Antibiotic Treatment Outcomes of Buruli Ulcer in Akwapem South and Suhum-Kraboa-Coaltar Districts

Abstract

The World Health Organization (WHO) having recognized Buruli ulcer disease as an important cause of human suffering introduced treatment guidelines of a new protocol of 8-week initial therapy of intramuscular streptomycin and oral rifampicin in 2005. Although there has been some level of success in the treatment of Buruli ulcer with this new antibiotic protocol, some patients do not respond favourably as expected. Also, the response to chemotherapy of BU lesions including large ulcerated forms, which are currently the most common forms in Africa remains insufficiently documented. So this study set out to assess the treatment outcomes of all categories of BU lesions and determine factors that influence the healing of these lesions. This was implemented by employing a non-randomized clinical intervention design by serially recruiting 154 patients over a period of two years. Measurements of lesions were made using tracing sheets to obtain their respective surface areas. Swabs and fine needle aspirates were taken and confirmed by direct smear microscopy for acid-fast bacilli (AFB), polymerase chain reaction or culture. All patients were given a directly observed treatment (DOT) of a daily combination of intramuscular streptomycin (15mg/kg body weight) and oral rifampicin (10mg/kg body weight) for 8 weeks. There was also daily dressing for all wounds irrespective of size and weekly assessment for all forms of lesions. Patients were counseled regularly on BU management and the necessity for adhering to treatment. All patients were followed up for a minimum of 34 weeks. BU lesions were found among ages 2- 84 years. About 37% of the total study participants were less than 15 years and almost equal numbers in the age groups between 15 -49 years and over 50 years old. In those below 15 years of age there was an almost equal gender distribution whilst, in the older age groups more females than males were affected. It was found that 93.5% (144/154) of the study participants presented with ulcers. All those who reported within two months of noticing their lesions for the first time achieved 100% treatment success irrespective of category of lesion. There was 97.4% treatment success rate for all BU lesions with no recurrences within 34 weeks of treatment. About 30% of lesions showed an apparent deterioration response to treatment (paradoxical reactions) after an initial improvement at some points during treatment starting from week 2 to week 18 reaching a peak at week 10. Factors that hastened healing were smaller size of the initial lesion, regular wound dressing, removal of slough, treatment with topical antibiotics and absence of paradoxical reactions. We concluded that the combination of intramuscular streptomycin and oral rifampicin is efficacious in healing all forms of Buruli ulcer disease. Optimal and regular wound dressing regular counseling, consistent wound evaluation and timely interventions play important roles in the healing of BU lesions. In view of these findings we recommended that the National Buruli Ulcer Control Programme in collaboration with the District Assemblies and District Health Management Teams should organize regular health education activities to encourage patients to report early to health institutions and also ensure that drug treatment is combined with wound dressing effectively and efficiently in order to achieve the desired results.