Question 6

College answer

Syllabus topic/section:

2.1.3 Sepsis and Infections / Rarer infections with specific ICU considerations melioidosis: L1

Discussion:  Several candidates failed to answer at all or wrote very little. Marks were allocated to the specifics of Burkholdaria infections; however, candidates are reminded that this entrance to transition year fellowship examination is based on objective demonstration of competence in clinical practice and general intensive care principles.
The general intensive care aspects of the patient presentation meant that candidates were expected to demonstrate knowledge of management of sepsis. Some candidates were able to score near pass marks by demonstrating they were aware of aspects of treatment of sepsis and septic shock as outlined in the stem. We recommend attempting every question as demonstrating competence in general intensive care principles are universal and more marks will potentially be gained as opposed to leaving a question unanswered.
Resuscitation of the septic shocked state, exploring potential source control/surveillance issues, antibiotic choice with rationale, and specific, relevant details of vasoactive drugs and fluid management was expected in part c) to demonstrate the standard required.

Discussion

The "rarer infections" section of the syllabus specifically names melioidosis, and the appearance of this illness in the exam should therefore not be surprising. However this was the first time it was asked about directly, whereas in other scenarios it was either a differential or a part of a pattern recognition exercise. 

a) Risk factors:

• Travel risk profile:  Southeast Asia, Northern Australia, South India,  Papua New Guinea
• Demographic risk factors: Agricultural workers, construction workers, ecotourists, Indigenous population
• High risk activities: freshwater swimming, drinking potable local water, alcohol consumption, having any broken skin 
• Comorbidities:  diabetes, renal disease, chronic lung disease, thalassaemia, malignancy, immunosuppression

b) Radiological investigations

• CXR and/or CT chest to delineate severity of respiratory disease
  • Classical radiology are bilateral nodular infiltrates with consolidation and cavitation
• CT abdomen: often liver renal and splenic abscesses are present, which require drainage
• CT pelvis: high likelihood of prostatic abscesses
• CT brain: occasionally present with brain abscesses

c) Management

• Resuscitation: standard management of septic shock:
  • Fluid resuscitation
  • Invasive monitoring with early central access and vasopressor (noradrenaline) use to target MAP > 65
  • Assessment re. need for intubation 
• Specific management:
  • ​​​​​​​​​​​​​​IV meropenem or ceftazidime × 2 weeks
  • Then, trimethoprim/sulfamethoxazole for 6 months as eradication therapy
  • GM-CSF is given to these patients routinely in some centres, is attributed with a mortality benefit which is based on mostly retrospective data
  • Abscess cavities need to be drained
• Supportive management:
  • ​​​​​​​Folate to prevent TMP/SMX induced bone marrow suppression
  • Surveillance for secondary bacterial infection