Buruli ulcer

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

Provisional guidelines

Important notes for health workers

  • Because of the nature of the pathology of the M. ulcerans disease – necrosis of skin and subcutaneous tissue – surgery will be required in some cases for excision of necrotic tissue and/or skin grafting.
  • To speed up healing, dead tissue should be conservatively removed. This should not be delayed because of antibiotic treatment.
  • Simple debridement should be performed whenever wounds are dressed. This is painless if it does not involve live tissue. Radical debridement requires anaesthesia and is usually performed in an operating theatre.
  • Any patient with strongly suspected M. ulcerans disease should be treated with the recommended combination of rifampicin and an aminoglycoside (usually streptomycin) under direct observation for 8 weeks (see Table 1 and Section 8).
  • The two antibiotics should always be given in combination to prevent selection of drug-resistant mutants. Other drug combinations are not recommended at this stage because of lack of supportive data from animal and human studies.
  • For ulcers which are responding well to antibiotic therapy, perform the usual dressing and debridement during and after stopping antibiotics, and continue dressing the wound until healing is complete.
  • If surgery is performed, both antibiotics should be administered about one hour before the surgical procedure to provide the best possible perioperative antibiotics coverage.
  • If deemed clinically necessary, monitor patients regularly for any adverse effects (hearing, and renal- and liver-function tests).
  • Other lines of management include specific or broad-spectrum antibiotics for secondary bacterial infection, physiotherapy and splints, and appropriate referrals for specialist treatment.

Feedback is invited from health workers who use this provisional guidance. Any comments, reports and experiences should be sent to:

Global Buruli Ulcer Initiative
Communicable Diseases
World Health Organization
20, avenue Appia
CH-1211 Geneva 27

Tel.: +41 22 791 2803
Fax: +41 22 791 4777
E-mail: buruli@who.int