eMedicine Specialties > Infectious Diseases > Mycobacterial Infections
Mycobacterium gordonae: Treatment & Medication
Updated: Nov 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Collect more data to establish the presence of disease. Clinical response to specific antimycobacterial therapy indicates possible disease presence. As with other mycobacterial organisms, slow resolution of radiographic infiltrates is expected.
- The most effective treatment regimen has not been established, but in vitro susceptibilities suggest clarithromycin and, possibly, azithromycin, quinolones (especially levofloxacin), and ethambutol as treatment options. Rifabutin may be beneficial, and rifampin shows variable results.
- The recommended duration of therapy is not established, although treating patients until culture results are documented as negative is reasonable.
- Whether additional or extended (as with tuberculosis) treatment prevents relapse remains unknown.
Consultations
- Infectious disease specialist
- Pulmonologist
- Hematologist (if bone marrow is involved)
Medication
While the most effective treatment regimen has not been established, in vitro susceptibilities suggest clarithromycin and, possibly, azithromycin, quinolones (eg, levofloxacin, moxifloxacin), and ethambutol as treatment options. Rifabutin may be beneficial, and rifampin has shown variable results.
In vivo activity of doxycycline and trimethoprim-sulfamethoxazole is not known.
M gordonae has been shown to be resistant to isoniazid, pyrazinamide, and streptomycin.
The recommended duration of therapy is not established.
Antimycobacterials
Empiric antimycobacterial therapy must be comprehensive.
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Very active drug for nontuberculous mycobacterial disease, but acquired resistance from monotherapy is a concern.
Adult
500-1000 mg PO bid
Pediatric
7.5 mg/kg PO bid
To avoid uveitis, do not exceed 300 mg of rifabutin when used with clarithromycin; toxicity increases with coadministration of fluconazole, astemizole, and pimozide; 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, and 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
Documented hypersensitivity; coadministration with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies 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 half dose or increase dosing interval if CrCl <30 mL/min; irritative diarrhea not due to Clostridium difficile; superinfections may occur with prolonged or repeated antibiotic therapies
Ethambutol (Myambutol)
Standard drug for nontuberculous mycobacterial disease. Diffuses into actively growing mycobacterial cells and impairs cell metabolism by inhibiting synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance demonstrated. Mycobacterial resistance is frequent with previous therapy. Use in these patients in combination with second-line drugs that have not previously been administered. Administer qd until permanent bacteriological conversion and maximal clinical improvement is observed. Absorption not significantly altered by food.
Adult
15 mg/kg (7 mg/lb) PO qd
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Aluminum salts may delay and reduce absorption (administer several hours before or after ethambutol dose)
Documented hypersensitivity; optic neuritis (unless clinically indicated)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Liver disease (only a few cases of liver toxicity have been observed); reduce dose in patients with impaired renal function; may cause adverse visual effects that may be reversible if promptly discontinued; monthly monitoring of visual acuity and color vision is recommended; approximately 1% of ophthalmologic complications occur with doses of 15 mg/kg PO qd; approximately 10% of ophthalmologic complications occur with doses of 25 mg/kg PO qd
Levofloxacin (Levaquin)
May be useful. Aide effects are very rare (eg, GI or CNS abnormalities, tendinitis). For treatment of mycobacterial infection in combination with rifampin and other antituberculosis agents.
Adult
500-1000 mg PO qd or divided bid
Pediatric
<12 years: Not established
>12 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; reduces therapeutic effects of phenytoin; probenecid may increase 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 studies 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
Rifampin (Rifadin, Rimactane)
For use in combination with at least one other antituberculous drug. Inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Often used for nontuberculous mycobacterial disease.
Adult
600 mg PO qd
Pediatric
10-20 mg/kg PO; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFT results occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistry values prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Rifabutin (Mycobutin)
Ansamycin antibiotic derived from rifamycin S. Inhibits DNA-dependent RNA polymerase, preventing chain initiation in susceptible strains of Escherichia coli and Bacillus subtilis but not in mammalian cells. If GI upset occurs, administer dose bid with food. May be more active with nontuberculous species.
Adult
300-600 mg PO qd
Pediatric
Not established; 5 mg/kg/d PO suggested
Reduce to 150 mg PO qd with coadministration of protease inhibitor (eg, indinavir, nelfinavir); decreases levels of many other medications (eg, estrogens); do not exceed 300 mg qd when used with clarithromycin; steady-state zidovudine plasma levels may decrease after repeated rifabutin dosing, but this does not affect inhibition of HIV by zidovudine
Documented hypersensitivity; uveitis; thrombocytopenia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not administer to patients with active tuberculosis; periodically perform hematologic studies in patients receiving prophylaxis because of association with neutropenia and, more rarely, thrombocytopenia
Azithromycin (Zithromax)
Treats mild-to-moderate microbial infections. Dosing qwk is possible.
Adult
10 mg/kg PO on day 1, 5 mg/kg on days 2-5, then 10 mg/kg qwk; 1200 mg PO qwk used in adults
Pediatric
10 mg/kg PO on day 1, 5 mg/kg on days 2-5, then 10 mg/kg qwk
May cause QT prolongation with cisapride, itraconazole, sparfloxacin, and other medications (probably very rare); 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; hepatic impairment; do not administer with pimozide
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 patients who are hospitalized, geriatric, or debilitated
More on Mycobacterium gordonae |
| Overview: Mycobacterium gordonae |
| Differential Diagnoses & Workup: Mycobacterium gordonae |
 Treatment & Medication: Mycobacterium gordonae |
| Follow-up: Mycobacterium gordonae |
| References |
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References
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American Thoracic Society. Diagnosis and treatment of disease caused by nontuberculous mycobacteria. This official statement of the American Thoracic Society was approved by the Board of Directors, March 1997. Medical Section of the American Lung Association. Am J Respir Crit Care Med. Aug 1997;156(2 Pt 2):S1-25. [Medline].
Jun HJ, Jeon K, Um SW, Kwon OJ, Lee NY, Koh WJ. Nontuberculous mycobacteria isolated during the treatment of pulmonary tuberculosis. Respir Med. Dec 2009;103(12):1936-40. [Medline].
Konishi M, Uno K, Kasahara K, Mori K, Yoshimoto E, Maeda K, et al. [A case of pulmonary Mycobacterium gordonae infection progressed for no therapy]. Nihon Kokyuki Gakkai Zasshi. May 2007;45(5):436-40. [Medline].
Lessnau KD, Milanese S, Talavera W. Mycobacterium gordonae: a treatable disease in HIV-positive patients. Chest. Dec 1993;104(6):1779-85. [Medline].
Sneath PH, Mair NS, Sharpe ME, eds. The Mycobacteria. Genus Mycobacterium. In: Bergey's Manual of Systematic Bacteriology. Vol 2. 2nd ed. Baltimore, Md: Williams & Wilkins; 1986:1447.
Sánchez-Morgado JM, Gallagher A, Johnson LK. Mycobacterium gordonae infection in a colony of African clawed frogs (Xenopus tropicalis). Lab Anim. Jul 2009;43(3):300-3. [Medline].
Umeda Y, Matsuno Y, Imaizumi M, Mori Y, Iwata H, Takiya H. Extralobar pulmonary sequestration infected with Mycobacterium gordonae. J Thorac Cardiovasc Surg. Jan 2009;137(1):e23-4. [Medline].
Weinberger M, Berg SL, Feuerstein IM, Pizzo PA, Witebsky FG. Disseminated infection with Mycobacterium gordonae: report of a case and critical review of the literature. Clin Infect Dis. Jun 1992;14(6):1229-39. [Medline].
Further Reading
Keywords
tap water bacillus, tap water isolate, tap water bacteremia, nontuberculous mycobacteria, mycobacteria, non-tuberculous mycobacteria
