eMedicine Specialties > Dermatology > Bacterial Infections
Bacillary Angiomatosis: Treatment & Medication
Updated: May 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Bacillary angiomatosis often responds dramatically to oral erythromycin, an effect largely unexplained by this compound's bacteriostatic properties. An antiangiogenic effect of erythromycin has been postulated and tested with in vitro models of B quintana infection.13 Erythromycin seems to profoundly down-modulate endothelial cell proliferation, irrespective of its bacteriostatic effects, which may be a key component of its efficacy in the treatment of patients with bacillary angiomatosis.
- Other oral antibiotics and antituberculosis drugs, including tetracycline, trimethoprim-sulfamethoxazole, and rifampin, may also be effective.
- Bacillary angiomatosis may be life threatening without therapy.
Medication
Oral erythromycin, 2 g qd, in divided doses, is the authors' first choice, with administration often resulting in the skin lesions gradually fading in the next 4 wk; however, if they persist, even in diminished form, medication is changed to tetracycline, 2 g qd, or then to trimethoprim and sulfamethoxazole. If the infection appears serious, adding a bactericidal medication, such as a third-generation cephalosporin or an aminoglycoside, may be prudent during initial 3 wk of therapy. One patient responded favorably to azithromycin plus ciprofloxacin started together with antiretroviral therapy.14
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Erythromycin (E.E.S., Eryc, Ery-Tab, Erythrocin)
Macrolide antibiotic isolated from a Streptomyces strain. Spectrum is between penicillin and tetracyclines. Highly bacteriostatic. The mechanism of action involves binding to the 50S ribosomal subunit and inhibiting microbial protein synthesis.
Adult
500 mg PO q6h
Pediatric
Not established
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; use enteric-coated preparations or erythromycin stearate to avoid gastric juice destruction
Azithromycin (Zithromax)
Spectrum is between penicillin and tetracyclines. Highly bacteriostatic.
Mechanism of action involves binding to the 50S ribosomal subunit and inhibiting microbial protein synthesis.
Adult
500 mg PO on day 1 and 250 mg PO qd for 4 d
Pediatric
Not established
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients; fewer gastrointestinal side effects than erythromycin; more expensive
Clarithromycin (Biaxin)
A 6-methoxy erythromycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. Highly bacteriostatic. Spectrum is between penicillin and tetracyclines.
Adult
250-500 mg PO bid
Pediatric
Not established
Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; fewer GI adverse effects than erythromycin; more expensive
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Important form of tetracycline effective in bid dosing.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra)
Synthetic antibacterial combination product.
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Sterile solution for IV infusion only in BA.
Adult
160 mg TMP/800 mg SMZ IV over 1 h once
Pediatric
Not established
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in pregnancy and breastfeeding women; discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, people with long-term alcoholism, elderly people, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Rifampin (Rifadin, Rimactane)
Effective in treatment against tuberculosis organisms and meningococcal organisms.
Adult
300-600 mg IV over 30 min; not to exceed 600 mg/d
10 mg/kg PO; not to exceed 600 mg/d
Pediatric
10-20 mg/kg PO/IV; not to exceed 60 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity; severe adverse reactions to isoniazid (eg, drug fever, chills, arthritis, acute liver disease of any etiology)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; urine, feces, saliva, sputum, sweat, and tears may be colored red-orange by rifampin; PO contraceptives may be affected; soft contact lens may be permanently stained
Tetracycline (Sumycin)
Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Primarily bacteriostatic. Active against a wide range of gram-positive and gram-negative organisms.
Adult
1-2 g/d PO divided bid/qid
Pediatric
<8 years: Not recommended
>8 years: 10-20 mg/lb (25-50 mg/kg) PO divided bid/qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
More on Bacillary Angiomatosis |
| Overview: Bacillary Angiomatosis |
| Differential Diagnoses & Workup: Bacillary Angiomatosis |
 Treatment & Medication: Bacillary Angiomatosis |
| Follow-up: Bacillary Angiomatosis |
| Multimedia: Bacillary Angiomatosis |
| References |
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Further Reading
Keywords
bacillary angiomatosis, BA, epithelioid angiomatosis, bartonellosis, Bartonella henselae, B henselae, bartonellosis, Bartonella quintana, B quintana, catscratch disease, cat scratch disease, cat scratch fever, catscratch fever, trench fever
