Affiliations: Royal Darwin Hospital, Tiwi, NT, Australia,
Geelong Hospital, Geelong, VIC, Australia
Correspondence to: Bart L. De Keulenaer, MD, Royal Darwin Hospital, Intensive Care Unit, Rocklands Dr, 0810 Tiwi, NT, Australia; e-mail: firstname.lastname@example.org
We would like to comment on the retrospective review of melioidosis by Chan et al in a recent issue of CHEST (November 2005).1 We commend the authors on their work, which reinforces the high mortality rate associated with this infection, particularly in those patients with a critical illness.
Contrary to their assertion that melioidosis in the ICU setting has not previously been described, we have previously published2our experience of 42 critically unwell patients with culture-confirmed melioidosis. In our series, we noted a fall in the mortality rate from 95% to 9.5% coincident with the introduction of granulocyte colony-stimulating factor (G-CSF) in patients with septic shock. We also acknowledged that the large fall in the mortality rate that we observed may have been at least partly explained by other potential confounders, including the adoption of a closed intensive care model, the earlier use of antibiotics active against Burkholderia pseudomallei, and more aggressive fluid resuscitation. We have also demonstrated that pneumonia and biochemical markers of organ dysfunction are generally associated with mortality in patients with melioidosis.3
Studies of melioidosis have been difficult to compare due to the large clinical spectrum of illness and variations in the definitions of “severe melioidosis.” This is reflected in the differences in the rates of bacteremia between studies. However, severe sepsis (as defined by Chan et al1) and septic shock (as defined in our series) represent the group with the highest mortality rate due to melioidosis. The mortality rate that we observed in patients who received G-CSF in our series was lower than that observed by Chan et al1 in a population with a similar severity of illness. Chan et al1 did not differentiate pneumonia with septic shock from pneumonia without septic shock; the Darwin experience suggests that pneumonia with septic shock is associated with an 84% mortality rate.4
We suggest that the measures associated with the fall in mortality at our institution, namely, the use of G-CSF, the routine use of empiric antibiotics for melioidosis, and the use of aggressive fluid resuscitation, should be considered for patients with severe sepsis in melioidosis-endemic areas. We have participated in studies aimed at identifying patients with melioidosis by the use of clinical criteria and rapid diagnostics,5 and we are in the process of conducting a clinical trial of G-CSF for the treatment of severe melioidosis in Thailand.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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