title: Mycobacterium ulcerans treatment--can antibiotic duration be reduced in selected patients?
abstract: BACKGROUND
  Mycobacterium ulcerans (M. ulcerans) is a necrotizing skin infection endemic to the Bellarine Peninsula, Australia. Current treatment recommendations include 8 weeks of combination antibiotics, with adjuvant surgery if necessary. However, antibiotic toxicity often results in early treatment cessation and local experience suggests that shorter antibiotic courses may be effective with concurrent surgery. We report the outcomes of patients in the Barwon Health M. ulcerans cohort who received shorter courses of antibiotic therapy than 8 weeks.
  A retrospective analysis was performed of all M. ulcerans infections treated at Barwon Health from March 1, 1998 to July 31, 2013. Sixty-two patients, with a median age of 65 years, received < 56 days of antibiotics and 51 (82%) of these patients underwent concurrent surgical excision. Most received a two-drug regimen of rifampicin combined with either ciprofloxacin or clarithromycin for a median 29 days (IQR 21-41 days). Cessation rates were 55% for adverse events and 36% based on clinician decision. The overall success rate was 95% (98% with concurrent surgery; 82% with antibiotics alone) with a 50% success rate for those who received < 14 days of antibiotics increasing to 94% if they received 14-27 days and 100% for 28-55 days (p<0.01). A 100% success rate was seen for concurrent surgery and 14-27 days of antibiotics versus 67% for concurrent surgery and < 14 days of antibiotics (p = 0.12). No previously identified risk factors for treatment failure with surgery alone were associated with reduced treatment success rates with < 56 days of antibiotics.
  
  
  CONCLUSIONS
  In selected patients, antibiotic treatment durations for M. ulcerans shorter than the current WHO recommended 8 weeks duration may be associated with successful outcomes.
authors: Department of Infectious Diseases, Barwon Health, Geelong, Australia.
authors: Raquel
authors: R
authors: Cowan
authors: Department of Infectious Diseases, Barwon Health, Geelong, Australia.
authors: Eugene
authors: E
authors: Athan
authors: Department of Infectious Diseases, Barwon Health, Geelong, Australia.
authors: N Deborah
authors: ND
authors: Friedman
authors: Department of Infectious Diseases, Barwon Health, Geelong, Australia.
authors: Andrew J
authors: AJ
authors: Hughes
authors: Department of Plastic Surgery, Barwon Health, Geelong, Australia.
authors: Anthony
authors: A
authors: McDonald
authors: Department of Plastic Surgery, Barwon Health, Geelong, Australia.
authors: Peter
authors: P
authors: Callan
authors: Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia; WHO Collaborating Centre for Mycobacterium ulcerans, VIDRL, Melbourne, Australia.
authors: Janet
authors: J
authors: Fyfe
authors: Department of Infectious Diseases, Barwon Health, Geelong, Australia; Manson Unit, Mèdecins Sans Frontières, London, United Kingdom; Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
authors: Daniel P
authors: DP
authors: O'Brien
mesh_terms: D000276:Adjuvants, Immunologic / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000904:Antibiotics, Antitubercular / Q000627:therapeutic use*; D001315:Australia; D054312:Buruli Ulcer / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery; D002939:Ciprofloxacin / Q000627:therapeutic use; D017291:Clarithromycin / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019911:Mycobacterium ulcerans / Q000187:drug effects*; D012189:Retrospective Studies; D012293:Rifampin / Q000627:therapeutic use; D012307:Risk Factors; D016896:Treatment Outcome; D028761:Withholding Treatment
chemical_list: D000276:Adjuvants, Immunologic; D000904:Antibiotics, Antitubercular; D002939:Ciprofloxacin; D017291:Clarithromycin; D012293:Rifampin