Buruli ulcer

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

Provisional guidelines


Treatment

For the purposes of this guidance, patients are divided into three categories of treatment according to the size of the lesion and other complications (see Table 2). Although the optimal duration of therapy is yet to be determined, based on available data, antibiotic treatment is recommended for 8 weeks. If a lesion deteriorates (enlarges) during antibiotic treatment, review the initial clinical diagnosis. The lesion should be excised and tissue samples sent for histological diagnosis if possible. If a patient develops adverse effects (see Table 3), review antibiotic treatment.

If surgery is combined with antibiotic therapy, the aim is to use minimal surgery to excise necrotic tissue when antibiotics have arrested progress of the disease. The timing of these tissue-conserving interventions is at the discretion of the health worker (in this case, a clinician). Small early lesions are a special case when there are facilities to excise the whole lesion immediately. If small early lesions are immediately excised, it is not known for how long antibiotics need to be administered after surgery in order to prevent recurrence, but 4 weeks is recommended currently.

Note: The three categories of treatment are only guidance for management and do not cover every clinical presentation. Therefore clinical judgment will be needed for other presentations and their treatment options.

For example, ulcerative plaque or oedematous forms, irrespective of the size of the ulcer, should be treated as in category II, i.e. at least 4 weeks of antibiotics before and after surgery (total duration 8 weeks) with the aim of reducing the extent of excision. Bone and joint involvement should be given priority over other forms of the disease. For cosmetic reasons, lesions on the face should be treated sufficiently with antibiotics before any surgical intervention is attempted.



Table 2: Categories and aims of treatment, level of healthcare system and diagnosis required

Table 3: Symptom-based approach to identifying and managing the side-effects of rifampicin and streptomycin treatmenta, b

a Source: (25).
b It must be emphasized that evidence from studies suggests that side-effects are rare. However, close monitoring of patients and strict observation of this guidance are necessary.
c These side-effects occur principally when rifampicin intake is intermittent and dose exceeds 10 mg/kg.

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