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Original Article Clinical Characteristics and Outcomes of Bacteraemic Original Article Clinical characteristics and outcomes of bacteraemic melioidosis in a teaching hospital in a northeastern state of Malaysia: a five-year review Zakuan Zainy Deris1, Habsah Hasan2 and Mohd Noor Siti Suraiya 1 1Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan,Malaysia 2Epidemiology and Infection Control Unit, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Abstract Background: Melioidosis is an important public health problem causing community acquired sepsis in the northeastern part of Malaysia. Methodology: From January 2001 to December 2005, we reviewed case reports of all bacteraemic melioidosis admitted to a tertiary teaching hospital, Hospital Universiti Sains Malaysia. Results: Thirty-five patients had positive blood culture for meliodosis and 27 case reports were traceable for further analysis. The mean age was 46.8 + 20.0 years. Twenty patients (74.1%) were male. The main clinical presentation was fever that occurred in 23 (85.2%) patients. Eighteen patients (66.7%) had lung involvement and three patients had liver abscess. Two patients presented with scrotal swelling, one of whom further developed Fournier's Gangrene. Nineteen (70.4%) patients had underlying diabetes, five of whom were newly diagnosed during the admission. Thirteen (48.1%) patients were treated with high-dose ceftazidime and six (22.2%) patients were treated with imipenem. Eight (29.6%) patients were not given anti-melioidosis therapy because the causative agents were not identified until after the patients died. The patients were admitted 16.8 days + 18.1. Seventeen patients (63.0%) died in this series, 13 patients of whom died within four days of admission. Conclusions: The wide range of clinical presentations and the fatal outcomes of melioidosis require a high level of suspicion among physicians to develop an early appropriate therapy and reduce the mortality rate. Key words: melioidosis, clinical features, Malaysia J Infect Dev Ctries 2010; 4(7):430-435. (Received 12 September 2009 – Accepted 7 April 2010) Copyright © 2010 Mohd Noor et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction However, not many publications on meliodosis come Melioidosis is a tropical infectious disease caused from Malaysia. This study aimed to determine the by Gram-negative bacteria Burkholderia demographic profiles, clinical characteristics, and pseudomallei. This soil-borne disease is endemic in outcome of patients with bacteraemic melioidosis southeast Asia and northern Australia. Melioidosis who attended Hospital Universiti Sains Malaysia, has a diverse spectrum of clinical presentation and Kelantan. can affect any organ. It is important to define the demographic profiles, clinical characteristics, and Materials and methods outcomes of melioidosis because of the regional A retrospective study was performed in Hospital differences that have been described in the Universiti Sains Malaysia (HUSM) by reviewing the prevalence of organ involvement [1,2]. blood culture results from the years 2001 to 2005 Kelantan State, which is located in the using the WHO-net program. HUSM is an 800-bed northeastern part of Malaysia, has a heavy monsoon tertiary teaching hospital that is located in Kelantan, a season from November to March every year. This northeastern state of Malaysia. state is located in what is known as the Malaysian All confirmed cases of bacteraemic melioidosis rice bowl and has more than 60,000 hectares of were selected for the study Bacteraemic melioidosis paddy fields [3]. Thousands of people are at risk of is defined as any positive blood culture for B. contracting B. pseudomallei, which is a great public pseudomallei with or without sepsis. The patients’ health concern and an important cause of community records were reviewed accordingly to determine the acquired sepsis in the northeastern part of Malaysia. demographic profiles, clinical characteristics, and Mohd Noor et al. – Bacteraemic Melioidosis in Malaysia J Infect Dev Ctries 2010; 4(7):430-435. outcomes. Anti-melioidosis therapy for intensive The main clinical presentation was fever that phases used in HUSM during the study period was occurred in 23 (85.2%) patients. Eighteen patients intravenous injection every eight hours of either 40 (66.7%) had lung involvement and three patients had mg/kg ceftazidime or 20 mg/kg imipenem. The use of liver abscess. Two patients presented with scrotal other antimicrobial agents or the use of ceftazidime swelling, one of whom further developed Fournier's or imipenem below these suggested doses without Gangrene. The mean total white cell count during renal dose adjustment was not considered anti- admission was 15.8 + 7.5 X103 cell/mL. Seven melioidosis therapy. Death due to melioidosis was patients had normal total white cell counts during defined as a patient’s death within 72 hours of blood presentation and five of them died. culture positive for B. pseudomallei or a patient’s Nineteen (70.4%) patients had underlying clinical sepsis parameter that did not improve after diabetes, five of whom were newly diagnosed during the last blood culture positive for B. pseudomallei. the admission. Four (14.8%) patients had chronic Organ involvement of melioidosis was defined as renal diseases, and five patients had no identified present with clinical findings and/or investigative underlying disease. One patient had underlying modalities of malfunctioning of that organ. The systemic lupus erythematosus. affected organ was probably the primary site of For anti-melioidosis therapy, thirteen (48.1%) bacteraemia or its malfunction was a complication of patients were treated with high dose ceftazidime and bacteraemia. In HUSM, at least 5 ml of blood six (22.2%) patients were treated with imipenem. were collected aseptically and inoculated into Eight (29.6%) patients were not given anti- BACTECTM (Becton Dickinson, New Jersey, USA) melioidosis therapy because identification of the blood culture bottles and incubated in the causative agents was not made until after the patient BACTECTM automated blood culture system. B. died. The patients were admitted for 16.8 + 18.1 pseudomallei was identified by the growth of silver- days. whitish colonies on blood agar, was Gram negative, Seventeen patients (63.0%) died in this series of oxidase positive, produced a neutral-alkaline reaction which 16 died directly due to bacteraemic on triple sugar iron, was motile, grew on 42oC and melioidosis and 13 patients died within four days of was colistin-resistant which were also confirmed by admission. One of the patients (patient 11 in Table 1) API NE ® system (bioMérieux, France). was taken home against medical advice in an Results were expressed in terms of the number extremely ill state, failing to respond to imipenem. It and percentage or the mean + standard deviation. For is likely that this patient also died. This case was categorical variables, the differences in patient analyzed as death due to melioidosis. characteristics and associated factors were tested by In the association studies, death due to Chi-square and Fisher’s exact test. For continuous melioidosis among bacteraemic melioidosis was variables, the independent t-test was used. The p associated with shorter hospitalization, no identified value of ≤ 0.05 was considered significant. All underlying disease, and no anti-melioidosis therapy. analyses were done using SPSS software (SPSS, Chicago, Illinois, USA) in the Medical Informatics’ Discussion Laboratory, School of Medical Sciences, Universiti There was no specific age for melioidosis. Sains Malaysia. Neonatal melioidosis is not uncommon in Malaysia. The youngest case in this series was a 15-day-old boy Results who presented with abdominal distention and shock. Out of 69,934 blood-culture request forms, 63 Our centre had reported one case of neonatal (0.09%) were positive for B. pseudomallei coming meningitis due to B. pseudomallei in 1998 [4]. from 35 patients. We managed to trace the case Another reported case of neonatal melioidosis in folders of 27 cases for further analysis (Table 1). The Malaysia was from the east coast state of Pahang in mean age was 46.8 + 20.0 years. The youngest was 2005 [5]. A case series of paediatric melioidosis in 15 days old and the eldest was 80 years old. Twenty Kuala Lumpur reported one case of bacteraemic patients (74.1%) were male. Fifteen (55.6%) patients melioidosis in a neonate [6]. The baby was admitted presented during the northeast monsoon rainy season. for neonatal sepsis with fatal outcome. Only one patient’s work was directly related to We agree with the previous report from Kuala gardening soil. Lumpur that the correlation of melioidosis and rainfall is less strong in Malaysia compared to that in 431 Mohd Noor et al. – Bacteraemic Melioidosis in Malaysia J Infect Dev Ctries 2010; 4(7):430-435. Table 1. Summary of bacteraemic melioidosis cases in Hospital Universiti Sains Malaysia from January 2001-December 2005 Antibiotic therapy Age Month of Organ TWC on No Gender Occupation Presentation Associated illness for intensive Outcome (year) admission Involvement admission phase Fever Working DM Died due to 1 45 Male October Abdominal Lung 8.0 Ceftazidime at rice mill Renal failure melioidosis distention Jaundice Fever
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