eMedicine Specialties > Ophthalmology > Infectious Disease

Actinomycosis: Treatment & Medication

Author: Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Oct 13, 2008

Treatment

Medical Care

  • Keratitis: Actinomycetes are usually susceptible to penicillins and cephalosporins.32,33,34,35 The treatment of keratoactinomycosis used to be excision of necrotic tissue, followed by cauterization. However, good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.
  • Canaliculitis: Actinomycetes are usually susceptible to penicillins and cephalosporins. Postoperatively, patients may be treated with topical cefazolin for 1 month. Adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis has been reported.36
  • Endophthalmitis: Intraocular, periocular, topical, and systemic therapy.

Surgical Care

  • Keratitis: All reported cases of keratoactinomycosis responded to therapy, which included intraocular, topical, and systemic antibiotics, as well as pars plana vitrectomy and partial iridectomy. Urgent keratoplasty for a corneal infection by Actinomyces species was reported in a 41-year-old man.
  • Canaliculitis: Failure to resolve canaliculitis by using topical treatment requires surgical exploration of the canalicular system and removal of any casts.8,15 Extensive surgery is not always required. A 2-snip punctoplasty, cast removal, curettage, probing, and adjunctive antibiotic therapy usually result in resolution of the canaliculitis. Cultivation of the surgically obtained dacryoliths and secretion enables reliable proof of Actinomyces and allows for an appropriate therapy for canaliculitis. Even though Actinomyces is sensitive to penicillin, cure of canaliculitis does not occur until all the concretions and the granulations that are present in the canaliculus are meticulously removed.
  • Endophthalmitis: A diagnostic and therapeutic, 3-port, pars plana vitrectomy may be performed in cases where a diagnosis has not been achieved.21

Consultations

An external disease and cornea specialist may provide care for the anterior segment.

An oculoplastics consult may be required for eyelid and orbital involvement.

A posterior segment surgeon is necessary for endophthalmitis.

Medication

Actinomyces organisms are usually susceptible to penicillins and cephalosporins. Good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Penicillin G (Pfizerpen)

Exerts bactericidal action against penicillin-susceptible microorganisms during the stage of active multiplication. Acts by inhibiting biosynthesis of cell wall mucopeptide, rendering the cell wall osmotically unstable. Not active against penicillinase-producing bacteria, which include many strains of staphylococci

Adult

Topical: 100,000-333,000 U/mL in topical
Subconjunctival: 0.5-1.0 million U/mL
Intravitreal injection: 2,000 U / 0.1 mL intravitreal injection, and probenecid 0.5 g PO qid (possible retinal toxicity)
Oral: 400,000 U PO qid (rarely used; poor stomach absorption)
IV: 2-6 million U IV q4h and probenecid 0.5 g PO qid
IM: Depends on formulation

Pediatric

Topical: 10,000-20,000 U/mL
IV: 50,000 U/kg/d IV divided bid/tid

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Pregnancy

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

Precautions

Caution in impaired renal function


Cefazolin (Ancef, Kefzol, Zolicef)

First-generation cephalosporin with excellent activity against gram-positive cocci, including penicillinase-producing Staphylococcus aureus, penicillinase-producing Staphylococcus epidermidis, group A beta-hemolytic streptococci (Streptococcus pyogenes), group B streptococci (Streptococcus agalactiae), and Streptococcus pneumoniae. Ineffective against Bacteroides fragilis and only weak activity against gram-negative organisms.

Adult

Topical: 133 mg/mL
Subconjunctival: 100 mg/mL
Intravitreal injection: 2.25 mg / 0.1 mL intravitreal injection, and probenecid 0.5 g PO qid
IV/IM: 500-1,000 mg IV/IM q6h

Pediatric

25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin

Pregnancy

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

Precautions

Prolonged use may result in overgrowth of nonsusceptible organisms; caution in GI disease, particularly colitis

Antiparasitic agents

Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.


Sulfacetamide sodium 10% (Sulamyd, Bleph-10)

N-acetyl-substituted derivative; at 30% solution, topical sulfacetamide has pH of 7.4 and has good tissue penetration.

Adult

Solution: Instill 1-3 gtt in affected eye q2-3h, while awake, with less frequent administration at night
Ointment: Apply 0.5-inch ribbon into the conjunctival sac 1-4 times/d

Pediatric

<2 months: Not established
>2 months: Administer as in adults

Effects of sulfonylurea hypoglycemic agents, hydantoin anticonvulsants, and oral anticoagulants increase when administered concurrently with sulfacetamide sodium; PABA antagonizes effects of sulfonamides; PABA esters (eg, procaine) may inhibit antibacterial effect of these agents; trimethoprim enhances effects of sulfacetamide

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 severely dry eye; ointment may retard corneal epithelial healing; if inflammation or pain persists >48 h or becomes aggravated, reevaluate therapy; adverse effects include local irritation, brow ache, blurred vision, transient burning and stinging, and sensitivity reactions (rare cases of Stevens-Johnson syndrome and exfoliative dermatitis have been reported); GI upset and bone marrow depression have been described

More on Actinomycosis

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

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Further Reading

Polenakovik H. Actinomycosis. eMedicine Journal [serial online]. April 14, 2006; Available at: http://www.emedicine.com/Med/topic31.htm.

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Keywords

actinomycosis, Actinomycetales, Actinomycetaceae, Actinomycetes, Actinomyces, Actinomyces israelii, A israelii, keratoactinomycosis, keratitis, canaliculitis, anaerobic bacillus, Actinomyces gerencseriae, Actinomyces naeslundii, Actinomyces odontolyticus, Actinomyces viscosus, Actinomyces turicensis, Actinomyces meyeri, Propionibacterium propionicus, Actinobacillus actinomycetemcomitans, Prevotella, Fusobacterium, Bacteroides, Staphylococcus, Streptococcus, Enterobacteriaceae, actinophytosis

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
Manolette R Roque, MD, MBA is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Jorge G Camara, MD, Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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