Mozzies, Melioidosis and Mango Madness

Running HITH in the Remote Tropics of Australia

Dr Krispin Hajkowicz Infectious Diseases and General Physician, Royal Brisbane and Women’s Hospital Senior Lecturer, University of Queensland School of Medicine Former Infectious Diseases Physician, Royal Darwin Hospital

Darwin!

Mozzies, Melioidosis and Mango Madness

• Service profile

• Unique challenges

• Melioidosis

• Malaria

• Mango Madness

Royal Darwin HITH

• ~520 admissions per year

• Melioidosis in wet season

• Skin and soft tissue infection

• Bone and joint infection

• Cystic fibrosis

• Usual others in small numbers eg VTE in Grey Nomads

RDH HITH Admissions 2012

Cellulitis, uncomplicated 23%

Deep vein thrombosis, no PE 19%

Melioid 16%

Pulmonary embolism 10%

Osteomyelitis 9%

Re-Warfarinisation 7%

Native joint septic arthritis 5%

Diabetic foot 3%

Cystic Fibrosis, exacerbation or tune-up

2%

Malaria 2%

Endocarditis 1%

Other 3%

Unique Cross-Cultural Setting

• ~25% Indigenous Australians

• Some from remote communities

• “Long-grassers”

• HITH often the only care possible

Extremes of Weather

• Cyclone management plan

Floods

• Impact on patients

• Impact on staff

Fires

• Planned burn-offs from April-October

• Respiratory disease

Extreme Temperatures

• Impact on infusors, medical equipment

• Impact on patients, wounds, PICC dressings

• Impact on staff

Remoteness • Limited surgical services

• Staffing challenges

• Relatively high turnover of staff

• Cost

• Lack of peer support

Melioidosis

• Tropical environmental bacterium Burkholderia pseudomallei

• Surface water and soil, mainly in the wet season

Melioidosis

• Causes – Pneumonia – septic shock – Osteomyelitis and septic arthritis – Skin and soft tissue infection

– Deep abscesses – Other

• Usually in diabetes, immune suppression, kidney impairment, other chronic disease

• “Intensive-phase” intravenous antibiotic therapy critical to prevent relapse

Ceftazidime Elastomeric Infusors

Ceftazidime Elastomeric Infusors

• 73 Patients with Melioidosis Managed with ceftazidime elastomeric infusors – 81% males, 58% Indigenous Australians

• 64 Cured • Treatment failures

– 3 Recrudescences on IV antibiotics – 6 Relapses following completion of IV treatment – Due to non-adherence – All successfully retreated

• PICC line complications – 14/73, three readmissions to hospital

• Conclusions

– Excellent treatment outcomes through HITH/OPAT

– PICC line complications no different to inpatients and other audits

– Lack of stability data for ceftazidime elastomerics at prolonged high temperatures did not affect clinical outcome

Updated – Melioid and HITH

• October 2009- September 2012

• 133 of 215 (62%) patients with melioidosis received ceftazidime elastomeric infusor ( almost all via HITH)

• Median ceftazidime infusor duration 14 days (IQR 8-22)

New Data – Melioid Outcomes on HITH

• 93% cured

• 4% recrudesced

• 0.8% (1 pt) relapsed

• 3% died after HITH discharge

0

5

10

15

20

25

30

35

Skin abscess Bacteraemia with no focus

Pneumonia Deep-seated collection

Osteomyelitis Central nervous system infection

Du

rati

on

of

infu

sors

(d

ays)

Antibiotic Duration-Determining Focus

Median duration of infusors ± interquartile range according to Antibiotic Duration-Determining Focus

Data and analysis - Dr Matthew Pittman

0

2

4

6

8

10

12

14

16

0

100

200

300

400

500

600

700

800

900

1000

No. cases Rainfall (mm)

Rainfall and Melioidosis N

o. o

f C

ases

Rain

fall (

mm

)

wet

89/90

dr

y

‘90

wet

90/91

wet

92/93

wet

91/92

wet

93/94

wet

94/95

dry

‘91

dry

‘92

dry

‘93

dr

y

‘94

dr

y

‘95

wet

95/96

dry

‘96

wet

96/97

dry

‘97

wet

98/99

dry

‘99

wet

97/98

dry

‘98

wet

99/00

dry

‘00

Cyclone

Les

Cyclone

Thelma

r = 0.6

p < 0.001

HITH - Malaria

• Non-severe P. falciparum stabilised in hospital

• Monitoring

• Directly observed oral artesunate therapy

Skin and Soft Tissue Infections • Wet season nm-MRSA

• Group A Streptococcus

• Crusted/Norwegian Scabies

• Waterborne infection, (Vibrio vulnificus)

KRISPIN.HAJKOWICZ@HEALTH.QLD.GOV.AU

Professor Bart Currie

Ms Paulene Kittler

Dr Catherine Marshall

Dr Matthew Pittman

Dr Sarah Huffam

Thank You!