eMedicine Specialties > Dermatology > Mycobacterial Infections
Mycobacterium Marinum Infection of the Skin: Treatment & Medication
Updated: Jul 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Treatment is usually medical in nature, using bacteriocidal agents. The duration of therapy is empiric, with the recommendations to continue therapy for 4-6 weeks following clinical resolution of the lesions. Treatment of some infections may last as long as 25 months or longer.15
- Effective antimicrobials include tetracyclines, fluoroquinolones, macrolides, sulfonamides, and others.
- Drug resistance varies and has been reported with all classes of antibiotic treatment listed above. Combination therapy is used for cases with documented antimicrobial resistance or those not responding to single-agent therapy.15
- Spontaneous resolution has been reported. Treatment with radiation, cryotherapy, and heat probes has been reported.
- See Medication for further discussion of single- and combination-agent therapies.
Surgical Care
- Surgical drainage of most skin lesions often is unnecessary.
- Infection of deep structures such as the tendon sheaths, joint space, or bone should be managed with the help of a surgeon. Debridement of necrotic tissues of the synovium, tendon sheaths, and/or bone may be needed to control infection in spite of appropriate systemic antibiotic therapy. Amputations are rarely necessary.16
Consultations
- A variety of specialists may be involved in the diagnosis and treatment, such as dermatologists, rheumatologists, and infectious disease physicians.
Medication
- The mainstay of therapy for infection by M marinum is antimicrobials, including antibiotics and antimycobacterials.
- The organism is sensitive to rifampin plus ethambutol, tetracyclines (minocycline [MCN],17 doxycycline [DCN]), trimethoprim-sulfamethoxazole (TMP-SMZ), clarithromycin,18 and fluoroquinolones (ciprofloxacin, ofloxacin, sparfloxacin).
- Antimicrobials are administered singly or in combination.15 Successful combinations include:
- TMP-SMZ and MCN or DCN
- MCN, levofloxacin, and clarithromycin
- DCN and clarithromycin or ciprofloxacin
- DCN, clarithromycin, and ethambutol
- Clarithromycin and ciprofloxacin or ethambutol
- Ciprofloxacin and rifampin
- Ciprofloxacin and clarithromycin (increased risk of QT prolongation)
- Ciprofloxacin and ethambutol
- Combination antimycobacterial agents include the following:
- Rifampin and ethambutol: This combination is regarded as highly effective therapy, especially for severe disease or in patients with impaired immune systems.
- Streptomycin, ethambutol, and isoniazid
- Clarithromycin, alone or in combination: This agent has shown the most efficacy of the macrolide antibiotics. One case report discusses the use of azithromycin in combination with ethambutol. Erythromycin has not demonstrated efficacy for treating M marinum infections.
- Combining rifabutin or rifampin with macrolide antibiotics is not recommended because of the decreased efficacy of the macrolide and the increased levels of rifabutin or rifampin.
- Most strains of M marinum have been found to be resistant to medications typically used for Mycobacterium tuberculosis, including isoniazid, streptomycin, pyrazinamide, and para-aminosalicylic acid.13 In contrast, ethambutol is effective in combination with antimycobacterial or antibiotics, but not as a single agent.
- The duration of therapy is empiric; multiple sources recommend extended therapy for 4-6 weeks following clinical resolution of lesions.15
Antimicrobial agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Therapy must be taken regularly and continued for a sufficient period.
Rifampin (Rifadin, Rimactane)
Found to be effective as monotherapy and is successful when given in combination with another antimicrobial. Inhibits DNA-dependent bacterial RNA but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to negative results from sputum culture.
Adult
600 mg PO qd
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral 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
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
Has produced liver dysfunction; urine and other secretions turn reddish; 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
Ethambutol (Myambutol)
Only effective when combined with another antimicrobial agent, preferably rifampin. Diffuses into actively growing mycobacterial cells (eg, tubercle bacilli). Impairs cell metabolism by inhibiting synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance demonstrated. Mycobacterial resistance is common with previous therapy.
Adult
25 mg/kg/d PO; not to exceed 2500 mg/d
Pediatric
<13 years: Not recommended
>13 years: Administer as in adults
Aluminum salts may delay and reduce absorption (give several hours before or after ethambutol dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated)
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
Reduce dose in impaired renal function; may have adverse visual effects, which may be reversible if promptly discontinued (physical examination should include ophthalmoscopy, finger perimetry, and color discrimination testing); elevated serum uric acid levels occur; precipitation of acute gout has been reported
Minocycline (Dynacin, Minocin) or Doxycycline (Doryx, Vibramycin)
Effective monotherapy; however, strains of M marinum resistant to doxycycline but sensitive to minocycline have been reported. Also treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.
Adult
100 mg PO bid
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h
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 doxycycline but is unusual with minocycline; reduce dose in renal impairment; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur.
Trimethoprim and sulfamethoxazole (Bactrim, Septra)
Several case reports have shown effectiveness of this drug. Reports indicate that it can help eradicate organisms unresponsive to either antituberculars or tetracyclines. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Not recommended
>2 months: 15-20 mg TMP/kg/d PO in 3-4 divided doses for 14 d
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 or breastfeeding; discontinue at first appearance of 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 intravenous infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, long-term alcoholism, elderly patients, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; 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); give fluids to prevent crystalluria and stone formation
Clarithromycin (Biaxin)
Cases of organisms resistant to conventional antitubercular therapy have responded to clarithromycin but not erythromycin. Use of azithromycin has not been reported. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Has bactericidal activity against atypical Mycobacterium species (eg, M marinum).
Adult
500 mg PO bid
Pediatric
15 mg/kg PO divided bid
Toxicity increases with coadministration of fluconazole or pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, or HMG CoA-reductase inhibitors; serious cardiac arrhythmias may occur with coadministration of cisapride; 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 of pimozide or cisapride
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 not recommended with CrCl <25 mL/min; give 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
Ciprofloxacin (Cipro)
Fluoroquinolones are effective alone or in combination with other medications to eradicate M marinum. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult
500 mg PO bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
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
Severe hypersensitivity reactions characterized by rash, fever, eosinophilia, jaundice, and hepatic necrosis with fatal outcome rarely occur; tendon ruptures requiring surgical repair or prolonged disability have been reported; crystalluria rarely occurs because human urine is usually acidic; alkalinity of urine should be avoided; may cause nervousness, agitation, insomnia, anxiety, nightmares, or paranoia; moderate-to-severe phototoxicity manifested as an exaggerated sunburn reaction can occur if directly exposed to sunlight; fatal reactions may occur when coadministered with theophylline
Levofloxacin (Levaquin)
For treatment of tuberculosis and some atypical mycobacterial infections in combination with rifampin and other antituberculosis agents.
Adult
500-1000 mg PO qd or divided bid
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
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
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
More on Mycobacterium Marinum Infection of the Skin |
| Overview: Mycobacterium Marinum Infection of the Skin |
| Differential Diagnoses & Workup: Mycobacterium Marinum Infection of the Skin |
 Treatment & Medication: Mycobacterium Marinum Infection of the Skin |
| Follow-up: Mycobacterium Marinum Infection of the Skin |
| References |
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References
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Further Reading
Keywords
mycobacterial skin infection, fish tank granuloma, tropical fish tank granuloma, M marinum, Mycobacterium, Mycobacterium marinum, mycobacteria other than tuberculosis, MOTT, nontuberculous mycobacteria, mycobacteria, acid-fast mycobacteria, saltwater infection, freshwater infection, marine infection, marine bacteria, water-borne bacteria, water-borne bacterial infection
