Is Fortum (ceftazidime) a recommended antibiotic for treating melioidosis in patients from endemic areas such as Southeast Asia or northern Australia?

Is Fortum (Ceftazidime) Recommended for Melioidosis?

Yes, Fortum (ceftazidime) is an acceptable antibiotic for treating melioidosis, but carbapenems (meropenem or imipenem) are now preferred as first-line agents for severe disease based on superior clinical outcomes. 1

Initial Intensive Phase Treatment

First-Line Recommendations

Carbapenems are the preferred first-line agents for severe melioidosis:

• Meropenem or imipenem should be used for at least 14 days in the intensive phase 1
• Observational studies demonstrate that meropenem achieves better clinical outcomes than ceftazidime in severe melioidosis 2, 1
• All clinical B. pseudomallei isolates show consistent susceptibility to carbapenems 1

Ceftazidime as an Alternative

Ceftazidime remains an acceptable alternative when carbapenems are unavailable:

• Dosing: 100 mg/kg/day (approximately 2g every 8 hours for adults) for at least 14 days 2, 1
• A landmark 1992 randomized trial showed ceftazidime reduced mortality by 50% compared to conventional therapy (chloramphenicol/doxycycline/TMP-SMX), with overall mortality dropping from 47% to 18.5% 3
• Ceftazidime can be administered as 24-hour continuous infusions via peripherally inserted central catheters for outpatient management, which has proven safe and effective 4
• WHO guidelines specifically note that ceftazidime use can be considered in settings where melioidosis is endemic 2

Critical Pitfall to Avoid

Never use ceftriaxone or cefotaxime for melioidosis:

• These third-generation cephalosporins are associated with significantly higher mortality rates compared to ceftazidime 2, 1
• B. pseudomallei is inherently resistant to first- and second-generation cephalosporins, as well as penicillin, ampicillin, gentamicin, streptomycin, polymyxin, ertapenem, azithromycin, and moxifloxacin 2, 1

Extended Intensive Phase Duration

Extend treatment beyond 14 days for complicated cases:

• 4-8 weeks or longer for patients with critical illness, extensive pulmonary disease, deep-seated abscesses, organ abscesses, osteomyelitis, septic arthritis, or neurologic melioidosis 2, 1
• This extended duration is necessary because of the intracellular nature of B. pseudomallei and risk of relapse 1

Eradication Phase (Mandatory Following Intensive Phase)

All patients require 3-6 months of oral eradication therapy to prevent relapse:

• Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice 2, 1, 5
• Weight-based dosing: <40 kg: 160/800 mg twice daily; 40-60 kg: 240/1200 mg twice daily; >60 kg: 320/1600 mg twice daily 1
• Add folic acid 0.1 mg/kg up to 5 mg daily to prevent antifolate effects 1
• TMP-SMX monotherapy is as effective as combination therapy with doxycycline in preventing the 13% relapse rate seen over 10 years 1

Alternatives for Eradication Phase

If TMP-SMX is contraindicated or not tolerated:

• Amoxicillin-clavulanate 20/5 mg/kg every 8 hours (maximum 1500/375 mg every 8 hours) plus doxycycline 100 mg twice daily 1
• Note: This combination is significantly less effective than TMP-SMX 1
• Amoxicillin-clavulanate is preferred for pregnant women and children who cannot tolerate TMP-SMX 2, 1

Clinical Context

The question of whether "Fortum or not" reflects real-world clinical decision-making in endemic areas. While ceftazidime (Fortum) was historically the gold standard based on the pivotal 1989 trial showing 50% mortality reduction 2, more recent observational data from 2004 onward demonstrates meropenem's superiority in severe cases 6. However, ceftazidime remains widely used, particularly in resource-limited settings and for outpatient management via continuous infusion 4, and is explicitly endorsed by WHO for endemic areas 2.

The practical algorithm: Use meropenem/imipenem if available for severe disease; ceftazidime is acceptable if carbapenems are unavailable or for less severe cases, but avoid ceftriaxone/cefotaxime entirely. 2, 1