Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

non-localised disease or patient systemically unwell

1st line – intensive intravenous antibiotic therapy

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ACUTE
|
non-localised disease or patient systemically unwell
1st line – 

intensive intravenous antibiotic therapy

Intravenous antibiotic therapy with ceftazidime, meropenem, or imipenem/cilastatin should be administered.[8][43][84][57][85]

Duration of therapy is determined by the severity and nature of the clinical features.

Minimum duration is 10 to 14 days, which should be extended to 4 weeks if: pneumonia requiring ICU or associated with mediastinal lymphadenopathy or extensive bilateral chest x-ray changes; presence of internal organ abscesses, septic arthritis, or other deep-seated collections, with 4-week duration timed from last aspiration of pus (e.g., with prostatic abscesses or septic arthritis).[8][84] 

Extend duration to at least 6 weeks (minimum) if osteomyelitis is present.

Extend to at least 8 weeks if the patient has neurological melioidosis or mycotic aneurysm.

In resource-poor settings it may not be affordable to extend treatment, but a minimum of 10 to 14 days of intensive treatment is recommended.[57][87]

Duration of intravenous therapy is best timed from last culture-positive drainage of pus.[84]

Intensive intravenous antibiotic therapy should be followed by oral eradication therapy.

Primary options

ceftazidime: children: 50 mg/kg intravenously every 6-8 hours, maximum 8 g/day; adults: 2 g intravenously every 6-8 hours

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OR

meropenem: children: 25 mg/kg intravenously every 8 hours, maximum 3 g/day; adults: 1 g intravenously every 8 hours

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OR

imipenem/cilastatin: children: 25 mg/kg intravenously every 6 hours, maximum 4 g/day; adults 1 g intravenously every 6 hours

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Consider – trimethoprim/sulfamethoxazole plus abscess drainage

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ACUTE
|
non-localised disease or patient systemically unwell
|
with a collection, skin abscess, or bone/joint, genitourinary, or CNS infection
Consider – 

trimethoprim/sulfamethoxazole plus abscess drainage

Additional treatment recommended for SOME patients in selected patient group

In patients with a collection (abscesses in internal organs), skin abscess/ulcers, and in bone/joint, genitourinary, and CNS infections (but not for pneumonia), oral or intravenous (if available) trimethoprim/sulfamethoxazole may be added to the intensive therapy regimen.[8][86]

Concomitant administration of folic acid should be considered when giving trimethoprim/sulfamethoxazole in high doses for a long duration to reduce potential adverse effects associated with the drug’s anti-folate effect (e.g., bone marrow toxicity).[8]

Collections should be drained where practicable (especially prostate and muscle abscesses and large liver abscesses), but splenic abscesses usually do not require drainage.

Primary options

trimethoprim/sulfamethoxazole: children ≥2 months of age: 6-8 mg/kg orally/intravenously twice daily; adults <40 kg body weight: 160 mg orally/intravenously twice daily; adults 40-60 kg body weight: 240 mg orally/intravenously twice daily; adults >60 kg body weight: 320 mg orally/intravenously twice daily

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Plus – resuscitation and intensive care therapy

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ACUTE
|
non-localised disease or patient systemically unwell
|
with melioidosis septic shock
Plus – 

resuscitation and intensive care therapy

Treatment recommended for ALL patients in selected patient group

State-of-the-art resuscitation and intensive care therapy with severe sepsis guidelines are necessary to reach the current best-care overall mortality of 10%.[65]

The mortality benefit of adding granulocyte-colony stimulating factor (G-CSF) to the treatment regimen in patients with melioidosis septic shock remains unproven, but it is used in some intensive care units experienced in treating melioidosis.[8][92][93]

localised disease

1st line – oral eradication therapy

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ACUTE
|
localised disease
1st line – 

oral eradication therapy

Some patients with localised disease (confirmed by imaging to exclude other foci) who are systemically well may safely be treated with oral eradication therapy alone.[10][85]

Oral trimethoprim/sulfamethoxazole is the treatment of choice.[8][43][84][57][85][88][89] Concomitant administration of folic acid should be considered when giving trimethoprim/sulfamethoxazole in high doses for a long duration to reduce potential adverse effects associated with the drug’s anti-folate effect (e.g., bone marrow toxicity).[8]

However, bone marrow suppression, rash, and rising creatinine and potassium are not uncommonly seen in melioidosis patients treated with trimethoprim/sulfamethoxazole. In patients who are intolerant of trimethoprim/sulfamethoxazole, alternative therapies include amoxicillin/clavulanate or doxycycline (in adults only).[91] Both of these agents have been associated with higher risk of recurrence, and so trimethoprim/sulfamethoxazole should be used wherever possible.[85]

In children older than 2 months of age and pregnant women beyond the first trimester, trimethoprim/sulfamethoxazole remains the drug of choice, but amoxicillin/clavulanate is an alternative.[85]

Eradication therapy should be continued for a minimum of 3 months, and extended to 6 months if neurological melioidosis or osteomyelitis are present.[8][43][84][85]

Primary options

trimethoprim/sulfamethoxazole: children ≥2 months of age: 6-8 mg/kg orally twice daily; adults <40 kg body weight: 160 mg orally twice daily; adults 40-60 kg body weight: 240 mg orally twice daily; adults >60 kg body weight: 320 mg orally twice daily

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Secondary options

amoxicillin/clavulanate: children: 20 mg/kg orally three times daily; adults <60 kg body weight: 1000 mg orally three times daily; adults >60 kg body weight: 1500 mg orally three times daily

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OR

doxycycline: adults: 100 mg orally twice daily

ONGOING

intensive intravenous antibiotic therapy completed; localised disease responsive to oral eradiation therapy

1st line – switch to or continue oral eradication therapy

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ONGOING
|
intensive intravenous antibiotic therapy completed; localised disease responsive to oral eradiation therapy
1st line – 

switch to or continue oral eradication therapy

Once intensive intravenous therapy is completed, patients should be switched to oral eradication therapy. For those with localised disease and treated initially with oral therapy, this treatment should be continued. In both cases, eradication therapy should be continued for a minimum of 3 months, and extended to 6 months if neurological melioidosis or osteomyelitis are present.[8][43][84][85]

Oral trimethoprim/sulfamethoxazole is the treatment of choice.[8][43][84][57][85][88][89] Concomitant administration of folic acid should be considered when giving trimethoprim/sulfamethoxazole in high doses for a long duration to reduce potential adverse effects associated with the drug’s anti-folate effect (e.g., bone marrow toxicity).[8]

However, bone marrow suppression, rash, and rising creatinine and potassium are not uncommonly seen in melioidosis patients treated with trimethoprim/sulfamethoxazole.

Alternative eradication therapy for patients intolerant of trimethoprim/sulfamethoxazole is amoxicillin/clavulanate or doxycycline (in adults only).[91] Both these agents have been associated with higher risk of recurrence, and therefore trimethoprim/sulfamethoxazole should be used wherever possible.[85]

In children older than 2 months of age and pregnant women beyond the first trimester, trimethoprim/sulfamethoxazole remains the drug of choice, but amoxicillin/clavulanate is an alternative.[85]

Primary options

trimethoprim/sulfamethoxazole: children ≥2 months of age: 6-8 mg/kg orally twice daily; adults <40 kg body weight: 160 mg orally twice daily; adults 40-60 kg body weight: 240 mg orally twice daily; adults >60 kg body weight: 320 mg orally twice daily

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Secondary options

amoxicillin/clavulanate: children: 20 mg/kg orally three times daily; adults <60 kg body weight: 1000 mg orally three times daily; adults >60 kg body weight: 1500 mg orally three times daily

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OR

doxycycline: adults: 100 mg orally twice daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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