Case Presentation:

A 43 year old diabetic woman presents with dyspnea and a dry cough. Her vital signs are:  BP 84/42, HR 135 RR 37 T 38.5.  Lobar consolidation is seen on chest xray.  She decompensates and is intubated, a central line is placed, and IV fluids are started.  Her husband reports that they had just returned from  a vacation in Thailand one week earlier.

Clinical Question:

Does the recent travel change your choice of empiric antibiotics?

Answer:

The patient should also be covered for melioidosis, and infection caused by Burkholderia pseudomallei.

• Infection can occur via direct contact with, inhalation of, or ingestion of the bacteria.
• B. pseudomallei is highly endemic in Thailand and Northern Australia, but melioidosis has been contracted in the Americas and other parts of Asia and Australia. (True epidemiology is unknown due to difficulties in culturing the bacteria)
• Clinical presentation most frequently involves pulmonary infection, abscess formation, or bacteremia.
• Labs that don't have experience with this bacteria have difficulty culturing it and it is often misidentified.
• Treatment is 10-14 days of ceftazidime or a carbapenem.
• After recovery, the patient requires TMP-SMX for 3-6 months for bacterial eradication. 

Bottom Line:

Patients presenting with severe infections and recent travel to an endemic area should receive emperic antibiotics with ceftazidime or a carbapenem until another source is identified. 

University of Maryland Section of Global Emergency Health

Author: Jenny Reifel Saltzberg, MD, MPH

References

 

Wiersinga WJ, Currie BJ, Peacock SJ.  Melioidosis. N Engl J Med. 2012;367(11):1035-44.

http://www.cdc.gov/melioidosis/index.html