eMedicine Specialties > Infectious Diseases > Bacterial Infections
Moraxella Catarrhalis Infections
Updated: Nov 17, 2009
Introduction
Background
Moraxella catarrhalis is a gram-negative, aerobic, oxidase-positive diplococcus that was first described in 1896. The organism has also been known as Micrococcus catarrhalis, Neisseria catarrhalis, and Branhamella catarrhalis. For most of the 20th century, M catarrhalis was considered a saprophyte of the upper respiratory tract associated with no significant pathogenic consequences.
Although the commensal status of M catarrhalis in the nasopharynx is still accepted, the organism is a common cause of otitis media and sinusitis and an occasional cause of laryngitis. M catarrhalis causes bronchitis and pneumonia in children and adults with underlying chronic lung disease and is occasionally a cause of bacteremia and meningitis, especially in immunocompromised persons. Bacteremia can be complicated by local infections such as osteomyelitis or septic arthritis. M catarrhalis is also associated with nosocomial infections.
Pathophysiology
Different studies have shown that M catarrhalis colonizes the upper respiratory tract in 28%-100% of humans in the first year of life. In adults, the colonization rate is 1%-10.4%. Colonization appears to be an ongoing process with an elimination-colonization turnover of various strains. Transmission is believed to be due to direct contact with contaminated secretions by droplets.
The endotoxin of M catarrhalis, a lipopolysaccharide similar to those found in the Neisseria species, may play a role in the disease process. Some strains of M catarrhalis have pili or fimbriae, which may aid adherence to the respiratory epithelium. Some strains produce a protein that confers resistance to complement by interference with formation of the membrane attack complex. M catarrhalis also expresses specific proteins for iron uptake that act as receptors for transferrin and lactoferrin.
Humoral responses against M catarrhalis appear to be age-dependent, with the titer of immunoglobulin G (IgG) gradually increasing in children. Antibody responses to outer-membrane proteins have been obtained, predominantly in the IgG3 subclass.
Frequency
United States
M catarrhalis is the third most common cause of otitis media and sinusitis in children (after Streptococcus pneumoniae and Haemophilus influenzae). M catarrhalis is estimated to be responsible for 3-4 million cases of otitis media annually, with an associated health care cost (direct and indirect) of $2 billion each year.
Mortality/Morbidity
The most significant infections caused by M catarrhalis are upper respiratory tract infections, including otitis media and sinusitis in children and lower respiratory tract infections in adults. Infections with M catarrhalis in adults are more common if underlying conditions are present, especially in elderly persons. In a study of 42 cases of pneumonia with M catarrhalis isolated as single agent in sputum cultures, the mortality rate attributable to the underlying problems within 3 months of pneumonia was 45%.
Sex
In one study involving adult patients, the male-to-female ratio was 1.6:1.
Age
M catarrhalis infections may occur at any age. Although colonization is more common in children, only a small percentage of positive cultures findings have clinical significance in the pediatric population. In one study, 9% of cultures positive for M catarrhalis in children younger than 5 years and 33% of isolates from children aged 6-10 years were found to be clinically significant. However, all cultures positive for M catarrhalis had clinical importance in adults.
Clinical
History
- Common cold: In 29% of common-cold episodes due to bacterial pathogens (including M catarrhalis), affected children continued to be symptomatic 10 days after the first appearance of symptoms.1
- Otitis media: A clinical history of acute otitis media and otitis media with effusion with symptoms includes otalgia, fever, and hearing loss. Otitis media is a very common condition, especially in children. Approximately 70% of children have at least one episode of otitis media during childhood. M catarrhalis has been isolated in 3%-17.3% of middle ear exudates in children with otitis media.2,3
- Sinusitis: Clinical history commonly includes headache, pain in the maxillary or frontal area, fever, and cough. Young children present with persistent nasal discharge (lasting >2 wk) and cough, especially at night. M catarrhalis has been isolated in 22% of maxillary sinus aspirates in children as a single pathogen and in 72% of aspirates in combination with other organisms such as S pneumoniae and/or H influenzae.4
- Lower respiratory tract infections
- Adult patients with a history of conditions such as chronic obstructive pulmonary disease (COPD), pneumoconiosis, asthma, malignancies, or immunosuppression, with findings characteristic of bronchitis or pneumonia or exacerbations of their underlying condition, may have an M catarrhalis infection. Lower respiratory tract infections with M catarrhalis were also associated with smoking in 77% of patients in a meta-analysis. M catarrhalis was isolated from sputum and transtracheal aspirate specimens at rates of 0.2%-8.1%. In more than 30% of cases, H influenzae and/or S pneumoniae was isolated in addition to M catarrhalis.5,6,7,8
- In children, lower respiratory tract infections have been associated with a history of recent respiratory syncytial virus or cytomegalovirus infection or with more debilitating conditions such as bronchopulmonary dysplasia, ventricular septal defect, leukemia, Arnold-Chiari syndrome, prematurity, or HIV infection.9,10
- Nosocomial infections: Outbreaks of infections with M catarrhalis have been reported, mostly involving pulmonary units or pediatric intensive care units.
- Bacteremia: No primary site of infection was found in 46% of patients with M catarrhalis bacteremia. Bacteremia is rare with M catarrhalis community-acquired pneumonia.11 The following conditions have been found to predispose to M catarrhalis bacteremia:
- Immunodeficiency or chronic respiratory conditions such as COPD, bronchiectasis, or cystic fibrosis9,5,6,10,7,8
- Neutropenia, systemic lupus erythematosus, or leukemia
- Endocarditis: M catarrhalis endocarditis has been described in patients with previous history of valvular conditions or prosthesis, as well as in patients who were previously healthy. It has also been described as a complication of balloon angioplasty.12,13
- Sporadic cases of other infections with M catarrhalis include the following:
- Meningitis
- Neonatal ophthalmia
- Septic arthritis
- Keratitis
- Urinary tract infection
- Wound infection
- Peritonitis in patients on dialysis
- Conjunctivitis
- Periorbital cellulitis14
- Acute urethritis resembling gonorrhea15
Physical
Physical findings in M catarrhalis infections are similar to findings of infections with other organisms in the same location.
Differential Diagnoses
Bronchitis
Pneumonia, Community-Acquired
Sinusitis, Acute
Sinusitis, Chronic
Other Problems to Be Considered
Otitis media
Otitis media with effusion
Bacteremia
Endocarditis
Acute bronchitis
Chronic bronchitis
Other primary infections of other etiology
Workup
Laboratory Studies
- CBC count: Increased WBC count with neutrophilia may be present in M catarrhalis infections.
- Gram stain: Gram-negative diplococci are found on Gram stain of cultures. Strict adherence to the staining protocol is required. The accuracy of Gram stain for isolation of Neisseria/Moraxella species was reported to be in perfect agreement with the identification by culture.16
- Confirmation of the diagnosis of M catarrhalis infection is based on isolation of the organism in culture.
- Cultures can be taken from middle ear effusion, the nasopharynx, sputum, sinus aspirates, transtracheal or transbronchial aspirates, blood, peritoneal fluid, wounds, or urine.
- Colonies are approximately 0.2 cm in diameter, opaque, and nonhemolytic after incubation on chocolate or blood agar for 48 hours.
- Characteristically, colonies can be pushed along the surface of the agar like a hockey puck.
- With standard methods of identification, M catarrhalis can be differentiated from Neisseria species by not using sucrose, glucose, maltose, and lactose. Because Neisseria cinerea exhibits the same reaction pattern, the superoxol test must be added.
- For definitive identification, deoxyribonuclease (DNase) and nitrate reduction are performed; M catarrhalis produces DNase and reduces nitrate and nitrite levels.
- Several rapid confirmatory tests are available to identify M catarrhalis, and they are all based on the ability of M catarrhalis to hydrolyze tributyrin. This provides immediate identification and separation from human Neisseria species, which do not hydrolyze tributyrin.
- Serologic tests for infections with M catarrhalis are not widely used; cross-reactivity with Neisseria species in the detection of complement fixation antibodies by immunoelectrophoresis has been demonstrated. Serum antibodies to whole-cell proteins, to lipo-oligosaccharides, and to outer-membrane antigens have proved useful in the diagnosis of M catarrhalis infections. Other laboratory studies may be needed, depending on the site of infection and underlying conditions.
Imaging Studies
- Imaging studies may be needed, depending of the site of infection.
- Paranasal sinus radiography or CT scanning
- Chest radiography
- Abdominal radiography: Obtain a 3-way view if peritonitis is a possibility.
Procedures
- Various procedures may be needed, depending on the site of the infection and underlying conditions.
Treatment
Medical Care
Medical care of M catarrhalis infection depends on the infection site, age of the patient, underlying condition(s), and severity of the disease.
Consultations
- Consultation with an ear, nose, and throat specialist may be indicated in recurrent cases of otitis or sinusitis.
- Consultation with an infectious disease specialist is recommended for infections that do not respond to antibiotic treatment, infections in patients with underlying debilitating conditions, systemic infections with M catarrhalis, or infections in unusual locations.
Medication
Approximately 95% of M catarrhalis strains isolated in the United States produce beta-lactamase. Antibiotics such as penicillin, amoxicillin, and ampicillin are only effective against strains that do not produce beta-lactamase.
Topical ciprofloxacin/dexamethasone treatment for acute otitis media with otorrhea via tympanostomy tubes was found to have similar efficacy to that of topical ofloxacin in M catarrhalis infections.17
Treatment with oral azithromycin 500 mg once daily for 3 days was found comparable with a 10-day regimen of oral clarithromycin 500 mg twice daily in the treatment of acute exacerbation of chronic bronchitis.18
Telithromycin, a ketolide derivative of erythromycin A, demonstrated good in vitro activity against M catarrhalis in acute exacerbation of chronic bronchitis.19 However, severe liver disease associated with telithromycin use has been reported.20
The below antimicrobial drugs may be used in M catarrhalis infections, depending on the need for use of oral or parenteral medication, patient's age, underlying condition, sensitivity of the organism, and desired spectrum of coverage.
Antimicrobials
Therapy should cover likely pathogens in the context of this clinical setting. Nearly all M catarrhalis strains produce beta-lactamase.
Amoxicillin-clavulanate, second- and third-generation oral cephalosporins, and trimethoprim-sulfamethoxazole (TMP-SMX) are the most recommended agents. Alternatively, azithromycin, clarithromycin, or dirithromycin can be used. More than 90% of M catarrhalis strains have been shown to resist amoxicillin, and these rates vary by region.21 All other agents listed below are also effective.
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Recommended dosing schedule of erythromycin may result in GI upset, causing one to prescribe an alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Although 10 d seems to be a standard course of treatment, treating until the patient has been afebrile for 3-5 d seems a more rational approach. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.
Dosing
Adult
500 mg (base, estolate, stearate) PO q6h or 400 mg (ethylsuccinate) PO q6h
Pediatric
20-50 mg/kg/d PO divided q6h
Interactions
Inhibits CYP450 1A2, 3A3/4 isoenzymes; 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; decreases metabolism of repaglinide, thus increasing serum levels and effects
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
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 side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Cefaclor (Ceclor)
Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.
Dosing
Adult
500 mg PO q8h
Pediatric
20-40 mg/kg/d PO divided q8-12h; not to exceed 2 g/d
Interactions
Alcoholic beverages consumed <72 h after taking cefaclor may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dosage by half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy; adjust dose in severe renal insufficiency; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Cefprozil (Cefzil)
Binds to 1 or more of the penicillin-binding proteins, which in turn inhibits cell wall synthesis and results in bactericidal activity.
Dosing
Adult
500 mg PO qd
Pediatric
<12 years: 7.5-15 mg/kg/d PO divided q12h for 10 d
>12 years: Administer as in adults
Interactions
Probenecid increases effect of cefprozil; coadministration with furosemide and aminoglycosides increases nephrotoxic effects of cefprozil
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Cefuroxime (Ceftin, Kefurox, Zinacef)
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose.
Dosing
Adult
500 mg PO q12h
Pediatric
Children: 250 mg PO bid for 20 d
Adolescents: Administer as in adults
Interactions
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential
Contraindications
Documented hypersensitivity
Precautions
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
Administer half dose if CrCl is 10-30 mL/min and quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMX includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Dosing
Adult
160 mg TMP/800 mg SMX PO q12h
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d PO tid/qid for 14 d, based on TMP
Interactions
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
Contraindications
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Precautions
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 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, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, persons with chronic alcoholism, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in 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
Cefotaxime (Claforan)
For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Dosing
Adult
Moderate-to-severe infections: 2 g IV q6h
Pediatric
Infants and children: 50-180 mg/kg/d IV/IM divided q4-6h
>12 years: Administer as in adults
Interactions
Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal impairment; has been associated with severe colitis
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Dosing
Adult
Moderate-to-severe infections: 1-2 g IV q12-24h; not to exceed 4 g/d
Pediatric
Neonates >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Interactions
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution with breastfeeding; caution with allergy to penicillin
Cefoperazone (Cefobid)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Presence of piperazine side chain makes it structurally different from other cephalosporins and enhances antipseudomonal activity. Gram-negative spectrum includes M catarrhalis. Dosage depends on severity of infection and susceptibility of organism.
Dosing
Adult
2 g IV q12h
Pediatric
Children and infants: 100-150 mg/kg/d IV/IM divided bid/tid; not to exceed 12 g/d
Adolescents: Administer as in adults
Interactions
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase cefoperazone levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May increase protime
Ceftazidime (Ceptaz, Fortaz)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Gram-negative spectrum includes M catarrhalis. Dosage depends on severity of infection and susceptibility of organism.
Dosing
Adult
2 g IV q8h; not to exceed 6 g/d
Pediatric
Children and infants: 30-50 mg/kg IV q8h; not to exceed 6 g/d
Adolescents: Administer as in adults
Interactions
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Ceftizoxime (Cefizox)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Gram-negative spectrum includes M catarrhalis. Dosage depends on severity of infection and susceptibility of organism.
Dosing
Adult
2 g IV q8h; not to exceed 12 g/d
Pediatric
Children and infants >6 months: 50 mg/kg IV/IM q6-8h; not to exceed 12 g/d
Adolescents: Administer as in adults
Interactions
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftizoxime levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal insufficiency; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and consequently, growth.
Dosing
Adult
500 mg PO q12h
Pediatric
<18 years: Not recommended
Interactions
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin 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)
Contraindications
Documented hypersensitivity
Precautions
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
May cause seizures; avoid in renal insufficiency and in patients with CNS disorders
Levofloxacin (Levaquin)
For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.
Dosing
Adult
500 mg PO qd
Pediatric
<18 years: Not recommended
Interactions
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; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Contraindications
Documented hypersensitivity
Precautions
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, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may develop with prolonged or repeated antibiotic therapy
Azithromycin (Zithromax)
Treats mild-to-moderate microbial infections
Dosing
Adult
500 mg PO on day 1; followed by 250 mg PO qd on days 2-5
Pediatric
<6 months: Not established
>6 months: 10 mg/kg PO once on day 1; not to exceed 500 mg/d, followed by 5 mg/kg PO qd on days 2-5; not to exceed 250 mg/d
Interactions
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Contraindications
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals; 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.
Dosing
Adult
500 mg PO q12h
Pediatric
15 mg/kg PO divided bid
Interactions
Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin 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, HMG CoA-reductase inhibitors; 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
Contraindications
Documented hypersensitivity; coadministration of pimozide
Precautions
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; 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
Dirithromycin (Dynabac)
Not available in the United States. Inhibits RNA-dependent protein synthesis by binding to 50S ribosomal subunit. Antimicrobial spectrum includes M catarrhalis. Dosage depends on severity of infection and susceptibility of organism. Dosage depends on severity of infection and susceptibility of organism. In children, age, weight, and severity of infection determine proper dosage.
Dosing
Adult
500 mg PO qd; administer with meal
Pediatric
Not established
Interactions
May increase serum digoxin levels; may increase risk of ergot toxicity with ergotamine or dihydroergotamine
Contraindications
Documented hypersensitivity
Precautions
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
Associated with GI distress, pseudomembrane colitis, dizziness, headache, insomnia, pruritus
Follow-up
Further Outpatient Care
- Follow-up care with the patient's primary care physician is highly recommended.
- Worsening symptoms warrant a return visit to the primary care physician.
Deterrence/Prevention
- Universal precautions, good hand-washing technique, and sterilization of instruments and tubes used in intubations, aspiration, or invasive procedures may reduce or prevent the nosocomial infections caused by M catarrhalis.
- Research is under way to create a vaccine to prevent M catarrhalis infections. Clinical trials are planned for the near future.22,23 It is projected that 4.2 million episodes of otitis media would be prevented by a combined pneumococcal-nontypeable H influenzae-Moraxella vaccine.24
- Cessation of smoking and prevention of passive smoking may reduce M catarrhalis infections.
Complications
- Recurrence
- Bacteremia/sepsis
- Meningitis
- Mastoiditis
- Hearing loss
- Pleural effusion
- Shock
- Death
Prognosis
- The prognosis of M catarrhalis infection is poor in hospitalized patients with underlying conditions, especially the following:
- Patients hospitalized for prolonged periods
- Patients in pulmonary units or pediatric intensive care units
- Patients of advanced age
Patient Education
- Hand washing, smoking cessation, and good health habits (eg, proper rest, exercise, diet) are helpful both in the treatment process and in prevention of any infection.
Miscellaneous
Medicolegal Pitfalls
- Treating patients who are extremely young or extremely old, patients with debilitating conditions, or patients with immunosuppression with supportive care only or with antibiotics that may not cover M catarrhalis infections
- Failure to recognize antibiotic-resistant strains
- Failure to consider M catarrhalis as cause of infection
- Failure to provide follow-up care for patients
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Keywords
Moraxella catarrhalis, Neisseria catarrhalis, N catarrhalis, Micrococcus catarrhalis, M catarrhalis, Branhamella catarrhalis, B catarrhalis, upper respiratory tract infections, lower respiratory tract infections, otitis media, sinusitis, chronic obstructive pulmonary disease, COPD, pneumonia, Moraxella catarrhalis infection, M catarrhalis infection, M catarrhalis endocarditis, M catarrhalis pneumonia, M catarrhalis otitis media, M catarrhalis sinusitis, M catarrhalis bacteremia, Moraxella catarrhalis endocarditis , Moraxella catarrhalis pneumonia , Moraxella catarrhalis otitis media , Moraxella catarrhalis sinusitis , Moraxella catarrhalis bacteremia
Contributor Information and Disclosures
Author
Michael Constantinescu, MD, Staff Pathologist, Christus St Frances Cabrini Hospital
Michael Constantinescu, MD is a member of the following medical societies: American Society for Clinical Pathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.
Coauthor(s)
Joseph A Bocchini, Jr, MD, Medical Director of Children's Hospital, Director of Clinical Virology Laboratory, Chairman, Professor, Chief of Infectious Disease Section, Department of Pediatrics, Louisiana State University at Shreveport
Joseph A Bocchini, Jr, 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, Louisiana State Medical Society, Pediatric Infectious Diseases Society, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.
Ronald Silberman, PhD, Director of Clinical Microbiology Laboratory, Louisiana State University Hospital; Professor, Department of Pathology, Louisiana State University Medical Center at Shreveport
Ronald Silberman, PhD is a member of the following medical societies: American Society for Microbiology
Disclosure: Nothing to disclose.
James D Cotelingam, MBBS, MD, Head of Hematopathology, Director of Clinical Laboratories, Professor, Department of Pathology, Louisiana State University at Shreveport
James D Cotelingam, MBBS, MD is a member of the following medical societies: American College of Physician Executives, American Society for Clinical Pathology, Association of Military Surgeons of the US, College of American Pathologists, and New York Academy of Sciences
Disclosure: Nothing to disclose.
Medical Editor
Maria D Mileno, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.
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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
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Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings
CME Editor
Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
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.
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