Kidney International (2014) 86 867 nephrologists sans frontières http://www.kidney-international.org © 2014 International Society of Nephrology Rachel M.S. Chalmers 1 , Sandawana W. Majoni 1 , Linda Ward 2 , Greg J. Perry 1 , Zulfikar Jabbar 1 and Bart J. Currie 2,3 1 Department of Renal Services, Royal Darwin Hospital, Darwin, Northern Territory, Australia; 2 Global and Tropical Health Division, Menzies School of Health Research, Casuarina, Northern Territory, Australia; and 3 Infectious Diseases Department, Northern Territory Medical Program, Royal Darwin Hospital, Darwin, Northern Territory, Australia Correspondence: Sandawana William Majoni, Royal Darwin Hospital, Rocklands Drive, Tiwi, Northern Territory 0810, Australia. E-mail: [email protected] Background Melioidosis, an infection caused by the Gram-nega- tive bacillus Burkholderia pseudomallei, is endemic in Southeast Asia and northern Australia. 1 Presen- tations include disseminated sepsis with multiorgan abscesses, pneumonia, genitourinary infection, skin and soſt tissue infection, osteomyelitis/septic arthri- tis, and neurological melioidosis. It can be acute or chronic and localized or systemic. Pneumonia is the most common presentation. 2 It is the commonest cause of severe community-acquired pneumonia in the tropical Top End of northern Australia dur- ing the monsoonal wet season. 3 erapy requires at least 2 weeks of intravenous antibiotics followed by at least 3 months of oral therapy to eradicate infection. B. pseudomallei has been isolated in soil, mud, and pooled water samples in Darwin 4,5 and remote communities in tropical northern Aus- tralia. 6 Transmission is via percutaneous inocula- tion and inhalation of aerosolized bacteria such as during severe weather events, and also via aspira- tion and occasionally ingestion. 2 It is resistant to many antibiotics and has a propensity for latency with potential for activation many years aſter ini- tial infection. 7 Chronic kidney disease is an independent risk factor for melioidosis and is associated with a higher mortality rate. 8 Other risk factors include diabetes, chronic lung disease, malignancy, immunosuppression, hazardous alcohol and kava use, rheumatic heart disease and/or congestive cardiac failure (RHD/CCF), indigenous ethnic- ity, and male gender. 2,8 e Darwin Prospective Melioidosis Study has documented all cases of melioidosis in the Top End of the Northern Territory since 1 October 1989. Melioidosis is notifiable in the Northern Territory. is makes it likely that very few cases of melioido- sis were missed in the 23 years of the study. A high burden of the disease in end-stage renal disease (ESRD) dialysis patients was noted, in particular during the 2011–2012 wet season. is analysis was performed as the initial step toward determining whether antibiotic prophylaxis would be appropriate in dialysis patients during the wet season. Results In the 23 years from 1989 to mid-2012 there were 785 individuals with melioidosis in the Top End of the Northern Territory. Of these, 27 patients (3.4%) had ESRD established on dialysis at the time of diagnosis of melioidosis. ree patients were treated with peritoneal dialysis and 24 with hemodialysis. Mortality in the dialysis group was 11%, compared with 13% in the non-dialysis group (P = 0.72). e median ages were 49 (37–70) years and 50 years (8 months to 91 years) in the dialysis and non-dialysis groups, respectively. irty- three percent of the dialysis cohort were male compared with 66% of the non-dialysis cohort (P < 0.001). Eighty-five percent of the dialysis group were indigenous compared with 51% of the non-dialysis group (P = 0.001). Using the most recent 15 years of population and dialysis data, we performed comparisons of crude incidence rates and relative risk of melioi- dosis in the two populations. In the non-dialysis population, the incidence rate was 24.0/100,000 patient-years, compared with 988.8/100,000 patient-years in dialysis, giving a crude relative risk for those on dialysis of 38.4 (95% confidence interval 25.7–57.5). Dialysis patients had significantly higher rates of other risk factors. These included diabetes (63% versus 41%, P = 0.02) and RHD/CCF (22% versus 8%, P = 0.01). Chronic lung disease, smok- ing, immunosuppression, hazardous alcohol and kava use, and malignancies were not significantly different (Table 1). Dialysis patients were more likely to present with bacteremia without an evident underlying clinical focus on admission (37% versus 11%, P < 0.001; Table 2). e rate of septic shock was similar (19% versus 22%, P = 0.64). All melioi- dosis cases in dialysis patients presented as acute illness, compared with 88% in the non-dialysis population (P = 0.15). Dialysis patients had a Melioidosis and end-stage renal disease in tropical northern Australia Kidney International (2014) 86, 867–870. doi:10.1038/ki.2014.228
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