CASE PRESENTATION: Here, we report two cases of melioidosis from Nepal. Both of them were diabetic male who presented themselves with fever, multiple abscesses and developed sepsis. They were treated with multiple antimicrobial agents including antitubercular drugs before being correctly diagnosed as melioidosis. Consistent with this, both patients were farmer by occupation and also reported travelling to Malaysia in the past. The diagnosis was made consequent to the isolation of B. pseudomallei from pus samples. Accordingly, they were managed with intravenous meropenem followed by oral doxycycline and cotrimoxazole.
CONCLUSION: The case reports raise serious concern over the existing unawareness of melioidosis in Nepal. Both of the cases were left undiagnosed for a long time. Therefore, clinicians need to keep a high index of suspicion while encountering similar cases. Especially diabetic-farmers who present with fever and sepsis and do not respond to antibiotics easily may turn out to be yet another case of melioidosis. Ascertaining the travel history and occupational history is of utmost significance. In addition, the microbiologist should be trained to correctly identify B. pseudomallei as it is often confused for other Burkholderia species. The organism responds only to specific antibiotics; therefore, correct and timely diagnosis becomes crucial for better outcomes.
METHODS: We selected randomized controlled trials, assessing efficacy of antibiotics for the treatment of leptospirosis as a case study. A pairwise meta-analysis was conducted using a random effect model, assuming that different studies assessed different but related treatment effects. The analysis was then extended to a network meta-analysis, which consists of direct and indirect evidence in a network of antibiotics trials, using a suite of multivariate meta-analysis routines of STATA (mvmeta command). We also assessed an assumption of 'consistency' that estimates of treatment effects from direct and indirect evidence are in agreement.
RESULTS: Seven randomised controlled trials were identified for this analysis. These RCTs assessed the efficacy of antibiotics such as penicillin, doxycycline and cephalosporin for the treatment of human leptospirosis. These studies made comparisons between antibiotics (i.e. an antibiotic versus alternative antibiotic) in the primary study and a placebo, except for cephalosporin. These studies were sufficient to allow the creation of a network for the network meta-analysis; a closed loop in which three comparator antibiotics were connected to each other through a polygon. The comparison of penicillin versus the placebo has the largest contribution to the entire network (31.8%). The assessment of rank probabilities indicated that penicillin presented the greatest likelihood of improving efficacy among the evaluated antibiotics for treating leptospirosis.
CONCLUSIONS: Findings suggest that network meta-analysis, a meta-analysis comparing multiple treatments, is feasible and should be considered as better precision of effect estimates for decisions when several antibiotic options are available for the treatment of leptospirosis.
METHODS: Two independent reviewers (KY and SJ) screened two electronic databases, PubMed and Scopus, for randomized clinical trials on the use of systemic doxycycline as an adjunct to scaling and root planing in improving periodontal status and glycemic control in diabetic patients with periodontitis using predetermined selection criteria within a 3-month period. The reviewers independently did data screening, data selection, data extraction and risk of bias. Quality of studies involved was analysed using the revised Cochrane Risk of Bias 2.0. Weighted standard mean differences (SMD) and 95% confidence intervals were calculated using a random effects meta-analysis model. Publication bias was evaluated using funnel plot. Quality of evidence was evaluated by Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS: Electronic searches provided 1358 records and six studies were selected. The meta-analyses indicated that there was no statistically significant difference in the improvement of periodontal status with the use of systemic doxycycline as an adjunct for scaling and root planing (SRP). SMD of clinical attachment levels (- 0.22 [- 0.52, 0.08]) and HbA1c levels (- 0.13 [- 0.41, 0.15]) were calculated. Overall risk of bias is high in 2 out of 6 studies involved.
CONCLUSION: Systemic doxycycline when used in addition to scaling and root planing yields no significant improvement of clinical attachment levels for periodontal status and reduction of HbA1c levels in treatment of diabetic patients with periodontitis when comparing the test group to the control group.
Materials and Methods: For this systematic review and meta-analysis, PubMed and Scopus databases were searched till November 2018 for English publications. RCTs that compared the effect of local doxycycline adjunct to SRP among smokers with periodontitis were selected. Patient characteristics, disease characteristics, and outcome data on clinical attachment level (CAL) and periodontal probing depth at 1, 3- and 6-month follow-up was extracted. Quality of selected studies was assessed by the revised Cochrane Risk of Bias 2.0 tool. Random effects model and trial sequential analysis were performed. GRADE approach was used to assess the quality of evidence. P > 0.05 was considered as statistically significant.
Results: Five trials were included in the review. Local use of doxycycline as an adjunct to SRP was effective in gain of 1.1 mm (0.47-1.74, P = 0.091) in CAL at 6 months calculated from two studies. The evidence was of low quality, and at least a total of 866 patients are required for conclusiveness.
Conclusion: Local doxycycline as an adjunct to SRP significantly improved clinical attachment in smokers with periodontitis and can be recommended. Studies are required with long-term follow-up and patient-related outcome data.
METHOD: Prospective case series.
RESULTS: Doxycycline is widely used in treating corneal melts, ocular surface diseases, meibomian gland disease, recurrent epithelial cell erosion, rosacea, and keratitis sicca. This prospective case series highlights the successful treatment of five patients with leaking blebs and conjunctiva erosion from glaucoma filtration surgery with the use of oral doxycycline. There was no adverse event reported in our cases.
CONCLUSIONS: This study suggests that oral doxycycline may be a feasible non-surgical treatment modality due to its ability to inhibit collagenolysis, restore the Meibomian gland function, thereby stopping breakdown and promote conjunctival tissue healing.