Melioidosis: refining management of a tropical time bomb

762 www.thelancet.com Vol 383 March 1, 2014 Melioidosis, dubbed the Vietnamese time bomb after reports of lengthy disease latency in war veterans, is caused by Burkholderia pseudomallei and manifests as acute, subacute, or chronic disease. Bacteraemic disease especially when associated with pneumonia is the most lethal form, especially if associated with septic shock, but infection with or without abscess formation can occur in any organ system. Although most presentations occur soon after exposure, the organism’s ability to evade host immune mechanisms and to survive and multiply in phagocytes gives rise to latency—latency of up to 62 years has been reported. Seroprevalence rates vary widely but are highest in northeast Thailand, where most children show evidence of exposure. It remains unclear how many of those with serological evidence of exposure harbour latent B pseudomallei with the potential for subsequent activation. Several risk factors cause some people to have an increased risk of melioidosis, with diabetes being the most common. For those with culture-confi rmed melioidosis, treatment recommendations include an initial intensive intravenous course of at least 10 days with ceftazidime or a carbapenem. This course is followed by a so-called oral eradication phase of at least 3 months. The initial clinical response might indicate a need to modify the duration of the intensive phase, but the optimum antibiotic regimen and duration for eradication are uncertain. Recurrent melioidosis was noted in 13% of patients treated in Australia, but its prevalence has fallen over the past decade, possibly attributed to improved compliance, choice, and dosing of antibiotic regimens. Higher rates of recurrence in Thailand have been associated with inadequate duration of treatment. In The Lancet, Ploenchan Chetchotisakd and colleagues present fi ndings from the MERTH trial, in which they enrolled 626 patients with melioidosis, randomly allocating them to receive trimethoprimsulfamethoxazole alone (the recommended regimen in Australia) or trimethoprim-sulfamethoxazole Melioidosis: refi ning management of a tropical time bomb eff ectiveness of muscle training, the trial also shows the potential for prevention of prolapse symptoms through lifelong attention to pelvic fl oor muscle exercise, and possibly intentional use of muscles to protect the pelvic fl oor during physical strain, such as that infl icted by heavy lifting. The results of this trial should encourage clinicians to refer women to physiotherapists, and to other health-care professionals who can implement behavioural and physical therapies for prolapse in a range of health-care settings.