Melioidosis: Current Diagnostic Approach and Role in Clinical practice

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Melioidosis: Current Diagnostic Approach and Role in Clinical practice. Rob Baird Royal D arwin Hospital. The Darwin Prospective Melioidosis Study. 820 cases over 24 years 109 deaths (13%). Darwin. B. pseudomallei : Selective culture. - PowerPoint PPT Presentation

Text of Melioidosis: Current Diagnostic Approach and Role in Clinical practice

Australian Tropical Bacteriology

Melioidosis: Current Diagnostic Approach and Role in Clinical practiceRob BairdRoyal Darwin HospitalThe Darwin Prospective Melioidosis Study

Darwin820 cases over 24 years109 deaths (13%)

Colonies are small, light blue and dry on Ashdown agar.Typical wrinkled colonies after 72 hours incubation.

B. pseudomallei : Selective cultureAshdown Broth contains colymycin and crystal violet to suppress Gram positive bacteria and common coliformsUsed for screening purposes, and when melioidosis is suspected. Screening is performed mainly on throat and rectal swabs but also on sputum, urine or wound swabs.

Broths are incubated 35 degrees C for 5 days with lids loosened, then subbed to Ashdown agar. Broths are checked daily.Note: the positive is suggested by a growth at the air/broth interface, for this aerobic bacteria

B. pseudomallei : Selective cultureDifferent diagnostics:Acute disease: Blood v swabs v sputumChronic disease: exposure

B. Pseudomallei diagnostic algorithms at Royal Darwin Hospital:One for blood cultures, one for plate culturesBlood culture signalsMicroscopyGram stainBiochemistry IDSusceptibility testingPCRHighly motile, bipolar stainingPlate culture growthMicroscopyGram stainOxidaseAgglutinationHighly motile, bipolar staining, oxidase positive, agglutinatesDoctor notifiedPossible, probable, confirmedBiochemistry IDSusceptibility testingPCRB. pseudomallei: Susceptibility testingSusceptibility testing of B. pseudomallei isolates is performed to detect resistance to the antimicrobials used in therapy. Resistance in Northern Territory bacterial isolates is rare but described.

Susceptibility methods for testing B. pseudomallei isolates, unlike most common bacteria are more limited, as there are no disc diameter zone sizes available in CLSI and EUCAST methodologies, and automated susceptibility systems such as Vitek 2, produce results which are partially indicative but do not good correlations with formal MIC testing.

The gold standard is agar micro dilution, however E tests are widely available and correlate well with agar microdilution MICs. The links below are illustrative:Etest MIC testing methods and interpretation for B. pseudomallei

Pooled MIC data for > 230 Northern Territory patient B. pseudomallei isolates from 2009-2012:

CeftazidimeMeropenemTrimethoprim-sulphamethoxazoleDoxycycline

Ceftazidime

E test result 1.5 mg/LMeropenem

E test result 1.0 mg/LTrimethoprim/Sulphamethoxazole

E test result 0.125 mg/LB. pseudomallei : E test interpretation

Performed by CLSI methodMeropenem, and ceftazidime give clear-cut end-points and are read at complete inhibition, as compared to trimethoprim/sulphamethoxazole

Routine antimicrobial testing of melioid isolates by Etest is performed for meropenem, ceftazidime, trimethoprim/sulphamethoxazole and doxycycline. Performed by CLSI methodMeropenem, ceftazidime and doxycycline give clear-cut end-points and are read at complete inhibition.Trimethoprim/sulphamethoxazole does not have clear cut endpointThe MIC value is taken at 80% inhibition.Picture on left shows the 2 inhibition ellipses.The first one at 0.19 mg/LThe second at about 1.5mg/LTherefore at 80% inhibition the MIC is 1.0 mg/LMIC above 2.0mg/L is resistant

B. pseudomallei : E test interpretation

Trimethoprim/sulphamethoxazole1.0mg/L

B. Pseudomallei: Pooled MIC data 2009-2012