Post-Exposure Prophylaxis

• Administer TMP-SMX (co-trimoxazole) within 24 hours of exposure for post-exposure prophylaxis, particularly for immunosuppressed patients or following potential biological attack 1, 2
• Animal studies demonstrate 100% survival rates when co-trimoxazole is administered within 24 hours post-infection 2

Common Pitfalls

• Delayed diagnosis is common because B. pseudomallei can be misidentified by VITEK systems, leading to inappropriate antibiotic selection 1
• Melioidosis should be considered in patients with unexplained fever in endemic regions (Southeast Asia, Northern Australia) or in immigrants/veterans from these areas, even decades after exposure 4, 5, 6
• The disease can present with prolonged latency and reactivate years after initial exposure, mimicking tuberculosis with apical cavitary lung disease 5, 6
• Selective culture media such as Ashdown's agar significantly increases yield from clinical specimens in endemic areas 1