eMedicine Specialties > Infectious Diseases > Mycobacterial Infections

Mycobacterium Chelonae: Treatment & Medication

Author: F Matthew Kuhlmann, MD, Fellow, Division of Infectious Diseases, Washington University School of Medicine
Coauthor(s): Keith F Woeltje, MD, PhD, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine
Contributor Information and Disclosures

Updated: Aug 26, 2009

Treatment

Medical Care

Local wound care for cutaneous lesions is always appropriate. With local care and antibiotics, small lesions may improve without surgical intervention.

Surgical Care

  • Surgical debridement of cutaneous or subcutaneous lesions, especially if the lesions are extensive, is usually required for cure.
  • Surgical excision combined with local wound care may be sufficient for cure as evidenced in one pediatric case and inference from infections due to M abscessus13
  • Surgical debridement of ocular and bone lesions is almost always required.
  • If the infection involves an implanted device, removal of the device is almost always necessary for cure.
  • Consider surgical excision of pulmonary lesions only if the response to therapy is lacking or if the organism is relatively resistant to antibiotics.
  • Surgical excision of lymphadenitis is the therapy of choice and is usually curative.

Consultations

  • Obtain a consultation with an infectious diseases specialist for diagnostic and therapeutic guidance.
  • Obtain a consultation with a pulmonologist for lung lesions, possible bronchoscopy, and therapeutic guidance.
  • Obtain a consultation with a dermatologist for possible biopsy of cutaneous lesions.
  • Obtain a consultation with a surgeon for debridement and/or biopsy. Indwelling catheter placement may also be necessary if long-term antibiotics are to be administered.
  • If local expertise in NTM infections is not available, consider obtaining expert advice from a national center, such as the National Jewish Medical and Research Center in Denver, Colo, or a regional medical school, such as the Mycobacterial Disease Clinic at The University of Texas Health Center at Tyler.

Medication

Prolonged antibiotic therapy is generally required for M abscessus infections and should be considered for M chelonae infections. For serious disease due to M chelonae, a minimum of 4 months of combination therapy is required, usually with clarithromycin and an additional agent. If osteomyelitis is present, therapy should be extended to a minimum of 6 months.2

Although numerous reports have documented cases of successful therapy with one drug (eg, clarithromycin), reports also describe resistance to treatment; therefore, antibiotic therapy with 2 drugs is preferable in most patients.14 In fact, only one clinical trial has assessed monotherapy against M chelonae; clarithromycin was used in the trial, and one patient’s infection relapsed with a resistant strain.15 Test all initial isolates for antibiotic sensitivity to guide therapy because the sensitivity patterns between given isolates can vary considerably.16 Susceptibility testing does not guarantee clinical success, as correlations of susceptibility testing and clinical response have not been assessed. M chelonae tends to be more antibiotic resistant than M fortuitum.

In many patients, the disease has been long-standing, and no urgency in initiating therapy is indicated. In this setting, waiting for the results of sensitivity testing before beginning treatment provides much greater certainty in the choice of an antibiotic regimen. First-line antituberculous drugs (eg, isoniazid, rifampin, pyrazinamide) have no role in the treatment of M chelonae infection.17

Amikacin is the preferred aminoglycoside for treating rapidly growing mycobacteria; however, tobramycin remains the most active aminoglycoside against M chelonae. M chelonae is universally resistant to cefoxitin. Imipenem also has activity against M chelonae and is the preferred carbapenem.2 Ciprofloxacin and levofloxacin have activity against these organisms. Of these, ciprofloxacin has been reported most often, but levofloxacin has the better in vitro activity. Moxifloxacin also has good in vitro activity.18 Clarithromycin and azithromycin have both been used successfully and are more active than erythromycin, which should no longer be considered.

Doxycycline has activity against some isolates. Sulfamethoxazole has limited activity against M chelonae.19 Linezolid has good in vitro activity against M chelonae and has been used successfully alone and in combination to treat infections with this organism.20,21 Tigecycline has good in vitro activity against both M chelonae and M fortuitum, but no clinical data exist on its use; tigecycline should be considered only in the absence of other options.22

Topical amikacin and ciprofloxacin have been reported as useful for ocular disease. Topical quinolones may also be effective. For keratitis, fourth-generation quinolones may have increased penetration over older preparations for topical application. Additionally, they may provide some synergy with amikacin or clarithromycin.23

Treatment with immunomodulatory agents such as interleukin (IL)–12 or interferon (IFN)–γ may be of benefit in refractory disease but should be performed only in consultation with a specialist.24

No standard duration of therapy is reported. Treatment usually lasts for many months, and courses that are 6 months or longer are not unusual. Administer drugs for a duration long enough to allow for a complete resolution of clinically apparent lesions. How much additional therapy is needed to prevent relapse is unclear. Some experts obtain monthly sputum cultures in patients with NTM pulmonary disease and treat for at least a year after the last positive sputum culture.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. In some patients, waiting for sensitivity information rather than starting empiric therapy may be prudent.


Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Use alone or in combinations. Frequently used as a component of oral therapy.

Adult

500 mg PO bid

Pediatric

7.5 mg/kg PO bid; not to exceed 500 mg bid; not approved in children <20 months

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; serious cardiac arrhythmias may occur with coadministration of cisapride; 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

Documented hypersensitivity to macrolides; concurrent use of drugs that increase QT interval

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; administer one-half dose or increase dosing interval if CrCl <30 mL/min; superinfections may occur with prolonged or repeated antibiotic therapies


Azithromycin (Zithromax)

Use alone or in combinations.

Adult

500-600 mg/d PO

Pediatric

<6 months: Not established
>6 months: 10 mg/kg/d PO; not to exceed 500-600 mg/d
>16 years: Adult dosage

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

Documented hypersensitivity to macrolides; concurrent use of drugs that prolong QT interval

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 or prolonged QT intervals; caution in hospitalized, geriatric, or debilitated patients


Amikacin (Amikin)

Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition. Use patient's IBW for dosage calculation. Often used with cefoxitin or imipenem for severe pulmonary or disseminated disease.

Adult

5-7.5 mg/kg IV q12h (average 400 mg IV q12h) in patients with normal renal function; aim for a trough <5 mcg/mL to minimize risk of toxicity; aim for peaks near 20 mcg/mL

Pediatric

Administer as in adults

Enhances effects of neuromuscular blockers; high concentrations of penicillin/cephalosporin may decrease effect; amphotericin, loop diuretics, vancomycin, enflurane, and methoxyflurane increase toxicity; coadministration with amphotericin B increases nephrotoxicity; may cause respiratory depression

Documented hypersensitivity; impaired vestibular dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Adjust dose in renal function; monitor renal function at least weekly; in patients with obesity, base initial dose on average of actual and IBW; avoid other nephrotoxic and ototoxic drugs if possible; not intended for long-term therapy; caution in renal failure (patient not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission


Tobramycin (AKTob, Tobrex)

Has activity against most isolates of M chelonae. Usually used with clarithromycin for severe pulmonary or disseminated disease.

Adult

3 mg/kg/d IV/IM divided tid
Infrequent dosing regimens (eg, once daily) are also likely to work

Pediatric

6-7.5 mg/kg/d IV/IM divided tid/qid (2-2.5 mg/kg q8h or 1.5-1.9 mg/kg q6h)

Increases effects of neuromuscular blockers; potentiates effect of extended spectrum penicillins; concurrent administration with amphotericin B, cephalosporins, and loop diuretics increases risk of nephrotoxicity (avoid additional nephrotoxins)

Documented hypersensitivity; coadministration with cidofovir

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal impairment, preexisting auditory or vestibular impairment, and neuromuscular disorders; aminoglycosides are associated with nephrotoxicity and ototoxicity; age >65 y or <1 mo


Moxifloxacin (Avelox)

Good in vitro activity, but no documented clinical use.
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.

Adult

400 mg/d PO/IV

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, cimetidine increase serum levels; NSAIDs enhance CNS-stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia

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); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in patients with CNS disorders and have caused tendinitis or tendon rupture, known Q-T prolongation, concurrent administration of drugs that cause Q-T prolongation


Ciprofloxacin (Cipro)

Inhibits bacterial DNA synthesis and, consequently, growth. Use alone or in combinations.

Adult

500 mg PO q12h or 400 mg IV q12h

Pediatric

<18 years: Not currently approved for use in mycobacterial infections; although sometimes used in these patients for acute infections, long-term use required for treatment of M chelonei infection is likely problematic

May increase levels of cyclosporine, theophylline, and caffeine; antacids and other metal cations decrease absorption; NSAIDs increase CNS adverse effects; coadministration with warfarin increases INR; may cause hyperglycemia or hypoglycemia with insulin/oral hypoglycemic therapy; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations

Documented hypersensitivity; avoid in CNS/seizure disorders; current use of tizanidine

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 occur with prolonged or repeated antibiotic therapy


Ciprofloxacin ophthalmic (Ciloxan)

For use with or without systemic antibiotics (either oral or parenteral). Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains susceptible to ciprofloxacin.

Adult

1-2 gtt in the eye(s) q2h while awake for 2 d and 1-2 gtt q4h while awake

Pediatric

<1 year: Not recommended
>1 year: Administer as in adults

Documented hypersensitivity; coadministration with steroid combinations after uncomplicated removal of a foreign body from cornea

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

Do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy


Levofloxacin (Levaquin)

Probably fluoroquinolone of choice.

Adult

500-750 mg/d PO/IV (1000 mg or bid use can be considered with more severe disease)

Pediatric

<18 years: Not currently approved in mycobacterial infections; although sometimes used in these patients for acute infections, long-term use required for treatment of M chelonei infection may be problematic

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 1-2 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones

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


Linezolid (Zyvox)

Has been used alone and in combination for the treatment of M chelonae infection. Ninety percent of isolates of M chelonae are susceptible in vitro to linezolid.
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process.

Adult

400-600 mg PO/IV q12h

Pediatric

Preterm neonate <7 days: 10 mg/kg PO/IV q12h
Term neonates to children aged 12 years: 10 mg/kg PO/IV q8h
>12 years: Administer as in adults

May cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, or vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake; may cause myelosuppression or pseudomembranous colitis inhibitors

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

Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in patients with uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor CBC count); unnecessary use may lead to drug resistance; may cause peripheral or optic neuropathy
In March 2007, the FDA issued an alert that linezolid may increase the risk of mortality in patients with infections due to organisms other than gram-positive bacteria (as of this writing, these findings are under further review)


Imipenem/cilastatin (Primaxin)

Usually used with amikacin for severe pulmonary or disseminated disease.

Adult

500 mg to 1 g IV q6h

Pediatric

>3 months: 15-25 mg/kg IV q6h, each dose not to exceed 500 mg (not to exceed 2 g/d)

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

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, especially in elderly age, renal dysfunction, and preexisting seizure disorders; adjust dose for impaired renal function; avoid use in children <12 y with CNS infections; may cause hepatitis and blood dyscrasias


Doxycycline (Bio-Tab, Doryx, Vibramycin)

Because sensitivity to doxycycline is variable, usually not part of initial empiric regimen.

Adult

100 mg PO qd/bid

Pediatric

<8 years: Not recommended
>8 years: Administer as in adults

Bioavailability is slightly decreased with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; decreased levels with CYP3A4 inducers; may increase effects of CYP3A4 substrates

Documented hypersensitivity; severe hepatic dysfunction; children <8 y

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may rarely occur with prolonged exposure to sunlight or tanning equipment


Tigecycline (Tygacil)

Good in vitro activity, but no documented clinical use.
A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino-acyl tRNA molecules in ribosome A site.

Adult

Infuse each dose over 30-60 min
100 mg IV once, then 50 mg IV q12h
Severe hepatic impairment (ie, Child Pugh class C): 100 mg IV once, then 25 mg IV q12h

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Coadministration decreases warfarin clearance and increases warfarin Cmax and AUC (monitor aPTT and INR); coadministration of antibiotics with oral contraceptives may decrease contraceptive effect

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Should be considered only in patients with limited other options given lack of clinical data
Caution in severe hepatic impairment (reduce dose); may adversely effect tooth development; may permit clostridia overgrowth, resulting in antibiotic-associated colitis; may have adverse effects similar to tetracyclines (eg, photosensitivity, pseudotumor cerebri, pancreatitis, antianabolic action)

More on Mycobacterium Chelonae

Overview: Mycobacterium Chelonae
Differential Diagnoses & Workup: Mycobacterium Chelonae
Treatment & Medication: Mycobacterium Chelonae
Follow-up: Mycobacterium Chelonae
Multimedia: Mycobacterium Chelonae
References
Further Reading
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Keywords

Mycobacterium chelonei, M chelonei, M chelonae, Mycobacterium chelonae, Mycobacterium abscessus, M abscessus, nontuberculous mycobacterium, nontuberculous mycobacteria, mycobacterium other than tuberculosis, MOTT, Mycobacterium tuberculosis, mycobacterial cutaneous infection, NTM, NTM lung disease, AIDS, HIV, Runyon classification, Runyon's classification, Runyon classification group IV, Runyon group IV, rapidly growing mycobacteria, osteomyelitis, keratitis, corneal ulcers

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Contributor Information and Disclosures

Author

F Matthew Kuhlmann, MD, Fellow, Division of Infectious Diseases, Washington University School of Medicine
F Matthew Kuhlmann, MD is a member of the following medical societies: American Medical Association and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Keith F Woeltje, MD, PhD, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Washington University School of Medicine
Keith F Woeltje, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Medical Informatics Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

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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