eMedicine Specialties > Ophthalmology > Infectious Disease
Actinomycosis: Treatment & Medication
Updated: Oct 13, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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
Documented hypersensitivity
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
Documented hypersensitivity
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
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
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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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
Treatment & Medication: Actinomycosis