Volume 200 - Issue 2
Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort
Author: Christina M Steffen
Med J Aust 2014; 200 (2): 85-86. || doi: 10.5694/mja13.10780
Published online: 3 February 2014
Published online: 3 February 2014
To the Editor: O’Brien and colleagues report high rates of recurrence of Mycobacterium ulcerans disease after surgery without adjuvant antibiotics.1
In the other major Australian endemic focus for M. ulcerans, the Daintree region of far north Queensland (where it is known as Daintree ulcer), nearly all of 92 confirmed cases between 1964 and 2008 were treated with surgery alone, with 10 recurrences.2
In 2011, there was an outbreak of 65 confirmed cases. ...
To the Editor: O’Brien and colleagues report high rates of recurrence of Mycobacterium ulcerans disease after surgery without adjuvant antibiotics.1
In the other major Australian endemic focus for M. ulcerans, the Daintree region of far north Queensland (where it is known as Daintree ulcer), nearly all of 92 confirmed cases between 1964 and 2008 were treated with surgery alone, with 10 recurrences.2
In 2011, there was an outbreak of 65 confirmed cases. Of 43 patients referred to Cairns surgeons, 40 underwent surgery: 26 had surgery alone and 14 had surgery plus antibiotics. Antibiotics were given for oedematous, plaque or larger (> 2 cm) ulcers. The duration of preoperative antibiotic treatment varied from 2 to 8 weeks for oedematous infections. To date, during follow-up of over 12 months, there have been two recurrences, both in the surgery-alone group.
Before confirmation in the early 2000s that antibiotic treatment was effective, surgery was first-line treatment of M. ulcerans disease. Poor access to surgical services in major endemic areas such as West Africa led to antibiotic treatment becoming, of necessity, the first-line treatment.3,4
Patients with Daintree ulcer express reluctance to take antibiotics because of the long course required, the cost and side effects. They usually opt for surgery to be rid of the problem and to avoid the need for ongoing dressings in a tropical climate. The local general practitioners and surgeons have considerable experience with the disease and this may be a factor in keeping recurrence rates low.
Surgery remains essential in achieving wound closure in larger lesions.5 In our population, small ulcers (< 2 cm) are excised without adjuvant antibiotics, with a low recurrence rate, but recurrences nevertheless. The challenge is to achieve the best combinations of antibiotics and surgery to minimise time to complete healing while eliminating the risk of recurrence.
Competing interests
No relevant disclosures.
References
- O’Brien DP, Walton A, Hughes AJ, et al. Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort. Med J Aust 2013; 198: 436-439. 0_CHDCHGAA
- Steffen CM, Smith M, McBride WJ. Mycobacterium ulcerans infection in North Queensland: the “Daintree ulcer”. ANZ J Surg 2010; 80: 732-736. 0_i1142868
- World Health Organization. Buruli ulcer: progress report, 2004-2008. Wkly Epidemiol Rec 2008; 83: 145-154. 0_i1142870
- World Health Organization. Treatment of Mycobacterium ulcerans disease (Buruli ulcer): guidance for health workers. Geneva: WHO, 2012. http://www.who.int/iris/bitstream/10665/77771/1/9789241503402_eng.pdf (accessed Nov 2013).
- Johnson PDR, Hayman JA, Quek TY, et al; Mycobacterium ulcerans Study Team. Consensus recommendations for the diagnosis, treatment and control of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer) in Victoria, Australia. Med J Aust 2007; 186: 64-68. 0_CBBBHHIA