Buruli ulcer

Provisional guidance on the role of specific antibiotics in the management of Mycobacterium ulcerans disease (Buruli ulcer)

Important issues to consider

What treatment should be given for recurrence?

It is assumed the initial diagnosis of M. ulcerans disease was correct. In the case of a recurrence at the original site when antibiotics were given for 8 weeks, if possible, samples (preferably punch biopsy) should be taken for culture before restarting rifampicin and streptomycin treatment, since some lesions may be caused by an immune response to dead organisms and they may be sterile. Antibiotics should then be administered for 4 weeks and surgery undertaken to excise the lesion at the optimum time.

If antibiotics were given for less than 8 weeks in the first course, a longer period of treatment should be considered for the recurrence, but should not exceed 12 weeks.

If severe side-effects develop with these antibiotics, what alternative antibiotics should be used?

Since, at present, there are no alternative drugs of proven value, stop treatment if severe side-effects develop, e.g. shock or jaundice resulting from rifampicin, and severe dizziness or hearing impairment resulting from streptomycin. There is an increased risk from streptomycin if the duration of treatment is more than 90 days; remember that aminoglycoside toxicity is cumulative and thus special attention should be given to patients who have previously been treated with an aminoglycoside, whichever aminoglycoside was used, the duration and reason for its use. Operate and send specimens to the laboratory. If hearing impairment is conductive, and not sensorineural, treat the cause and continue antibiotic treatment. Good evaluation of patients is vital.

What about streptomycin for children?

At present, there is no alternative aminoglycoside for the treatment of M. ulcerans disease in children. Close clinical monitoring of adverse effects is therefore essential. Painful daily injections of streptomycin are a problem for children, so efforts should be made to give successive injections at different sites. Small-bore needle should be used.

What about streptomycin for pregnant women?

The use of streptomycin is contraindicated during pregnancy and surgery should therefore be the first line of treatment for pregnant women. Pregnancy should be ruled out before antibiotic treatment of women of reproductive age is started.

What about coinfection with other mycobacteria (TB and leprosy)

Coinfection is uncommon, but any patient with M. ulcerans disease who is coinfected with the mycobacteria causing either TB or leprosy, the standard treatment for TB or leprosy should be continued. The rifampicin and streptomycin components of the regimen should be given daily for the duration of treatment of M. ulcerans disease after which the standard treatment regimens for TB or leprosy should be continued.