eMedicine Specialties > Dermatology > Fungal Infections

Actinomycosis: Treatment & Medication

Author: Talib Najjar, DMD, MDS, PhD, Professor of Oral and Maxillofacial Surgery and Pathology, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Aug 13, 2008

Treatment

Medical Care

The presence of associated bacteria in actinomycosis appears to be fundamental to the development of clinical infection (see Lab Studies). Therefore, antibiotic coverage should be aimed at all associated organisms in patients with actinomycosis. An aerobic environment is an unfavorable condition for the growth of Actinomyces species and thus halts the infection.16,19,20,21,22

With the combination of administering penicillin therapy and creating an aerobic envirorment with surgery, cure has become the rule rather than the exception.

  • The treatment of choice for actinomycosis includes large doses of antibiotics and prolonged therapy coupled with drainage of the abscesses or radical excision of the sinus tracts. High penicillin concentrations are necessary to penetrate areas of fibrosis and suppuration and possibly the granules themselves. Occasionally, extensive actinomycosis may respond to intravenous penicillin alone, rendering surgery unnecessary.
  • If the actinomycosis is recognized early, cervicofacial infection has an excellent prognosis with the use of antibiotics alone. In the treatment of actinomycosis, tetracyclines are as effective as penicillin. Intravenous penicillin G (10-20 million U/d for 2-6 wk) followed by oral penicillin (2-4 g/d for an additional 3-12 mo) is the typical therapy for the most deep-seated infections.23
  • Actinomyces organisms are also susceptible to chloramphenicol, erythromycin, tetracyclines, and clindamycin but not to metronidazole or aminoglycosides.
  • When tuberculosis is suspected, the effects of rifampin therapy can mask the signs of undiagnosed pulmonary actinomycosis.
  • Because the bacterial species in actinomycosis do not vary in terms of their susceptibility to first-line drugs (eg, penicillin, tetracyclines, erythromycin, first-generation parenteral cephalosporins, clindamycin), infection with strains other than A israelii should also respond to adequate courses of treatment with penicillin G or any of its alternatives. Serum concentrations of sulfonamides (4-8 mg/dL) inhibit some strains of A israelii; therefore, proven cases of actinomycosis (that are not mistaken instances of nocardiosis) may occasionally respond to sulfonamides. Oral cephalosporins and semisynthetic penicillins (eg, oxacillin, dicloxacillin) are less active in vitro and are best avoided.24
  • The acquired resistance of Actinomyces species to antimicrobials, particularly to penicillin G, has not been confirmed in vivo. When the response to penicillin is poor, consider an undrained abscess or an associated infection with a resistant bacterium. European investigators favor the use of ampicillin for initial therapy because associated bacteria are less susceptible to penicillin G in vitro, and they use metronidazole or clindamycin as a secondary agent when Bacteroides fragilis or Bacteroides thetaiotaomicron is present. Imipenem produces an impressive response in extensive, complicated, and relapsing abdominothoracic infections that fail to respond to several surgical procedures and trials of penicillin G.25

Surgical Care

Surgical management in actinomycosis has consisted of various treatment modalities, including excision of sinus tracts, drainage of the abscess cavities, removal of the bulky infected masses, and irrigation and curettage of the osteomyelitic bony lesions.

The abscesses of actinomycosis should be drained, or sinus tracts should be radically excised. With the combined use of penicillin and surgery, cure has become the rule rather than the exception.

Consultations

An oral and maxillofacial surgeon should be consulted because the jaws are involved.

Medication

The goals of pharmacotherapy in the treatment of actinomycosis are to eradicate the infection, reduce morbidity, and prevent complications.

Antibiotics

Actinomycosis therapy must cover all likely pathogens in the context of this clinical setting. Antibiotic selection should be guided by blood culture sensitivity whenever feasible.


Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Prolonged therapy, including >1 year, may be necessary.

Adult

Cervicofacial: 1-6 million U/d IV in divided doses q4-6h for 2-6 wk
Thoracic and abdominal: 10-20 million U/d IV in divided doses q4-6h (administer slowly) for 2-6 wk; administer penicillin VK thereafter

Pediatric

<1 week or <1.2 kg: 25,000 U IV q12h
1-4 weeks: 25,000 U q8h IV (1.2-2 kg) or q6h (>2 kg)
<12 year but > 1 month: for mild/mod disease use 25,000-50,000 U/kg/d IV divided qid; for severe disease use 250,000-400,000 U/kg/d IV in 4-6 divided doses
>12 years: Administer as in adults

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, decreasing effectiveness of penicillins when administered concurrently

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in severe renal impairment (modify dosage), history of seizures, or hypersensitivity to cephalosporins; hemolytic anemia reported


Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K, Robicillin VK, Veetids)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Has better GI absorption than penicillin G

Adult

2-4 g/d PO in 4-6 divided doses (best if 1 h ac or 2 h pc) for 6-12 mo

Pediatric

<1 month: Not established
>1 month: 15-62.5 mg/kg/d PO in 3-6 divided doses for 6-12 mo; not to exceed adult doses

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, decreasing effectiveness of penicillins when administered concurrently

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in severe renal impairment (modify dosage), history of seizures, or hypersensitivity to cephalosporins; hemolytic anemia reported

More on Actinomycosis

Overview: Actinomycosis
Differential Diagnoses & Workup: Actinomycosis
Treatment & Medication: Actinomycosis
Follow-up: Actinomycosis
Multimedia: Actinomycosis
References
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References

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  9. Najjar TA, McKeon J, Smith L, Parson R. Septic arthritis of TMJ secondary to experimental osteosynthesis. J Dent Res. 1980;59A:306.

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Further Reading

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Keywords

actinomycosis, Actinomyces israelii, A israelii, inflammatory disease, bacterial infection, Actinomyces naeslundii, A naeslundii, Actinomyces viscosus, A viscosus, Actinomyces odontolyticus, A odontolyticus

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Contributor Information and Disclosures

Author

Talib Najjar, DMD, MDS, PhD, Professor of Oral and Maxillofacial Surgery and Pathology, University of Medicine and Dentistry of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Janet Fairley, MD, Professor and Head, Department of Dermatology, University of Iowa
Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Federation for Medical Research, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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