Catscratch Disease Medication

  • Author: Stephen J Nervi, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 21, 2011
 

Medication Summary

In general, treatment beyond analgesia and recommendation for warm compresses is unnecessary for patients with catscratch disease (CSD) because the condition spontaneously resolves without sequelae in most cases.

Currently, only limited and/or anecdotal evidence supports the use of antibiotics in the treatment of typical CSD in immunocompetent hosts. Bartonella henselae is susceptible to many antibiotics in vitro. However, the susceptibility patterns do not predict efficacy in vivo. Bartonella is an intracellular bacterium and responds poorly to penicillin derivatives in vivo despite susceptibility in vitro.

A single treatment for all Bartonella -related diseases has not been identified, so treatment must be tailored to specific situations. Immunocompromised patients tend to develop more-severe Bartonella infections and may require prolonged antibiotic treatment.

Some patients, usually ones who are immunocompromised, develop a Jarisch-Herxheimer–like reaction shortly after receiving antibiotic therapy.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. These agents reduce the duration of lymphadenopathy and decrease constitutional symptoms. B henselae, a gram-negative bacillus, is sensitive to various antibiotics in vitro. Few clinical studies are available, but not all of the antibiotics to which the organism is sensitive in vitro are effective in vivo.

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Azithromycin (Zithromax, Zmax)

 

This agent inhibits RNA-dependent protein synthesis at the chain elongation step. It Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.

Azithromycin concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.

This agent treats mild-to-moderate microbial infections. Plasma concentrations are very low but tissue concentrations are much higher, giving it value in treating intracellular organisms. It has a long tissue half-life.

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Doxycycline (Doryx, Doxy, Periostat, Vibramycin)

 

Doxycycline inhibits protein synthesis by binding with the 30S and possibly the 50S ribosomal subunit(s) of susceptible bacteria; may also cause alterations in the cytoplasmic membrane.

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Ciprofloxacin (Cipro, Proquin XR)

 

Ciprofloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-sensitive Staphylococcus aureus (MSSA), S epidermidis, and most gram-negative organisms. It has no activity against anaerobes. This agent inhibits bacterial DNA gyrase and consequently growth; it inhibits relaxation of supercoiled DNA and promotes breakage of double-stranded DNA. Continue treatment for at least 2 d after signs and symptoms have disappeared (7-14 d typically).

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Rifampin (Rifadin)

 

Rifampin inhibits bacterial RNA synthesis by binding to the beta subunit of DNA-dependent RNA polymerase, blocking RNA transcription.

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Erythromycin (E.E.S., Erythrocin, Ery-Tab, EryPed)

 

Erythromycin inhibits RNA-dependent protein synthesis at the chain elongation step; it binds to the 50S ribosomal subunit, resulting in blockage of transpeptidation.

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Gentamicin

 

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. This agent binds bacterial 30S and 50S ribosomal subunits. It is used in combination with both an agent against gram-positive organisms and an agent that covers anaerobes.

Gentamicin is not the drug of choice for CSD. Consider using it if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.

Dosing regimens are numerous; adjust dose based on creatinine clearance (CrCl) and changes in volume of distribution. Gentamicin may be given IV or IM. Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); a peak level may be drawn 0.5 h after 30-min infusion.

Trimethoprim and sulfamethoxazole (Bactrim DS, SeptraDS)

 

This combination agent inhibits bacterial growth by inhibiting dihydrofolate reductase, depleting folic acid. Its antibacterial activity includes common urinary tract pathogens, except Pseudomonas aeruginosa.

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Clarithromycin (Biaxin)

 

Clarithromycin is a semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms. It may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes, causing bacterial growth inhibition.

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Contributor Information and Disclosures
Author

Stephen J Nervi, MD  Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Stephen J Nervi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Rose A Ressner, DO  Staff, Department of Infectious Diseases, Walter Reed Army Medical Center

Rose A Ressner, DO is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Joyce R Drayton, MD  Assistant Professor, Department of Internal Medicine, Division of Infectious Disease, Morehouse School of Medicine

Joyce R Drayton, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Preventive Medicine, American Holistic Medical Association, Infectious Diseases Society of America, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS  Associate Professor, Department of Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases,Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Jack A Coleman, MD Consulting Staff, Franklin Surgical Associates

Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US

Disclosure: Accarent, Inc. Honoraria Speaking and teaching

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Allan D Friedman, MD, MPH Chairman, Division of General Pediatrics, VCUH Health System; Professor of Pediatrics, Virginia Commonwealth University

Allan D Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Lynn L Horvath, MD Clinical Assistant Professor of Medicine/Infectious Disease, University of Texas Health Science Center; Consulting Staff, Department of Infectious Disease, Brooke Army Medical Center

Lynn L Horvath, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership; Revent Medical Honoraria Review panel membership

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi

Disclosure: emedicine $50.00 Author of chapter; MERCK None Other

Carrie L Kovarik, MD Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, University of Pennsylvania School of Medicine

Carrie L Kovarik, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

John M Leedom, MD Professor Emeritus of Medicine, Keck School of Medicine of the University of Southern California

John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Kim Lundstrom, MD Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Longmont Clinic

Kim Lundstrom, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Medical Association

Disclosure: Nothing to disclose.

Gauri Mankekar, MBBS, MS, DNB, PhD Consultant Otorhinolaryngologist, Department of Otolaryngology, PD Hinduja National Hospital, India

Gauri Mankekar, MBBS, MS, DNB, PhD is a member of the following medical societies: Association of Medical Consultants of Mumbai, Association of Otolaryngologists of India, and Cochlear Implant Group of India

Disclosure: Nothing to disclose.

Jill McKenzie, MD Resident, Division of Dermatology, University of Washington School of Medicine

Jill McKenzie, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Kerrie J Spoonemore, MD, PharmD Clinical Instructor, Department of Dermatology, University of Washington

Kerrie J Spoonemore, MD, PharmD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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Papulopustular lesions of a primary inoculation site on the hand of a 16-year-old patient. These lesions had been present for approximately 3 weeks. A catscratch antigen skin test was positive with 15-mm induration. No treatment was administered, and her condition resolved spontaneously in 2.5 months. Courtesy of Andrew Margileth, MD.
A crusted primary inoculation papule on the neck of a 4-year-old child. Note the adjacent lymphadenitis. This patient had contact with cats and had multiple scratches. Courtesy of Andrew Margileth, MD.
This 13-year-old girl developed fatigue and malaise after being licked and scratched by a cat. The typical conjunctival granuloma was accompanied by a parotid mass and intraparotid adenitis. No treatment was administered, and all her signs and symptoms resolved in 3 months. Courtesy of Andrew Margileth, MD.
This 9-year-old boy developed catscratch disease (CSD) encephalitis and a papular pruritic dermatitis after sustaining cat scratches and developing regional lymphadenitis. He was in a coma for 4 days but experienced a complete and rapid recovery within 3 weeks. Biopsy of the skin rash revealed nonspecific changes. The CSD antigen skin test result was positive. Courtesy of Andrew Margileth, MD.
This 2.5-year-old boy was recovering from catscratch disease acquired 10 months before when he developed this neck abscess over a period of 3 weeks. Biopsy revealed caseating granulomas; acid-fast bacillus and Warthin-Starry stain results were negative. Courtesy of Andrew Margileth, MD.
This 10-year-old child had contact with dogs but not cats. The impressive lymphadenitis had been present for 5 weeks and was not tender. Pathologic examination of a biopsy specimen of the lymph node revealed nonspecific changes. She had a positive catscratch disease skin test result and negative purified protein derivative skin test results. Treatment with cephalexin was administered with a good response. Complete resolution occurred in 4.5 months. Courtesy of Andrew Margileth, MD.
Warthin-Starry stained sections of lymph node showing chains and clusters of organisms. Courtesy of Andrew Margileth, MD.
Table 1. Clinical Manifestations of CSD[4]
Sign or SymptomPercentage, %Average Duration, d
Adenopathy10014-180
Adenopathy only5214-180
Inoculation site59-937
Fever >101°F (38.3°C)32-606
Malaise/fatigue2913
Headache134
Anorexia, weight loss, emesis145
Splenomegaly1211
Sore throat52
Rash58.5
Parotid swelling2-
Conjunctivitis4.5-
Table 2. Clinical Manifestations of Atypical CSD[14, 3]
Clinical Feature Margileth,



n = 1174, %



Carithers,



n = 1200, %



Typical presentation88.495
Inoculation lesion (skin, eye, mucous membrane)58.6
Unusual presentation11.65
Parinaud oculoglandular syndrome6.34
Encephalopathy2.30.25
Systemic disease, severe, chronic2
Erythema nodosum0.60.42
Atypical pneumonia0.2
Breast tumor0.2
Thrombocytopenic purpura0.10.08
Table 3. Response to Medications
Ciprofloxacin



500 PO bid



Case Report



5 adults



"Dramatic improvement" in a few days; defined as resolution of symptoms (ie, malaise and pain)Holley[60]
Gentamicin



5 mg/kg/d IV/IM



Case Report



3 febrile children; 2 with hepatitis, 1 with painful regional lymphadenopathy



Resolution of fever and systemic symptoms in 1-2 daysBogue et al[61]
TMP-SMZ



6-8 mg TMP/kg/d PO



Uncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



58% effective, 7-day course (see above)Margileth[41]
Rifampin 10-20 mg/kg/d PO/IVUncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



87% effective, 7- to 14-day course (see above)Margileth[57]
Azithromycin



500 mg PO qd for 1 day, then 250 mg PO qd for 4 days



Prospective placebo-controlled, double-blind study



29 patients



80% of lymph node volume (as measured by ultrasonography) resolved in 30 days in 7 of 15 patients on azithromycin vs 1 of 15 control patients Bass et al[56]
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