Towards Rational Use of Antibiotics for Suspected Secondary Infections in Buruli Ulcer Patients

BackgroundThe emerging disease Buruli ulcer is treated with streptomycin and rifampicin and surgery if necessary. Frequently other antibiotics are used during treatment.
Methods/Principal FindingsInformation on prescribing behavior of antibiotics for suspected secondary infections and for prophylactic use was collected retrospectively. Of 185 patients that started treatment for Buruli ulcer in different centers in Ghana and Bénin 51 were admitted. Forty of these 51 admitted patients (78%) received at least one course of antibiotics other than streptomycin and rifampicin during their hospital stay. The median number (IQR) of antibiotic courses for admitted patients was 2 (1, 5). Only twelve patients received antibiotics for a suspected secondary infection, all other courses were prescribed as prophylaxis of secondary infections extended till 10 days on average after excision, debridement or skin grafting. Antibiotic regimens varied considerably per indication. In another group of BU patients in two centers in Bénin , superficial wound cultures were performed. These cultures from superficial swabs represented bacteria to be expected from a chronic wound, but 13 of the 34 (38%) S. aureus were MRSA.
Conclusions/SignificanceA guide for rational antibiotic treatment for suspected secondary infections or prophylaxis is needed. Adherence to the guideline proposed in this article may reduce and tailor antibiotic use other than streptomycin and rifampicin in Buruli ulcer patients. It may save costs, reduce toxicity and limit development of further antimicrobial resistance. This topic should be included in general protocols on the management of Buruli ulcer.

**背景** 布鲁里溃疡（Buruli ulcer）是一种新发感染性疾病，临床标准治疗方案为联合使用链霉素（streptomycin）与利福平（rifampicin），必要时辅以外科手术干预。治疗过程中常需联用其他抗生素。

**方法与主要发现** 本研究回顾性收集了针对疑似继发感染（secondary infections）及预防用药（prophylactic use）的抗生素处方行为相关数据。研究纳入了在加纳与贝宁多家医疗中心启动布鲁里溃疡治疗的185例患者，其中51例收入院治疗。在这51例入院患者中，40例（78%）在住院期间接受了至少1个疗程的链霉素与利福平以外的其他抗生素治疗。入院患者的抗生素疗程数的中位数（四分位距，Interquartile Range, IQR）为2（1, 5）。仅12例患者因疑似继发感染使用抗生素，其余所有疗程均为继发感染预防用药，平均在切除术（excision）、清创术（debridement）或皮肤移植术（skin grafting）后持续给药至10天。不同适应症下的抗生素给药方案（antibiotic regimens）差异显著。在贝宁两家医疗中心的另一组布鲁里溃疡（BU）患者中，研究者对其创面表层拭子（superficial swabs）进行了细菌培养。培养所得菌群均为慢性创面常见定植菌，但34株金黄色葡萄球菌（Staphylococcus aureus, S. aureus）中有13株为耐甲氧西林金黄色葡萄球菌（Methicillin-resistant Staphylococcus aureus, MRSA），占比38%。

**结论与意义** 目前亟需制定针对疑似继发感染或预防用药的合理抗生素治疗指南。遵循本文提出的指南，可优化布鲁里溃疡患者链霉素与利福平以外的抗生素使用方案，减少不必要的用药。此举可降低治疗成本、减轻药物毒性，并延缓抗菌药物耐药性（antimicrobial resistance）的进一步发展。该议题应纳入布鲁里溃疡诊疗的通用规范中。