eMedicine Specialties > Infectious Diseases > Bacterial Infections
Bartonellosis: Treatment & Medication
Updated: Oct 13, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Catscratch disease
- Several therapies have been successful. Whether therapy should be provided at all is unclear because catscratch disease is ordinarily a self-limited condition that lasts weeks to months. Therapy is typically provided because of patient concerns about tender nodes and because early treatment is believed to reduce the possibility of disseminated complications.
- Cost-effective pharmaceutical choices include erythromycin or doxycycline. Azithromycin has been shown to be more effective than placebo in resolving lymphadenopathy; some consider azithromycin to be the drug of choice.
- If the initial therapeutic choice appears unsuccessful after 2-3 weeks, consider switching to azithromycin, co-trimoxazole, or a quinolone antibiotic. Neither penicillins nor cephalosporins (other than third-generation cephalosporins) are active against these organisms. Rifampin in combination with another drug, or the use of gentamicin, may be considered.
- The usual duration of therapy is 3-6 weeks. Patients who are bacteremic require at least 4 weeks of therapy. Patients with HIV and other immunocompromising diseases require more prolonged therapy. Patients who have vegetations due to bartonellosis often require valve replacement. At least initially, an aminoglycoside should be included in the treatment of endocarditis.24
- No definitive therapeutic study of CNS bartonellosis or neuroretinitis has been performed, but treating these patients seems prudent. Agents that penetrate the CNS or eye are favored, including doxycycline or azithromycin possibly with rifampin, clarithromycin, or a newer fluoroquinolone antibiotic. A combination of 2 drugs is favored because this may speed healing and because no single agent has been found to cure all cases in which it was used. Data from the literature do not support the use of corticosteroids.
- B quintana infection: For bacteremia or trench fever, patients should be administered a trial of doxycycline 100 mg orally twice daily for at least 4 weeks. A longer duration of therapy should be considered in immunocompromised patients. In addition, when the liver or other organs are involved, the duration of therapy is typically longer.
- Bacillary angiomatosis
- In persons with AIDS and bacillary angiomatosis, the primary pharmaceutical choices include erythromycin, doxycycline, or more expensive drugs such as azithromycin, clarithromycin, or a fluoroquinolone.
- Doxycycline combined with rifampin is effective in patients with severe disease. Such patients often require extended treatment (≥3 mo).
- B bacilliformis infection
- Chloramphenicol has been established as therapy in developing countries, but doxycycline could be used.
- Duration of therapy should be at least 1 week, and longer courses may be required.
Surgical Care
In an editorial entitled "Bartonellosis: light and shadows in diagnostic and therapeutic issues" in Clinical Microbiology and Infection (2005), Manfredi et al wrote, "The role of surgical debridement and the unpredictable activity of antimicrobial agents warrant further investigation." The authors go on to point out that "The need for, selection and duration of antimicrobial therapy for CSD remain contentious. Suppurative nodes that become tense and painful should be drained, but incision of non-suppurative lesions should be avoided, as chronic draining fistulae or compromised healing may result."25
Consultations
- Infectious diseases specialist
- Possible consultation with a surgeon for biopsy or drainage
Medication
Bartonellosis is generally treated with macrolides, tetracyclines, aminoglycosides, or chloramphenicol. Chloramphenicol is not usually used to treat either B henselae or B quintana infection, although it has been used to treat B bacilliformis infection. Chloramphenicol has been primarily used to treat Oroya fever.
Duration of therapy is commonly at least 3 weeks. Patients should be monitored for evidence of response and drug toxicity. Because these infections often fail to respond to therapy or patients experience relapse later, switching to antibiotics from other classes (eg, erythromycin, clarithromycin, azithromycin, trimethoprim and sulfamethoxazole, or ciprofloxacin) may be needed. Gentamicin may also be effective.
Longer duration of therapy, from 3 weeks to 2 months, may be required for patients who have peliosis hepatis or disseminated disease, including bacteremia.
A culture-negative endocarditis treatment regimen should include an aminoglycoside (gentamicin) for 2 weeks and ceftriaxone with or without doxycycline for 6 weeks.
If bartonellosis is proven, the guidelines recommend using a regimen consisting of doxycycline for 6 weeks plus gentamicin (1 mg/kg IV q8h for 14 d).
Valve replacement is required in approximately 80% of cases, but overall prognosis is good, with survival rates of 80%.
Patients in the acute phase of Carrión disease should receive ciprofloxacin and, alternatively, chloramphenicol plus penicillin G. Patients in the eruptive phase of the disease should receive rifampin and, alternatively, azithromycin or erythromycin.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting.
Doxycycline (Vibramycin)
Inhibits protein synthesis and bacterial growth by binding to 30S, and possibly 50S, ribosomal subunits of susceptible bacteria. For B quintana infection, bacillary angiomatosis, peliosis hepatitis, and AIDS.
Adult
Asymptomatic B quintana bacteremia: 100-200 mg PO qd for 15 d; longer duration of therapy may be needed
Pediatric
<8 years: Not recommended
>8 years: Not established
Bioavailability decreases minimally with antacids that contain aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives; half-life decreases with coadministration of barbiturates, phenytoin, carbamazepine, rifampin, and ethanol; increases cyclosporine concentration
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity occurs in rare cases; reduce dose in renal impairment; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth
Erythromycin (EES, E-Mycin, Eryc)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
Erythromycin base or equivalent: 250 mg PO qid
Erythromycin ethyl succinate: 400 mg PO qid
Pediatric
Erythromycin ethyl succinate: 30-50 mg/kg/d PO qid
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, diarrhea, or abdominal colic occur
Azithromycin (Zithromax)
Treats mild-to-moderate microbial infections.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd; may need to repeat if symptoms do not resolve
Pediatric
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum 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
Bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function; may prolong QT interval; caution in hospitalized, geriatric, or debilitated patients
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
IR: 250-500 mg PO bid
ER: 500-1000 mg PO qd
Pediatric
IR: 7.5 mg/kg PO bid
Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; 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; cardiac arrhythmia may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmia and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration with 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 is not recommended with CrCl <25 mL/min; superinfections may occur with prolonged or repeated antibiotic therapies
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against Pseudomonas species, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult
500-750 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 ciprofloxacin 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
Adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult
160 mg TMP/800 mg SMZ 1 SS tab PO bid
Pediatric
<2 months: Do not administer
>2 months: 5 mL/kg susp PO bid
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
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, chronic alcoholics, elderly patients, those receiving anticonvulsant therapy, those with 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); administer fluids to prevent crystalluria and stone formation
Chloramphenicol (Chloromycetin)
Binds to 50S ribosomal subunits and inhibits bacterial growth by hindering protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50 mg/kg/d PO/IV divided q6h
Pediatric
Administer as in adults
Coadministration with barbiturates may cause chloramphenicol serum levels to decrease, while barbiturate levels may increase and cause toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity
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
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 3 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, or anemia; caution in pregnancy at term or during labor because of potential toxic effects on fetus (ie, gray syndrome)
Gentamicin (Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and another agent that covers anaerobes.
Adult
1-2 mg/kg IV/IM q24h; usually reserved for very ill patients or for those who have not responded to initial therapy or have relapsed
Pediatric
Administer as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, possibly prolonging respiratory depression; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly) with prolonged very high serum levels
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patient not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
More on Bartonellosis |
| Overview: Bartonellosis |
| Differential Diagnoses & Workup: Bartonellosis |
 Treatment & Medication: Bartonellosis |
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Further Reading
Keywords
bartonellosis, Bartonella infection, catscratch disease, cat scratch disease, CSD, catscratch fever, cat scratch fever, trench fever, urban trench fever, bacillary angiomatosis, bacillary peliosis, peliosis hepatis, Parinaud oculoglandular syndrome, Parinaud's oculoglandular syndrome, Oroya fever, Carrión disease, Carrión’s disease, verruga peruana, Bartonella bacilliformis, B bacilliformis, Bartonella henselae, B henselae, Bartonella quintana, B quintana, Bartonella vinsonii, B vinsonii, Bartonella clarridgeiae, B clarridgeiae, Bartonella elizabethae, B elizabethae, Bartonella tamiae, B tamiae, Bartonella rochalimae, B rochalimae, Bartonella alsatica, B alsatica, Pediculus humanus, P humanus, Phlebotomus, Lutzomyia, Ctenocephalides felis, C felis, Bartonella endocarditis, Peruvian wart
