Buruli ulcer

Role of specific antibiotics in Mycobacterium ulcerans (Buruli ulcer) management

Provisional guidelines

Growing evidence on the role of specific antibiotics

Data presented at the 6th WHO Advisory Meeting on Buruli Ulcer, 10–13 March 2003, at WHO headquarters in Geneva, Switzerland (19, 20), indicated that encouraging results had been obtained with the use of a combination of rifampicin and an aminoglycoside (streptomycin or amikacin2) for the treatment of small early M. ulcerans lesions.

The key findings were:

  • M. ulcerans could not be cultured from small early lesions after treatment for 4, 8 or 12 weeks;
  • treatment with antibiotics for 2 weeks was insufficient as M. ulcerans was cultured from excised tissue specimens after 2 weeks’ treatment;
  • prior antibiotic treatment reduced the surface area of most lesions by more than 50%, allowing less-extensive excision;
  • none of the lesions became worse while patients received antibiotic treatment, and there were no reported side-effects and no recurrences.

Further data were presented at the 7th WHO Advisory Group Meeting on Buruli Ulcer, 8–11 March 2004, at WHO headquarters in Geneva, Switzerland (21, 22). In a study in Benin, 88 patients were treated with a combination of rifampicin and streptomycin for a period of 4–8 weeks. In Ghana, a pilot study was conducted on 10 patients with oedematous lesions (the most aggressive form of the disease) for 2–8 weeks before surgery.

Two main findings emerged out of the two studies:

  • the lesions of about half of the patients in Benin were healed without the need for surgery and there were no deformities;
  • for those who required surgery (including patients with oedematous forms), only limited excision was needed.

The Benin study also showed that patients can be treated on an ambulatory basis under direct supervision once a firm diagnosis has been made by an experienced health worker (in this case, a clinician). This ambulatory antimicrobial treatment was even possible for patients who needed surgery later.

If these results can be confirmed, detection of small early lesions and treatment with antibiotics will have a considerable impact on the control of the disease and more people will have access to effective treatment. It is also extremely important to determine the duration of antibiotic therapy necessary to achieve maximum benefit in treating the various forms of M. ulcerans disease.

At the International Training Workshop on the Management of Buruli Ulcer held in Yaoundé, Cameroon from 19 to 23 July 2004, participants unanimously agreed to use a combination of rifampicin and an aminoglycoside (streptomycin or amikacin) in the management of the disease, based on this provisional guidance (23).