Paul Lane on Tropical Microbiology

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Paul Lane, an Intensivist from tropical Queensland gave this lecture at Bedside Critical Care 2012. The talk can be heard at www.intensivecarenetwork.com

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Paul Lane on Tropical Microbiology

  1. 1. Tropical Microbiology Dr Paul Lane CICM Daydream Is 2012
  2. 2. OutlineMelioidosisLeptospirosisQuestions…
  3. 3. LeptospirosisZoonotic disease, spirochaetes calledleptospiresNatural reservoir in RodentsEnter thru skin cut, intact mucousmembranes with subsequent bloodstreamspread to all organsSoldiers, Banana workers (1million/yr)Outbreaks can occur in tropical areasaffected by disaster
  4. 4. PresentationWeil’s/ Canecutters diseaseProinflammatory cytokines activate Tolllike receptors…detonation!Unwell, fever, myalgia, liver, renal injurywith low plateletsPulmonary Haemorrhage, ARDS…maincause of DEATHVasodilation, inotropesSpirochaetes found in CNS
  5. 5. Immune responsePatients often get worse!!Cochrane support this!Traditional recommendation is PenicillinOnset of Jarisch Herxheimer reactionImmune mechanisms play a key role inpathogenesis of disease, particularlypulmonary
  6. 6. Evolution of my practice…Constantin etal J Rheum 1996Antineutrophil cytoplasmic antibodies inleptospirosisReturned travellers treated withimmunosuppression and got better!!Change to meropenum, IV steroids asinitial therapy….less pulmonary bleeding
  7. 7. What’s out thereSri Lanka 2008 outbreak, started IVmethylprednisolone ( 500mg/3dys thenoral)…studied 230 patients20% down to 10%Once severe organ dysfunctionestablished steroids less helpful
  8. 8. Other studiesIndia Shenoy etal 2006 30 patientsMumbai floods 200560% vs 18%IF GIVEN EARLY….(first 12 hrs)Other small case series…
  9. 9. Newer advancementsCyclophosphamide (IV 60mg/kg stat)Trivedi etal 2009 Severe PulmonaryInvolvement…failed steroids90% to 40% mortalityPlasma Exchange ( same author)236 severe pulm disease…protocol of 2washes 25ml/kg removal and low dosecyclophosphamide…again better survival
  10. 10. What do I do…Early steroid (1mg/kg BD MP)Meropenum by infusionGet aggressive early if lung hitEarly CRRTPlasma Exchange +/- CP
  11. 11. ExtrasProphylaxis probably doesn’t workDoxycycline if allergicDiagnosis….CLINICALFinding Leptospira (CSF, blood, urine)Rising titre (MAT)Positive IgM (EIA)NAT
  12. 12. Questions??
  13. 13. MelioidosisWhitmore Disease/ FlandersBacteria isolated from morphine addicts inRagoon 1912B. mallei vs B. pseudomallei“Vietnamese Time Bomb”…26yrincubationInhalation, cut in skin exposed tosoil/water, ingestion
  14. 14. In NQ15-25 cases/yr, 1/5 die1/3 cases in ‘dry season’Better with public educationRecent JCU work reveals run off waterduring high rainfall contains moreorganisms then soil
  15. 15. PresentationAcute Fulminant SepsisLethal CAP plus Sepsis (50%)Genitourinary infectionAbscesses/Osteomyelitis/Septic ArthritisEncephalitis, ParalysisReactivated disease, often asymptomaticChronic Disease (1/16)Prostatic Melioidosis in 20%
  16. 16. PresentationDM, excess ETOH, CRF, steroids andChronic Lung DiseaseCan be ‘normal’Normally easily Dx, tell lab-modifiedcultureSerology occasionally-Neuro/reactivateddisease.RETURNED TRAVELLER- no advice isgiven….
  17. 17. AntibioticsResistant organism ( pen, ceph, gent, cipro)Guidelines for CAP in endemic areas1990’s IV Ceftazadime (14days)oral trimethoprim/sulfamethoxazole (6mths)Now Meropenum infusion (lower MIC)No seizures, better killing profile and decreaseendotoxin release ( yet to show better survival)Dramatic fall in mortality (Stephens, Currie)G CSF??? ( Not in NEJM review)
  18. 18. CaseFebrile child.Limb weakness following lacerationCamping in bushMild encephalopathy
  19. 19. Questions?

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